Dr Budoff's Blog

Posts Tagged ‘wrist surgeon houston’

Luno-Triquetral Ligament Injuries

Tuesday, December 27th, 2011

Now that Kobe Bryant suffered a luno-triquetral ligament injury in his wrist, many people are interested in this problem. The luno-triquetral ligament keeps two of the wrist’s small bones, the lunate and the triquetrum, aligned and connected to each other so that they move together in a normal, synchronous fashion during wrist motion. Luno-triquetral ligament injuries can cause significant pain and can lead to arthritis, but are not as dangerous as the more common scapho-lunate ligament injuries (please see my previous blog on scapho-lunate ligament injuries). Luno-triquetral ligament injuries are also usually better tolerated than are scapho-lunate ligament injuries, causing less pain and disability.

Similar to scapho-lunate ligament injuries, luno-triquetral ligament injuries can occur from either repetitive overuse or from trauma, such as a fall onto the outstretched hand or a twisting injury, often due to power tools. Luno-triquetral ligament injuries can lead to pain on the back (dorsum) of the wrist that is worse with activities, especially when putting pressure onto the extended wrist, such as when doing a push-up, getting up off of the floor, getting out of a pool, or opening a door. They also can cause pain with forearm rotation, such as when using tools, turning a doorknob, etc.

The diagnosis of luno-triquetral ligament injuries is suspected based on a physical examination performed by a hand surgeon. Tenderness over the luno-triquetral ligament and pain about the ligament when extending the wrist makes one suspicious of a luno-triquetral ligament injury. The hand surgeon will perform various maneuvers to determine whether or not the lunate and triquetral bones are moving together correctly.

MRI is not very accurate for diagnosing luno-triquetral ligament injuries, even if intra-articular dye is added to the study (ie. an MR arthrogram). The best way to diagnose luno-triquetral ligament injuries is by arthroscopy. However, MRIs are usually performed before arthroscopic surgery to rule out other problems outside the joint that the arthroscope can’t see, such as occult ganglion cysts, avascular necrosis or interrupted blood supply of the lunate, etc.

In mild cases, when the luno-triquetral ligament is ‘sprained’ and not significantly torn, immobilization using a splint or a cast, a steroid injection and avoiding loading the extended wrist (see the above activities that do this) for an extended period of time (often over a year) may be enough to quiet things down. Weight-lifting and push-ups can be performed in a splint that keeps the wrist in neutral position. As an aside, although most people perform the bench press and other weight-lifting exercises with the bar pressing their wrist back into extension, this is poor form, and may lead to wrist problems.

If non-operative management fails to provide sufficient pain relief, the next step is to confirm the diagnosis and to visualize the degree of luno-triquetral ligament instability. This is done arthroscopically. Wrist arthroscopy is a minimally invasive out-patient procedure that involves minimal down-time. After confirming the luno-triquetral ligament injury, the unstable torn ends of the ligament are debrided (shaved down) and an absorbable screw is placed between the lunate and triquetrum. This screw often provides stability and pain relief. A cast is worn for 6 weeks after surgery. This arthroscopic treatment has approximately an 80% success rate. As for scapho-lunate ligament injuries, there is a 20% failure rate for all surgical treatments of luno-triquetral ligament injuries.

Some people have long ulna bones that push against the triquetrum, causing luno-triquetral ligament injuries. In these cases, the ulnar bone may need to be shortened to take the stress off of the luno-triquetral joint. Shortening the ulna also tightens up the other ligaments around the luno-triquetral joint, providing further stability and symptom relief. The success rate of ulnar shortening is 81-84% and, in fact, many believe that ulnar shortening is the best long-term answer for luno-triquetral ligament injuries. In order to tighten up the ligaments about the luno-triquetral joint, the ulnar shortening has to be performed in the middle of the ulna bone, in its shaft. This is an outpatient procedure that involves removing a few millimeters of bone from the center of the ulnar shaft. A plate is placed to protect the ulna while it heals, which takes approximately 3 months. A cast is worn for the first 6 weeks, and then a removeable brace is used until the bone is fully healed. The main drawback to this procedure is that sometimes the ulna takes over 3 months to heal. Often, a bone stimulator is used to speed up the healing process. A bone stimulator is a painless device applied 20 minutes a day the operative area. Most activities, including many sports, can be restarted without the bone fully healed on x-ray.

If the luno-triquetral ligament injury is very severe because the secondary, back-up ligaments around it have also torn, or if the luno-triquetral ligament injury has already led to arthritis, the wrist is treated with a luno-capitate partial wrist fusion, the same procedure used to treat wrist arthritis (please see the Wrist Arthritis section of my website). Lunocapitate fusion is an outpatient procedure that involves fusing the lunate and the capitate together. The triquetrum and the scaphoid are both removed. A cast is worn for approximately 6 weeks and then therapy is begun. This is a predictable procedure that works very well for advanced wrist problems, including arthritis.

The good news about luno-triquetral ligament injuries is that they are usually not as serious as scapho-lunate ligament injuries. An injection and immobilization is often all that is needed. However, if problems persist, there are a number of outpatient surgeries that can provide relief.

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Flexor Carpi Ulnaris (FCU) Tendinosis

Friday, December 2nd, 2011

The flexor carpi ulnaris (FCU) tendon is on the palmar side of your wrist, above the small finger. It is one of the major tendons that flexes your wrist. Occasionally, overuse can cause damage to the FCU tendon. As opposed to the flexor carpi radialis (FCR) tendon, which runs in a sheath and can get ‘pinched’ by it (see previous blog on the FCR tendon), the FCU tendon has no sheath. FCU overuse leads to painful degeneration of the FCU tendon itself, similar to the tendon degeneration found in tennis elbow and painful rotator cuffs.

Initial treatment is usually a steroid injection and physical therapy. The strengthening exercises are easy and can be learned in 1-2 visits, and then performed every day at home. They should take no longer than 5 minutes each day. If the FCU pain doesn’t resolve after a few months, then a surgical option may be considered.

Fortunately, there is a quick, effective, minimally-invasive outpatient surgical option available that is not very painful. In fact, I published a study on this procedure in 2005.1 All patients who had this procedure performed had excellent pain relief. The degenerative part of the tendon is removed through a small incision and the remaining good part of the tendon repaired. A splint is worn for a few days after surgery, and then normal activities can be restarted, as tolerated.

So if the FCU tendon is causing pain, it can be effectively treated either nonoperatively, or with a small outpatient surgical procedure. Either way, this pain from overuse can usually be cured.

Reference 1: Flexor Carpi Ulnaris Tendinopathy, Budoff JE, Kraushaar BS, Ayala G, The Journal of Hand Surgery, Vol 30A(1):125-129, 2005.

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Distal Radius Osteotomy

Tuesday, April 5th, 2011

Many wrist fractures heal in ‘suboptimal’ position, either because they were not surgically fixed or because the surgical fixation did not turn out well. When a wrist fracture heals in poor position (called a ‘malunion’) it can lead to deformity, pain, stiffness, weakness, and dysfunction, especially in active individuals. If the malunion includes a malalignment inside of the wrist joint, this usually leads to arthritis.

The choice is between accepting the poor wrist position for life or having the bone ‘rebroken’ and fixed (or refixed, as the case may be) in a better position. This is called an osteotomy. As with many other things, if an osteotomy is going to be performed, it is better to perform it early rather than late. Early on, the original fracture line may be visible and it may be possible to reopen up the original fracture, which allows the wrist bone to be put into a fully normal position, or close to it. Once the fracture has healed and remodeled, this is no longer possible, and an approximation needs to be made. Performing the osteotomy early on is crucial if the malunion goes inside the joint, as surgery inside of a joint requires precision if the joint is to be made perfectly smooth again.

Once the osteotomy is made, it is then fixed with a plate in better position, just as a fresh distal radius fracture is plated. In order to ‘fill in the gaps’ in the bone created by the repositioning, bone graft is often needed for filler. Traditionally, this has been taken from the ‘hip’ (iliac crest), but it’s much less painful to take it from around the elbow. Bone taken from the body is much better for this purpose than bone taken from a cadaver, or synthetic bone, which are usually good enough for fresh fractures. Taking bone from around the elbow is not usually very painful, and rarely causes any problems.

After surgery, the wrist is immobilized for 1-2 weeks, depending primarily on the quality of the bone fixed. Then therapy is begun to regain motion. A splint is used as needed for 6 weeks.

Most patients who undergo osteotomy of a wrist fracture that has healed in poor position are extremely happy. This is a common, outpatient procedure, and should be considered in any active patient who is having problems from a wrist fracture that has healed in poor position.

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Flexor Carpi Radialis (FCR) Tendinitis

Thursday, March 31st, 2011

The flexor carpi radialis (FCR) is one of the tendons that helps flex the wrist. It is located on the palmar surface of the wrist, near the base of the thumb. Overuse, such as occurs with repetitive lifting with the palm up, may lead to FCR tendinitis. This is similar to DeQuervain’s tendinitis in that it’s often caused by a space problem.

Like the tendons involved in DeQuervain’s syndrome, the FCR tendon runs in a sheath. Overuse can lead to swelling within that sheath, leading to compression/pinching of the FCR tendon. This leads to tendon pain,usually located about an inch above your wrist. This pain is often increased by lifting with your palm up and by grip, both of which stress the tendon.

Treatment starts with activity modification, lifting with the palm down when necessary, a splint that is worn during periods of heavy activity and a steroid injection to decrease inflammation and swelling. If that fails, then the FCR’s tunnel (sheath) can be surgically released. This is a simple, outpatient procedure that takes only 5-10 minutes. It can be performed under local anesthesia. Like the DeQuervain’s release, it is highly effective.

After surgery, keep the wound clean and dry for 3 days. Then you can shower and get it wet, but try not to submerge it under water for 10 days. Also try to avoid heavy activities for a week or two. Once released, the FCR tendon starts to heal. How long it takes to feel better depends on how much damage it had before it was released and how much the FCR tendon gets to rest following surgery.

In summary, wrist pain due to FCR tendinitis is fairly common and very treatable.

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Wrist Arthritis

Saturday, November 13th, 2010

Wrist arthritis is very common. Wrist arthritis may occur from ligament injuries, fractures, or from chronic overuse. Wrist arthritis leads to pain, stiffness and often swelling of the wrist.

Regardless of why the wrist arthritis occurred, nonoperative treatment should usually be tried first. Nonoperative treatment consists of splinting, a steroid injection, and limiting activities to within the limits of pain. Non-steroidal anti-inflammatory medications, such as ibuprofen or Naprosyn can also be tried.

If these fail, surgical treatment can be extremely effective. Most cases of wrist arthritis can be treated by fusing only one of the two wrist joints, called the “midcarpal joint”. Bone graft (healthy bone that helps the joint fuse) is taken from the distal radius, the large bone of the wrist, through the same incision. I performed a study that demonstrated that removing the scaphoid bone, which is usually involved in the arthritic process, increases motion following partial wrist fusion.1 This should essentially always be done.

The traditional way to perform a partial wrist fusion is by a “four-corner” fusion, where 4 of the wrist’s bones are fused together using two screws. Please see the “Wrist Arthritis” section of this website for an x-ray and description of the four-corner fusion. However, recently I’ve changed to a lesser surgery, which fuses only two bones, the lunate and the capitate, using a single screw. This seems to generate less pain and heal quicker than the traditional four-corner fusion. Essentially, it’s less surgery for the same result.

Partial wrist fusions are performed as an outpatient surgery. Following surgery, a cast is worn for 4-6 weeks. If a normal wrist had this fusion performed on it (which would obviously never happen), it would lose approximately 35-40% of its motion. However, arthritic wrists are already stiff to some degree, and so less motion is lost in these cases. In some cases, where the arthritis has led to very severe stiffness, a gain in functional motion may actually occur. Hand therapy is often used once the cast is removed to maximize motion.

This is an easy surgery to recommend, as most patients do extremely well and return to work, sports and the other activities that they enjoy, without the pain that used to keep them from being so active.

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Triangular Fibrocartilage (TFC) Tears

Thursday, October 7th, 2010

The triangular fibrocartilage complex (TFC) is a very common source of pain on the ulnar (small finger) side of your wrist. The TFC is the main ligament that stabilizes the distal radio-ulnar joint (DRUJ). The DRUJ is the part of the wrist joint that lies between the two bones of your forearm (the radius and ulna) and allows your forearm to rotate. The TFC also functions as a shock-absorber for your wrist, like a meniscus in the knee.

The TFC may become injured by a fall, sports injury, car crash, or other trauma. TFC tears are especially common with wrist fractures, and are often the main cause of wrist pain after the fractures have healed. Sometimes, the TFC can get worn through over time and tear without any injury if the ulna bone (the forearm bone on the small finger side) is longer than your radius (the forearm bone on the thumb side). This relatively long ulna puts a lot of pressure on the TFC with wrist use.

MRIs are not very accurate in diagnosing TFC injuries, which are better diagnosed based on a good history and physical examination. Nonoperative treatment starts with a splint, a steroid injection, avoiding forceful forearm rotation (like when using tools) and avoiding putting weight on the extended wrist (like when pushing to get up off the floor, out of a pool, pushing a heavy door open, etc). If you weight-lift, you want to use a splint while lifting to avoid keep the wrist from extending. All heavy weight lifting should be done with the wrist in neutral, not extension.

If nonoperative management fails and the TFC tear is still painful, the next step is often a diagnostic arthroscopy. If there’s just a flap of injured tissue causing the problems, but the DRUJ is stable, the flap can be removed arthroscopically. If the TFC is torn, but the DRUJ is stable, the TFC tear can be repaired arthroscopically. If the TFC is torn and the DRUJ is unstable (loose), an open repair is usually the best treatment. The results from these surgeries are usually very good. If a TFC repair is performed, an above-elbow cast will be used for 4 weeks, and then therapy is started.

Often times, the TFC injury is either caused or exacerbated by the ulna being longer than the radius. In these cases, the ulna may have to be shortened to prevent the TFC from re-tearing. The ulnar shortening can be performed at the same time as the TFC repair. Sometimes, if the relative ulnar length is not too bad, a TFC repair is done without ulnar shortening. In these cases, if pain persists the ulnar shortening is then performed as a 2nd surgery.

Ulnar shortenings are traditionally done through a long incision: A small length of bone (usually 2-4 mm) is removed from the middle of the ulna and a plate is put on to stabilize the ulna while it heals. A short-arm cast is worn for 6 weeks and heavy activities are avoided until the bone is healed, which can take 3-4 months. However, a newer technique of ulnar shortening can be performed through a smaller incision, with a quicker healing time. In these cases, after 2 weeks only a removable splint is used. The newer type of ulnar shortening usually heals in 6 weeks. Most, but not all, patients will have this newer option available to them.

In summary, TFC tears are very common. Fortunately, there is effective treatment for them. All of the surgeries discussed here are performed as outpatient procedures (you go home the same day), and newer techniques are available that allow patients to return to activities quicker, with fewer problems.

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When is Carpal Tunnel Syndrome Not Carpal Tunnel Syndrome?

Saturday, September 25th, 2010

Carpal tunnel syndrome is the most common nerve compression in the arm. It causes the fingers of the hand to fall asleep, become numb, burn or tingle. But that doesn’t mean that everything that causes numbness about the hand is carpal tunnel syndrome.

If the small and ring fingers are the only digits involved, then the numbness is probably caused by cubital tunnel syndrome, ie. compression of the ulnar (funny bone) nerve about the elbow.

Sometimes elbow or shoulder pain, from tennis elbow, rotator cuff disease, etc. can cause pain to radiate down the arm as far as the hand. But these referred pains don’t go all the way down to the fingers and make them numb.

The median nerve, the same nerve that is pinched by carpal tunnel syndrome at the wrist, can also be pinched further ‘upstream’ about the elbow. This is known as pronator syndrome. Often times, pronator syndrome can occur at the same time with carpal tunnel syndrome; this is known as a ‘double crush’, because the nerve is compressed in two places at once.

Pinched nerves at the neck can also cause numbness in the fingers. These usually affect the thumb, but any fingers can be involved, depending on the nerve root that is being pinched.

Of course, the opposite also happens. People often think that they have a pinched nerve in their neck when they’ve really got carpal tunnel syndrome. This happens fairly often because carpal tunnel syndrome is so common and nerve studies fail to diagnose carpal tunnel syndrome in approximately 20-33% of patients.

So how do you know where the problem is?

First, you should see a hand surgeon, who should be an expert in diagnosing conditions affecting the hand. General orthopaedic surgeons, plastic surgeons, and other types of physicians may have some knowledge about hand disorders, but don’t have the subspecialty training and experience to predictably diagnose some of the less common conditions, especially when the signs are subtle. You know what they say about jacks of all trades. You want to see a specialist to give you the best chance of getting the correct diagnosis. The physical examination that a specialist does can usually determine the real source of the problem.

For some ‘quick and dirty’ rules, that aren’t 100% accurate, but can point you in the right direction: carpal tunnel syndrome usually bothers people more at night and when gripping things: a book, a steering wheel, etc. It can affect the thumb, index, middle and ring fingers in any combination. It can also affect the small finger, but not the small finger alone; if the small finger (and maybe the ring finger) are the only fingers involved, then it’s not carpal tunnel syndrome. It may be cubital tunnel syndrome, thoracic outlet syndrome or a pinched nerve in the neck.

Numbness that is worse with activities and is associated with an ache in the forearm near the front of the elbow is often pronator syndrome. Numbness that is worse when the neck is moved all the way to one side is often due to a pinched nerve at the neck. Numbness on the back of the hand is often referred from the elbow or shoulder, and not due to carpal tunnel syndrome.

However, for the best chance of an accurate diagnosis, go see a hand surgeon specialist who has the extra training and experience to best diagnose conditions of the hand.

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Wrist Ganglions

Friday, July 30th, 2010

Gangions are the most common cause of a bump or mass around the wrist. These are 100% benign. They’re simply herniations of fluid from an underlying joint caused by a weakness in its ligaments. When there is damage to the ligaments or the joint capsule (balloon) around the joint, an area of weakness is created. The joint fluid that lubricates your joint can herniate through this area of weakness, forming a fluid-filled cyst called a ganglion. A one-way valve mechanism forms from the joint lining and prevents the fluid from going back into the wrist, trapping it in the cyst. Because they come from your joints, ganglions can sometimes get bigger during periods of heavy activity and get smaller during periods of rest.

It’s important to understand that not every bump is a ganglion. However, ganglions can be diagnosed fairly easily. Ganglions on the back of the wrist can be aspirated in the clinic. This involves numbing the overlying skin with a small needle and some lidocaine, similar to the novocaine used by dentists. A larger needle is then placed through the numbed skin to draw out the gelatinous fluid inside. This causes the ganglion to disappear or at least decrease in size, and in 1/3-1/2 of cases provides a permanent cure. Sometimes the ganglion has separations and subcompartments within it that make it difficult to fully aspirate. These ganglions with multiple compartments have a lower rate of cure by aspiration.

Ganglions on the palmar surface of the wrist are not usually aspirated. They are usually intertwined with the radial artery, and a large needle could injure the artery or the nearby median nerve. Ganglions can also occur in the fingers, in unusual locations about the wrist, or over other joints.

Once a ganglion is diagnosed, it does not have to be removed. Except in rare cases where it presses directly on a nerve, it will not cause any damage. However, ganglions can cause pain with activity and many people want them removed because they often look unsightly.

Ganglion excision surgery is quick and highly effective. While the literature quotes a 5-10% rate of recurrence for ganglions on the back of the wrist and a 10-20% rate of recurrence for ganglions on the palmar surface of the wrist, as far as I know, I’ve never had a wrist ganglion recur in an adult after I have personally removed it. The key is to remove enough of the joint capsule (the balloon around the joint) that the capsule can’t scar back to itself and so it remains partially open. This prevents the reformation of a one-way valve and creates a permanent “two-way valve” which prevents the recurrence of the ganglion.

After surgery, activity is fairly unrestricted. The wound should be kept clean and dry for 4 days, at which time the dressing can be removed and the wound can get wet in the shower and pat dry. A band-aid can be placed over it. The wound should not be submerged under water for two weeks.

Ganglions in children have a much higher recurrence rate following both aspiration and surgical removal. Strong consideration should be given to not operating in children until they’ve reached ‘skeletal maturity’, around the age of 16 years. However, the mass should be evaluated by a hand surgeon to ensure that it is, in fact, a ganglion and not another type of lesion.

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