Dr. Budoff's Blog

Arthroscopic Rotator Cuff Repair

September 12th, 2011

The rotator cuff is made up of the muscles and tendons that help you elevate your shoulder (for details, please see the rotator cuff section in my main website). If the rotator cuff becomes damaged enough, a tear may occur. However, not all rotator cuff tears require surgery.

Rotator cuff tears can occur naturally as part of the aging process and may be normal in people aged 60 years or greater. So people who are 60 years or older who haven’t experienced any trauma and who can raise their arms over the head can be treated nonoperatively, at least initially. A steroid injection with a therapeutic strengthening program will decrease pain and other symptoms in roughly 2/3 of these patients. After 3 months, if the pain is not satisfactorily improved, an arthroscopic rotator cuff repair can be considered.

For those younger than 60 years who have had trauma, and especially for those with shoulder weakness or who are unable to elevate their arm, a rotator cuff repair should be performed. I prefer to perform rotator cuff repairs arthroscopically, which decreases postoperative pain and stiffness. The sooner the repair is performed after the rotator cuff tears, the better. If a traumatic tear is not fixed in a timely manner, which is usually a number of months, it can retract, become stiff and the muscles attached to the torn tendon can atrophy and turn to fat.

Arthroscopic rotator cuff repair is performed as an outpatient procedure. If desired, a nerve block can be performed by the anesthesiologist. This involves a needle stick into the area above the shoulder to block all of the nerves going into the arm so that nothing is felt for 12-24 hours. This is optional, and some have it done and some do not. If you don’t have a high pain tolerance you might want to consider getting the block. For those who don’t get the nerve block, I inject morphine into the shoulder joint and perform a single nerve block, which can ‘take the edge off’ of the pain for 8 to 12 hours. Regardless, arthroscopic rotator cuff repairs performed without subacromial decompression (bone removal), are not very painful. As noted on my website’s main section on rotator cuff repairs, the modern literature, including my own original research papers, has shown that removing bone from the acromion is not only unnecessary, but is painful, leads to stiffness and can cause unwanted biomechanical changes in the shoulder.

While the surgery is not very painful, the postoperative course following a rotator cuff repair is highly inconvenient. An abduction pillow, a sling with a pillow on it that is nearly-universally hated, is worn for 6 weeks. There is no ‘active’ arm elevation (ie. using the operated shoulder to lift the arm) for 6 weeks, and no lifting anything heavier than a telephone for 3 months. Please add a ‘2 week penalty’ to all of those time-periods for very large rotator cuff tears, very old rotator cuff tears and revision (redo) rotator cuff repairs. Physical therapy is used depending on how much the patient can do on their own after surgery. Some need a lot of therapy, some hardly any.

The rotator cuff tendons are very slowly healing tissues. It takes about 1-1.5 years before the shoulder feels ‘as good as it’s going to get’. However, when all is said and done, most patients who obey the restrictions and perform their home exercises are much improved and extremely happy with the improvements in their pain relief, strength and shoulder function.

Tags: ,,,,,,,,,,
No Comments »

Scapho-Lunate (SL) Ligament Injuries

August 26th, 2011

Scapho-lunate (SL) ligament injuries are serious injuries to the wrist. The scapho-lunate ligament connects two of the most important bones of the wrist together: the scaphoid and the lunate. The scapho-lunate ligament keeps those small bones of the wrist moving together in a normal, synchronous fashion. Tears of the scapho-lunate ligament can cause significant pain and usually lead to arthritis after 10-15 years, sometimes earlier.

Scapho-lunate ligament injuries can occur from either repetitive overuse or from trauma, such as a fall onto the outstretched hand. Scapho-lunate ligament injuries 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.

The diagnosis of scapho-lunate ligament injuries is suspected based on a physical examination performed by a hand surgeon. Tenderness over the scapho-lunate ligament and pain about the ligament when extending the wrist makes one suspicious of a scapho-lunate ligament injury. The hand surgeon will perform a ‘scaphoid shift’ test, which attempts to determine whether or not the scaphoid and lunate bones are moving together correctly. A negative test does not mean that the ligament is not affected, only that other supportive ligaments may be intact enough to prevent a shift under the low loads imposed during a physical examination. On the other hand, a positive scaphoid shift test signifies a significant scapho-lunate ligament injury.

MRI is not very accurate for diagnosing scapho-lunate ligament injuries, even if intra-articular dye is added to the study (ie. an MR arthrogram). The best way to diagnose scapho-lunate 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 (occult ganglion cysts, avascular necrosis or interrupted blood supply of the lunate, etc).

In mild cases, where the scapho-lunate ligament is ‘sprained’ and not significantly torn, a splint, a steroid injection and avoiding loading the extended wrist (see the above activities that do this) for an extended period of time (well 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 scapho-lunate instability. This is done arthroscopically. Wrist arthroscopy is a quick, minimally invasive out-patient procedure that involves minimal down-time. As above, an MRI is usually obtained before surgery, but because the MRI is not very accurate for problems inside the wrist joint, it is only used to rule out problems outside the wrist joint that the arthroscope can not see.

If the scapho-lunate ligament is intact and the scaphoid and lunate bones are stable, then the pain may be coming from ‘dorsal capsulitis’, a somewhat controversial inflammatory condition of the joint lining next to the scapho-lunate ligament that can mimic a scapho-lunate ligament injury. Dorsal capsulitis can be addressed arthroscopically by removing some of the joint capsule (the joint covering). There is no harm incurred by removing this piece of joint capsule. Following this arthroscopic procedure, there is no splinting and activities can slowly be restarted within a week following surgery. If any other problems are found within the wrist joint, they can be addressed arthroscopically or noted for further discussion with the patient if they are too severe for arthroscopic management.

If the scapho-lunate ligament injury is due to a traumatic event that occurred within the past 3 months in a young patient, ligament repair can be considered. Let me state now for the record that anything that is done to treat a scapho-lunate ligament injury has at least a 20% failure rate. Period. Sometimes more. Scapho-lunate ligament injuries are still one of the big unsolved problems in hand and wrist surgery today.

A scapho-lunate ligament repair is performed through an open incision. The scapho-lunate ligament is repaired back to the bone with a small anchor, which is looks a lot like the head of a harpoon. It sticks into the bone and has stitches on it that hold the ligament back down against the bone. The scapho-lunate ligament repair is protected by an absorbable screw between the scaphoid and the lunate. The screw absorbs over time. This eventually causes it break, with a disconcerting, but harmless, ‘pop’ a few months after surgery. However, by the time it breaks it has already stabilized the scaphoid and lunate together enough that the ligament has healed, if it’s going to heal.

If there is no acute injury, or it’s been over 3 months following an injury, a scapho-lunate ligament repair will probably fail. As a failed scapho-lunate ligament repair can lead to permanent stiffness, it’s not a surgery that I recommend if the odds of success are poor. In this situation, which is the most common situation, if the symptoms are too much to live with reconstruction can be considered. I also prefer reconstructions rather than scapho-lunate ligament repair in patients between the ages of 40-60 years, as stiffness following scapho-lunate ligament repair becomes more common in patients over 40. Reconstruction techniques stabilize the scaphoid by other methods than scapho-lunate ligament repair. There are many different reconstruction techniques described in the hand literature. The reason that so many techniques have been described is that none of them work predictably. Again, there is at least a 20% failure rate with any treatment of scapho-lunate ligament injury.

My own personal philosophy when all treatments have a significant failure rate is to perform techniques with higher success rates that also have low complication rates. At the current time, until better reconstructive options come along, there are two techniques that I prefer. Both involve using tendons to substitute for the loss of the scapho-lunate ligament. One of the techniques is a little less surgery, and one is a little more surgery. Both are performed on an outpatient basis.

The lesser surgery involves moving one of the wrist’s extensor tendons (the extensor carpi radialis longus, or ECRL) to the scaphoid to stabilize the scaphoid during wrist motion. It is simple and quick. Following surgery a cast is worn for 4 weeks and then hand therapy is started to regain wrist motion. I prefer the ECRL transfer for lesser degrees of scapho-lunate ligament instability in patients whom wish to avoid significant stiffness; older patients, for example.

The bigger surgery is called a ‘modified Brunelli reconstruction’. This involves taking roughly 1/3 of the flexor carpi radialis (FCR) tendon and pulling it through a hole created in the scaphoid. This is then pulled over the scaphoid and lunate bones and tied down with an anchor to reconstruct a tether between the scaphoid. A pin is placed to hold the scaphoid in position and a short arm cast is used for 4-6 weeks, depending on how bad the instability is.

If the patient is 55-60 years or older, it may be better to just remove the scaphoid and perform a lunocapitate fusion, as detailed in the ‘Wrist Arthritis’ section of the website. This outpatient procedure involves a cast for 6 weeks and provides motion similar to what an older patient could expect from a scapho-lunate ligament reconstruction.

I know that’s a lot of information, but scapho-lunate ligament injuries are a complex topic that is still without a predictable solution. We have some good surgeries available, if needed, but no great surgeries as of yet. However, if realistic goals are understood, most patients are quite happy with their surgical treatments.

Tags: ,,,,,,,,,,,,,,,,,,
No Comments »

Metacarpophalangeal Joint (MPJ) and Proximal Interphalangeal (PIP) Joint Arthroscopy

August 17th, 2011

The metacarpophalangeal joint (MPJ) is the large joint where the finger connects to the hand. The proximal interphalangeal (PIP) joint is the middle joint of the finger. If pain occurs at these joints, initial treatment consists of buddy-taping the finger to its neighbor and an injection. If the injection works, but wears off, the injection can be repeated.

If pain persists after two injections, it is often because a ligament has been partially torn and the torn part is folded into the joint. This can irritate and inflame the joint, similar to irritation due to a pebble in a shoe.

These cases respond extremely well to arthroscopic debridement. The torn part of the ligament is shaved out and the pain relief is usually significant. If the underlying cause is found to be early arthritis, that will be revealed and appropriate management discussed (please see previous blogs).

Both metacarpophalangeal joint arthroscopy and proximal interphalangeal joint arthroscopy are minimally-invasive procedures performed on an outpatient basis. The ‘stab wounds’ are small and pain is usually minimal. Early motion is encouraged. Stiffness is uncommon, and the need for post-operative hand therapy is often short. The wounds only need to be kept dry for 3 days, and then showering is permitted. Heavy use and power grip are best avoided for a week or two.

In short, both metacarpophalangeal joint arthroscopy and proximal interphalangeal joint arthroscopy are minimally-invasive procedures that are helpful to both diagnose and treat many disorders of the metacarpophalangeal joints and proximal interphalangeal joints that have failed appropriate non-operative management.

Tags: ,,,,,,,,,,,,,,
No Comments »

Proximal Interphalangeal (PIP) Joint Replacement

August 2nd, 2011

The proximal interphalangeal joint is the middle joint of the finger. Injuries to the proximal interphalangeal joint often lead to arthritis. The treatment of proximal interphalangeal joint arthritis starts with buddy taping of the finger to its neighboring digit and a steroid injection into the proximal interphalangeal joint. If significant proximal interphalangeal joint pain continues then the options for treatment are usually either fusion or replacement.

The proximal interphalangeal joint of the index finger is best fused. The index finger is used for pinch. When the index finger opposes the thumb to create power during pinch, this creates a significant sideways stress on the proximal interphalangeal joint. Current proximal interphalangeal joint replacements simply cannot handle this sideways stress, and will become unstable. On the other hand, fusion leads to a stiff but pain-free and stable platform for pinching. The loss of proximal interphalangeal joint motion is not a significant problem for the index finger.

Because the middle, ring and small fingers are used for grasp, motion of the proximal interphalangeal joint of these digits is important. For that reason, proximal interphalangeal joint replacement may be considered. As for most joint replacements, they have less problems as the patient’s age increases. The reason for this is because joint replacements have a limited ‘life expectancy’, and do not last as long in younger, higher demand individuals. Having said that, the newer joint replacements may be better suited for younger, higher demand individuals, within reason.

Proximal interphalangeal joint replacement is performed as an outpatient surgery. The newer metal and polyethylene (a fancy plastic) replacements usually work better than the pyrocarbon implants that were popular a few years back. An example of the newer (SR-PIP) joint implant can be seen at www.totalsmallbone.com/us/products/hand/sr_pip.php4

After proximal interphalangeal joint replacement, motion is started within a few days after surgery with hand therapy. Ultimate motion is about 50% of normal, about 60°. It is unclear how long the newer proximal interphalangeal joint replacements will last.

Unfortunately, these newer unlinked proximal interphalangeal joint replacements are not appropriate for patients with advanced rheumatoid arthritis. Rheumatoid arthritis is a much rarer inflammatory condition than the typical osteoarthritis (wear and tear) that is much more common. If you’re not sure what type of arthritis you have, unless a rheumatologist (arthritis expert) has formally diagnosed you with rheumatoid arthritis, you most probably have simple osteoarthritis or a similar condition. People with rheumatoid arthritis have poor ligaments. Because of this, unlinked replacements, such as the SR-PIP, will become unstable. In cases of rheumatoid arthritis, one-piece linked silastic (a type of rubbery plastic) replacements provide some intrinsic stability and are better options. The post-operative therapy is the same. In cases of rheumatoid arthritis, motion is limited more by the conditions of the finger’s tendons than the joint replacement itself.

So if you are suffering with proximal interphalangeal joint arthritis, there are now better treatment options than were previously available. Most patients are very happy with the pain relief and function afforded by these newer implants.

Tags: ,,,,,,,,,,,
No Comments »

Proximal Interphalangeal (PIP) Joint Injuries

July 29th, 2011

The proximal interphalangeal joint is the middle joint of your finger. It is an unforgiving joint when injured, and often becomes extremely stiff. What most people don’t realize is that the bones of the fingers heal extremely quickly, and if this joint suffers a severe injury it can become irreparable within only 2-3 weeks. That’s a good reason to see a hand surgeon quickly following a proximal interphalangeal joint injury.

If the proximal interphalangeal joint becomes dislocated, without a fracture, these are almost always stable injuries. Splinting them is often counterproductive, because it leads to stiffness. This stiffness can become severe enough within 3-4 weeks so that nothing short of a surgical release will allow motion to regained. However, if motion is begun early an almost normal joint can be regained, with full function.

An unfortunate, but common enough scenario is that there is a proximal interphalangeal joint fracture-subluxation. That means that a critical part of the joint is broken (fractured), which allows the joint to sublux (partially dislocate). This leads to pain and stiffness. If not treated, arthritis often ensues within 6-12 months, or sooner. Even after optimal treatment, the joint will never be the same. The joint will always be thick, may have tenderness and ache sometimes (like when the weather changes) and will never regain full motion.

Proximal interphalangeal joint fracture-subluxations are difficult injuries to treat early, and late treatment is even more problematic. The priorities for early treatment of proximal interphalangeal joint fracture-subluxation are 1) Reduce the joint subluxation so that the joint is located. Failure to do this essentially guarantees early arthritis, 2) Obtain joint motion. Otherwise, the joint becomes extremely stiff, 3) And this priority is, by far, the least important of these three goals: try to reduce the joint fragments. Please note that this is not always possible, and that many people can do well without the joint fragments reduced, as long as the first two goals are met.

The fracture part of these injuries is often highly comminuted, meaning that it is made up of many very small fragments than cannot be reduced (placed back into good position) by opening the fracture directly. Relying only on open surgery to reduce these fractures often has a high rate of stiffness and suboptimal results.

The best treatment of an acute (<1-2 week old) proximal interphalangeal joint fracture-subluxation to accomplish at least the first two goals is a ‘dynamic external fixator’. This is a device constructed of wires and rubber bands in the operating room. The one that I prefer was invented by my late friend, Joe Slade, MD. Many comment that it looks somewhat like a radio antennae coming out of the finger. While that is true, it’s the best technique that I have found for treating early proximal interphalangeal joint fracture-subluxations. While no surgery, especially for severe injuries such as these, works 100% of the time, this one consistently reduces the joint and allows for early motion (with the help of post-operative hand therapy, which is extremely important). A small open incision often allows for reduction of the joint fragments.

Slade dynamic external-fixators usually need to be worn for 6 weeks. And they need to be taken care of. It is extremely important that the patient be responsible in looking after these. These require protective splints over them all the time except bathing or performing motion exercises to prevent them from catching on clothes, surrounding people or objects. The wires cannot be allowed to get bent. Extra rubber bands need to always be carried in case one breaks. Follow-up X-rays are taken every week to start, then every two weeks. Therapy sessions must be attended and ‘homework’ performed to regain motion. The fixators are removed in the office, usually after 6 weeks. This does not hurt very much, and is nothing to worry about.

If the proximal interphalangeal joint fracture-subluxation is not seen within 1-2 weeks, the Slade dynamic external fixator can often be used, but now the joint often has to be opened to clean out scar tissue and allow the joint to reduce. This creates more scar and the ultimate result is often not as good. After 4-6 weeks, the proximal interphalangeal joint fracture-subluxation cannot be fixed, and needs to be reconstructed (replaced).

The best reconstruction, in most cases, is a hemi-hamate arthroplasty. This involves removing a portion of the hamate (a wrist bone) with its cartilage and using it to replace the destroyed proximal interphalangeal joint surface through an open incision. While it probably works better than the other options for proximal interphalangeal joint fracture-subluxations presenting late, the joint often becomes stiff, and the results are not nearly as good as for early injuries treated by the Slade dynamic external fixator. Remember that scar has formed before the surgery, and the original joint surfaces are now destroyed. Some amount of arthritis is often present by this time.

Once significant arthritis has occurred, treatment options are limited to joint replacement or fusion. Both of these are salvage options. Newer options for joint replacement work better, but no artificial joint can ever be as good as your natural joint. Therefore, it’s best to get these injuries treated early to have the best chance at a good result.

Tags: ,,,,,,,,,,,,,,,,,,
No Comments »

Hamate Hook (Hamulus) Fractures

June 16th, 2011

Fractures of the Hook of the Hamate (also called the “Hamulus”) occur mainly in people who play racket or batting sports, such as tennis, golf or baseball. Hamate hook fractures lead to pain in the base of the palm on the small finger’s side.

If seen soon after injury, Hamate Hook fractures are placed in a below-elbow cast for 6 weeks. Unfortunately, even with cast immobilization, only half of these fractures heal. When a fracture fails to heal it is called a ‘nonunion’. Hamate hook nonunions often continue to cause pain. Fortunately, the pain can be effectively relieved by simply removing the fractured bone fragment. While the ulnar nerve, the major nerve to the hand, wraps around the hamate’s hook, in the hands of a skilled hand surgeon the complication rate from this surgery is low. The wrist is splinted for just a few days to facilitate wound healing, and activities may be resumed as tolerated. Many well-known professional athletes have had this procedure performed and returned to their usual high level of competitive performance.

Sometimes the hamate hook nonunion does not cause pain. However, most surgeons still recommend excising the hamate’s broken hook because the flexor tendons to the small finger rub against it. The sharp edge of the hamate hook’s fractured end can damage the flexor tendon to the small finger, which leads to significant hand dysfunction and is a much tougher problem to treat. If a patient understands the risk of tendon injury, and is willing to accept it, then he or she can elect to leave an asymptomatic nonunion untreated.

So whether the hook of the hamate heals in a cast or not, it can be effectively and treated by a skilled hand surgeon with excellent long-term results. Simple removal of the fractured or non-united hook usually returns even professional athletes to their former level of performance.

Tags: ,,,,,,,,,,,,,
1 Comment »

Stiff Fingers

May 26th, 2011

Stiff fingers may occur following injuries to the hand or wrist. The first-line treatment for this is hand therapy, often using splints with springs or rubber bands on them to stretch out the digits. If therapy fails and the finger stiffness is decreasing hand function, a surgical solution can be considered.

Surgical release is often very effective for stiff fingers, especially to regain flexion/bending. The surgical release is performed in the morning. Therapy begins that afternoon. The therapy is intensive, often 5 days/week for a month, then 4 days/week for a month, then 3 days/week for a month. The surgery is not very painful. The therapy can be painful and it’s often a good idea to take a pain pill before therapy if someone else can drive you there. Most people who work with the therapist and do their homework (ie. performing motion exercises several times a day, every day, on their own) regain excellent finger flexion and excellent hand function.

Obtaining finger extension is also possible, although not as predictable. The proximal interphalangeal (PIP) joint is the joint most commonly ‘stuck’ in flexion. Open surgery is not very effective for regaining PIP joint extension. To regain PIP joint extension, the best way is probably by using a ‘digit widget’. The digit widget is a device that is attached to the middle finger bone by a minor surgery. This surgery doesn’t hurt much at all. The digit widget attaches to a rubber band, which is attached to a removable Velcro glove that goes over the hand. This rubber band places an extension force on the PIP joint 24 hours a day. Therapy is not very intensive, but is performed roughly once a week, in order to check the digit widget’s position and often supplement it with splinting of the adjacent metacarpophalangeal joint (MPJ). The digit widget is left in place for 6 weeks and then removed in the office (which also doesn’t hurt very much). Night splints are worn for 6 months to minimize the chance of recurrence. The digit widget is usually very effective. If you’re interested, you can look up the digit widget on the internet at http://www.handbiolab.com/products/digit-widget/

For all surgical releases, results are best if only one finger is involved. If more than one finger is involved, then the time and attention of therapy is divided, and results may not be as good for each individual digit.

So if you have a stiff finger that is causing hand dysfunction and therapy isn’t working, you should be aware that effective surgical options exist. The surgeries are not very painful. However, the post-operative therapy is very intensive, and time must be set aside in your schedule to attend therapy for the releases to be effective. Hand therapy is a necessary and integral part of the treatment, as is ‘home work’, involving performing motion exercises on your own. As with most surgeries, motivated patients do best.

Tags: ,,,,,,,,,,,,,,,,,
No Comments »

Acromioclavicular (AC) Joint Arthritis

May 17th, 2011

Arthritis of the AC joint leads to pain at the top of the shoulder. This happens more frequently in laborers and weight-lifters, but is very common in the general population as well. The diagnosis of AC joint arthritis is best made on physical examination. This is because arthritic changes of the AC joint are extremely common on X-rays and MRI. In fact, 90% of people over the age of 30 have AC joint arthritis on X-ray and/or MRI. However, seeing some arthritis on X-ray or MRI doesn’t mean that the AC joint is actually causing pain; more commonly, it is a ‘red herring’, and not the cause of problems.

If pain is coming from the AC joint, the first treatment is non-operative. Weight-lifters can try widening or narrowing their grip on the bar to see if helps. A steroid injection can be helpful, at least temporarily. If the steroid wears off, then the pain can be lived with or addressed surgically.

The surgery involves removing a small amount, 5-7 mm, of bone from the outside of the clavicle. This creates a space where the AC joint was so that the two bones, the acromion and the clavicle, don’t rub together anymore. Distal clavicle excision can usually be accomplished arthroscopically, except in circumstances where a bone spur has grown so far outside the joint that an open incision is required to remove it.

The distal clavicle excision is usually performed in conjunction with any other necessary arthroscopic shoulder procedures. Arthroscopic distal clavicle excision requires no specific post-operative activity limitations. While the bone may be sore for a few months, this procedure usually provides lasting relief from the pain of AC joint arthritis. Distal clavicle excision is a commonly performed very successful outpatient procedure that has been performed for decades and has “stood the test of time”.

Tags: ,,,,,,,,,,,,,
No Comments »

Distal Radius Osteotomy

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.

Tags: ,,,,,,,,,,,,,,,,
1 Comment »

Flexor Carpi Radialis (FCR) Tendinitis

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.

Tags: ,,,,,,,,,,,,
No Comments »