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Welcome to First Choice Physical Therapy’s resource for Cervical Spinal Stenosis.

The spinal cord is a column of nerve tissue protected by a bony tube in the spinal column. Conditions that narrow the space in this tube put the spinal cord at risk of getting squeezed. This narrowing is called stenosis. When the narrowing occurs in the spinal column of the neck it is called cervical spinal stenosis, or cervical stenosis. Pressure against the spinal cord as a result of spinal stenosis causes injury to the spinal cord, which is termed myelopathy. Myelopathy is a condition that demands medical attention as it can cause serious problems including problems with the bowels and bladder, changes in the way you walk, and can affect your ability to use your fingers and hands.

This guide will help you understand:

• the anatomy of the spine and neck
• what causes cervical spinal stenosis
• how the condition is diagnosed
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts make up the spine and neck?

The spine is made up of a column of bones called vertebrae. A round block of bone, called a vertebral body, forms the bulk of each vertebra. A bony ring attaches to the back of the vertebral body, forming a canal. Two parts form this bony ring. The first part, the pedicle, attaches to the back of each vertebral body. Each pedicle bone connects with the second part of the ring, called the lamina. The two laminas meet at the back and form into the part of the vertebrae called the spinous process, which is the pointy part you can feel at the back of your neck.  The lamina forms a protective roof over the back of the spinal cord. When the vertebra bones are stacked on top of each other, the bony rings of the vertebrae form a long bony tube that surrounds and protects the spinal cord as it passes through the spine.

An intervertebral disc fits between each vertebral body and provides a space between the spine bones. The disc works like a shock absorber and protects the spine against the daily pull of gravity. The disc also protects the spine during activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.

These ligaments also help to resist rotation and shearing in the spine. Ligaments are strong connective tissues that attach bones to other bones.

Why do I have this problem?

The bony spinal canal normally has more than enough room for the spinal cord. Typically, the canal is just less than ¾ of an inch, or 17-18 millimeters around, which is less than the size of a small bottle cap. Spinal stenosis occurs when the canal narrows to around half an inch, or 13 millimeters or less. When the size drops even further, severe symptoms of myelopathy occur. The symptoms of myelopathy result from the actual pressure against the spinal cord itself as well as the reduced blood supply in the spinal cord as a result of the pressure.

Spinal stenosis may develop for any number of reasons. Some of the more common causes of spinal stenosis include:

• degeneration
• congenital stenosis
• spinal instability
• disc herniation
• constriction of the blood supply to the spinal cord
• chronically poor posture

Degeneration is the most common cause of spinal stenosis. Wear and tear on the spine from normal aging and from repeated stress and strain can cause many problems in the cervical spine. The intervertebral disc can begin to collapse, shrinking the space between the vertebrae. Bone spurs (small bony projections) may form that protrude into the spinal canal and reduce the space available for the spinal cord. The ligaments that hold the vertebrae together may become thicker and can also push into the spinal canal. All of these conditions narrow the spinal canal.

Congenital Stenosis

Some people are born with a spinal canal that is narrower than normal. This is called congenital stenosis. They may not feel problems early in life, but having a narrow canal to begin with places them at risk for stenosis. Even a minor neck injury can set people with a smaller spinal canal up to have pressure against the spinal cord. People who are born with a narrow spinal canal often have problems later in life, because the already narrowed canal tends to become even narrower due to the normal degenerative effects of aging.

Spinal Instability

Spinal instability can cause spinal stenosis. Spinal instability means that there is extra movement among the bones of the spine. Instability in the cervical spine can occur if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. Alternatively spinal stability can occur in people who have diseases that loosen their connective tissues. For example, rheumatoid arthritis can cause the ligaments in the upper bones of the neck to loosen, allowing the topmost neck bones to shift and close off the spinal canal. Whatever the cause, extra movement in the bones of the spine can lead to spinal stenosis and myelopathy.

Disc Herniation

Spinal stenosis can occur when a disc in the neck herniates. Normally, the shock-absorbing disc is able to handle the downward pressure of gravity and the strain from daily activities. However, if the pressure on the disc from everyday activities becomes too much or there is an injury which damages the disc, such as a blow to the head or neck, the nucleus inside the disc may rupture through the outer annulus and squeeze out of the disc. This is called a disc herniation. If an intervertebral disc herniates straight backwards, it can press against the spinal cord and cause symptoms of spinal stenosis. If it herniates to the side instead of straight back it generally compresses the smaller nerves which leave the spinal column rather than the spinal cord itself. Constriction of the blood supply to the spinal cord

The changes that happen with degeneration and disc herniation can choke off the blood supply to the spinal cord. The sections of the spinal cord that don’t get blood have less oxygen and don’t function normally, which leads to symptoms of myelopathy.

What does cervical stenosis feel like?

Cervical stenosis usually develops slowly over a long period of time. This is partly because degeneration in later life is the main cause of spinal stenosis. Symptoms rarely appear all at once when degeneration is causing the problems. A severe injury or a herniated disc may cause symptoms to come on immediately.

Most patients with cervical spinal stenosis have problems with their hands. The area where the spinal cord is compressed in patients with cervical stenosis is very close to the nerves that go to the arm and hand. The problem that compresses the spinal cord in the neck may also compress the nerves where they leave the spinal column. The main complaint is that their hands start to feel numb. The pressure can also cause numbness on the skin of the arm or hand. Due to the weakness in the muscles that develops from the pressure on the nerves supplying the muscles, another complaint is that the patient feels clumsy when doing fine motor activities like writing or typing. Gripping and letting go of items also becomes difficult because the muscles along the inside edge of the palm and fingers weaken. Nerve pressure can also cause pain, which can radiate from the neck to the shoulder, upper back, or even down one or both arms.

Shoulder weakness is a symptom that also develops in many patients. This happens most often when the spinal cord is compressed in the upper part of the neck. The deltoid muscle, which covers the top and outside of the shoulder, and the shoulder blade muscles are the most affected muscles. These muscles weaken and begin to show signs of wasting (atrophy) from not receiving adequate nerve input.

In some patients the first sign of cervical spinal stenosis to appear is a change in the way they walk. Patients don’t realize this problem is coming from their neck but the pressure on the spinal cord in the neck can not only affect the arms, but can also affect the nerves and muscles in the legs, which leads to changes in the way they walk. Eventually their walking pattern gets jerky and they lose muscle power in their legs.

Pressure against the spinal cord can also create problems with the bowels and bladder. Mild spinal cord pressure makes you feel like you have to urinate more often but it also makes it difficult to get urine to flow (urinary hesitancy). Moderate disturbances cause people to have a weak flow of urine, which makes them dribble urine. In addition they also have to strain during bowel movements. In severe cases, people aren’t able to voluntarily control their bladder or bowels; this is called incontinence.

How will my healthcare professional identify the condition?

Diagnosis begins with a complete history and physical examination.  Your healthcare professional will inquire about what your symptoms are, such as pain, tingling or numbness, clumsiness, weakness in your hands or legs, and difficulties walking. They will want to know where exactly your symptoms are, when your symptoms started, and if your symptoms are getting better or worse. They will also want to know if your symptoms came on gradually or if you feel that they were associated with a specific traumatic event.  Your healthcare professional will also inquire about how your problem is affecting your daily activities such as work, home duties, or any recreational activities you may be involved in.

Next your healthcare professional will do a physical examination.  They will assess your neck range of motion by either asking you to put your neck into a variety of positions or placing your neck into specific positions in order to see which neck movements cause pain or other symptoms.  They will want to feel your neck and check the mobility in the joints.  Next they will want to check the strength in your arms, hands, and legs and may also assess the range of motion of these joints.  Your skin sensation and reflexes will also be tested. Your healthcare professional will also want to watch you walk to see if there are any subtle changes in your walking pattern.

Investigations

What investigations may need to be done?

X-rays are used to look for the cause of pressure against the spinal cord. X-ray images can show if degeneration has caused the space between the vertebrae to collapse and may show if a bone spur is pressing against the spinal cord.

If more information is needed, a magnetic resonance imaging (MRI) scan may be ordered. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the spinal cord and can show where it is being squeezed. An MRI machine creates pictures that look like slices of the area your healthcare professional is interested in. This test does not require any special dye or a needle.
A computed tomography (CT) scan may also be ordered. The CT scan is a detailed X-ray that lets doctors see slices of bone tissue. The image can show if bone spurs are protruding into the spinal column and taking up space around the spinal cord.

In addition to any of the above tests it may also be recommended that you have electrical tests of the nerves that go to your arm and hand. An electromyography (EMG) test is used to check if the motor pathway in a nerve is working correctly. A somatosensory evoked potential (SSEP) test may also be requested in order to locate more precisely where the spinal cord is getting squeezed. The SSEP is used to measure whether a nerve is able to receive and send sensory information such as pain, temperature, and touch. The function of a nerve may be recorded with an electrode placed over the skin or with a needle that is inserted into the nerve or sensory center of the brain.

What can be done for cervical spinal stenosis?

Nonsurgical Treatment

In acute situations, at first your healthcare professional may suggest immobilizing the neck with a soft neck collar. The collar is a padded ring that wraps around the neck and is held in place by a Velcro strap.  Keeping the neck still for a short time can calm inflammation and pain. Patients wear the collar during waking hours for up to three months, and only take it off to shower and engage in rehabilitation. Slowly the time that the collar is worn each day is tapered.

Some patients are given an epidural steroid injection (ESI). The injection is given in a part of the spinal canal called the epidural space. This is the area between the dura (the material that covers the spinal cord) and the spinal column. It is thought that injecting steroid medication into this space fights inflammation around the nerves and discs. This can reduce the swelling and give the spinal cord more room.

Non-surgical Rehabilitation

Physical Therapy at First Choice Physical Therapy can be very useful for cervical spinal stenosis if the disease has not progressed too far.  Our treatment will focus on relieving your pain and improving your range of motion. Depending on what your exact symptoms are, your rehabilitation will also focus on maintaining or improving the strength and coordination in your hands and legs, as well as potentially assist in decreasing any altered sensations of your skin that you may be feeling.

Your therapist may use a variety of modalities to assist with your symptoms. Many patients find heat applied to the neck is comforting. Ice may also be used, if preferred.  In addition, electrical modalities such as ultrasound or interferential current may also be used.  Hands-on treatment such as massage, stretches or traction of the neck can also be very useful.  Traction is a way to gently stretch the joints and muscles of the neck. It can be done using a machine with a special head halter, or your therapist can apply the traction with their hands.  They can also teach you how to perform self-traction while at home, which may also assist with your symptoms.

Your therapist will prescribe a series of range of motion exercises for your neck, and also for related areas such as your shoulders.  These exercises may be done under the supervision of your therapist in the clinic but will also be required to be done as part of your home exercise program.  Strengthening exercises are also an extremely important part of your rehabilitation if you suffer from cervical spinal stenosis. As explained above, the muscles supplied by nerves that are being affected by the stenosis will become weak.  By doing strengthening exercises the muscles have a better chance at maintaining the strength they already have or improving any strength which has been lost.

Coordination exercises may be prescribed in addition to the strength exercises in order to get the muscles of the hands (and feet, if necessary) working well.  Proprioception exercises, which assist with the ability to know where your body is in space, will be also be prescribed.
If you have lost any sensation due to your cervical spinal stenosis then your therapist may also prescribe exercises to help maintain or improve your sensation. Even simple hand-rubbing can help to stimulate your sensation if it has been altered.

If necessary, your therapist will encourage gait-retraining exercises. If you are not walking normally due to the effects of the spinal stenosis, your gait will not be as efficient as it should be, and this abnormal pattern can lead to secondary injuries.  If necessary, your therapist will prescribe a walking aid such as a cane or stick in order to ensure you are safe and prevent any falls while you are improving your walking pattern.

Maintaining good posture is very important when dealing with cervical spinal stenosis. Your therapist will ensure that you know what the proper posturing position is for when you are sitting, standing, walking or engaging in any other regular activity you do.  Due to the already small anatomical area in the neck for the nerves and spinal cord to be contained, poor posturing can make a significant difference to the symptoms you feel.  In order to assist your posturing or aid your symptoms, your therapist may use tape near your neck or shoulder areas or in some cases may even suggest the use of a specialized brace that assists with maintaining posture.

Lastly, your therapist will educate you on the importance of restricting any aggravating activities that you engage in during the day. Heavy and repeated motions of the neck, arms, and upper body can be particularly irritating to cervical spinal stenosis. Your therapist can also provide advice on the best sleeping posture to aid your symptoms.

Unfortunately spinal myelopathy caused by cervical spinal stenosis can be a very serious condition. If your condition is causing significant problems or is rapidly getting worse, immediate surgery may be recommended rather than trialling any non-surgical treatments.

What surgical procedures may be done?

When there are signs that pressure is building on the spinal cord, surgery may be required, and sometimes it is required immediately. Surgeries used to treat spinal stenosis include:

• Laminectomy
• Discectomy and fusion
• Corpectomy and strut graft
• Laminectomy

As explained under ‘Anatomy’, the lamina is the bony covering layer of the spinal canal. It forms a roof-like structure over the back of the spinal cord. When bone spurs or disc contents have pushed into the spinal canal, a laminectomy is done to take off the lamina bone in order to release pressure on the spinal cord.

Some surgeons completely remove the entire lamina bone, which is called a total laminectomy. Others prefer to keep the lamina in place by forming a hinge on one edge of the bone. Cutting partially through the lamina on one side forms this hinge.  A second cut is made all the way through the lamina on the other side, which is then lifted away from the spinal cord. The hinged side eventually forms a bone union, which holds the opposite side open and keeps pressure off the spinal cord.

Anterior Cervical Discectomy and Fusion

A fusion surgery joins two or more bones into one solid bone. Fusion of the neck bones is most often done through the front of the neck. During this surgery the surgeon takes out the intervertebral disc (discectomy) between two vertebrae. A layer of bone is shaved off the flat surfaces of the two vertebrae to be fused. This causes the surfaces to bleed which in turn stimulates the bone to heal. (This is similar to the way two sides of a fractured bone begin to heal.) A section of bone is grafted from the top part of the pelvis bone and inserted into the space where the disc was taken out. This separates the two vertebra bones, taking pressure off the spinal cord. As the bone graft heals in place, the vertebral bones fuse together into one solid bone.

Corpectomy and Strut Graft

A corpectomy relieves pressure over a large part of the spinal cord. In this procedure, the surgeon takes off the front part of the spinal column and removes several vertebral bodies. The spaces are then filled with bone graft material. Metal plates and screws are generally used to hold the spine in place while it heals. A corpectomy is used in cases of severe spinal stenosis.

What should I expect after surgery?

Your post-surgical rehabilitation will depend on which surgical procedure you have had done.  Some patients leave the hospital shortly after surgery, but some surgeries require patients to stay in the hospital for a few days. A Physical Therapist may see you to initiate treatment in your hospital room after surgery. These initial therapy sessions are designed to help you learn how to move about and begin doing routine activities without putting extra strain on your neck. Your therapist will remind you of using proper posturing during all your activities and will give you tips on comfortable and safe sleeping habits.  Depending on the surgery you have had done and the post-surgical rehabilitation protocol of your specific surgeon, range of motion and gentle strengthening exercises may be started.

In cases where a fusion or graft has been done, you may be placed in a halo vest or rigid neck brace. These braces are used to restrict the motion in the neck in order to allow the fusion to heal. Bone fusion may take several months.  When the surgeon is absolutely certain the bones have fused together, you will be able to discontinue using the neck brace or halo vest.

Once your surgeon recommends it, you can begin post-surgical rehabilitation at First Choice Physical Therapy. During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving any pain and inflammation that may exist from the surgical procedure itself. We may use modalities such as ice, heat, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or any related areas.

Due to the effects of your surgery as well as any period of immobilization in a brace, your neck range of motion will be restricted. Your therapist will prescribe range of motion exercises for you to do at the clinic and to also do as part of your home exercise program.  It should be noted that you may lose a small portion of your overall range of motion due to the surgical procedure you have had done, but your therapist will ensure that you maximize your available range of motion, and that you are moving well within whatever range of motion you have.

If you have been wearing a neck brace for any period of time then your neck muscles will be weak and deconditioned.  Even if you have not been in a brace, the neck muscles can be weak and deconditioned due to the pain and original symptoms of the cervical stenosis. Any area that has become weak will require strengthening. Your therapist will also prescribe strengthening exercises for your neck as well as related areas such as your shoulders, upper back, and core area. Your therapist will focus on ensuring that you perform all your exercises with precise technique in order to avoid any secondary injuries.  Maintaining good posture during all of your activities of daily living will also help to strengthen your muscles. For this reason your therapist will be adamant in reminding you of proper posturing technique and will encourage it as often as possible. You will need to be extremely cautious about overdoing activities in the first few weeks to months after surgery.  Your therapist will be crucial in guiding you in regards to your exercise limits, but you will be responsible for ensuring you do not overdo any activities at home.

At First Choice Physical Therapy we also highly recommend maintaining the rest of your body’s fitness with regular exercise while recovering from surgery.  Several types of cardiovascular machines can be used including an upper body bike, a stationary bike, or a treadmill for walking.  Cardiovascular activity in a pool may also be appropriate. Your Physical Therapist at First Choice Physical Therapy can discuss which cardiovascular activity would be best for you and provide a program for you to maintain your general fitness while you recover from your surgery.

As therapy sessions taper down, your therapist at First Choice Physical Therapy will help you with decisions about getting back to work and your previous recreational activities.  Ideally, patients are able to go back to their prior activities, however, some patients may need to modify their activities to avoid future problems.
Generally rehabilitation after surgery for cervical spinal stenosis proceeds very smoothly with the Physical Therapy we provide at First Choice Physical Therapy.  If for some reason, however, your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that your neck is tolerating the rehabilitation well and to ensure that there are no complications that may be impeding your recovery.

The wrist joint is replaced with an artificial joint (also called a prosthesis) much less often than other joints in the body, such as the knee or the hip. Still, when necessary, this operation can effectively relieve the pain caused by wrist arthritis. When severe arthritis has destroyed the wrist joint, artificial wrist replacement surgery (also called wrist arthroplasty) can help restore wrist strength and motion for many patients.

This guide will help you understand:

• how the wrist is constructed
• what parts of the wrist are replaced
• what to expect after surgery

What parts of the wrist are involved?

The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The wrist joint is actually made up of many joints and many bones. These joints and bones let us use our hands in many ways. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.

The wrist is made up of eight separate small bones, called the carpal bones. The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. The metacarpal bones are the long bones that lie mostly underneath the palm. The metacarpals are in turn attached to the phalanges (the bones in the fingers and thumb).

One reason that the wrist is so complex is that every small bone forms a joint with the bone next to it. This means many small joints make up the wrist joint. Ligaments connect all the small bones to each other, and to the radius, ulna, and metacarpal bones.

Articular cartilage is the smooth, rubbery material that covers the bone surfaces in most joints. It protects the bone ends from friction when they rub together as the joint moves. Articular cartilage also acts sort of like a shock absorber. Damage to the articular cartilage eventually leads to degenerative arthritis.

What conditions lead to wrist joint replacement?

The main reason for replacing any arthritic joint with an artificial joint is to stop the bones from rubbing against each other. This rubbing causes pain. Replacing the

Painful Arthritic Joint

with an artificial joint gives the joint a new surface, which lets it move smoothly without causing pain.

Many operations are used to treat problems in the wrist. A fusion surgery can get rid of pain and restore strength in badly degenerated wrist joints.

Fusion surgeries make the wrist strong again, but they greatly reduce the wrist’s range of motion. This makes fusion surgery a poor choice for some people.

Arthritis caused by systemic diseases, such as rheumatoid arthritis, often affects both wrists.

People with arthritis in both wrists probably should not have two fusion surgeries.

Two wrist fusions make it very difficult to do everyday activities.

If both wrists require surgery, many surgeons recommend fusing one wrist for strength and replacing the other wrist with an artificial wrist joint. This allows the patient to have one strong hand and one hand with a good range of motion.

What do I need to know before surgery?

Some severe degenerative problems of the wrist may require replacement of the painful joint with an artificial wrist joint. You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

You may also need to spend time with the physical or occupational therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this pre-operative visit is to record a baseline of information. Your therapist will check your current pain levels, your ability to do your activities, and the movement and strength of each wrist.

A second purpose of the pre-operative therapy visit is to prepare you for surgery. You’ll begin learning some of the exercises you’ll use during your recovery. Your therapist can also help you anticipate any special needs or problems you might have at home, once you’re released from the hospital.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. Come prepared to stay in the hospital for at least one night.

What happens in a wrist replacement surgery?

Before we describe the procedure, let’s look first at the artificial wrist itself.

The Artificial Wrist

Some early artificial wrist joints were made entirely of flexible silicon plastic. These plastic joints were used primarily as spacers to keep the joint surfaces from rubbing together.

Modern artificial wrist joints are made of metal and plastic. The part that fits against the end of the radius bone of the forearm is called the radial component. It is made up of two pieces. A flat metal piece is placed on the front part of the radius. It has a stem that attaches down into the canal of the bone. A plastic cup fits onto the metal piece, forming a socket for the artificial wrist joint.

The part that replaces the small wrist bones is called the distal component. This piece is made completely of metal. It is globe shaped to fit into the plastic socket on the end of the radius. The metal distal component is attached by two metal stems that fit into the hollow bone marrow cavities of the carpal and metacarpal bones of the hand.

The plastic used in artificial joints is tough and slick. It allows the two pieces of the new joint to glide easily against each other as you move your wrist. The ball and socket allow movement of the wrist in all directions.

The Operation

Wrist replacement surgery can be done under general anesthesia or regional anesthesia. General anesthesia puts you to sleep. Regional anesthesia puts only your arm to sleep.

The surgeon will first make an:

Incision

through the skin on the back of the wrist. The tendons that run over the back of the wrist are then moved out of the way, and the surgeon cuts open the joint capsule that surrounds the wrist joint.

The surgeon needs to make room for the artificial joint. To do this, most of the first row of:

Carpal Bones are Removed

from the wrist. The end of the radius is also shaped to fit the prosthesis.

The hand bones and the radius bone of the forearm are then prepared with special rasps. The rasps are used to:

Bore Holes

in the bone for the metal stems of the:

Replacement Joint

The surgeon will take some time to get the stems to fit tightly. The joint is put in place and tested through its range of motion to make sure it moves correctly. Once the surgeon is satisfied with the fit, the stems of each metal implant are:

Cemented into Place

The tendons are then placed back into their proper place, and the skin is stitched together.

Does the surgery cause any problems?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following artificial wrist replacement are

• infection
• loosening
• nerve and blood vessel injury

Infection

Infection following joint replacement surgery can be very serious. The chances of developing an infection are low, about one or two percent. Sometimes infections show up very early, before you leave the hospital. Other times infections may not show up for months, or even years, after the operation.

Infection can also spread into the artificial joint from other infected areas. Once an infection lodges in your joint, it is almost impossible for your immune system to clear it. You may need to take antibiotics when you have dental work or surgical procedures on your bladder and colon. The antibiotics reduce the risk of spreading germs to the artificial joint.

If an infection occurs that involves the implant, a second operation will most likely be needed to remove the implant and fuse the wrist.

Loosening

The major reason that artificial joints eventually fail is that they loosen where the metal or cement meets the bone. A loose joint prosthesis causes pain. Once the pain becomes unbearable, another operation will probably be needed to fix the artificial joint or to perform a wrist fusion.

There have been many advances in extending the life of artificial joints. However, most replacements will eventually loosen and require another surgery. In the case of an artificial knee, you can expect about 12 to 15 years, but artificial wrist joints tend to loosen sooner. The risk of loosening is much higher in younger, more active patients.

Nerve and Blood Vessel Injury

All of the nerves and blood vessels that go to the hand travel across the wrist joint. Because wrist replacement surgery takes place so close to these nerves and blood vessels, they may become injured during the procedure. If the retractors holding the vessels out of the way during surgery cause the damage, the symptoms are usually temporary. The nerves and blood vessels rarely suffer any kind of permanent injury after wrist replacement surgery, but this type of injury can happen.

What can I expect after surgery?

After surgery, your wrist will probably be put in a splint and covered by a bulky bandage. You may also have a small plastic tube that drains blood from the joint. Draining prevents excessive swelling from the blood. (This swelling is sometimes called a hematoma.) The draining tube will probably be removed within the first day.

The bandage and splint will keep the wrist in a natural position during healing. Your surgeon will want to check your wrist within five to seven days. Stitches will be removed after 10 to 14 days, although most of them will have been absorbed into your body. You may have some discomfort after surgery. Your surgeon can give you medication to control any pain.

You should keep your hand elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting.

What can I expect after surgery?

You will probably wear an arm-length cast with the wrist placed in a neutral position for up to six weeks after surgery. Then your Physical Therapist  at First Choice Physical Therapy can direct you in a personalized recovery program. Although the time required for rehabilitation varies, as a guideline, recovery from wrist replacement surgery takes up to three months.

Our first few Physical Therapy treatments will focus on controlling the pain and swelling from surgery. We may use heat treatments, gentle massage and other types of hands-on treatments to ease muscle spasm and pain.

Then our Physical Therapist will have you begin gentle range-of-motion exercises. Strengthening exercises are then used to give added stability around your wrist joint. Our Physical Therapist will show you ways to grip and support items in order to do your tasks safely and with the least amount of stress on your wrist joint. As with any surgery, you need to avoid doing too much, too quickly.

Some of the exercises you’ll do are designed to get your hand and wrist working in ways that are similar to your work tasks and daily activities. Our Physical Therapist will help you find ways to do your tasks that don’t put too much stress on your wrist joint. Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

At First Choice Physical Therapy, our goal is to help you control your pain, improve your strength and range of motion, and regain your hand’s fine motor skills. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

A ganglion is a small, harmless cyst, or sac of fluid, that sometimes develops in the wrist. Doctors don’t know exactly what causes ganglions, but a ganglion that isn’t painful and doesn’t interfere with activity can often be left untreated without harm to the patient. However, treatment options are available for painful ganglions or ones that cause problems.

This guide will help you understand:

• what parts of the wrist are involved
• how doctors diagnose the condition
• what treatment options are available

What parts of the wrist are involved?

The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The wrist is actually a collection of many joints and bones. These joints and bones let us use our hands in lots of different ways. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.

The wrist is made of eight separate small bones, called the carpal bones. The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. The metacarpal bones are the long bones that lie underneath the palm.

Carpal Bones

Ligaments connect and hold all these wrist bones together.

The ligaments allow the bones to move in all directions. These ligaments meld together to form the joint capsule of the wrist. The joint capsule is a watertight sac of tissue that surrounds the wrist bones. Inside the wrist capsule are the joints themselves. The joint capsule contains a small amount of lubricant, called synovial fluid, that allows the bones to move together easily. The many tendons required to move the fingers run just outside the joint capsule.

Ganglions are generally attached by a stalk of tissue to a nearby joint capsule, tendon, or tendon sheath (tissure covering the tendon).

Wrist ganglions are attached to the wrist joint capsule. Typically only one ganglion appears, often in a location that is predictable to doctors. However, ganglions have been seen in almost every joint in the hand and wrist.

Sixty to 70 percent of wrist ganglions are dorsal wrist ganglions A dorsal wrist ganglion is found on the back of the hand, often centered over the wrist, though it can appear in any number of areas along the back of the wrist. A dorsal wrist ganglion may be not be visible from the outside. Doctors refer to this hidden type of ganglion as occult, or concealed.

A yolar wrist ganglion typically appears on the palm side of the wrist in the wrist crease just below the thumb. This is the second most common type of wrist ganglion.

Yolar Wrist Ganglion

Why do I have this problem?

Doctors don’t know why ganglions develop. In some cases, the wrist has been injured previously. Repetitive injuries, such as those that can occur from playing tennis or golf frequently, seem to play a role in ganglion development as well.

One theory suggests that wrist ganglions are formed when connective tissue degenerates or is damaged by wear and tear. The damaged tissue forms a weakened spot in the joint capsule, just like a weak spot on a car tire that allows the inner tube to bulge through. The joint fluid may escape through this weakened area and begin to collect in a cyst outside the joint. Over time this cyst grows larger. The joint fluid seems to move out of the wrist joint into the ganglion, but not the other way. In the end, a clear, sticky fluid fills the cyst. The fluid is a mix of chemicals normally found in the joint.

What does a ganglion feel like?

A patient with a dorsal wrist ganglion may feel a bump or mass on the back of the wrist. With a volar wrist ganglion, the bump is felt on the wrist crease below the thumb. The mass may appear suddenly, or it may develop over time. The ganglion may occasionally increase or decrease in size.

The wrist may ache or feel tender. The ganglion may also interfere with activities. A volar wrist ganglion may compress the median or ulnar nerve, causing trouble with sensation and movement. An occult dorsal wrist ganglion may be quite painful and tender, even though it is smaller than other ganglions. Typically the symptoms from a ganglion are not harmful and generally do not grow worse. These cysts will not turn into cancer.

How do doctors diagnose the problem?

Your doctor will ask for a history of the problem and examine your hand and wrist. Usually, this is all that’s required to diagnose a ganglion. An occult dorsal wrist ganglion, however, may be more difficult to locate because of its small size.

What can be done to treat a ganglion?

Treatment for dorsal and volar wrist ganglions may be either surgical or nonsurgical. The relative risks and benefits of any ganglion treatment should be considered carefully.

Nonsurgical Treatment

Dorsal Wrist Ganglions

In the past, dorsal wrist ganglions were treated by breaking them without rupturing the skin. This was done with a mallet (or bible) or simply with firm pressure. However, because ganglions often reappeared after this type of treatment, it is no longer used.

Observation is often sufficient treatment for wrist ganglions. Ganglions typically are harmless and usually do not grow worse over time. Nor do they usually cause damage to the tendons, nerves, or the joint as a whole. As many as 50 percent of wrist ganglions may eventually go away by themselves.

Beyond observation, closed rupture with multiple needle punctures is another nonsurgical treatment option for dorsal wrist ganglions. In this procedure, the cyst wall is punctured with a needle, and anti-inflammatory and numbing drugs are injected into the cyst. This treatment can shrink the cyst and alleviate symptoms. However, the ganglion is likely to reappear.

Volar Wrist Ganglions

Observation is the most common nonsurgical treatment for volar wrist ganglions.

Surgery is recommended when the patient feels significant pain or when the cyst interferes with activity.

It is also recommended if the ganglion is compressing nerves in the wrist, since this can cause problems with movement and feeling in the hand.

Surgery is usually done using regional anesthesia, which means only the arm is put to sleep, but it can also be done under a general anesthesia in which you go to sleep.

Dorsal Wrist Ganglion

Doctors have two options to surgically treat dorsal wrist ganglions.

The first is cyst puncture and aspiration. (Aspiration means drawing the fluid out with suction.) However, this procedure has less than a 50 percent success rate.

Excision, or removal, of the cyst is the second option.

Removing the cyst is usually effective if the stalk that connects the cyst to the joint capsule and a bit of the surrounding capsule are removed.

Usually only a single incision is made, but depending on the location of the ganglion, a second incision may be necessary.

To remove a dorsal wrist ganglion, a small incision is made in the back of the wrist. The tendons that run across the back of the wrist and into the fingers are retracted (or moved) out of the way. This allows the surgeon to see the ganglion and follow it down to where it attaches to the wrist capsule. Once the surgeon locates this stalk, the entire ganglion is removed, including the area where it attaches to the joint capsule. The joint capsule may or may not need to be repaired with sutures. Finally, the skin incision is closed with sutures.

Removing Dorsal Wrist Ganglion

Volar Wrist Ganglion

Puncture and aspiration is not recommended for volar wrist ganglions located in certain areas because of the possibility of nerve and blood vessel damage. In other areas, needle puncture has a better success rate.

Excision is the most common surgery for a volar wrist ganglion. Removing the cyst  is usually effective if the stalk that connects the cyst to the joint capsule and a bit of the surrounding capsule are removed. The surgical procedure is basically the same, except the volar ganglion is usually very close to the radial artery (the artery in the wrist used to feel someone’s pulse). In some cases, the volar ganglion even winds around the artery. This makes removing the ganglion a bit more difficult. The surgeon must be careful to protect the artery, while at the same time removing the cyst down to the joint capsule, just like with the dorsal ganglion.

Both of these procedures have risks. Even after excision surgery, a ganglion may reappear, though this is uncommon. There is a slight risk of infection with both procedures. Excision can sometimes result in decreased motion, instability, and nerve or blood vessel damage. Removing a volar ganglion has a greater risk of nerve and blood vessel damage. However, the vast majority of people have two arteries that travel into the hand. If one is injured, the other is sufficient to provide an adequate blood supply to the hand.

A bulky dressing is applied to the wrist and forearm. You will be encouraged to move your fingers and wrist soon after surgery. Stitches are removed after two weeks. Physical Therapy exercises should be continued until you can move your wrist normally.

You may simply be asked to observe the ganglion for changes. When you visit First Choice Physical Therapy, our therapist may issue you a splint to keep your wrist from moving and to allow the ganglion to shrink. We can show you how to massage the area in order to move fluid out of the ganglion. If you find that the ganglion has gotten bigger, notify your doctor.

Arthritis of the wrist has many causes, and there are many ways of treating the pain. These treatments can be very successful, at least for awhile. But eventually the entire wrist can become so painful that nonsurgical treatments don’t work anymore. At this point, your surgeon may recommend a wrist fusion. Wrist fusion may also be necessary after severe trauma to the wrist. Fusion is sometimes called arthrodesis.

This guide will help you understand:

• how a wrist fusion eases the pain of arthritis
• how surgeons perform the operation
• what the recovery process is like

What parts of the wrist are involved?

The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The wrist is actually a collection of many joints and many bones. These joints and bones let us use our hands in many ways. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.

The wrist is made up of eight separate small bones, called the carpal bones.

The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. The metacarpal bones are the long bones that lie mostly within the palm. The metacarpals are in turn attached to the phalanges, the bones in the fingers and thumb.

One reason that the wrist is so complex is that every small bone forms a joint with the bone next to it. This means that what we call the wrist joint is actually many small joints. Ligaments connect all the small bones to each other, and to the radius, ulna, and metacarpal bones.

Articular cartilage is the smooth, rubbery material that covers the bone surfaces in most joints. It protects the bone ends from friction when they rub together as the joint moves. Articular cartilage also acts sort of like a shock absorber. Damage to the articular cartilage eventually leads to:

Degenerative Arthritis

When the articular cartilage is worn away over time, the bones begin to rub against each other. This causes the pain of degenerative arthritis. Degenerative arthritis is also called osteoarthritis.

Why do I need wrist fusion surgery?

Many of the small joints in the wrist can become arthritic. When this happens, the wrist joint can become extremely painful. Moving your wrist may become difficult because of the pain and stiffness. Your grip can also get weak from the pain. Whenever the hand grips or uses strength in any way, the wrist feels the force. This happens because the muscles running from the forearm to the hand contract, tightening the wrist bones together. This causes pain.

In advanced problems with arthritis, the alignment of the wrist can change, leading to deformity. Fusing the bones together is a way to improve the alignment and prevent further deformation. Fusion may also be needed to align the wrist after a severe wrist injury.

A fusion of any joint eliminates pain by making all the bones grow together into one solid bone. When the bone ends can no longer rub together, there is no more pain. Fusion surgeries are used in many joints. Fusion surgeries were very common before the invention of artificial joints.

A wrist fusion is somewhat different from fusion in other joints. Most joints are made up of only two bones. Wrist fusion involves getting 12 or 13 bones to grow together.

The goal of a wrist fusion is to get the radius in the forearm, the carpal bones of the wrist, and the metacarpals of the hand to fuse into one long bone. The ulna of the forearm is not included in the fusion. The joints between the ulna and the radius are what allow you to turn the palm of your hand up and down. By not fusing the ulna, you should still be able to rotate your hand. However, you will not be able to bend your wrist after the operation.

A wrist fusion is a trade-off. You will lose some motion, but you will regain a strong and pain-free wrist. Regaining strength is especially important to younger people who need to work with their hands. These patients need strength more than flexibility. Wrist fusion gives them a strong wrist that is good for gripping. Patients who need more movement than strength should consider another type of operation, such as an artificial wrist joint replacement.

What do I need to do before surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The amount of time patients spend in the hospital varies

What happens during wrist fusion surgery?

Surgeons fuse wrists in many different ways. In the past, most of the procedures used a bone graft from your pelvis. Surgeons now try to take a small amount of bone from the end of the radius bone instead. A bone graft involves taking bone tissue from one area and transplanting it into another area. This encourages the ends of the bone to grow together. If your surgeon grafts bone from your pelvis, you will have two incisions, one on the back of your wrist, and another on the side of your hip. Your surgeon may also try to fuse the bones without a graft.

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you to sleep during surgery. In some cases, surgery is done using a local anesthetic, which numbs just the wrist and hand. With a local anesthetic you may be awake during the surgery, but your surgeon will make sure you don’t see the operation.

Once you have anesthesia, your surgeon will make sure the skin of your wrist and hand are free of infection by cleaning the skin with a germ-killing solution. The surgeon then makes an incision down the back of the wrist. Since most of the blood vessels and nerves are on the other side of the wrist, going through the back helps prevent nerve and vessel damage.

Next, the tendons and ligaments are moved to the side. This allows the surgeon to see all the bones and joints of the wrist. The articular cartilage is then removed from each joint that will be fused. At this point, the wrist joint consists of many small bones with space between them where the cartilage is missing. If you are getting a bone graft, the

Graft

is placed between each of the spaces in the wrist bones.

The surgeon places a metal plate with screw holes on the back of the wrist. The plate goes from the radius to the metacarpal bone of the middle finger. The plate is attached to the bone with metal screws. The plate keeps the bones from moving so that they stay in proper alignment while they grow together. The plate usually stays inside your hand permanently. It is not removed unless it causes problems.

At the end of the operation, the incisions are stitched together. Your arm is placed in a large, rigid splint or cast, and you are woken up and taken to the recovery room.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following wrist fusion are:

• infection
• nerve and blood vessel injury
• tendon irritation
• nonunion of the bones

Infection

Any surgery carries the risk of infection. You will probably be given antibiotics before the procedure to reduce the risk. If you get an infection, you will need more antibiotics. If the areas around the bone graft and metal plate become infected, you may need surgery to drain the infection.

Nerve and Blood Vessel Injury

All of the nerves and blood vessels that go to the hand travel across the wrist joint. Because the operation is performed so close to them, it is possible to injure either the nerves or the blood vessels during surgery. Retractors that hold the nerves and vessels out of the way during surgery may cause temporary damage. Permanent injury to the nerves or blood vessels rarely happens, but it is possible.

Tendon Irritation

The plate that is screwed into the back of the wrist can irritate the tendons that cross this part of the wrist. If this happens, you may need short-term treatment with medication, ice, or visits to a physical or occupational therapist. If pain and irritation still don’t go away after trying these treatments, your surgeon may have to remove the plate. Surgeons will try to wait to do this until they are certain the bones have fused together.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis (false joint). If the joint motion from a nonunion continues to cause pain, you may need a second operation. In the second procedure, the surgeon usually adds more bone graft and checks that the plates and pins are holding the bones still. The bones need to be completely immobilized for fusion to occur.

What can I expect after surgery?

After surgery, you will wear an elbow-length cast for about six weeks. This holds the wrist still while the ends of the bones fuse together. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, although most of them will have been absorbed by your body. You may have some discomfort after surgery. Your surgeon can give you pain medicine to control the discomfort.

You should keep your hand and wrist elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

What will my recovery be like?

A removable splint usually replaces the cast after six to eight weeks. You can then take the splint off to do your exercises during the day. The joints in your fingers may feel stiff or sore from the immobility caused by the cast. If you still have pain, or if the stiffness in the joints above or below the wrist doesn’t improve, you may be able to benefit from a Physical Therapy program at First Choice Physical Therapy .

Our first few Physical Therapy treatments will focus on controlling the pain and swelling from surgery. We may use gentle massage and other types of hands-on treatments to ease muscle spasm and pain. Then our Physical Therapist will have you begin gentle range-of-motion exercises for the joints above and below the wrist.

Your surgeon will X-ray the wrist several times after surgery to make sure that the bones are healing properly. Once your surgeon is sure that fusion has occurred, our therapist will begin a strengthening program. It will take some time to regain the strength in your hand and arm. As with any surgery, you need to avoid doing too much, too quickly.

Strengthening exercises will give you added stability around the wrist joint. Some of the exercises that we’ll recommend are designed to get your hand and wrist working in ways that are similar to your work tasks and daily activities. Our Physical Therapist will teach you ways to use your hand and arm so that you can do your tasks safely and with the least amount of stress on your wrist. Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, improve strength, and to regain fine motor abilities with your wrist and hand. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you’ll be in charge of doing your exercises as part of an ongoing home program.

Intersection syndrome is a painful condition of the forearm and wrist. It can affect people who do repeated wrist actions, such as weight lifters, downhill skiers, and canoeists. Heavy raking or shoveling can also cause intersection syndrome.

This guide will help you understand:

• what part of your forearm is causing the problem
• what may have caused this condition
• how health care professionals diagnose it
• what can be done to stop the pain
• what is First Choice Physical Therapy’s approach to rehabilitation

What part of the forearm is causing my pain?

The pain from intersection syndrome is usually felt on the top of the forearm, about three inches above the wrist. At this spot, two muscles that connect to the thumb cross over (or intersect) the two underlying wrist tendons (tendons connect muscles to bones).

The two muscles that cross over the wrist tendons control the thumb. They are the extensor pollicis brevis and the abductor pollicis longus. These two muscles start on the forearm, cross over the two wrist tendons, and connect on the back part of the thumb. When these muscles work, they pull the thumb out and back.

The extensor carpi radialis brevis and the extensor carpi radialis longus muscles run lengthwise along the back of the forearm. The tendons of these two muscles attach on the back of the hand. The action of these two wrist tendons pulls the wrist back, into extension.

Most of the tendons around the wrist are covered with a thin tissue called tenosynovium. Tenosynovium is very slippery. It allows tendons to glide against one another and the surrounding muscles, fat, and skin with very little friction.

What caused my condition?

If you overuse the wrist extensor tendons, the slippery tenosynovial lining may become inflamed from the constant rubbing against the two thumb muscles. As the tenosynovium becomes more irritated and inflamed, it swells and thickens. You feel pain when you move your wrist because the swollen tendons are rubbing against the thumb muscles.

Wrist extensor tendons work like the bow used by violin players. The wrist extensor tendons are like the bow, and the thumb muscles are like the strings. As the wrist curls down and in, the wrist tendons rub back and forth against the thumb muscles. The friction builds up, much like the effect of rubbing two sticks together. This can lead to irritation and inflammation of the tenosynovium covering the wrist extensor tendons.

The wrist extensor tendons are strained by any activities that cause the wrist to curl down and in, toward the thumb. These wrist movements are especially common in downhill skiers when they plant their ski poles deeply in powder snow. The same movement is involved when pulling a rake against hard ground. Racket sports, weight lifting, canoeing, and rowing can also stress the wrist extensor tendons.

What does intersection syndrome feel like?

The friction on the wrist tendons causes pain and swelling in the tenosynovium that covers the tendons. The friction hampers the smooth gliding action. You may hear a squeaking sound and feel creaking as the tendons rub against the muscles. This is called crepitus. You may have swelling and redness at the intersection point. Pain can spread down to the thumb or up along the edge of the forearm.

Diagnosis begins with a complete history. Your Physical Therapist at First Choice Physical Therapy will ask questions about where precisely the pain is, when the pain began, what you were doing when the pain started, and what movements aggravate or ease the pain.

Next we will do a physical examination. We will palpate all around the wrist to determine you most tender point. We will also look for swelling or redness in the area. Next we will check the strength of your muscles around the wrist, elbow, and hand. We may ask you to resist certain movements while checking for pain or discomfort. We may even do a grip strength test to determine if your condition has caused you to lose some of your strength and to get a baseline measure so we can easily track your improvement with rehabilitation.
Usually we can make the diagnosis of intersection syndrome just from your history and during the physical examination; most of the time no special diagnostic tests are required.
The main challenge in diagnosing this syndrome is distinguishing it from de Quervain’s tenosynovitis. De Quervain’s tenosynovitis is a condition that is very similar to intersection syndrome.

Both syndromes involve inflammation in the tendons of the wrist. However, the pain begins in different spots. Intersection syndrome causes pain at the intersection point, about three inches up the forearm. De Quervain’s tenosynovitis causes pain along the edge of the wrist, closer to the hand. Your Physical Therapist at First Choice Physical Therapy will examine your forearm and wrist carefully to locate exactly where your pain is coming from and to ensure that the correct diagnosis is determined.

What treatment options are available?

Nonsurgical Rehabilitation

Your initial treatment for intersection syndrome at First Choice Physical Therapy will aim to decreasethe inflammation and pain around the area. Simply icing your wrist can often assist with the inflammation and relieve a great deal of the pain. In cases of more chronic pain, heat may be more useful. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to help decrease the pain and inflammation. Massage for the small muscles around the painful area or the larger muscles of the forearm may also be helpful at this stage.

As this syndrome often comes on due to repetitive activity, it is most important to stop or change the activities that are causing your symptoms.  Taking frequent breaks when doing repeated hand and thumb movements is also important. If possible, we will encourage you to avoid repetitive hand motions such as heavy grasping, wringing, or turning and twisting movements of the wrist. Downhill skiers may get relief by avoiding heavy planting and dragging of their ski poles and by getting a shorter pole with a smaller basket diameter which reduces the drag and force transmitted to the wrist.

In addition to giving the wrist as much rest as possible, keeping your wrist in a neutral alignment will also assist in the healing process. In other words, keep it in a straight line with your arm, without bending it down and in. This position avoids the stress caused by stretching the tendons in this area.  Your Physical Therapist may even suggest the use of a splint for the area, which keeps the thumb and wrist from moving excessively and helps to keep the wrist in the neutral position. Resting for the wrist extensor tendons and the thumb muscles allows the area to begin healing.

As part of your treatment your Physical Therapist may check your workstation set-up and observe the way you do your daily tasks. We will also educate you about healthy body alignment and proper wrist positions. It is our belief at First Choice Physical Therapy that preventing future problems is as much a part of our treatment as getting rid of your existing pain.

Once the initial pain and inflammation has calmed down, your Physical Therapist will focus on improving the mobility and strength of your wrist and thumb. Simple regular wrist stretching exercises will be prescribed and should be done within the limits of pain.  Strengthening exercises will also be prescribed. These exercises will focus on improving both the strength of the wrist and thumb muscles, but also the ability of the hand to grip and exert force when twisting or grabbing. Exercises to improve strength will include eccentric exercises for the area. Eccentric contractions occur as the muscle lengthens and the tendon is put under stretch while resisting a force. Your Physical Therapist will advise you when it is the appropriate time to start these exercises.  Eccentric exercises for the wrist are done by dropping the wrist down slowly at first and then, as able, progressing to a quick motion. These exercises will put the enough stress through the injured area to start building up the tensile strength in the tissues and associated muscles. In addition to eccentric exercises, therapeutic putty might be used which adds some resistance to finger and hand motions, or simple ball gripping or handle twisting exercises may be prescribed. As you become stronger, weights or resistance bands will be used to further build up strength.  Fine motor control and dexterity exercises for your thumb and hand may also be added into your rehabilitation routine depending on your occupation or the cause of your injury. If possible, we will tailor the exercises we give you to simulate the functional activities used in daily living or in your occupation.

Being that intersection syndrome is most often caused by repetitive stress in the first place, close monitoring of your rehabilitation program by your Physical Therapist at First Choice Physical Therapy is necessary to ensure excessive stress is avoided and that you do not re-injure the area during your rehabilitation.

The use of anti-inflammatory medications may be helpful to control the swelling of thetenosynovium and ease symptoms. These medications include common over-the-counter medications such as ibuprofen and aspirin or stronger prescribed medications. Your Physical Therapist may suggest you see your doctor to discuss the use of anti-inflammatories or pain-relieving medications in conjunction with your Physical Therapy treatment.

If rehabilitation, rest, and oral medications fail to control your symptoms, we may liaise directly with your doctor regarding their opinion on an injection of cortisone. Cortisone is a very effective anti-inflammatory medication. Cortisone injections will usually control the inflammation in the early stages of the problem, however, cortisone’s effects are generally temporary, lasting from several weeks to months. This pain-free window of time, however, often allows your Physical Therapist at First Choice Physical Therapy enough time to implement rehabilitation that can cease the onset of further episodes of pain and injury.

If nonsurgical treatment is successful, you should see improvement in four to six weeks. You may need to continue wearing your splint to control symptoms. You should continue to try to do your activities using healthy body and wrist alignment and limit activities that require repeated motions of the wrist and thumb..

Surgery is rarely necessary to treat intersection syndrome. In extremely persistent cases, a surgeon may choose to remove some of the thickened tenosynovium around the tendons.

The operation is called a tendon release.

The tendon release procedure can usually be done on an outpatient basis, which means that you won’t have to spend the night in the hospital. It can be done using a general anesthetic, which puts you to sleep, or a regional anesthetic. A regional anesthetic blocks the nerves going to only a certain part of the body. You may get an axillary block, which puts the arm to sleep, or a wrist block, which puts only the hand to sleep. It is even possible to perform the surgery by simply injecting lidocaine around the area of the incision.

During the surgery a small incision is made over the spot where the two muscles cross over the two wrist tendons.  The surgeon identifies the irritated tendons, and then separates and removes the inflamed tenosynovium from the tendons.  The skin is then stitched together, and your hand is wrapped in a bulky dressing. Your stitches will be removed 10 to 14 days after surgery.

A period of rehabilitation is needed after surgery and Physical Therapy at First Choice Physical Therapy will begin once your surgeon allows it. Your first treatment sessions will initially aim to decrease the inflammation and pain around the surgical area. Icing your wrist frequently post surgery will assist with the inflammation and relieve a great deal of the pain. Similar to the rehabilitation outlined in the non-surgical rehabilitation section above, your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to help decrease the pain and inflammation post surgery. Massage for the muscles of the forearm near the surgical site may also be helpful at this stage.

Simple finger movement exercises will be the first exercises we prescribe after your surgery and we will encourage them regularly throughout your day. These movements will assist with draining any swelling around the surgical site and will ensure that scar adhesions that can limit movement do not form. Gentle stretching within limits of pain will also be encouraged. Combining simple finger movements and elevation of your hand above your heart level whenever possible is a particularly effective method for draining swelling from the surgical area and hand. When your hand is down by your side, gravity causes the swelling to pool in the hand and fingers and can impede rapid recovery.

Your Physical Therapist may also mobilize your wrist if your range of motion is slow to recover. This hands-on technique encourages the stiff joints to move gradually into their normal range of motion and encourages the wrist tendons to glide smoothly under the thumb muscles.

When appropriate, your Physical Therapist will begin to add strengthening exercises to your rehabilitation program including gentle resistance and gripping. Again, the exercises prescribed will be similar to the exercises outlined above in non-surgical rehabilitation and will eventually include the use of some form of resistance, such as putty, weights or elastic bands, to build up the strength you will need to return to your regular activities. Post-surgical rehabilitation versus non-surgical rehabilitation may require more exercises that emphasize the fine motor control and dexterity of the hand.
As surgery is often a last resort to treat the symptoms of intersection syndrome, strict adherence to the exercise limits set by your Physical Therapist as well as suggested activity modifications is crucial in order to avoid recurrence of the injury. It should be noted, that even as the injury itself heals, you might have tenderness over the incision for several months post surgery.

Generally post-surgical rehabilitation at First Choice Physical Therapy goes very smoothly and you are able to return to your full activities over several months.  If, however, during post-surgical rehabilitation your pain continues longer than it should or therapy is not progressing as your First Choice Physical Therapy Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the surgical area is tolerating the rehabilitation well and ensure that there are no complications that may be impeding your recovery.

Fractures of the wrist are common injuries. When you fall, it is only natural to put your hand out to break the fall and prevent more serious injuries to your face and body. The forces that go through your wrist when you fall on your outstretched hand are many times the weight of the body.  Conditions that make a fall more likely, such as icy, wet, or uneven surfaces can increase the risk of a wrist fracture.

A strong pain-free wrist is needed for everyday activities like lifting, gripping and carrying. The wrist is also important for positioning the hand in space, so an injury to this region can be very debilitating and must be treated carefully to preserve function.
Despite being such a common injury, there are a variety of fractures that can occur and such a large number of treatment options that there are still gaps in our knowledge and uncertainties about how to treat each individual wrist fracture.

This guide will help you understand:

• the anatomy of the wrist
• what the symptoms of a fracture are
• what can cause these fractures
• how health care professionals diagnose these fractures
• what the treatment options are
• what First Choice Physical Therapy’s approach to rehabilitation is

What structures are most commonly injured?


The wrist is not a bone but rather a joint between the two bones of the forearm (the radius and the ulna) and the carpal bones of the wrist. The hand is a collection of small thin bones called the metacarpals and the phalanges. The two rows of carpal bones sit between the bones of the forearm and the metacarpal bones of the hand.

The end of the radius is a shallow cup. The shape of the bones alone is not enough to make the wrist a “stable” joint when compared to a joint like the hip. Strong ligaments attach all the bones of the wrist together, which keeps the joints stable and limits excess movement.

The radio-carpal ligament complex goes from the tip of the radius (called the radial styloid) and spreads out to attach to several bones of the wrist. This ligament is stretched by ulnar deviation (tilting the wrist towards the baby finger side) and also limits the total amount of ulnar deviation available. The equivalent ligament on the ulnar side goes from the ulnar styloid and limits radial deviation (tilting toward the thumb). Aside from ulnar and radial deviation, the other movements at the radiocarpal joint are flexion (bending forward at the wrist) and extension (bending back). The ligaments of the wrist joint that are on the back and front limit these movements.  Rotation of the wrist is a combination of these motions.

The end of the ulna does not actually contact the carpal bones. There is a disk of fibrous material called the triangular fibrocartilage (or “TFC”) in between. The TFC also connects to the radius bone and  to the ulnar styloid.  This disk together with the ligaments coming from the ulna and the radius are referred to as the TFCC or triangular fibrocartilage complex.

The distal radioulnar joint (DRUJ) has a very important movement associated with it that makes your hand very functional: rotation of the forearm. Normally, without any injury, you can place your hand and forearm on a table-top either palm down or palm up. The ulna acts as the axis of rotation and the radius rolls around it. If your lay your uninjured arm on a table palm downwards then roll it to the palm up position you will note that the little finger stays in much the same position while the thumb moves from the inside to the outside. These movements are called pronation and supination.

Important nerves, arteries and tendons pass over the wrist joint and may be injured in a fracture. The tendons that move the fingers take origin from muscles in the forearm. Those that bend the fingers (flexors) pass close to the bone on the palmar side of the hand. In a displaced fracture they can be lacerated or get trapped between the fracture fragments.

The median nerve, which runs down the front of the forearm, can be injured by a fall on the outstretched hand. This nerve supplies sensation to the thumb side of the hand. Both the median nerve and the tendons of the fingers travel through a space called the carpal tunnel into the hand. Bleeding into this space and pressure on the nerve by fracture fragments can compress the median nerve, all of which cause an acute carpal tunnel syndrome. The ulnar nerve, which runs along the inside of the elbow and the inside of the forearm, may also be injured in a wrist fracture. The arteries to the hand are not usually damaged in a typical wrist fracture but should be carefully examined.

How do fractures of the wrist commonly happen?

The most common mechanism of injury for a wrist fracture is a fall on the outstretched hand. The broken end of the radius is pushed up and back relative to the rest of the forearm. This causes a deformity of the forearm and wrist that looks like a “dinner-fork”. Dr. Abraham Colles recognized this appearance of the wrist as a sign of a fracture nearly 200 years ago long before the invention of X-rays.  For this reason, a wrist fracture is still commonly called a “Colles’ Fracture”. Although this pattern is common, there are actually several other fracture patterns giving rise to a confusing number of names such as a Smiths Fracture, Barton’s, Die-punch, Galeazzi, and others. Each of these types of fractures has different fracture patterns and different causes.

In the elderly, simple falls are by far the most common reason for a wrist fracture. In younger people it takes more force to break the bone so distal radius fractures are seen following higher energy events such as motor vehicle accidents, falls from a height, industrial accidents, and sports injuries. Getting your hand caught in machinery can result in a very severe distal radius fracture. Open fractures, where the bone breaks through and opens up the skin, are relatively rare but may occur in high-energy accidents.

What types of fractures can occur?

Doctors prefer to call wrist fractures distal radius fractures because this is more descriptive and more accurate regarding the location of the fracture. There are a wide variety of fracture patterns depending on the direction and amount of the injuring force, the position of the wrist when it was injured and the inherent strength of the bone.

Doctors classify these fractures according to:

• whether there is damage to the radiocarpal joint surface
• whether there is damage to the ulnar styloid
• how much splintering (multiple fragmentation) of the bone has occurred

Another very important way to classify these fractures is as unstable or stable. In unstable fractures, the fracture fragments are highly likely to move further out of position during the healing period. The bone fragments are weak and may compress (crumble) further. They can be pulled further out of position by forces from muscles, ligaments, and other bone fragments. Stable fractures are ones that are not likely to move further out of position. Whether a fracture is stable or unstable is an important judgment call by the treating doctor and may well affect the mode of treatment.

As mentioned above, wrist fractures most commonly occur when you fall on the outstretched hand. The wrist is usually extended (bent back) and pronated (palm down) so that the palm of the hand hits the ground. The force of the fall pushes the wrist into further extension, and often radial deviation. The force causes the bone at the end of the radius to break. In addition, the radial deviation may stress the ulnocarpal ligament, which often pulls off (or avulses) the small ulnar styloid. Unfortunately, the compressive force on the end of the radius is often enough to crush the bone into multiple pieces. This means that the bone fragments are squashed and no longer their normal shape.  For this reason, even if the fragments are put back together the healed bone may not return to its normal shape.

A distal radius fracture is a common “Fragility Fracture” in the elderly. A fragility fracture is a fracture that results from mechanical forces that would not ordinarily cause a fracture in a healthy young adult.  The fracture is a sign that osteoporosis has affected the bones. In younger people, it takes a good deal of force to break the wrist. A distal radius fracture in a young person prompts a careful search for other concurrent injuries due to the force that would have been involved.

What symptoms do wrist fractures cause?

Pain in the wrist following an accident or fall is the hallmark of a fracture. The pain and tenderness is felt at the lower end of the forearm and is made worse by any movement of the hand or by rotating the forearm. Deformity of the wrist area is commonly seen with the hand being carried back above the line of the forearm. Within a few minutes of the injury you will also notice swelling of the wrist and hand. If the nerves to the hand have been stretched or compressed you may experience numbness in the fingers or thumb. If tendons are trapped you may find that the fingers are bent and cannot be straightened. Bruising of the region and fracture blisters may be seen within a few hours of the injury.
The symptoms of pain, swelling, and bruising will continue for several days. They are caused, in part, by the injury to the muscles of the region and by bleeding into the tissues from the broken bone fragments. This “soft tissue injury” resolves slowly as the body reabsorbs the swelling and converts the blood collections into scar tissue.

Treatment of the fracture is focused on keeping the bone fragments immobile in an acceptable position until the bones heal. This treatment does not speed up the resolution of the soft tissue injury, although it may help with the pain from the bone fragments themselves.

How will my fracture be evaluated?

At the scene of the accident, first aid for a broken wrist should include splinting the wrist and applying a sling. The patient should be carefully examined for wounds and loss of sensation in the hand, and transported to hospital as soon as possible.

In the Emergency Room (ER), the focus of the evaluation will be on treating shock and pain, making sure that the injury is accurately diagnosed, and that no other injuries are present. It is necessary to examine the whole arm so clothing must be removed and this may mean cutting it off to prevent further pain or injury. Any wounds should be dressed.

The wrist region will be x-rayed. This may include the forearm and elbow if there is suspicion of injury further up the arm. At least two x-ray views are normally taken; an antero-posterior (AP) with the back of the hand on the film, and a lateral (from the side).

In a lot of situations the finding of a wrist fracture will result in referral to an orthopaedic surgeon, however, some fractures may be treated initially by the ER doctor and then followed by your family doctor. The evaluation by the orthopaedic surgeon will include getting a history of the accident and the symptoms.  Both the wrist and arm will be examined and your general medical status will be evaluated. The x-rays will be reviewed.

Often no further radiology tests are needed but sometimes a Computerized Tomography (CT) scan is done to show all the bone fragments of a complex fracture.

The surgeon will then discuss the prognosis of your injury and the treatment options. This discussion will take into account the type of fracture, your expectations and functional demands, and your health status. The consequences and potential complications of each treatment option will also be discussed. Your input into the treatment choice is very important.

What treatments should I consider?

The goals of treatment of distal radius fractures are:

• To relieve the pain of the injury
• To facilitate healing by immobilizing the fracture fragments
• To ensure that the fracture heals in a position which does not compromise wrist function
• To protect the region during the healing process
• To allow return to normal function as soon as possible

There are a wide variety of treatment options available to treat distal radius fractures.

Non-operative treatment is the mainstay of treatment, particularly in the elderly. Long experience has shown that although these fractures may not heal in perfect alignment, this does not usually cause a significant loss of function in the elderly population. The risks associated with surgery and anesthesia makes the choice of non-operative treatment attractive.

Some fractures, however, do need to be treated by surgery. During the last few years, a number of new surgical techniques and implants have been developed. These new tools and techniques are more successful at holding the bone fragments in a good position while the fracture heals. These improvements have prompted a re-evaluation of surgery as a treatment for many wrist fractures. Today, improvements in anesthetic technique and surgical implants have made surgery a good option for all unstable wrist fractures.

CAST

If the fracture is stable and non-displaced then its position does not need to be improved by manipulation, which means moving the bones. These fractures can be treated in a cast. Treating with a cast accomplishes three of the goals of treatment; it improves the pain by splinting the fracture very securely; it protects the fracture; and lastly, it makes it more likely that the fracture fragments will stay in position by preventing movement of the wrist.

A cast must be tight enough to hold the forearm and wrist securely but not so tight that it compresses the damaged and swollen tissues of the forearm. This can be a difficult issue because the region is usually very swollen at the time the cast is put on. In addition, there is often more swelling in the following few days after the cast is put on so the cast may get even tighter. As the swelling goes down it may then get too loose.  Monitoring the circulation and sensation in your fingers is important to ensure that the cast is not too tight.

To combat the problem of the cast becoming too tight with increased swelling quite often the cast is “split” right after it has hardened. A small strip of plaster is removed down one side of the cast and the padding is cut to allow the cast to spread apart if the arm swells. When the swelling has gone down the cast can be closed up again to tighten it around the arm.  Another popular stabilization option is to splint the wrist with a “slab” of plaster for the first few days and apply a cast once the swelling has gone down.

Follow-up of a fracture in a cast may require frequent visits to the cast clinic. The doctor needs to know that the cast is fitting comfortably and that the fracture has not shifted too far out of position. This usually involves repeat x-rays at intervals during the healing period. It is sometimes necessary to replace the cast. If the cast becomes loose, gets wet, or breaks it should be replaced immediately. This can normally be done in the doctor’s office without the need for anesthesia.  Some patients wonder how the cast can be cut without cutting the skin. The cast cutter is a special type of saw. Although a cast cutter looks like a regular saw, it works by vibration. The blade only rotates a few millimeters then reverses. Anything hard, like the cast, resists this small movement and is cut.  Anything soft and giving, like your skin, will vibrate with the cutter and all you will feel is a buzz. In rare cases if the skin is so tense that it doesn’t move when a cast cutter blade touches it, you can get a small cut, therefore if you do feel any pain with the cast cutter, say so immediately.

Your cast will be removed when there is evidence of bone healing on x-ray. At six weeks there is usually enough new bone formation (callus) to allow for removal of the cast. This new bone is still quite weak though and you should protect the fracture for a few weeks longer.  Sometimes protecting it after the cast is removed means wearing a removable splint. You can take off the splint to do rehabilitation (see below) however, you should not use the wrist for heavy activity until the doctor is satisfied that the fracture is adequately healed.

Closed Reduction & Cast

Frequently the position of the fracture is not acceptable. The angulation or the impaction is so severe that the function of the wrist would be impaired if allowed to heal in this position. In these cases, the surgeon may opt to improve the position of the fracture by manipulating it. This is called a fracture reduction. Manipulating a fracture is painful and requires a general, local, or regional anesthetic.

Regional anesthesia is accomplished by injecting a local anesthetic into the armpit next to the nerves that run to the hand. This makes the entire arm numb for about two hours. This is called an axillary nerve block. Another valuable regional anesthesia technique is an intravenous block. A tourniquet stops the circulation to the arm and local anesthetic is injected into the venous system. This makes the arm numb from the tourniquet down to the hand. A third option is to inject local anesthetic directly into the fracture site. This is called a hematoma block.

These anesthetic techniques eliminate all painful sensations from the fracture and allow the doctor to manipulate the fracture fragments into an improved position. Once that has been done the wrist is splinted to allow the swelling to go down, and a cast is applied either immediately or a bit later. An immediate x-ray is taken to make sure that the fracture position is now acceptable. Some surgeons prefer to include the elbow in the cast after a closed reduction. This eliminates rotation of the forearm and may reduce the likelihood that the fracture position will move, or displace.

Although a closed reduction and cast improve the position of the fracture fragments, there is no certainty that the position will be maintained all the way through the healing period. The muscles that move the wrist and fingers all cross the fracture site. As they contract they put a compressive force on the fracture. In unstable fractures, some settling of the fracture may occur. This may result in recurrence of deformity at the fracture site and may require more aggressive treatment.

Closed Reduction & Pinning

When more control of the fracture fragments is necessary, some type of surgical intervention is usually required. One minimally invasive option is to perform a closed reduction and pinning of the fracture. This procedure is suggested when the fracture is considered unstable, but the fragments can be manipulated into an acceptable position. Driving smooth sterile stainless steel pins through the skin and across the fracture stabilizes the fragments. The ends of the pins are cut outside the skin and bent to prevent them migrating any deeper.

This procedure is performed in the operating room using a special x-ray machine called a fluoroscope. This machine projects an x-ray image on a TV screen and allows the surgeon to see the fracture fragments as the pins are being inserted. The procedure requires some type of anesthesia, either a general anesthetic or a regional block.
After this procedure is complete the wrist is dressed and a cast is applied. Once the fracture has healed and is stable the pins are removed. The pins are smooth so they come out easily and an anesthetic is not required for this procedure. The pins may hold the fracture fragments in the correct relationship but they may not prevent the fracture from impacting further if the bone is crushed or very fragile.

Closed Reduction & External Fixation

Another method of stabilizing the unstable fracture is the external fixator. After the fracture is manipulated into a better position, special threaded pins are drilled into the bone above and below the fracture. These pins are connected by a system of rods. This procedure also requires a fluoroscope and some type of anesthesia, either a general anesthetic or a regional block.

The external fixator apparatus allows the surgeon to distract the fracture, which keeps tension on it so that it is less likely to shorten and collapse. The external fixator also holds the fracture immobile so a cast is not needed. The apparatus is maintained until fracture healing has advanced and the fracture is stable at which time the pins are then removed. Usually there is minimal discomfort and this can be done without anesthesia.

Unfortunately, in some cases this apparatus may not be successful in maintaining the reduction of the fracture due to the action of the muscles alluded to above.  In addition, the apparatus itself may be uncomfortable for the patient and the pins may cause problems with the tendons if they transfix them. Pin track infections can also be a problem.

Open Reduction & Internal Fixation (ORIF)

This technique has gained popularity and is the preferred method of treatment by many surgeons for unstable distal radius fractures. For this technique the bone is exposed by an incision on the front or back of the wrist depending on the exact anatomy of the injury. The fracture fragments are reduced into anatomical position and held there with a metal plate.

Sometimes additional bone (a bone graft) is also inserted into the fracture to make it stronger and speed up healing. The advantage of this technique is that the bone fragments can be put back in position more easily under direct visual control and the fixation is stronger. It is not always necessary to remove the fixation (implant) after healing.

Casting is not needed after the surgery although the wrist may be splinted for comfort. It is usually possible to move the wrist early on and this is encouraged to help prevent stiffness. This option has been suggested for patients with a light job who need to return to work as early as possible.

The main disadvantages of ORIF are the greater exposure of the fracture, which leads to concerns about infection and loss of blood supply, and the longer more elaborate surgery that may cause greater stress to the patient.

Many surgeons prefer nonsurgical methods of treatment for elderly patients, who often have multiple medical problems.  In addition, many surgeons are not confident that there is convincing evidence, which shows that ORIF makes a major difference to the long-term function of elderly patients who have low demands. Despite the commonness of the problem it is difficult to study these issues and settle them once for all.

What are the potential complications of this fracture?

Complications are events or conditions that make the process of recovering from the fracture more complex. Although most complications are rare, much of the management of the injury is directed at avoiding complications, detecting them early and treating them if they occur. Doctors, nurses and Physical Therapists will ask patients to move their fingers right after an operation on the wrist as these early movements can help to detect early complications.

Malunion

The term malunion implies that the fracture has healed but is not in the correct anatomic position. There are three aspects of malunion of distal radius fractures that give rise to concern 1) irregularity of the distal radius joint surface, 2) tilting of the joint surface, and 3) shortening of the radius. A gap or step in the joint surface greater than 1 mm is a cause for concern as it increases the long-term possibility arthritis of the joint.
Post-traumatic arthritis of the joint is actually quite rare and there is still no absolute certainty about the amount of irregularity that will cause it.  Most doctors agree, however, that an irregular joint surface should be avoided if possible. Tilt of the distal radius is even more difficult to evaluate.  A severe degree of tilt affects the distal radioulnar joint and rotation of the forearm.  Although, once again, there is no consensus, many doctors prefer to avoid a high angle of tilt and would operate to prevent it.

Shortening of the radius results in impingement between the ulna and the carpal bones, which is often painful.

Preventing malunion is important, as the treatment for it is difficult. Once the bone is healed it is a major undertaking to “take down” the fracture by surgery and fix it into a better position. A “wait and see” approach is often preferred rather than an immediate surgical procedure to fix a malunion. If another surgery is required, there are various operations used for reconstruction of a painful or poorly functioning wrist.

Nerve Injury

The median and ulnar nerves are often compressed by the impact of a fall and may be damaged to the extent that their function is affected. Once this is established it may be necessary to decompress the nerve. Recovery after this surgery is usually complete but delay in treating a nerve injury should be avoided. If you have numbness in your hand after a fracture you must immediately inform your doctor about it.

Another source of nerve injury is from the hardware used to treat the fracture. Pins inserted through the skin may come close to or penetrate into nerves that pass over the fracture. The radial nerve on the thumb side of the wrist is quite vulnerable to this type of injury. It causes pain similar to an electric shock and may also cause numbness, however most often this resolves when the pin is removed. Damage to a nerve may also result in a sensitive, tender scar.

Compartment Syndrome

Fractures of the distal radius cause damage to the muscles of the forearm and involve bleeding into the muscle compartments. Both these processes cause increased pressure in the muscle compartments, which may be further increased by bandages or casts. If the pressure gets too high the blood supply of the muscle tissue is impaired causing further damage and a further increase in intra-compartment pressure.

The hallmark symptom of compartment syndrome is relentlessly increasing pain made worse by active or passive finger movements. For this reason patients are encouraged to move their fingers as soon as possible so any unwarranted pain can be detected. If it is only mildly uncomfortable this is evidence against a compartment syndrome. Once established, compartment syndrome tends to get worse and cause muscle death with long lasting disability. The treatment is to immediately operate to open up the muscle compartments and relieve the pressure (fasciotomy). If this is done before any muscle dies the results are excellent although the scars on the forearm may be dramatic.

Infection

If the skin is wounded either by the accident (causing an open fracture) or by surgery there is a chance that bacteria will infect the wound.  Antibiotics are often routinely prescribed to reduce the chance of this happening. The risk of an infection following an operation with modern treatment is less than 2% (one in 50) but this is little consolation to you if you do get an infection.

Signs and symptoms of an infection include increased wound swelling, increased redness, increased tenderness, and the possibility of pus draining from the wound. It is normal to have a slight fever after an operation but with an infection this tends to go up and lasts longer. Cultures taken of the blood or drainage from the wound may reveal the bacteria responsible and assist in treatment.

The mainstay of treatment is the prolonged use of high-dose bacteria-specific antibiotics but further surgery is also very common. With surgery the wound is opened and washed out to reduce the number of bacteria and give the antibiotics a fighting chance. Sometimes the wound may be packed with antibiotic beads to increase the local concentration of the drug. Once the infection is under control the fracture should heal, however it may be necessary to remove all the metal implants as bacteria tend to grow on foreign material.

In the majority of cases the combination of early aggressive antibiotic treatment, wound washout, and removal of the hardware once the fracture is healed is successful in restoring the wrist to normal after an infection.

Complex Regional Pain Syndrome (CRPS)

This troublesome problem results in burning pain, swelling, and stiffness of the hand and wrist even though the fracture has healed. Normally after an injury the blood supply is increased to the injured area as part of the body’s marshaling of resources. Generally this increase only lasts a few days post-injury and then the blood supply returns to normal levels. After some wrist fractures, however, this does not happen and the increased blood supply causes prolonged swelling. This in turn makes it difficult to move the hand and wrist. As a result everything stiffens up and attempts to move the wrist are unusually painful.

It is not clear why CRPS occurs although there is a connection between pain and the blood supply reflex. CRPS was previously called Reflex Sympathetic Dystrophy (RSD) so this term may still be used but refers to the same process. The pumping action of the muscles helps to reduce swelling therefore CRPS is less common if you get the fingers, hand and wrist moving early.   This is another reason why you are asked by the Physical Therapist and other health care professionals to move your fingers right away.
Treatment of established CRPS is different for different individuals but includes exercises prescribed by a Physical Therapist, splints to eliminate the stiffness, medication for the pain, and compression gloves to help reduce the swelling. Nerve blocks may be helpful both for diagnosis and treatment. The prognosis of CRPS is good with most people recovering, however it may take a long time for complete recovery to occur.

Hardware Failure

Most implants that are used to stabilize fractures are made of metal and therefore subject to metal fatigue. Metal fatigue is a similar process as to when you want to shorten a piece of wire and so to do this you repeatedly bend it back and forth until it breaks. A metal implant, such as a wire or a plate that crosses over an unhealed fracture, also bends.  This movement is very small but “micromovement” does occur at fractures and the stress is transmitted to the implant. Once the fracture is healed this micromovement stops and there is almost no load on the hardware. It is a race between the bone healing and the implant breaking, which, in most cases, is won handily by the healing process.

Unfortunately, under some circumstances the hardware does fatigue and fail. If you carry loads or use vibrating machinery before the fracture is healed, this greatly increases the tendency of fatigue failure. The restrictions on activities such as lifting weights or riding a motorcycle too early may seem unnecessary or overcautious when your wrist is feeling strong and comfortable and when these activities do not hurt, however, the restrictions are based on the length of time it takes the bone to heal.

Until the bone is healed loading the hardware may have unexpectedly serious results. The risk of fatigue failure is also increased by smaller implants, with delay in healing, and with infection.  Gaps between the bone fragments may also increase the tendency of the metal to fatigue.

If the implant does break the bone may still heal in the current position if protected by a cast (and if you stop the activities that loaded it).  Alternatively, surgery may be repeated using a bone graft, which promotes healing and stabilizes the fracture.  Luckily, in the long term this complication is often seen as a “bump in the road” as the measures to heal the fracture usually succeed in the end.

Other Hardware Problems

Pins, plates and screws are often used in the surgical treatment of distal radius fractures. The location of these items of hardware often means that the tendons that pass to the hand need to glide over the plate or the protruding ends of the pins and screws. In a small percentage of cases the tendons are irritated and may even rupture. This is a relatively common complication of plates on the back of the wrist where there isn’t much room for the tendons. The main symptoms are pain in the wrist region when moving the fingers or thumb, and tenderness to the touch. If the tendon does rupture this will generally affect one specific movement such as straightening the thumb or index finger. The treatment for this complication is to remove the hardware that is causing the trouble. If the fracture is not healed, however, some other method of treatment may be necessary such as moving the plate to a different surface or into a different position.

What happens as I recover?

The bone of the distal radius is cancellous (spongy) and heals very well. New bone formation is often evident on x-ray at three weeks post injury but most surgeons keep the fixation in place or the cast on for six weeks. Non-union is rare. As with most bones it takes about three months for the bone to consolidate at the fracture site and to be strong enough to use normally. Overall bone and joint function, however, continue to improve for up to 18 months after a fracture.

If the bone has been compressed and there are gaps between the fracture fragments the process of healing may take longer. Healing times are not usually affected by surgery, which means that the bone does not heal any quicker if it has been operated on.

If your fracture has been treated by immobilization in a cast, then rehabilitation with a Physical Therapist at First Choice Physical Therapy can begin once the cast is removed. While you are in the cast simple finger movements as well as exercises to maintain your shoulder range of motion, such as lifting your arm overhead, will be your only exercises.

If you have had surgery to fixate your forearm fracture, then rehabilitation at First Choice Physical Therapy will begin as soon as your surgeon allows it. Each surgeon will set his or her own specific activity restrictions based on the type of fracture, the surgical procedure used, their personal experience, and whether or not the fracture is healing as expected. Generally, however, early non-weight bearing hand, wrist, and elbow movements will be allowed.

Even if extensive Physical Therapy for your wrist is not yet appropriate, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise.  Even older adults can reap benefits from maintaining their general fitness while their wrist fracture heals.  Activities such as walking or using a stationary bike or stepper machine are easy activities that can be done even while the wrist fracture is healing.  Avid runners may even be able to continue running with clearance from their doctor.  Weights or weight machines for your lower extremity and opposite arm are also acceptable to use as long as the restrictions regarding your healing wrist are strictly abided by.  Generally, lifting any weight with your injured limb will not be allowed while your wrist heals so you may require a friend to assist you with your workout setup if you are keen to continue during this time.  Your Physical Therapist at First Choice Physical Therapy can discuss the most appropriate way for you to maintain your fitness while abiding by your doctor’s restrictions, and can provide a general fitness program specific to your needs.

When the initial cast is removed or immediately after surgery, you may experience some pain when you start to move your wrist, elbow and forearm. If you were immobilized this pain is from not using the joints regularly. If you have had surgery, the pain is likely from the surgical process itself. Your pain may also be from concurrent soft tissue injury that occurred when you fractured your wrist. Your Physical Therapist at First Choice Physical Therapy will focus initially on relieving your pain. We may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the fracture site or anywhere along the arm or into the hand. In addition, we may massage the hand, forearm, wrist, or elbow to improve circulation and also assist with the pain.

The next part of your treatment will focus on regaining the range of motion, strength, and dexterity in your wrist, hand, elbow, and shoulder.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program.

These exercises may include the use of rehabilitation equipment such as pliable balls, exercise bands, or small weights that provide added resistance for your hand and wrist. Your Physical Therapist may even give you exercises for your shoulder.  The shoulder is the link from the wrist and hand to the rest of the body so it needs to be strong and well controlled for the upper limb, particularly the wrist and hand, to work well.  Your initial exercises will include those that do not put any of your body weight through the wrist, so you may simply just be moving the wrist back and forth, turning your palm up and down, or lifting a small weight. As your healing wrist allows, your Physical Therapist will add in exercises where you are putting some of your body weight through your wrist via your hand such as pushing on a door or doing push ups against a wall.

If necessary, your Physical Therapist will mobilize your joints in order to gain range of motion. This hands-on technique encourages any stiff joints in your wrist, hand and elbow to move gradually into their normal range of motion.

As a result of any injury, the receptors in your joints and ligaments that assist with proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobilization will add to this decline. Although your wrist is not traditionally thought of as a weight-bearing joint, even activities such as pushing up to get off of the couch, pulling a glass from a cupboard, or pushing a door open, require weight to be put through or lifted by your wrist and for your body to be proprioceptively aware of your limb. If you are active in sport, then proprioception of your upper extremity is paramount in returning you to your sport after a wrist fracture.  Your Physical Therapist at First Choice Physical Therapy will prescribe exercises for you to regain this proprioception. These exercises may include activities such rolling a ball on a surface with your hand, holding a weight up overhead while moving your shoulder, or push ups on an unstable surface. Advanced exercises will include exercises such as ball throwing or catching.

If your wrist fracture has occurred as a result of an accidental fall, your Physical Therapist will also assess your balance and give you exercises to improve your balance. They may also discuss other strategies you can implement to avoid falling again, such as removing throw rugs in your home or changing your footwear.  Preventing another fall is extremely important particularly if you are at risk of falling due to your age or some other medical reason, or if your bones are osteoporotic.

Fortunately, gaining range of motion, strength, and proprioception after a wrist fracture occurs quickly. You will notice improvements in the functioning of your wrist even after just a few treatments at First Choice Physical Therapy.  As you improve, we will advance your exercises to ensure your rehabilitation is progressing as quickly as your healing wrist allows.  Once your wrist can tolerate it, advanced exercises may include things such as holding a push up position with your hands on a basketball, or dips in a chair where you are taking nearly your whole body weight through your wrist.

Generally, the strength and stiffness one experiences after a wrist fracture responds very well to the Physical Therapy we provide at First Choice Physical Therapy.  If, however, your pain continues longer than it should or therapy is not progressing as your First Choice Physical Therapy Physical Therapist would expect, we will ask you to follow-up with your doctor to confirm that the fracture site is tolerating the rehabilitation well and, if you have had surgery, to ensure that there are no hardware issues that may be impeding your recovery.

Long-term function after a wrist fracture is difficult to predict. In elderly people, who are the population most at risk for wrist fractures, it is difficult to measure function. What may occur is that the patient accepts some stiffness and pain after the fracture, doesn’t complain, and finds other ways to manage activities of daily living. Due to these adaptations, for many years, it was believed that the long-term outcome after a wrist fracture was good even if there was significant residual collapse and deformity. The more that long-term function is studied, however, the more this view is challenged. It is probably more true to say that those patients adapt to a residual wrist problem than to say there is no problem in the long-term.