Wrist Conditions
Wrist ganglion
Ganglions are fluid-filled sacs the arise from a joint or tendon sheath and commonly encountered in the wrist and hand. They may cause swelling or discomfort, and may fluctuate in size.
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Ganglions usually arise spontaneously, may not be bothersome for the patient, and often require no treatment. The link between ganglions and injuries in the medical literature is not well-established.
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For ganglions that are bothersome, an open or arthroscopic (keyhole) operation are often curative.
Wrist ligament injuries
The wrist is a complex series of bones, joints and ligaments. Ligaments join adjacent bones and can span from the forearm bones (radius and ulna) to the bones of the wrist, or between the bones of the wrists. Ligaments are important for joint stability. Injury to wrist ligaments can occur from a simple sprain or through a higher-energy mechanism such as a fall whilst skiing, fall from a ladder, etc. There are different grades of injury - from a simple sprain, to a full rupture.
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Many ligament injuries settle naturally. Some require simple painkillers, temporary splinting or hand therapy treatment. Injuries that do not settle may require further surgical treatment. These may require arthroscopic debridement ("clean-up") procedures, or occasionally ligament reconstructive surgery. The nature of surgery is determined by a number of factors, such as symptoms, functional demands of the patient, degree of injury, and the type and importance of the ligament.
Wrist arthritis
Wrist arthritis may involve part or most of the wrist bones. Wrist arthritis can be due to gradual wear-and-tear, after injury, or secondary to an inflammatory causes, such as infection or rheumatoid arthritis.
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Treatment depends on the degree of symptoms that the patient experiences. In mild/early cases, treatment is supportive and can include hand therapy, splinting and steroid injections. This can be effective in many patients.
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In cases where symptoms are more severe, surgery can be an option. Surgery can involve fusion of bones (partial- or total wrist fusion), excision of painful bones, replacement of joints, or debridement ('clean-up'). Open and arthroscopic (keyhole) procedures may be available depending on the nature of the disease.
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Radiograph (a) shows a wrist with advanced arthritis. Post-operative radiographs (b) after a total wrist fusion using a plate and screws.
Distal radioulnar joint arthritis
Arthritis can just involve the joint between the end of the forearm bones (radius and ulna). This joint allows rotation of the forearm. Arthritis in this area can be challenging to treat. Options involve injections, resection (salvage) procedures or arthroplasty (replacement)
Radiograph (a) shows a wrist with advanced distal radio ulnar joint arthritis. Post-operative radiographs (left) after a hemiresection procedure with soft-tissue interposition in the gap between the bones.
Pre-and post-op radiograph showing patient with distal radio ulnar joint osteoarthritis (a) and following replacement of the ulnar head (b)
TFCC tears and ulnocarpal impaction
There is an important series of structures within the wrist in combination called the TFCC (Triangular fibrocartilage complex). The TFCC acts as a shock absorber and stabiliser of the wrist. Injury to this can caused by a fall directly on to the hand, together with a rotational movement. TFCC tears can be caused together with a broken wrist (radius and/or ulna). TFCC tears may also be a result not of trauma, but of impact between the ulna bone of the forearm, and the adjacent small bones of the wrist (such as the lunate or triquetrum) over a longer period of time.
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TFCC tears may not be symptomatic, but can present with pain, clicking or a sensation of instability when the wrist is loaded. They are difficult to diagnose often, and require specialist examination and imaging studies such as MRI scan.
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Many TFCC tears settle and require no treatment. TFCC tears that continue to cause pain, and mechanical symptoms such as instability may benefit from surgery to repair or reconstruct the structure. In cases with long-standing impaction as the cause, surgery to disimpact the TFCC by shortening the ulna bone with the joint through arthroscopic (keyhole) surgery (known as a 'wafer' procedure), or further down the forearm (osteotomy) may be beneficial.
Radiograph (a) of a patient with wrist pain. MRI scan (b) showing a torn TFCC. An arthroscopic view showing the TFCC tear.
MRI scan (a) showing a peripheral TFCC tear. Arthroscopic image (b) showing the tear being debrided with a shaver prior to repair.
Distal radius malunion
Fractures to the distal radius are one of the commonest presenting fractures to the emergency department. A number of simple fractures heal well in a simple cast and more complex fractures are often identified as requiring surgery soon after injury. Some distal radius fractures remain in a poor position after treatment (surgical or non-surgical), once the fracture has healed and patients may experience deformity, pain and mechanical symptoms such as clicking and catching in their wrist.
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Symptoms may arise from the mal-positioned bone or other associated injuries (such as a TFCC tear (see above section), or a ligament injury to the other bones in the wrist.
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Often symptoms can be improved by surgery to re-fracture, reduce and fix the distal radius in an improved position. We perform this using a plate with screws to hold the bone whilst it heals (often approximately 6-8 weeks after surgery).
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Pre (a) and post-operative radiographs (b) showing an improved position of the distal radius following a distal radius osteotomy. The bone is held with a plate and screws.
Kienbock's Disease
Kienbock's Disease is a rare but often disabling condition in the wrist. The disease is poorly understood and initially affects the blood flow to the lunate bone. The disease leads to damage to the cartilage and bone of the lunate, eventually causing the bone to fracture. The surrounding bones of the wrist are then affected and arthritis throughout the wrist can develop.
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Treatment initially is non-operative, usually for 6-12 months. If symptoms persist after that then further imaging is recommended. Surgical treatments are determined by a number of factors, including the patient's age, functional demands, the state of the lunate bone, and the state of the other bones in the wrist.
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Procedures performed can include surgery to offload the lunate, excise the lunate (and some of the surrounding bones), partial and full wrist fusion, and procedures to move surrounding bone (with its blood supply) into the lunate. Some procedures can be performed with arthroscopy (keyhole)
Radiograph (a) showing a patient with Kienbock's disease. The lunate bone (white arrow) is fragmented and collapsed. An MRI scan (b) of a different patient showing increased signal (white appearance) of the lunate consistent with Kienbock's disease.