Post wrist fusion (Page 1)

OrangePledge,

There are several different types of wrist fusions (arthrodesis). Some are partial fusions, in which only a few of the carpal bones are fused. Then there is a total wrist fusion, in which there is a fusion block from the radius through to the metacarpals.

If you had a total wrist fusion, your wrist is not supposed to move at all. This includes flexion and extension (bending up and down) and moving side to side. Pronosupination, or turning the palm up and down, actually comes from the elbow, through the DRUJ (the distal radial-ulnar joint).

The cracking noise is probably coming from the DRUJ. Since you have a long ulna (positive variance), it may to hitting the carpals as it goes through the rotation.


You should speak with your hand surgeon. There are procedures that can be done on the DRUJ, such as a Darrach or Sauve-Kapandji. But, as to the motion of the wrist, in a fusion you give up movement for stability and less pain. Hope you and your surgeon figure out what is causing your pain. Good luck.

Gaelic,

Yes I had a total wrist fusion and I know that I wouldn't have any kind of range of motion having it done. Actually I can move my wrist up and down just slightly which should not be happening. Also I can not turn my palm up just down
I have seen several orthopedic surgeons and no one will help me. I even seen the orthopedic doctor who invented the ulnar osteatomy devices and he said those two procedures would not help that I needed a joint replacement.
I call doctors offices and ask do you do wrist replacements and they say yes then I go there spend money on a visit for them to tell me they can't do the replacement.
I was told by several doctors the only doctor that could do a wrist replacement for me was in Louisville kentucy. Way too far for me.

Right now I actually think the ulna bone had pushed the carpals I say this because I have a big lump where the carpal bones are on one side of the hand (top part of hand on the ulnar side)
Have you heard of anyone having a positive variance after a wrist fusion.

OrangePledge,

It is actually fairly common for the patient to develop a positive ulnar variance after a total wrist fusion. That is why many hand surgeons will to a Darrach or Sauve-Kapandji procedure along with the fusion.

If you had a successful arthrodesis, you should have no motion in the wrist. The ability to put the palm up and down, actually comes from the elbow and the DRUJ.

I am not sure why they are saying you need a total wrist arthroplasty, as they usually cannot be done after a fusion. Joint replacement in the wrist is very new and were experimental until just a few years ago. Only a few practices did them. True, more hand surgeons are doing them, but usually in very specific cases. Most of the time the surgery is reserved for persons with very low demand, such as those with rheumatoid arthritis or are elderly.

So, to find someone to try a replacement after a fusion, will be very difficult, if at all. Even at the Klienert Clinic in Louisville, I don't know if any of those surgeons would try it without a very good reason. And there are a lot of very good hand centers around the country, besides just this one.

Most of the time, if a patient still has motion after a total wrist fusion, it has failed to completely fuse. Thus, it is most common to attempt to get the bones to fuse once more. This time using more bone graft (even a bone block), and compression plating.

The degeneration in the DRUJ, is most likely from the ulnar variance. The point at which the ulna articulates with the radius has been disrupted, by the distal radius settling. So, the joint no longer matches. That is also why you cannot fully pronosupinate the wrist. A Darrach procedure, which removes the distal end of the ulna, can be done after a wrist fusion, would take care of the joint problem.


Again, being told you need a replacement after a total fusion is very strange. But, just about anything can be done, but the results are not always the best. It is just not the usual course of events.

If the pain is your biggest concern, and you have motion in the fusion, then attempting to stop that motion by refusing the wrist, would probably be the best way. And, I am not sure why no surgeon has offered this to you, it's the usual standard.

But, you will have to figure out what you want to have done. If you want to try a replacement, then you will probably have to travel. About the only places that it might even be considered, would be in one of the big hand centers around the country. Sometimes, you can email these centers, with your history, current situation, studies, and they will be able to tell you over the internet if they can do what you want. But, in most cases, they will want to actually examine the wrist and studies, before giving you any advise.

Hope you find what you are looking for. Good luck.

Gaelic

Seems like you know your stuff! I do have one more question for you. You mention that it is fairly common to have a positive variance after a total wrist fusion and that most doctors do one of the necessary procedures. To me would seem ideal because so many patients that do have a total fusion have had other wrist surgeries. In my case anyways. I originally had a Tfcc tear. They did a debridement which on that particular procedure I have read that it is fairly common for a patient to later down the line have a positive ulnar variance.
So I was wondering I have searched high and low on the Internet and have never found where it is common for a patient to have a positive variance after a total wrist fusion. And I have looked and looked. Is there an article you have read? Or are you in the orthopedic field? I would really like to read an article if there is one.
I greatly appreciate your advice and time

OrangePledge,

Usually, a TFCC tear is caused by a long ulna. When a patient has ulnar sided wrist pain and has positive ulnar variance, you look for a TFCC tear. Rather than the other way around. A long ulna can also cause ulnar impaction (or ulnar abutment) syndrome. This is where the end of the ulna hits on the carpal bones when the wrist is ulnarly deviated (moved to the small finger side) because it is too long.

When a wrist fusion is done, the cartilage and cortical bone has to be removed from the bones to be fused. So, the end of the radius is removed, and all of the little carpal bones have to be decorticated. This removes a lot of bone stock, that has to be replaced with bone graft. So, you can see how, if there is not enough graft put in, there will be some subsidence. This can make the DRUJ unequal, with the ulnar being proud. Since you already started with a positive ulnar variance, any radial subsidence will just make the ulna all that more proud.


In terms of the ulnar head not being seated within the DRUJ properly, there are things that can be done other than just the Darrach or Sauve-Kapandji procedures. It is possible to take a few millimeters out of the ulna (in the shaft region), shortening it, placing a compression plate, thus reducing the ulnar head into the DRUJ. Also, there are ulnar head replacements. Here, the distal end of the ulna is cut off, and a stainless steel prosthesis (sort of looks like a thick button mushroom) is put in to take its place. In this procedure, it is very important to have good soft tissues, because the soft tissues will have to hold the metal head in the joint. This usually takes care of the problem in the DRUJ, as well as the long ulna (because the replacement can be placed exactly where it needs to be).



I suppose I should have phrased my statement about the ulnar causing problems after a wrist fusion a little differently. It is taught that if you do not address a proud ulnar during the fusion, you will end up with problems later. So, most of the times, it doesn't occur, because it is taken care of at the time of the fusion.

Dr. Hill Hastings II, who wrote the chapter on wrist arthrodesis in "Green's Operative Hand Surgery" (the hand surgeon's bible), writes: "Abbott and associates and most authors since have recommended preservation of the distal ulna to maintain stability at the DRUJ, when the long ulna must be addressed. If the ulna impinges against the triquetrum, I prefer to remove the triquetrum rather than resent the distal ulna. Excision of the triquetrum corrects the ulnocarpal impingement without creating unnecessary distal instability. Resection, however, is indicated when the DRUJ is degenerative, unstable, or ankylosed."

In the same chapter, a technique used by the AO Hand Study Group (Switzerland), includes a proximal row carpectomy, to help prevent ulnocarpal impingement (among other reasons).

In the postoperative expectations section, it states that there is up to a 3.5% incidence of DRUJ problems after total wrist fusion. Also, "ulnocarpal abutment can occur when there is a discrepancy between the combined heights of the radius and radial carpus and that of the ulna and the ulnar part of the carpus. When the surgeon chooses to maintain and incorporate the proximal row into the fusion, he or she must be sure by visual and radiographic means that the triquetrum does not interfere with the distal ulna. When insufficient space exists between the distal ulna and the triquetrum, the triquetrum should be excised." It is also noted in another section, that if the DRUJ has arthritic changes, is ankylosed (it doesn't move normally), or is very unstable, then the ulnar head should be removed.


Most of the published information on wrist fusions and their complications relates to failed unions, tendon problems, infection, failed hardware, etc. But, I did find one article by Tom Trumble, who is in Seattle, WA, that is in the Journal of Hand Surgery on the ulna impacting the carpal bones after a fusion:

"Ulno-carpal abutment after wrist arthrodesis." TE Trumble et al. J. Hand surg. Vol 13. p 11-15. 1988.

It is just a case report on three of his patients. In his cases, he decided to remove one of the carpal bones instead of the ulna. This is probably why the article was accepted for publication, because it describes a technique that, at the time, was novel. In his patients, removal of either the triquetrum or pisiform took care of the discomfort from the ulnar impaction.

There was an article in the international literature which described a fusion technique, where the distal end of the ulna was resected, then it was used as a block of bone graft between the radius and the third metacarpal. That way iliac crest graft did not have to be used. By taking out the ulnar head, any problems associated with the DRUJ or ulnar head were also eliminated.

So, as you can see the problem is well known, and it is supposed to be addressed at the time of the index surgery. But, that's a moot point now, you have the problem and it has to be taken care of.


The discomfort in the fusion mass is probably from a pseudarthrosis, which is usually treated with a repeat fusion.

In terms of the DRUJ and the ulnar positive variance, the first thing to determine is if the DRUJ can be salvaged. If it is too degenerated and arthritic, then a resection of the distal ulna is probably warranted. If the DRUJ is okay the way it is, then a resection of the triquetrum would probably take care of the impaction.

Of course, a distal ulnar head replacement could also be a choice, though it is not that common in wrist fusion cases. The other techniques are the more common ones.

To convert to a wrist replacement, after a total wrist fusion would probably be in the realm of experimental. You can probably find someone to do it, if you look hard enough. But, it is not really considered the norm.


So, hope you find a good hand surgeon who will evaluate your wrist thoroughly, figure out what would give you the best results with the least risks, and then give you the options. Good luck.

I looked up a bunch of stuff and found out what you mention.
On medscape I found an article on a total wrist fusion and I saw where it said about the positive variance and that it should be taken care of during the fusion. But what I read was a synthes compression plate could cause the variance/impingement. My doctor used a synthes fusion plate. But when I look up both on the internet it all comes down to the piece of hardware I had removed from my wrist fusion. Even did a Google gogles and it came up with the two names. Are these two plates initially the same thing? Cause even on the synthes web page searching returns the same result.

OrangePledge,

The Synthes LCP Total Wrist Fusion system was a big step forward. Before that we had to use either straight DCP plates or straight steinman pins. (Or bend the DCP plates yourself, to fit the patient's wrist contours - that is a real pain.) When Synthes came out with their plate, they had developed three: one straight, one with a slight curve, and then one with a 15 degree curve (which puts the wrist in slight dorsiflexion, which gives you the best anatomic position for grip strength).

The Synthes plates were also contoured on the ends, to be low profile. They attached to the distal radius, the third metacarpal, and you could also put in a screw in the carpal bones as needed.

So, you usually go down between the third and fourth extensor compartments, reflecting them aside with the tendons in them, decorticate the bones, make a grove in the distal radius, pack your bone graft, and apply the plate. Then you evaluate how the pronosupination is. If there is a problem with the ulna, address it now. (If you knew there was going to be a problem before surgery, you might change your starting incision to a little more ulnarly.) The joint capsules are closed, followed by the extensor compartments, and finally the skin. Place the patient in a bulky compressive dressing with a splint. The surgical dressing is changed at about 7 to 10 days, for a short arm cast. Remove cast when there is evidence of callus formation (fusion of the bones).

That is the general overall technique.

Synthes makes all types of orthopedic hardware. Their wrist fusion plate is just one system. It is not usually the plate itself that causes the positive variance, but rather, when using one of the plates, the surgeon takes too much bone out and the wrist fusion ends up short (and thus the ulna is long relatively). That's why it is important to check the rotation before closing the wounds. Most surgeons do the operation with the aid of a mini C-Arm, which is real time x-rays (fluoroscopy). That way you know right there exactly where the bones are.

If a patient has problems after the fusion, and you think the plate is proud, rubbing on the tendons, etc, (and the fusion mass is solid), taking the plate out may help. But, taking the plate out won't deal with positive ulnar variance.


The AO group in Switzerland also makes a total wrist fusion plate system. With their plate, it is recommended that the proximal row of carpals be removed during the procedure. Many of the other orthopedic hardware makers, also have plates that can be used for wrist fusion. Most surgeons prefer one system and will stick with it. Occasionally, the hospital buys a specific brand and all the surgeons have to use that one (or bring in their own.)

There are also several partial wrist fusion systems, called Spiders or Hubcaps, depending upon the maker. And there are also staples, wires, screws, and plastic implants designed to be used for partial fusions.


Hope you find a surgeon that can take care of you. Good luck.

I am sorry to bother you but you have really caught my attention.
After a wrist fusion while still in the operating room will a surgeon do an X-ray or use a fluoroscopy to make sure everything is "aligned" correctly? And if they do either one will the surgeon print that out? And if they do will the surgery center have those on file?

Also if the ulnar positive variance shows up on an X-ray 7 days post op is it likely that it happened during the fusion if it wasn't there before the fusion?
After my fusion which was on a Tuesday I had a check up on Friday the same week and I told the nurse practitioner my ulnar side was hurting. In fact I was figuring my arm would hurt where the plate was but that was not the case at all.

Oh yes one more thing also in my first post op X-ray my ulna is curving upwards when it wasn't before. I wish I could post pics of my X-rays.


I really thank you for taking the time to educate me.

OrangePledge,

It is no problem. Patients should understand what is going on.

When determining positive or negative variance of the ulna, the x-rays must be done in a very specific way. It is called the zero rotation view. If you Google "Wheeless, Ulnar Variance", you will get the Wheeless Textbook of Orthopedics out of Duke, and it describes exactly how the x-ray is done, if you really want to know. Because, the amount of variance can be changed by several millimeters just by the positioning of the arm during the x-ray.

But, if there was no variance before surgery and it's there after, it was then probably caused during the surgery. But, again, you have to make sure that the proper x-rays were taken before and after the procedure.

When the ulnar head does not set in the DRUJ properly, it is often very prominent at the distal forearm. The ulnar head is normally a bump, but it shouldn't really be prominent. (It is a spectrum, in some very thin patients, it is really noticable, but it definitely should not be painful.)


During surgery, most surgeons use a C-arm, in cases where there is going to be bony work. In some hospitals, the C-arm is hooked into the regular radiographic system, so pictures are kept on a disc or in the main system. In others, paper printouts are used for the C-arm. If this is the case, usually the surgeon keeps a copy (for his records, for the patient's office chart, if he/she is collecting for the boards, etc) and another copy is make for the patient's hospital chart. But, this is not mandatory. In some cases, the fluoroscopy is used during the surgery, but no "hard copies" are made.

It is taught in residency that you should obtain films of any case in which there has been bony work. But, in these days of cost containment, that is not always done. Many experienced surgeons just do not feel the need.


Hope that helps. If you have any other questions, I'll be happy to answer them, if I can. Good luck.

One last question. So with my ulnar positive variance / ulnar impingement syndrome DRUJ instability (the joint is damaged) what will happen if I do not get this corrected/fixed?

This has been diagnosed for over a year. Whenever I use my hand I have extreme pain. When I am not using my hand I have a lot of pain. When I write, drive, just anything my pain is unbearable, and at the end of the day my hand swells. I drop things etc.....

The surgeon that did the fusion won't do the other surgery because when I first told him about the positive variance on my X-ray all heck broke loose and he got mad at me the only reason he never mentioned it to me was because he wanted to see if the ulna would fuse with the carpals, ( I know that sound odd but I even double checked with him and he said it again) so when I told him the ulna shouldn't fuse that, that is how I rotate my hand palm up palm down he just got mad and said he was the doctor. But that's a whole new story.

All the other surgeons I have seen some say they just can't help and some say that it's a liability if they fix it.( whatever that really means)

I am frustrated because I used to do so much stuff and now a lot of what I could do I can't especially because it is my dominant hand.



I did look through my medical records and saw the doctor said he took 5 X-rays but then he put (fluoroscopy ) next to it, so I don't know if he would have printed out a copy or not I will look into it.

Thank you so much for helping me and teaching me a lot I didn't know.

OrangePledge,

I am so sorry that the surgeon treated you that way, it was very inappropriate. Especially since you were correct. If the ulna fused to the carpal bones, how could you rotate the forearm (pronosupination)? That's basic anatomy 101.

I mean, you can fuse the ulnar head to the radius (arthrodesis the DRUJ), then cut out about a centimeter of the distal ulnar shaft (which is the Sauve-Kapandji procedure), but, that allows rotation through the defect in the shaft.

About the x-rays, contact the hospital or surgical center. Ask for a copy of your medical records, including copies of any radiographic studies, not just the reports. Don't let them tell you that they can only be sent to your doctor, that is a common bluff. You may have to fill out a request for the records, and pay a fee for their reproduction, but you have a right to a copy of them.

I sort of get the feeling, that the surgeons in your area are "circling the wagons" around a colleague, who may not have done the technically best procedure that he could have. They may not want to get "involved", because they may feel the case may go to litigation. As a result, you will probably have to go somewhere else, to get a surgeon to take a fresh look at your situation.



As to your DRUJ, since you already have degenerative changes within it, it will do basically one of two things: stay the way it is, or get worse. With almost certainty, it will not get significantly better. But, it seems that it should be a fairly straight forward correction. There are a few different things that can be done, depending upon yours and the surgeon's preferences.

Again, it should be fairly straight forward. If you have motion in the fusion mass, that needs to be addressed. The most common procedure, would be to attempt the fusion again, by taking down the pseuarthrosis, bone grafting, and reapplying the plate. Then, something has to be done about the DRUJ. Since the DRUJ is already degenerated, just reducing the joint isn't going to help the pain significantly. So, then your options become; a Darrach (resection of the ulnar head), a Sauve-Kapandji, or possibly a distal ulna head replacement.

There are many very good hand centers throughout the US. Also, just about any fellowship trained hand surgeon should be able to take care of this. Just find a surgeon that you feel really comfortable with. Ask your questions. If the surgeon is too busy to explain things to your liking, find another one. There are surgeons out there who do take time with their patients.

A side note, do you wear a wrist splint for activity? Since you have motion in the wrist, you may be more comfortable if that motion is reduced. Just a small splint, may help your pain some. Just a thought.

I have a splint but it seems to make the pain worse when I wear it even tried several of them. In the last 4 years with 5 different doctors giving me different ones and all of them hurt more to wear them.
All the surgeries I have had they always put a cast on me after I have my post ipod visit and after the fusion I didn't just a weird long splint that hurt so bad when I wore it

I am going to call the surgery center where I had my fusion and get my records.

Also while I have slight movement in my wrist it is just that slight.

The splint was just a thought. Sometimes the straps are too tight for patients with DRUJ problems. Except for certain post-op splints, I usually left it up to the patient, if the splint made the person more functional, great, otherwise, they could go without it.

I hope you find a solution to your problem. Good luck.

Hi, and thanks to you both for a very interesting read. I have Kienbock`s wrist disease stage 4, and will be having a MRI scan next month. I have been told I will be having a total wrist fusion and was wondering if you could offer any advice with wrist replacement please? Or what would my options be?
Any help from you would be great.

Thanks

Scotty1969,

The decision between a total wrist arthrodesis, partial wrist arthrodesis, and a replacement depends upon several factors.

Kienbock's disease, also called lunatomalacia, is essentially avascular necrosis of the lunate. There are several treatments, depending upon the stage of the disorder. Early in the disease, a radial shortening or an STT (scaphoid-trapezium-trapezoid) fusion could be tried. But, once you have reached Stage 4, which is collapse and involvement of the bones around the lunate also, you are sort of limited to a total wrist fusion or replacement.


Arthrodesis, or fusion, is a tried and true surgery. It is recommended in young, manual laborers, for those patients who use their hands for lifting, working, pushing, pulling, basically hard work.

Replacement is usually reserved for the sedentary patient. One who is not going to do any type of physical activity. When they first came out, the replacements were used basically in the elderly, rheumatoid arthritic.

The main reason being, that the prosthesis could not stand up to the stress. They failed right and left, when any type of physical activity was involved. Recently, the prosthesis and the surgical techniques have improved, but, not to the point of being able to put them in young active patients.

Other factors that are also considered are the overall health of the patient, the quality of the bone stock around the wrist, dominant hand or not, and of course, activity level of the patient.


When a patient has a replacement done, if he/she is not already sedentary, he/she must be willing to NOT participate in heavy lifting, twisting, rotating, pushing, pulling, etc. Sports which use the upper extremities a lot are generally out. The prosthesis will last on average up to about 15 years. So, younger patients have to understand that they will have to have at least one other replacement in their lifetime. And every subsequent replacement is more difficult to do, more bone stock is lost, and has significantly more risks involved.


So, this is a decision that you and your surgeon will have to make together. Wish you the best. Good luck.

Thanks very much for the quick reply.

I am a 42 year old who has had to give up my beloved golf, throw in five young kids into the equation, and I think that the fusion has to be the right option for me.

Good luck to you also ORANGEPLEDGE. Hope you get everything sorted out.

Gaelic...You are a STAR...tyvm again

Kind Regards

It's been great reading the posts. After having RA for 25 years, I'm always up for learning more to be proactive with my health My question for anyone who can help is this...I'm 43 and had my wrist fused about 6 years ago. LOVED IT! Although I wish I could get my entire body fused, I've pretty much learned to live with the chronic pain. Well, my problem is that my wrist has been in incredible pain and feels like it did pre-surgery. I could describe it as feeling like it's slammed in the car door like it used to. Does anyone know if it's common to have to have fusions redone? I'm wondering if the plate or something has shifted or there could be an infection. It's red & hot just like the good ol' days....Going to call a hand surgeon asap. My original doc is retired now but thought maybe someone might read this who has had a similar situation. I had a synovectomy on my other wrist 15 years ago & know I can never have that done on that wrist a second time but is it dangerous to have a fused wrist redone? any help would be greatly appreciated! Denice

It's been great reading the posts. After having RA for 25 years, I'm always up for learning more to be proactive with my health My question for anyone who can help is this...I'm 43 and had my wrist fused about 6 years ago. LOVED IT! Although I wish I could get my entire body fused, I've pretty much learned to live with the chronic pain. Well, my problem is that my wrist has been in incredible pain and feels like it did pre-surgery. I could describe it as feeling like it's slammed in the car door like it used to. Does anyone know if it's common to have to have fusions redone? I'm wondering if the plate or something has shifted or there could be an infection. It's red & hot just like the good ol' days....Going to call a hand surgeon asap. My original doc is retired now but thought maybe someone might read this who has had a similar situation. I had a synovectomy on my other wrist 15 years ago & know I can never have that done on that wrist a second time but is it dangerous to have a fused wrist redone? any help would be greatly appreciated! Denice

Denice,

It is not uncommon for a wrist arthrodesis to have to be redone. And, in rheumatoids, it is probably more common than in the population that had it done for post-traumatic problems.

It is often difficult to tell the difference between an infection and inflammation in RA patients. It is possible that you have developed an infection in a previously solid fusion mass, but it would be rare. But, you should not be having pain in a solid fusion. That is a worrisome sign.

As to the synovectomy, actually, in some cases they can be done a second time. The purpose of a synovectomy (removal of the inflamed synovium) is to try to prevent the synovium from causing damage to the inside of the joint. So, it is usually recommended that synovectomies be done early, before there are any radiographic changes in the joint. Usually, by the time a patient gets around to maybe needing another synovectomy, there is enough damage to the joint, that they really wouldn't be very effective any more.

With the redo of an arthrodesis, the risks-benefits are basically related to why it is being done. Second time around procedures are always harder to do than the original one. And, if there is an infection, the infection would have to be cleared up first, before a repeat arthrodesis could even be considered.

It is unusual for a previously solid fusion mass to breakdown, but in rheumatoids, with their extreme inflammatory processes, it could be possible. In this case, where there is no infection, then a repeat arthrodesis could be done. Usually, the hardware is removed, any inflammatory tissue is removed, the bone ends freshened up, new bone graft packed, and some type of hardware placed. Some times a different type of hardware has to be used (ie Steinman pins instead of a plate), but not always.


So, it is a very good idea that you are seeing a hand surgeon. Pain in a previously painless, solid fusion mass is worrisome.

Good luck.

Gaelic,
I happened to come across this post as my I was looking for some information on positive ulnar variation.

My son started complaining of his wrist hurting in the summer. We took him to an orthopedic and got Xrays done and they some fluid in the ligaments and started on Physical Therapy and that conitnued for a month with no change in the pain. Then we did an MRI and went to a hand surgeon and he told us that his ulna is slightly longer than the radius and is the cause of the pain. He had him in a splint for a month and that didn't help either. THe doctor gave him a cortizone shot and that didn't help with the pain either. My son is a basketball player and continues to practice and play after removing the splint. Anything he does is very painful for him. Now his left wrist is also beginging to bother him. He says the pain is from the wrist to the elbow. He is only 15 and the doctor doesn't want to do surgery on him yet. He says he can feel the pain coming when his hands start to get cold. It is very painful for us to watch him being in this pain. It is kind of sad, he used to be in the starting line up ever since he started playing basketball and now he can't shoot properly. The only shots he takes are lay ups with great pain.

Can you PLEASE give us some suggestions on how to minimize the pain? We tried heat wraps, medicine patches, even homeopathic medicine. Nothing seems to help with pain and his restrictive motion.

Is there a possiblity he will outgrow this condition?

I would greatly appreciate it if you would be kind enough to reply.

Thanks,
Sman

Sman,

Your son is sort in the proverbial position, between the rock and a hard place.

With positive ulnar variance, the ulna basically keeps banging in to the carpal bones of the wrist. This can cause ulnar impaction syndrome, which is essentially a bad bone bruise. It can also cause tears in the TFCC (triangular fibrocartilage complex). The TFCC is a disc of cartilage, sort of like the meniscus in the knee, which sits on the end of the ulna.

So, your son could be having pain from the impaction of the bones hitting each other and/or from a torn cartilage. But, he has basically done all of the nonoperative treatments: rest, splinting, NSAIDs, steroids.


He has had an MRI of the wrist; did it show any signs of the ulnar impaction syndrome? This can be manifested by edema in the marrow of the carpal bones, and later on, by deformity or damage to the bones.

A TFCC tear should also show up on an MRI, though sometimes an arthrogram has to be done to pick up a small tear.


I am assuming that his pain is in the region of the ulnar head, on the ulnar side of the wrist (small finger side). If he is having pain from the positive ulnar variance, the pain should be at its maximum in that soft spot, just distal to the ulnar head (the bone that sticks out of that side of the wrist). He should have a positive ulnar grind test.

If his pain is somewhere else in the wrist, then something else may be causing the problems. Just because something shows up on x-ray, doesn't always mean it is the root of the problem.


But, if it is ulnar sided wrist pain, and the usual nonoperative treatments don't work, the next step would usually be surgical. A wrist arthroscopy would be able to evaluate the TFCC, the intrinsic ligaments of the wrist, and the articular surfaces.

If the TFCC was torn, that can usually be fixed or debrided through the 'scope.

Ulnar impaction/positive ulnar variance can be treated with the "Wafer" procedure. This is where a small portion (a wafer) of the distal ulnar is shaved off. This corrects the variance, and usually resolves the impaction.

Sometimes, instead of the arthroscopic procedure, an open ulnar shortening is done in the shaft of the ulna. Here, a wafer of bone is removed from the shaft and then the bone ends are fixed with a plate/screws. This also corrects the variance.

The problem is that you son probably still has open growth plates and the surgeon does not want to take the chance of damaging the physis (growth plate) at the ulnar head.

The open procedure would not affect the physis, but it is a fairly good sized operation, that would put him out of commission for several months.


The pain with weather changes is due to the barometric pressure change that comes in with a weather front. Joints are enclosed spaces with pressure that is equal to the outside environment. When the pressure drops quickly outside, the body has to adjust the joint, and in traumatized joints, the pressure difference can cause pain. Some people can predict the weather better than the meteorologist, by the way their joints hurt.


So, since you, your son, and your surgeon are going to have to make some decisions, it is important to know exactly what is causing the pain. Is the long ulna bumping into the wrist bone, and does he, or does he not, have a torn TFCC.

If the MRI does not show impaction or a torn TFCC, then why is he having pain? What is the diagnosis?


From there, it is really hard, because you have basically tried all of the usual treatments. If you find something that looks promising, there usually isn't any harm in trying it, to see if it might help.

If he has a torn TFCC, a 'scope could be done to treat it, without the bony procedure until he reaches skeletal maturity. Other than that, if he is having significant pain when playing, he may have to give up playing, which is difficult to do.

I don't really have any magical treatment. Ice, heat, wrist support, NSAIDs, occasional steroid injection, and maybe surgery, are the usual treatments.


But, again, do make sure you have a firm diagnosis, so that the treatment plan can be tailored to the problem.

Hope you find a solution, so that you son can play.

Good luck.


PS: You state you saw a hand surgeon, who would normally be the one to manage a wrist problem, but, you might want to see if you could consult a sportsmedicine orthopedic surgeon. Sometimes, hand surgeons tend to follow the usual treatment plans, rather than look at the patient as an athlete. Just a thought, if playing is extremely important.

Again, good luck.

Hi Gaelic,

Thank you so much for your response. The MRI showed some swelling and fluid but nothing torn. The surgeon thinks the pain is caused by the bone rubbing against the ligaments. He suggested to do an arthroscopy first to see what is going on with the ligaments and fix it. He is hesitant about the surgery becuase of his age and don't want to damage his growth plates like u said. He said he could cut the ulna in the middle and shorten it but worried because we are not sure how things will work out as the bones continue to grow. Also concerned about the healing because of something about the position of the bone and there is less protection. He let us decide and told my son to do whatever he does normally as the condition won't deteriorate. If he can withstand the pain and go with Tylenol and advil. His season is going to be over in Febrary. I will consult a sports orthopedic also.

So, the condition won't outgrow itself?

Thanks again for your suggestions.

sman

Sman,

Like the surgeon stated, you really don't know how a kid's bones are going to actually turn out once they are done growing.

We can make overall predictions, based on previous growth and current length, but, when the human body is involved, who knows.

So, it could be that: the bones (radius and ulna) equal out and the wrist is level or they could continue to grow like they are now and have the wrist end up with a final ulnar positivity.

Which is why the surgeon in hesitant to do the midshaft ulnar shortening while he is still growing. If the ulna slows down to equal out the joint naturally, then the ulna is going to end up being short (ulnar negative).

When kids are involved, you never know.

The arthroscopy, to look at the TFCC (which is the ligament the surgeon was talking about) would probably be okay, IF there is not damage to the growth plate at the end of the ulna. Even if the surgeon did not directly damage the physis (growth plate), just the act of doing the surgery can sometimes set up some inflammation and who knows how the joints is going to react. In adults, it's no problem. Some antiinflammatories and everything gets better. But, again, with kids...


So, if he continues to have an ulnar positive wrist, with time and activity, he MAY develop ulnar impaction syndrome and/or a torn TFCC. Not everyone has problems. But, when someone comes in with ulnar sided wrist pain and has a long ulna, those are the two conditions that are looked for.

You can imagine how a long ulna is going to bump into the wrist bones when the hand is moved to the small finger side. That is called carpal impaction. The carpals are the little bones of the wrist (there are eight of them). Usually, the ulna hits on the triquetrum and the lunate bones.

The TFCC (triangular fibrocartilage complex) is that disc of cartilage that covers the end of the ulna. It is held in place by a sling of ligaments. It acts like a bumper or cushion for the end of the ulna.

So, again, you can imagine, that when there is a long ulna, and that ulna keeps hitting the carpal bones, that disc is going to take the brunt of the force. It is going to be pinched, hit, twisted, and with time, it will either tear or the ligaments holding it will tear. Just like the meniscus in the knee can do.

But, again, not everyone sustains these problems. They are just potential ones.


Hope that your son is able to finish the season. Maybe his radius will catch up with the ulna and the wrist will become level. With kids, who knows...

I greatly appreciate you taking the time to explain everything. We will hope for the best.

Thanks a bunch again!