Dr Tawari is a fellowship trained wrist & hand surgeon in Mumbai, India. He undertook his fellowship in wrist & hand surgery at the Pulvertaft Hand Centre (UK) which is a pinnacle institute for wrist & hand surgery in the United Kingdom and the world.
The wrist joint is the most complicated joint in the body. It is made of multiple bones and soft tissues (tendons, ligaments, and muscles) – to enable the hands to be both flexible and strong.
Injuries to the wrist present a significant clinical challenge, and are always advocated to be treated by a trained specialist to obtain an early and complete functional recovery.
Dr Tawari routinely undertakes simple and complex wrist fracture surgeries, wrist arthroscopy, wrist reconstruction operations to deliver unequivocal results and functional recovery to his patients.
Common Wrist Problems and Related Information
Ganglion cysts are fluid-filled lumps that most commonly develop along the tendons or joints of wrists or hands. It looks like a water balloon on a stalk and contains a clear fluid or gelatinous material. Ganglion cysts are noncancerous, generally harmless and disappear without any treatment. However, if the cyst becomes painful or interferes with hand movement, they can be treated non-surgically or removed surgically.
The underlying cause for ganglion cysts is not clearly known, but seems to develop when the synovial tissue bulges outwards. It is commonly seen in women and young people between 15 to 40 years of age. Osteoarthritis, tendon or joint injuries, and repeated stress applied to the wrist can lead to the formation of the cysts.
Ganglion cysts manifest as a visible bump under the skin. They may or may not be painful. If a cyst presses on a nerve it can cause pain, muscle weakness and a tingling sensation.
Ganglion cysts can disappear without any treatment. Though aspiration can be suggested it is often unsuccessful as the fluid is thick & gelatinous often averted to aspiration.
If the cyst continues to be painful, limits activity, causes numbness or tingling of the hand or fingers, then surgery to remove the ganglion cyst is recommended.
Surgery can be open or with arthroscopy, and the outcome is very good. There is a small recurrence rate of 10% associated with wrist ganglion.
Carpal Tunnel Syndrome is a common, painful, progressive condition that is caused by compression of the nerve (median) at the wrist area.
Common symptoms include numbness and tingling sensation in all the fingers except little finger
Pain and burning sensation in hand and wrist that may radiate up the arm and elbow and weakness in hand with diminished grip strength.
Exact causes of the condition are not known. However factors often associated include congenital abnormalities, repetitive motion of hand and wrists, fractures and sprains, hormonal imbalance, and other medical conditions such as hypothyroidism, rheumatoid arthritis, diabetes, obesity, gout, overactive pituitary gland, or the presence of a cyst or tumor in the canal.
Carpal tunnel syndrome treated based on the severity and duration of the symptoms.
The Non surgical treatment includes:
- Treating underlying medical conditions
- Hand and Wrist splint to be worn at night
- Activity Modification
- Physiotherapy – Strengthening and stretching exercises
- Non-steroidal anti-inflammatory drugs
- Steroid injections
As it is a progressive condition, surgery is considered to prevent further damage to the nerve occurring due to on-going compression.
Surgery involves up to a 2- inch incision in the palm and wrist area, the transverse carpal ligament is dissected to release the pressure on the median nerve and enlarge the carpal tunnel. A newer endoscopic technique allows a small surgical scar and a shorter recovery duration.
Surgery has a very good success rate and over 95% of patients are satisfied. Post operative full recovery may take from 6 weeks to 3 months.
The wrist is comprised of two bones in the forearm, the radius and ulna, and eight tiny carpal bones in the palm. The bones meet to form multiple large and small joints. A wrist fracture refers to a break in one or more of these bones.
Types of wrist fracture include:
- Simple wrist fractures – The fractured pieces of bone are well aligned and stable.
- Unstable fractures – The fragments of the broken bone are not aligned and displaced.
- Open (compound) wrist fractures are severe fractures in which the broken bones cut through the skin. This type of fracture require immediate medical attention.
Wrist fractures caused due to fall, vehicular accidents or workplace injuries. Sports such as football, cricket or kabaadi may also be a cause of wrist fractures. Wrist fractures are more common in elderly people with osteoporosis.
Common symptoms of a wrist fracture include severe pain, swelling and limited movement of the hand and wrist. Other symptoms include:
- Deformed or crooked wrist
Fractures that are not displaced are generally treated with either a splint or a cast to hold the wrist in place.
If the wrist bones are displaced than surgery is often required. Devices such as rods, plates and screws are used to allow adequate alignment of fracture until healing. After surgery some motion exercises to keep your wrist flexible is encouraged. Hand Physiotherapy helps to improve function, strength and reduce stiffness.
The scaphoid is one of the eight small bones in the wrist. During wrist motion, the wrist bones move together to allow the wrist to achieve many positions that we take for granted. The scaphoid “directs” the motion of the other small bones.
The scaphoid generally breaks following a fall onto an outstretched hand. If the scaphoid is broken, the blood supply to the bone gets severed and it often takes a long time (a few months) to heal. A fracture that is healing more slowly than expected is a “delayed union” fracture. A scaphoid non-union fracture refers to a wrist fracture that is failing to heal.
Most patients with a scaphoid fracture will have pain and/or swelling along the thumb-side of the wrist.
Diagnosis is confirmed most commonly with x-rays. CT scan and/or MRI is required to gain knowledge on the shape and alignment of the scaphoid and assist with surgery (if required).
Treatment without surgery can include use of a brace, anti-inflammatory medication or cortisone injections for pain relief, but this is temporary. Treatment of a scaphoid fracture/non-union requires surgery with or without bone grafting.
The aim of treatment is to relieve pain, maximize function and prevent arthritis. In delayed presentation or failed intervention, other surgical options include radial styloidectomy, proximal row carpectomy, scaphoid removal and limited wrist fusion, wrist arthroplasty or total wrist fusion.
The scapholunate (SL) ligament connects two of the small carpal bones together, the scaphoid and lunate. These are located near the center of the wrist. The SL ligament ensures the bones move in unison and the wrist has a smooth rotation.
When it is ruptured, the bones separate in different directions, resulting in a painful loss of grip strength. This injury to the wrist is not uncommon and is often sustained by athletes.
- Pain in wrist on thumb side
- Weak grip
- Snapping or popping in wrist
Non-surgical treatment includes use of Splint or cast and anti-inflammatory medication.
Surgery for SL tears is often done arthroscopically using small incisions to repair the torn ligament. In severe SL tears, the ligament is repaired by sutures that are anchored into the bone. In chronic tears, the bones are realigned and ligament reconstructed. Recovery requires 6 weeks in a cast or splint and hand physiotherapy to regain function.
The triangular fibrocartilage complex (TFCC) is a cartilage structure located on the ulnar side of the wrist. It provides cushion and support to the small carpal bones in the wrist. It also play a major role to keep the forearm bones (radius and ulna) stable when the hand grasps or the forearm rotates. An injury or tear to the TFCC cause wrist pain and is often difficult to diagnose.
Types of Tears
Type 1 tears are traumatic tears and are associated with fall on an outstretched hand and/or excessive arm rotation.
Type 2 tears are degenerative tears. They occur over time due to ageing of the complex (wear & tear). Some inflammatory disorders, such as rheumatoid arthritis, gout can also result in these tears.
- Pain around the wrist ongoing for a long period of time.
- Swelling in the wrist
- Painful clicking in the wrist
- Loss of grip strength
- Athletes involved in racquet sports, cricketer especially batsman or golfers often have this injury.
- Degenerative tears are more common in people over 50.
Non-surgical treatment includes use of Splints or cast. Anti-inflammatory medication, Cortisone injection.
Surgical treatment is needed for tears that don’t respond to the conservative treatment or are traumatic. This can be performed via arthroscope (Keyhole). Recovery is 4 weeks in a cast or splint followed by hand therapy to get the wrist back to full function.
Ulnar impaction/abutment syndrome is a degenerative condition in which the ulnar head abuts the triangular fibrocartilage complex (TFCC) and ulnar-sided carpals. This abutment results in increased load bearing across the ulnar head, TFCC and ulnar carpals, and subsequent degeneration of the TFCC, chondromalacia of the osseous structures involved (ulna and carpals, especially the lunate), and disruption of the triquetrolunate ligament.
The most common pre-disposing factor for Ulnar Impaction Syndrome (UIS) is positive ulnar variance (increased ulnar length relative to radius).
Common symptom include pain, occasional swelling, reduced wrist movement, reduced forearm rotation, and tenderness distal to the ulnar head. The symptoms are aggravated by forceful grip.
Surgery is the treatment of choice and includes shortening of the ulna and repair of the TFCC.
Wrist arthroscopy is a minimally invasive surgical procedure performed to view, diagnose, and treat problems of the wrist joint.
Wrist arthroscopy may be necessary to help in diagnosing and treating these conditions:
- unexplained/ chronic wrist pain
- wrist fractures
- ligament tears
- ganglion cysts
Wrist arthroscopy is performed as a day surgery where patients are able to go home within several hours after their surgery. It is usually performed under regional or general anesthesia. One or two small half-inch incisions, known as portals, are made on the back of your wrist. The portals are placed in specific locations on the wrist, depending on the areas that need to be visualized.
The arthroscope and special surgical instruments are inserted into the wrist through these portals. Guided by the images relayed from the arthroscope, any necessary repairs depending on the particular problem is performed.
Recovery following wrist arthroscopy is generally more comfortable for the patient than an open surgery which requires a larger incision. There is usually less pain following the procedure and the healing time is faster when compared to an open procedure.
Wrist joint replacement surgery, also referred to as total wrist arthroplasty, involves replacement of a severely arthritic wrist joint with an artificial joint made of metal and plastic components. It is aimed to relieve pain and improve function of the wrist.
Injury, infection, and diseases such as osteoarthritis and rheumatoid arthritis can damage or wear out the articular cartilage. This may cause the wrist bones to rub against each other producing pain, stiffness and swelling of the wrist.
Early treatment is non-surgical and includes:
- Avoiding activities that may aggravate the symptoms,
- Immobilization of the affected wrist in a splint,
- Using NSAIDs (Non-Steroidal Anti-Inflammatory drugs),
- Steroid injections into the wrist joint and
- Performing specific wrist exercises.
The surgery is performed under general or regional anaesthesia. An incision is made over the back of the wrist. The damaged joint surfaces of the wrist bones are removed. The radius bone is hollowed out and a radial component of the prosthesis is fixed inside it with bone cement. Depending upon the design of the prosthesis, the carpal component is placed in the remaining row of carpal bones or into the third metacarpal bone of the hand. A plastic spacer is then fit between the metal components. Finally, a plaster cast is applied after closure.
Cast is retained for the first 2 – 3 weeks after the surgery. Once the cast is removed, a splint is put for further 4 weeks. Physiotherapy helps restore the movements of the wrist joint.
Certain activities that would put extra stress on the new joint or may result in a fall are avoided after a wrist replacement. A wrist replacement usually lasts for about 8 -10 years.