Wrist Joint Pain: A Complete Treatment Guide- Conservative, Medications, PT, Surgery:
.jpg)
Wrist joint pain is common following inflammatory disease of wrist joint and injuries. Wrist joint inflammatory disease includes bursitis, tendonitis, ligamental inflammation and arthritis. An injury to the wrist joints causes tendon tear, ligamental tear, dislocation and fracture. There are several choices of treatment for Wrist joint pain.
Wrist Joint Pain Can be Caused Due To:
• Wrist Joint Sprain
• Wrist Joint Bursitis
• Wrist Joint Tendonitis
• Wrist Joint Arthritis
• Wrist Joint Dislocation
• Wrist Joint Fracture
• Wrist Joint Infection or Septic Arthritis.
Following Are the Treatment Options for Wrist Joint Pain
1. Conservative Treatment
2. Medications
3. Physical Therapy (PT)
4. Interventional Pain therapy
5. Close Reduction Of Dislocation and Fracture
6. Surgical Treatment
Conservative Treatment for Wrist Joint Pain
Conservative Treatments Advised Are As Follows-
A. Restriction of Wrist Joint Activities
B. Heat and Cold Therapy
C. Daily Exercise
A. Restriction of Wrist Joint Activities
Wrist joint restriction is achieved by applying crape bandage to wrist, hand and forearm. Alternatively restriction is also achieved by use of wrist joint braces and placement of cast.
Indications for Wrist Joint Restriction Are As Follows-
• Painful Wrist Joint Movement
• Wrist Joint Swelling
• Wrist Joint Dislocation
• Wrist Joint Fracture
• Wrist Joint Sprain
• Wrist Joint Tendonitis
• Wrist Joint Bursitis
• Wrist Joint Tendonitis
• Wrist Joint Arthritis
• Wrist Joint Dislocation
• Wrist Joint Fracture
• Wrist Joint Infection or Septic Arthritis.
Following Are the Treatment Options for Wrist Joint Pain
1. Conservative Treatment
2. Medications
3. Physical Therapy (PT)
4. Interventional Pain therapy
5. Close Reduction Of Dislocation and Fracture
6. Surgical Treatment
Conservative Treatment for Wrist Joint Pain
Conservative Treatments Advised Are As Follows-
A. Restriction of Wrist Joint Activities
B. Heat and Cold Therapy
C. Daily Exercise
A. Restriction of Wrist Joint Activities
Wrist joint restriction is achieved by applying crape bandage to wrist, hand and forearm. Alternatively restriction is also achieved by use of wrist joint braces and placement of cast.
Indications for Wrist Joint Restriction Are As Follows-
• Painful Wrist Joint Movement
• Wrist Joint Swelling
• Wrist Joint Dislocation
• Wrist Joint Fracture
• Wrist Joint Sprain
• Wrist Joint Tendonitis
B. Heat or Cold Therapy for Wrist Joint Pain
Indication for Heat and Cold Therapy Is As Follows-
• Wrist Joint Soft Tissue Swelling
• Wrist Joint Edema
• Pain Caused By Tendon And Ligament Inflammation
• Chronic Pain Caused By Dislocation And Fracture
• Postoperative Pain
C. Daily Exercise
Daily exercise is advised to prevent muscle atrophy, joint stiffness and muscle weakness of wrist, hand and forearm.
Indication for Daily Exercise for Wrist Pain Are-
• Prevent Muscle Stiffness
• Prevent Muscle Atrophy
• Prevent Muscle Weakness
• Prevent Wrist Joint Stiffness
• Strengthen Hand And Forearm Muscle
2. Medication Therapy for Wrist Joint Pain
Following medications are prescribed for chronic pain and muscle spasm caused by wrist joint disease and injuries-
A. NSAIDs
B. Opioids
C. Anti-depressant analgesics
D. Anti-epileptic analgesics
E. Muscle Relaxants
A. NSAIDS (Non-Steroidal Anti-inflammatory Medications) For Wrist Joint Pain.
Indications for NSAIDs treatment for Wrist Pain-
• Chronic Pain Not Responding To Conservative Treatment.
• Wrist Joint Bursitis.
• Inflammation of the Ligament Following Injury (Sprained Wrist Joint).
• Inflammation of the Tendon (Wrist Joint Tendonitis).
• Inflammation of the Wrist Joint (Wrist Joint Arthritis).
• Inflammation of the Joint Caused By Wrist Joint Dislocation and Fracture.
• Inflammation associated with Wrist joint infection (septic arthritis).
NSAIDs Most Often Prescribed-
Motrin-
• Tablets are available as 200, mg, 600 mg and 800 mg.
• Daily dosage is 1600 to 2400 mg per day.
Naproxen-
• Tablets are available as 275 mg, 350 mg and 500 mg.
• Daily dosage- 750 to 1500 mg per day.
Daypro-
• Tablets available as 600 mg.
• Daily Dosage- 600 to 1200 mg per day.
Celebrex-
• Tablet available as 100 mg and 200 mg.
• Daily dosage- 200 to 400 mg per day.
B. Opioids for Wrist Joint Pain
Opioids Medications-
Opioids are divided in two groups as
• Short Acting Opioids
• Long Acting Opioids
Indications for Short Acting Opioids for Wrist Pain Are As Follows-
• Acute Pain- pain lasting less than 3 to 6 months.
• Post Surgical Pain.
• Breakthrough Pain.
a. Short Acting Opioid Medications for Wrist Joint Pain-
Hydrocodone: Vicodin, Lortab and Norco.
I. Vicodin- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 650 mg of Tylenol.
II. Daily Dosage- 15 to 60 mg of hydrocodone.
• Lortab- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 500 mg of Tylenol.
• Daily Dosage- 15 to 60 mg of hydrocodone.
1. Norco- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 350 mg of Tylenol.
2. Daily Dosage- 15 to 60 mg of hydrocodone.
3. Norco is preferred if higher dosage like 30 to 60 mg of hydrocodone is prescribed for pain treatment so tylenol dosage is kept below 2
4. gram.
Oxycodone- Oxy IR and Percocet.
I. Oxy-IR- Strength of pills- 5 mg, 7.5 mg and 10 mg.
II. Daily dosage- 15 to 60 mg.
1. Percocet- Pills contain Oxycodone and Tylenol.
2. Strength of Oxycodone- 5 mg, 7.5 mg and 10 mg.
3. Strength of Tylenol- 325 mg, 500 mg and 650 mg.
4. Daily dosage- 15 to 60 mg.
5. Maximum allowed dosage of Tylenol 4 gm.
Morphine-
1. MS IR (Morphine Sulphate Immediate Release)
2. Available as liquid and pill.
3. Liquid Strength- 20 mg/mL
4. Pill Strength- 15 and 30 mg
5. Daily Dosage 60 mg to 120 mg.
b. Long Acting Opioids for Wrist Joint Pain-
Indications for long acting opioids are as follows-
• Post Surgical Pain Not Responding To Short Acting Opioids.
• Chronic Pain Caused By:
1. Wrist Joint Sprain
2. Wrist Joint Tendonitis
3. Wrist Joint Dislocation
4. Wrist Joint Fracture
5. Wrist Joint Bursitis
• Chronic Pain Not Responding To
1. NSAIDs
2. Antiepileptic Analgesics
3. Anti-depressant analgesics
Long Acting Medications-
Oxycodone- Oxycontin
• Pills available as 10 mg, 20 mg, 40 mg and 80 mg.
• Suggested safe dosage per day- 40 mg to 160 mg.
Morphine- MS Contin
• Pills available as 15 mg, 30 mg, 60 mg, 100 mg and 200 mg.
• Suggested safe dosage per day- 90 mg to 200 mg.
Methadone
• Pills available as 10 mg.
• Suggested safe dosage per day- 40 to 80 mg.
C. Muscle Relaxants for Wrist Joint Pain-
Muscle pain or spasm of muscles of hand and forearm are treated with following muscle relaxants. Muscle relaxant causes sedation and sleepiness in few patients. Combination of opioids and muscle relaxants can be fatal. Physician will frequently monitor their patients for side effects and medication consumption behavior. Wrist pain due to muscle spasm or muscle pain is treated with one of the following muscle relaxants.
Baclofen
• Pills available as 5 mg, 10 mg, 15 mg and 20 mg.
• Suggested safe dosage per day- 30 to 60 mg.
Flexeril
• Pills available as 5 mg and 10 mg.
• Suggested safe dosage per day- 20 to 30 mg.
Skelaxin
• Pills available as 800 mg.
• Suggested safe dosage per day- 2400 to 3200 mg.
Robaxin
• Pills available as 500 mg and 750 mg.
• Suggested safe dosage per day- 1500 to 2150 mg.
3. Physical Therapy (PT) for Wrist Joint Pain
Physical therapy is a conventional treatment provided as an adjuvant therapy to medication, interventional pain therapy and surgery. Physical therapy is prescribed before surgery as a conservative treatment and after surgery as a supporting therapy. Patient with severe pain often resist physical therapy and in such situation injection of local anesthetics in wrist joint often precedes physical therapy.
Goal of Physical Therapy (PT)-
• Improve Joint Movements
• Enhance Muscle Strengthening
• Maintain Normal Muscle Tone
• Augment Coordination.
Indications for Physical Therapy to Treat Wrist Pain
• Chronic Wrist Joint Pain
• Muscle Spasm of Hand And Forearm Muscles
• Post Surgery Wrist Joint Stiffness
• Post Surgery Wrist Joint Instability
• Muscle Atrophy- Hand And Forearm Muscles
• Hand and Forearm Muscle Weaknesses
Physical Therapy Techniques-
• Exercise
• Stretching
• Ultrasound Therapy
• Infrared or Heat Therapy
• Cold Therapy
• Massage Therapy
4. Interventional Pain Therapy for Wrist Joint Pain
Interventional pain therapy is an invasive treatment. Choice of Interventional Pain Therapy is as follows
A. Needle Therapy
B. Nerve Ablation Treatment
C. Placement of Spinal Cord Stimulator
D. Placement of Intrathecal Catheter and Programmable Pump
A. Needle Therapy
Needle therapy treatment includes injection of medications using needles. Needle placement depends on the cause of pain.
Anatomical Area of Needle Placement to Relieve Wrist Joint Pain-
• Subcutaneous Injection- Indicated for subcutaneous abscess or cellulitis.
• Wrist Joint Injection or Wrist Joint Block (Injection within the joint) - Indicated for bursitis, sprain ligament, tendonitis, dislocation or fracture.
• Wrist Joint Nerve block (injection close to nerve)- indicated for pinch nerve and wrist joint neuritis.
• Cervical (neck) Epidural Injection- Indicated for chronic wrist joint pain.
• Brachial Plexus Block performed by placing needle in axilla or neck.
Medication Injected In Wrist Joint -
• Corticosteroid
• Local Anesthetics
• Chemical Nerve Ablation Using Phenol or Alcohol.
Wrist Joint Injection Procedure-
• Wrist joint injection in majority of the patient is performed under local anesthesia.
• Physician will spray the wrist joint skin with numbing medicine so first prick or insertion of needle is painless and then he will inject local anesthetics to numb all the tissue to be treated including skin.
• Needle placement is not very painful.
• Image intensifier (portable X-Ray) is used to identify wrist joint structure and depth of the needle during placement of needle for injection.
• Nerve to be treated is identified by nerve stimulator.
• Occasional ultrasound is used to evaluate needle placement during procedure.
• Few patients suffer with "needle phobia" (fear of needle) for such patients doctor will provide oral or intravenous antianxiety medications or sedation.
a. Corticosteroid Injection-
Cortisone injection is performed to reduced inflammation. Severe pain caused by inflammation and nerve irritation is initially treated with NSAIDs and opioids. Inadequate pain relief is later treated with cortisone injections. Initial 2 or 3 injections are performed within 6 to 8 weeks. Later cortisone injections are repeated every 3 to 6 months. Cortisone injection is not recommended for chronic pain caused by Gout and Septic Wrist Joint Arthritis.
Indications for Wrist Joint Corticosteroid Injection-
• Wrist Joint Sprain Caused By Inflammation of Ligaments.
• Wrist Joint Tendonitis Caused By Inflammation of Wrist Joint Tendon.
• Wrist Joint Bursitis Caused By Inflammation of Wrist Joint Bursa.
• Wrist Joint Arthritis Caused By Inflammation of Wrist Joint Cartilages and Bones.
• Wrist Joint Fracture Causing Severe Pain.
• Wrist Joint Dislocation Causing Inflammatory or Pinched Nerve Pain.
• Post-Surgical Pain.
Contraindication for Wrist Joint Corticosteroid Injection
• Gout
• Septic Arthritis
• Skin Infection
• Septicemia
• Allergies to Corticosteroids
b. Local Anesthetic Injection-
Therapeutic value of just local anesthetic injection is very limited. The procedure is performed only as a diagnostic procedure. Wrist joint is often treated with local anesthesia to relieve pain prior to aggressive physical therapy.
Indications for Wrist Joint Local Anesthesia Injection-
• Diagnostic Injection- Procedure is performed to evaluate cause of pain.
• Painful Physical Therapy- Injection is performed prior to aggressive physical therapy.
• Painful Wrist Joint- Injection is performed prior to nerve conduction or radiological study.
• Post-Surgical Pain- Intolerable pain following wrist joint surgery is treated with wrist joint injection using local anesthesia.
Contraindication for Wrist Joint Corticosteroid Injection
• Septic Arthritis
• Skin Infection
• Septicemia
• Allergies to Local Anesthetics
c. Chemical Nerve Ablation (Nerve Destruction)
Procedure is selectively performed using alcohol and phenol to destruct (ablate) irritated or pinched nerve. This treatment is very rarely needed for wrist joint pain.
Indication for Nerve Ablation to Treat Wrist Joint Pain-
• Chronic Wrist Joint Pain Caused By Nerve Irritation Or Pinched Nerve
• Pinched Nerve Pain Caused By Wrist Joint Fracture Or Dislocation Not Responding To Pain Medications, Physical Therapy, Corticosteroid Injection And Surgery.
• Pinch Nerve Pain Following Surgery.
• Radial, Median or Ulnar Nerve Neuropathy Causing Selective Peripheral Nerve Pain.
Nerve Ablation Techniques-
• Phenol Injection of Pinched or Irritated Nerve.
• Alcohol Injection of Pinched or Irritated Nerve.
Diagnosis of Pinched or Irritated Nerve-
• Pain Specialist Will Conduct Detailed Examination To Diagnose And Evaluate The Nerve Causing Pain.
• Pinched Or Irritated Nerve Is Identified By Nerve Conduction And Nerve Stimulation Study.
Procedure Notes-
• Procedure is performed in Out-Patient Surgery.
• Choice of Treatment Is Discussed With Patient Prior To Surgery.
• Treatment is performed under Local Anesthesia.
• Needle is placed over Nerve for Phenol or Alcohol Injection.
• Phenol Injection for Wrist Joint Pain- Phenol is selectively injected near or over the nerve. Procedure is painful and pain lasts for short period. Phenol destructs peripheral nerve by neurolysis. Procedure is very rarely performed.
• Alcohol Injection for Wrist Joint Pain- Alcohol is very rarely used. Alcohol injection is very painful and pain lasts for prolonged time. Nerve when regenerate causes severe neuropathic pain.
Complication Following Phenol or Alcohol Injection-
• Destruction of surrounding soft tissue, since liquid phenol and alcohol spreads rapidly in soft tissue
• Severe scar tissues are formed because of surrounding soft tissue damage. Chemical inflammation of soft tissue is induced by phenol and alcohol.
• Nerve regeneration follows severe neuropathic pain
• Cryo or radiofrequency nerve ablation is preferred over phenol or alcohol injection. Alcohol or phenol spreads over surrounding soft tissue causing severe destruction and scarring.
Contraindication for Wrist Joint Phenol or Alcohol Injection
• Septic Arthritis
• Skin Infection
• Septicemia
• Allergies to Phenol
B. Nerve Ablation Treatment for Wrist Joint Pain
Radiofrequency Nerve Ablation
Radiofrequency needle is much smaller in diameter than cryo probe. Radiofrequency needle is placed just like cryo probe over pinched or irritated nerve. Radiofrequency waves are generated at the tip of the needle, which results in increased temperature. Temperature is maintained between 75 to 90 degree C for 75 to 90 seconds to accomplish nerve ablation.
• Radiofrequency nerve ablation using radiofrequency heat.
• Alternative to phenol or alcohol injection is radiofrequency or cryo nerve ablation procedure,
• Radiofrequency or cryo needle following nerve stimulation is placed over pinched or irritated nerve. Radiofrequency needle generate temperature of 75 to 90 degree C over nerve and Cryo probe is cooled down to -90 degree C to cause a nerve lesioning resulting in nerve ablation.
Cryo Nerve Ablation
Procedure involves placing of cryo probe over irritated or pinched nerve. Cryo probe is much wider in diameter than radiofrequency needle. Procedure involves tiny incision to insert cryo probe. Probe is placed over nerve following nerve stimulation test. Probe temperature is maintained at -70 to 90 degree C for 3 minutes.
C. Placement of Spinal Cord Stimulator
Spinal Cord Stimulator is rarely indicated for wrist joint pain. Spinal Cord Stimulator includes stimulator and generator. Proximal (front) end of spinal cord stimulator is placed in epidural space. Distal (outer or back) end of stimulator is connected to generator. Generator creates electrical impulses, which is transmitted through stimulator to epidural space. Electrical impulses are transmitted to spinal cord through dura, arachnoid, CSF and pia membrane. Pain receptors are located over dorsal (back of the) spinal cord. Electrical impulses modulate pain receptors and transmission of pain impulses to brain. Modulation of pain receptors blocks transmission of pain impulses to brain. Spinal cord stimulator may not relieve all chronic pain.
Indications for Placement of Spinal Cord Stimulator-
• Pain caused by wrist joint diseases not responding to medication, physical therapy, interventional treatment and surgery.
• Chronic Pain caused by wrist joint injuries and not responding to medication, physical therapy, interventional treatment and surgery.
• Alternative therapy to opioids, if oral opioids are contraindicated because of serious side effects.
• Inadequate pain relief with intrathecal opioids.
Surgical Procedure for Spinal Cord Stimulator-
Placement Of Spinal Cord Stimulator Involves Two Stage Procedures.
• Diagnostic Phase
• Therapeutic Phase
Diagnostic Phase-
• First stage is diagnostic procedure.
• During diagnostic phase stimulator is placed over pinched nerve (peripheral electrode) at wrist joint or epidural space (epidural electrode) in neck.
• Stimulator is tried for 2 to 3 weeks to evaluate pain relief.
• Epidural or peripheral electrode is stimulated using external generator.
• Pain relief over 50% is considered satisfactory by majority of the patient and permanent placement is considered.
Therapeutic Phase-
• Permanent placement of stimulator and generator.
• Stimulator is placed after 1 to 1.5 cm skin incision either over peripheral nerve at wrist joint or epidural space in neck.
• Generator is placed following 2 to 2.5 cm skin incision under abdominal or gluteal skin.
• Distal (opposite) end is connected to generator.
• Generator is programmed from external programmer by physician.
• Generator is switched on or off and patient's programmer changes intensity of the stimulation.
• Continuous use of Generator will exhaust battery in 4 to 6 years requiring the generator to be changed.
Complications Involving Spinal Cord Stimulator
• Infection of stimulator and generator pockets.
• Bleeding in stimulator and generator pockets.
• CSF leak causing CSF fluid accumulation in stimulator pockets.
• Opioids side effects and inadequate pain relief.
• Meningitis.
• Encephalitis.
D. Placement of Intrathecal Catheter and Programmable Pump
Opioids are most effective pain medications. Therapeutic requirement of oral opioid dosage may change rapidly in few patients because of resistance and tolerance to opioids. Patient may be dependent or addicted to opioids resulting in increased demands of large daily dosage of opioids for adequate pain relief. Number of patients visiting ER because of opioid side effect has increased substantially in recent years. Fatality rate caused by opioids has significantly increased in last 10 to 15 years. Chronic pain not responding to oral opioids, physical therapy, interventional pain therapy or surgery is often treated by intrathecal pain medications.
Purpose of Intrathecal Catheter and Programmable Pump-
• Intrathecal pain medications are delivered into CSF from programmable pump through a catheter.
• Variable dose are delivered by changing concentration of opioids.
• Opioids are delivered close to spinal cord and pain receptors.
• Opioids modulate pain impulses going to brain.
• Pain felt is less by 50% or more than normal intensity of pain.
Device Details-
• Programmable pump is a flat metal box shaped like hockey puck and contains two chambers.
• Top chamber has computer device, which controls a motor.
• Motor delivers consistent amount of opioids stored in bottom chambers.
• Physician controls computer chips with programmer. Physician can change various modes of drug delivered to achieve optimum pain relief.
Indications for Intrathecal Catheter and Programmable Pump-
• Chronic Pain Caused By Wrist Joint Diseases And Injuries.
• Chronic Pain Not Responding To Medication, Physical Therapy, Interventions Treatment And Surgery.
• Oral Opioids Are Contraindicated Because Of Serious Side Effects.
• Inadequate Pain Relief With Spinal Cord Stimulator.
Complications Involving Intrathecal Catheter and Programmable Pump
• Infection Of Pump Or Catheter Pockets
• Bleeding On Pump Or Catheter Pocket
• CSF Leak Causing CSF Fluid Accumulation In Pump Or Catheter Pockets
• Opioids Side Effects
• Meningitis
• Encephalitis
5. Close Reduction for Wrist Joint Pain
Close Reduction is the treatment often tried for wrist joint dislocation and fracture. Isolated wrist joint dislocation and fracture of radius or ulna is often reduced to normal position without performing any surgery. Close reduction is performed under deep sedations or general anesthesia. Wrist joint movement is restricted with cast for 6 to 8 weeks. Orthopedic Surgeon mostly performs close reduction.
Procedure-
• Wrist joint is stretched and pulled by surgeon and his assistant in opposite direction until the joint is aligned in normal anatomical
• Fracture and dislocated fragments are maintained in normal aligned position until cast is applied.
• Wrist joint is examined using X-Ray or Image Intensifier to confirm the normal anatomical aligned position.
Indication for Close Reduction-
• Wrist Joint Dislocation
• Fracture of Radius or Ulna or Both
• Fracture of Carpal Bone
Advantages of Close Reduction Procedure-
• Procedure is Performed Under Sedation
• Open Reduction And Surgery Is Avoided
• Recovery Is Faster
• Infection Avoided
Disadvantages of Close Reduction Procedure-
• Procedure May Fail.
• Casting May Not Prevent Recurrence Of Dislocation Or Fracture.
Casting
• Casting is applied over wrist joint following close reduction, external fixation and internal fixation of fracture and dislocation. Casting is applied to prevent wrist movement and in few cases elbow joint movements.
• Casing is rigid mold made from plaster. Cast is often removed and replaced because of improper tightness, softness of the cast and to accommodate soft tissue swelling.
Indication for Heat and Cold Therapy Is As Follows-
• Wrist Joint Soft Tissue Swelling
• Wrist Joint Edema
• Pain Caused By Tendon And Ligament Inflammation
• Chronic Pain Caused By Dislocation And Fracture
• Postoperative Pain
C. Daily Exercise
Daily exercise is advised to prevent muscle atrophy, joint stiffness and muscle weakness of wrist, hand and forearm.
Indication for Daily Exercise for Wrist Pain Are-
• Prevent Muscle Stiffness
• Prevent Muscle Atrophy
• Prevent Muscle Weakness
• Prevent Wrist Joint Stiffness
• Strengthen Hand And Forearm Muscle
2. Medication Therapy for Wrist Joint Pain
Following medications are prescribed for chronic pain and muscle spasm caused by wrist joint disease and injuries-
A. NSAIDs
B. Opioids
C. Anti-depressant analgesics
D. Anti-epileptic analgesics
E. Muscle Relaxants
A. NSAIDS (Non-Steroidal Anti-inflammatory Medications) For Wrist Joint Pain.
Indications for NSAIDs treatment for Wrist Pain-
• Chronic Pain Not Responding To Conservative Treatment.
• Wrist Joint Bursitis.
• Inflammation of the Ligament Following Injury (Sprained Wrist Joint).
• Inflammation of the Tendon (Wrist Joint Tendonitis).
• Inflammation of the Wrist Joint (Wrist Joint Arthritis).
• Inflammation of the Joint Caused By Wrist Joint Dislocation and Fracture.
• Inflammation associated with Wrist joint infection (septic arthritis).
NSAIDs Most Often Prescribed-
Motrin-
• Tablets are available as 200, mg, 600 mg and 800 mg.
• Daily dosage is 1600 to 2400 mg per day.
Naproxen-
• Tablets are available as 275 mg, 350 mg and 500 mg.
• Daily dosage- 750 to 1500 mg per day.
Daypro-
• Tablets available as 600 mg.
• Daily Dosage- 600 to 1200 mg per day.
Celebrex-
• Tablet available as 100 mg and 200 mg.
• Daily dosage- 200 to 400 mg per day.
B. Opioids for Wrist Joint Pain
Opioids Medications-
Opioids are divided in two groups as
• Short Acting Opioids
• Long Acting Opioids
Indications for Short Acting Opioids for Wrist Pain Are As Follows-
• Acute Pain- pain lasting less than 3 to 6 months.
• Post Surgical Pain.
• Breakthrough Pain.
a. Short Acting Opioid Medications for Wrist Joint Pain-
Hydrocodone: Vicodin, Lortab and Norco.
I. Vicodin- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 650 mg of Tylenol.
II. Daily Dosage- 15 to 60 mg of hydrocodone.
• Lortab- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 500 mg of Tylenol.
• Daily Dosage- 15 to 60 mg of hydrocodone.
1. Norco- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 350 mg of Tylenol.
2. Daily Dosage- 15 to 60 mg of hydrocodone.
3. Norco is preferred if higher dosage like 30 to 60 mg of hydrocodone is prescribed for pain treatment so tylenol dosage is kept below 2
4. gram.
Oxycodone- Oxy IR and Percocet.
I. Oxy-IR- Strength of pills- 5 mg, 7.5 mg and 10 mg.
II. Daily dosage- 15 to 60 mg.
1. Percocet- Pills contain Oxycodone and Tylenol.
2. Strength of Oxycodone- 5 mg, 7.5 mg and 10 mg.
3. Strength of Tylenol- 325 mg, 500 mg and 650 mg.
4. Daily dosage- 15 to 60 mg.
5. Maximum allowed dosage of Tylenol 4 gm.
Morphine-
1. MS IR (Morphine Sulphate Immediate Release)
2. Available as liquid and pill.
3. Liquid Strength- 20 mg/mL
4. Pill Strength- 15 and 30 mg
5. Daily Dosage 60 mg to 120 mg.
b. Long Acting Opioids for Wrist Joint Pain-
Indications for long acting opioids are as follows-
• Post Surgical Pain Not Responding To Short Acting Opioids.
• Chronic Pain Caused By:
1. Wrist Joint Sprain
2. Wrist Joint Tendonitis
3. Wrist Joint Dislocation
4. Wrist Joint Fracture
5. Wrist Joint Bursitis
• Chronic Pain Not Responding To
1. NSAIDs
2. Antiepileptic Analgesics
3. Anti-depressant analgesics
Long Acting Medications-
Oxycodone- Oxycontin
• Pills available as 10 mg, 20 mg, 40 mg and 80 mg.
• Suggested safe dosage per day- 40 mg to 160 mg.
Morphine- MS Contin
• Pills available as 15 mg, 30 mg, 60 mg, 100 mg and 200 mg.
• Suggested safe dosage per day- 90 mg to 200 mg.
Methadone
• Pills available as 10 mg.
• Suggested safe dosage per day- 40 to 80 mg.
C. Muscle Relaxants for Wrist Joint Pain-
Muscle pain or spasm of muscles of hand and forearm are treated with following muscle relaxants. Muscle relaxant causes sedation and sleepiness in few patients. Combination of opioids and muscle relaxants can be fatal. Physician will frequently monitor their patients for side effects and medication consumption behavior. Wrist pain due to muscle spasm or muscle pain is treated with one of the following muscle relaxants.
Baclofen
• Pills available as 5 mg, 10 mg, 15 mg and 20 mg.
• Suggested safe dosage per day- 30 to 60 mg.
Flexeril
• Pills available as 5 mg and 10 mg.
• Suggested safe dosage per day- 20 to 30 mg.
Skelaxin
• Pills available as 800 mg.
• Suggested safe dosage per day- 2400 to 3200 mg.
Robaxin
• Pills available as 500 mg and 750 mg.
• Suggested safe dosage per day- 1500 to 2150 mg.
3. Physical Therapy (PT) for Wrist Joint Pain
Physical therapy is a conventional treatment provided as an adjuvant therapy to medication, interventional pain therapy and surgery. Physical therapy is prescribed before surgery as a conservative treatment and after surgery as a supporting therapy. Patient with severe pain often resist physical therapy and in such situation injection of local anesthetics in wrist joint often precedes physical therapy.
Goal of Physical Therapy (PT)-
• Improve Joint Movements
• Enhance Muscle Strengthening
• Maintain Normal Muscle Tone
• Augment Coordination.
Indications for Physical Therapy to Treat Wrist Pain
• Chronic Wrist Joint Pain
• Muscle Spasm of Hand And Forearm Muscles
• Post Surgery Wrist Joint Stiffness
• Post Surgery Wrist Joint Instability
• Muscle Atrophy- Hand And Forearm Muscles
• Hand and Forearm Muscle Weaknesses
Physical Therapy Techniques-
• Exercise
• Stretching
• Ultrasound Therapy
• Infrared or Heat Therapy
• Cold Therapy
• Massage Therapy
4. Interventional Pain Therapy for Wrist Joint Pain
Interventional pain therapy is an invasive treatment. Choice of Interventional Pain Therapy is as follows
A. Needle Therapy
B. Nerve Ablation Treatment
C. Placement of Spinal Cord Stimulator
D. Placement of Intrathecal Catheter and Programmable Pump
A. Needle Therapy
Needle therapy treatment includes injection of medications using needles. Needle placement depends on the cause of pain.
Anatomical Area of Needle Placement to Relieve Wrist Joint Pain-
• Subcutaneous Injection- Indicated for subcutaneous abscess or cellulitis.
• Wrist Joint Injection or Wrist Joint Block (Injection within the joint) - Indicated for bursitis, sprain ligament, tendonitis, dislocation or fracture.
• Wrist Joint Nerve block (injection close to nerve)- indicated for pinch nerve and wrist joint neuritis.
• Cervical (neck) Epidural Injection- Indicated for chronic wrist joint pain.
• Brachial Plexus Block performed by placing needle in axilla or neck.
Medication Injected In Wrist Joint -
• Corticosteroid
• Local Anesthetics
• Chemical Nerve Ablation Using Phenol or Alcohol.
Wrist Joint Injection Procedure-
• Wrist joint injection in majority of the patient is performed under local anesthesia.
• Physician will spray the wrist joint skin with numbing medicine so first prick or insertion of needle is painless and then he will inject local anesthetics to numb all the tissue to be treated including skin.
• Needle placement is not very painful.
• Image intensifier (portable X-Ray) is used to identify wrist joint structure and depth of the needle during placement of needle for injection.
• Nerve to be treated is identified by nerve stimulator.
• Occasional ultrasound is used to evaluate needle placement during procedure.
• Few patients suffer with "needle phobia" (fear of needle) for such patients doctor will provide oral or intravenous antianxiety medications or sedation.
a. Corticosteroid Injection-
Cortisone injection is performed to reduced inflammation. Severe pain caused by inflammation and nerve irritation is initially treated with NSAIDs and opioids. Inadequate pain relief is later treated with cortisone injections. Initial 2 or 3 injections are performed within 6 to 8 weeks. Later cortisone injections are repeated every 3 to 6 months. Cortisone injection is not recommended for chronic pain caused by Gout and Septic Wrist Joint Arthritis.
Indications for Wrist Joint Corticosteroid Injection-
• Wrist Joint Sprain Caused By Inflammation of Ligaments.
• Wrist Joint Tendonitis Caused By Inflammation of Wrist Joint Tendon.
• Wrist Joint Bursitis Caused By Inflammation of Wrist Joint Bursa.
• Wrist Joint Arthritis Caused By Inflammation of Wrist Joint Cartilages and Bones.
• Wrist Joint Fracture Causing Severe Pain.
• Wrist Joint Dislocation Causing Inflammatory or Pinched Nerve Pain.
• Post-Surgical Pain.
Contraindication for Wrist Joint Corticosteroid Injection
• Gout
• Septic Arthritis
• Skin Infection
• Septicemia
• Allergies to Corticosteroids
b. Local Anesthetic Injection-
Therapeutic value of just local anesthetic injection is very limited. The procedure is performed only as a diagnostic procedure. Wrist joint is often treated with local anesthesia to relieve pain prior to aggressive physical therapy.
Indications for Wrist Joint Local Anesthesia Injection-
• Diagnostic Injection- Procedure is performed to evaluate cause of pain.
• Painful Physical Therapy- Injection is performed prior to aggressive physical therapy.
• Painful Wrist Joint- Injection is performed prior to nerve conduction or radiological study.
• Post-Surgical Pain- Intolerable pain following wrist joint surgery is treated with wrist joint injection using local anesthesia.
Contraindication for Wrist Joint Corticosteroid Injection
• Septic Arthritis
• Skin Infection
• Septicemia
• Allergies to Local Anesthetics
c. Chemical Nerve Ablation (Nerve Destruction)
Procedure is selectively performed using alcohol and phenol to destruct (ablate) irritated or pinched nerve. This treatment is very rarely needed for wrist joint pain.
Indication for Nerve Ablation to Treat Wrist Joint Pain-
• Chronic Wrist Joint Pain Caused By Nerve Irritation Or Pinched Nerve
• Pinched Nerve Pain Caused By Wrist Joint Fracture Or Dislocation Not Responding To Pain Medications, Physical Therapy, Corticosteroid Injection And Surgery.
• Pinch Nerve Pain Following Surgery.
• Radial, Median or Ulnar Nerve Neuropathy Causing Selective Peripheral Nerve Pain.
Nerve Ablation Techniques-
• Phenol Injection of Pinched or Irritated Nerve.
• Alcohol Injection of Pinched or Irritated Nerve.
Diagnosis of Pinched or Irritated Nerve-
• Pain Specialist Will Conduct Detailed Examination To Diagnose And Evaluate The Nerve Causing Pain.
• Pinched Or Irritated Nerve Is Identified By Nerve Conduction And Nerve Stimulation Study.
Procedure Notes-
• Procedure is performed in Out-Patient Surgery.
• Choice of Treatment Is Discussed With Patient Prior To Surgery.
• Treatment is performed under Local Anesthesia.
• Needle is placed over Nerve for Phenol or Alcohol Injection.
• Phenol Injection for Wrist Joint Pain- Phenol is selectively injected near or over the nerve. Procedure is painful and pain lasts for short period. Phenol destructs peripheral nerve by neurolysis. Procedure is very rarely performed.
• Alcohol Injection for Wrist Joint Pain- Alcohol is very rarely used. Alcohol injection is very painful and pain lasts for prolonged time. Nerve when regenerate causes severe neuropathic pain.
Complication Following Phenol or Alcohol Injection-
• Destruction of surrounding soft tissue, since liquid phenol and alcohol spreads rapidly in soft tissue
• Severe scar tissues are formed because of surrounding soft tissue damage. Chemical inflammation of soft tissue is induced by phenol and alcohol.
• Nerve regeneration follows severe neuropathic pain
• Cryo or radiofrequency nerve ablation is preferred over phenol or alcohol injection. Alcohol or phenol spreads over surrounding soft tissue causing severe destruction and scarring.
Contraindication for Wrist Joint Phenol or Alcohol Injection
• Septic Arthritis
• Skin Infection
• Septicemia
• Allergies to Phenol
B. Nerve Ablation Treatment for Wrist Joint Pain
Radiofrequency Nerve Ablation
Radiofrequency needle is much smaller in diameter than cryo probe. Radiofrequency needle is placed just like cryo probe over pinched or irritated nerve. Radiofrequency waves are generated at the tip of the needle, which results in increased temperature. Temperature is maintained between 75 to 90 degree C for 75 to 90 seconds to accomplish nerve ablation.
• Radiofrequency nerve ablation using radiofrequency heat.
• Alternative to phenol or alcohol injection is radiofrequency or cryo nerve ablation procedure,
• Radiofrequency or cryo needle following nerve stimulation is placed over pinched or irritated nerve. Radiofrequency needle generate temperature of 75 to 90 degree C over nerve and Cryo probe is cooled down to -90 degree C to cause a nerve lesioning resulting in nerve ablation.
Cryo Nerve Ablation
Procedure involves placing of cryo probe over irritated or pinched nerve. Cryo probe is much wider in diameter than radiofrequency needle. Procedure involves tiny incision to insert cryo probe. Probe is placed over nerve following nerve stimulation test. Probe temperature is maintained at -70 to 90 degree C for 3 minutes.
C. Placement of Spinal Cord Stimulator
Spinal Cord Stimulator is rarely indicated for wrist joint pain. Spinal Cord Stimulator includes stimulator and generator. Proximal (front) end of spinal cord stimulator is placed in epidural space. Distal (outer or back) end of stimulator is connected to generator. Generator creates electrical impulses, which is transmitted through stimulator to epidural space. Electrical impulses are transmitted to spinal cord through dura, arachnoid, CSF and pia membrane. Pain receptors are located over dorsal (back of the) spinal cord. Electrical impulses modulate pain receptors and transmission of pain impulses to brain. Modulation of pain receptors blocks transmission of pain impulses to brain. Spinal cord stimulator may not relieve all chronic pain.
Indications for Placement of Spinal Cord Stimulator-
• Pain caused by wrist joint diseases not responding to medication, physical therapy, interventional treatment and surgery.
• Chronic Pain caused by wrist joint injuries and not responding to medication, physical therapy, interventional treatment and surgery.
• Alternative therapy to opioids, if oral opioids are contraindicated because of serious side effects.
• Inadequate pain relief with intrathecal opioids.
Surgical Procedure for Spinal Cord Stimulator-
Placement Of Spinal Cord Stimulator Involves Two Stage Procedures.
• Diagnostic Phase
• Therapeutic Phase
Diagnostic Phase-
• First stage is diagnostic procedure.
• During diagnostic phase stimulator is placed over pinched nerve (peripheral electrode) at wrist joint or epidural space (epidural electrode) in neck.
• Stimulator is tried for 2 to 3 weeks to evaluate pain relief.
• Epidural or peripheral electrode is stimulated using external generator.
• Pain relief over 50% is considered satisfactory by majority of the patient and permanent placement is considered.
Therapeutic Phase-
• Permanent placement of stimulator and generator.
• Stimulator is placed after 1 to 1.5 cm skin incision either over peripheral nerve at wrist joint or epidural space in neck.
• Generator is placed following 2 to 2.5 cm skin incision under abdominal or gluteal skin.
• Distal (opposite) end is connected to generator.
• Generator is programmed from external programmer by physician.
• Generator is switched on or off and patient's programmer changes intensity of the stimulation.
• Continuous use of Generator will exhaust battery in 4 to 6 years requiring the generator to be changed.
Complications Involving Spinal Cord Stimulator
• Infection of stimulator and generator pockets.
• Bleeding in stimulator and generator pockets.
• CSF leak causing CSF fluid accumulation in stimulator pockets.
• Opioids side effects and inadequate pain relief.
• Meningitis.
• Encephalitis.
D. Placement of Intrathecal Catheter and Programmable Pump
Opioids are most effective pain medications. Therapeutic requirement of oral opioid dosage may change rapidly in few patients because of resistance and tolerance to opioids. Patient may be dependent or addicted to opioids resulting in increased demands of large daily dosage of opioids for adequate pain relief. Number of patients visiting ER because of opioid side effect has increased substantially in recent years. Fatality rate caused by opioids has significantly increased in last 10 to 15 years. Chronic pain not responding to oral opioids, physical therapy, interventional pain therapy or surgery is often treated by intrathecal pain medications.
Purpose of Intrathecal Catheter and Programmable Pump-
• Intrathecal pain medications are delivered into CSF from programmable pump through a catheter.
• Variable dose are delivered by changing concentration of opioids.
• Opioids are delivered close to spinal cord and pain receptors.
• Opioids modulate pain impulses going to brain.
• Pain felt is less by 50% or more than normal intensity of pain.
Device Details-
• Programmable pump is a flat metal box shaped like hockey puck and contains two chambers.
• Top chamber has computer device, which controls a motor.
• Motor delivers consistent amount of opioids stored in bottom chambers.
• Physician controls computer chips with programmer. Physician can change various modes of drug delivered to achieve optimum pain relief.
Indications for Intrathecal Catheter and Programmable Pump-
• Chronic Pain Caused By Wrist Joint Diseases And Injuries.
• Chronic Pain Not Responding To Medication, Physical Therapy, Interventions Treatment And Surgery.
• Oral Opioids Are Contraindicated Because Of Serious Side Effects.
• Inadequate Pain Relief With Spinal Cord Stimulator.
Complications Involving Intrathecal Catheter and Programmable Pump
• Infection Of Pump Or Catheter Pockets
• Bleeding On Pump Or Catheter Pocket
• CSF Leak Causing CSF Fluid Accumulation In Pump Or Catheter Pockets
• Opioids Side Effects
• Meningitis
• Encephalitis
5. Close Reduction for Wrist Joint Pain
Close Reduction is the treatment often tried for wrist joint dislocation and fracture. Isolated wrist joint dislocation and fracture of radius or ulna is often reduced to normal position without performing any surgery. Close reduction is performed under deep sedations or general anesthesia. Wrist joint movement is restricted with cast for 6 to 8 weeks. Orthopedic Surgeon mostly performs close reduction.
Procedure-
• Wrist joint is stretched and pulled by surgeon and his assistant in opposite direction until the joint is aligned in normal anatomical
• Fracture and dislocated fragments are maintained in normal aligned position until cast is applied.
• Wrist joint is examined using X-Ray or Image Intensifier to confirm the normal anatomical aligned position.
Indication for Close Reduction-
• Wrist Joint Dislocation
• Fracture of Radius or Ulna or Both
• Fracture of Carpal Bone
Advantages of Close Reduction Procedure-
• Procedure is Performed Under Sedation
• Open Reduction And Surgery Is Avoided
• Recovery Is Faster
• Infection Avoided
Disadvantages of Close Reduction Procedure-
• Procedure May Fail.
• Casting May Not Prevent Recurrence Of Dislocation Or Fracture.
Casting
• Casting is applied over wrist joint following close reduction, external fixation and internal fixation of fracture and dislocation. Casting is applied to prevent wrist movement and in few cases elbow joint movements.
• Casing is rigid mold made from plaster. Cast is often removed and replaced because of improper tightness, softness of the cast and to accommodate soft tissue swelling.
6. Surgery for Wrist Joint Pain
External fixation does not include skin incision, but repair of torn ligament and internal fixations involves skin incision. Treatment involving skin incision is also known as open reduction of wrist joint dislocation and fracture.
Surgical Treatment of Wrist Joint Pain Includes Following Surgeries-
a. Repair of Torn Ligaments
b. External Fixation Of Fracture And Dislocation
c. Internal Fixation of Fracture and Dislocation
a. Repair of Torn Ligament-
Wrist joint pain caused by torn ligament is treated with suturing of two ends of torn ligaments. Surgery involves minor skin incision.
b. External Fixation of Wrist Joint Fracture or Dislocation
Isolated fracture or dislocation can be treated with external percutaneous fixation.
Procedure-
Fracture or dislocation is reduced under sedation like closed reduction. One or more pins are inserted in dislocated or fractured fragments through the intact skin. Fracture or dislocation is maintained in aligned position by external fixator.
External fixation does not include skin incision, but repair of torn ligament and internal fixations involves skin incision. Treatment involving skin incision is also known as open reduction of wrist joint dislocation and fracture.
Surgical Treatment of Wrist Joint Pain Includes Following Surgeries-
a. Repair of Torn Ligaments
b. External Fixation Of Fracture And Dislocation
c. Internal Fixation of Fracture and Dislocation
a. Repair of Torn Ligament-
Wrist joint pain caused by torn ligament is treated with suturing of two ends of torn ligaments. Surgery involves minor skin incision.
b. External Fixation of Wrist Joint Fracture or Dislocation
Isolated fracture or dislocation can be treated with external percutaneous fixation.
Procedure-
Fracture or dislocation is reduced under sedation like closed reduction. One or more pins are inserted in dislocated or fractured fragments through the intact skin. Fracture or dislocation is maintained in aligned position by external fixator.
Indication for External Fixation-
• Unstable Dislocation and Fracture of Wrist Joint Following Closed Reduction.
• Failed Closed Reduction.
Procedure Notes-
• Using X-Ray or image intensifier surgeon will identify fracture or dislocated segment of the wrist joint.
• Proximal (close to elbow joint) pin is inserted in proximal fragments of fracture or dislocated wrist joint bone. Distal pin (close to fingers) is inserted in distal fragment of fractured radius or ulna bone or dislocated carpal bone of the wrist joint.
• External fixator holds the external end of the pins.
• External fixator can pull pins away from each other thus maintaining an alignment and separation of dislocated or fractured fragments.
• Wrist joint is placed in cast until dislocation or fracture of wrist joint is healed.
Advantages of Percutaneous Fixation
• Open Surgery is avoided.
• Better Joint Stability after Reduction of Dislocated or Fractured Wrist Joint than Close Reduction.
• Permanent Placement Of Hardware Is Avoided.
• Minimum Soft Tissue Injury.
• Less Painful Procedure Than Open Fixation.
• Scarring and Surgical Trauma is Avoided.
• Cast is Applied For 2 to 3 Weeks In Most Cases.
Disadvantage-
• Bulky instruments and frame around wrist joint and forearm.
• Inability to use injured hand and arm.
Complications-
• Fail to Reduce Or Maintain Dislocated Or Fractured Wrist Joint.
• Infection Caused By Internal Pins.
• Nerve Injury While Placing Pins.
• Bleeding and Hematoma Resulting From Laceration Of Blood Vessels While Placing Pins In Fractured Segments.
• Laceration or Tear Of Ligaments And Tendon By Pin.
Internal Fixation (Plates, Screws, Pins)
Indications for Internal Fixation-
• Displaced Fracture
• Unstable Fracture After Closed Reduction
• Compound Fracture
• Failed External Fixation
• Fracture or Dislocation Needs To Be Reduced Under Vision To Prevent Permanent Nerve Injury In Presence Of Symptoms Like Tingling, Numbness And Weakness
• Dislocation Associated With Fracture
Advantage of Internal Fixation Procedure-
• Internal Fixation Prevents Vascular and Nerve Injury.
• Cast Can Be Removed in 2 to 3 Weeks.
• Early Physical Therapy Prevents Long-Term Muscle Atrophy And Joint Stiffness.
• Increased Joint Stability.
Disadvantage of Internal Fixation Procedure-
• Procedure is Performed Under Anesthetics.
• Recovery Involving Wound Healing Can Be Prolonged If Followed By Infection.
• Infection May Need Long-Term Antibiotic Treatment.
Complications of Internal Fixation Surgery
• Inability to maintain normal alignment of fracture or dislocated wrist joint.
• Plate and screws may be misplaced.
• Joint infection may force to remove hardware.
• Surgical soft tissue injury may cause nerve damage, vascular tear or tendon rupture.
Internal fixation Surgery Options-
There are several surgical options for treatment of dislocation and fracture of wrist joints.
Surgical Options Are As Follows-
• "K" Wire Placement
• Screw and Plate
Procedure-
• Fracture and dislocation is identified with X-ray and image intensifier.
• Skin incision is made following general anesthesia or regional anesthesia.
• Fracture or dislocation is exposed with special equipment. Fracture or dislocation is reduced manually. Fracture and dislocation is fixed with following procedures.
Fixation of Fracture or Dislocation-
• "K" Wires- "K" wire is a stainless steel wire, which holds the fragments of fractured bones together. Surgery is indicated for carpal or metacarpal fracture. K wires are also used to maintain dislocated wrist joint bones in normal anatomical position.
• Plate and Screws- Fracture or dislocation is reduced manually or by using equipment during surgery. The dislocated or fractured fragments are anchored in normal anatomical position by using a metal plate, which is fastened to adjacent bone by screws. Plate and screws are made of stainless steel or titanium. Plates are shaped to maintain anatomical curves of wrist joint.
• Unstable Dislocation and Fracture of Wrist Joint Following Closed Reduction.
• Failed Closed Reduction.
Procedure Notes-
• Using X-Ray or image intensifier surgeon will identify fracture or dislocated segment of the wrist joint.
• Proximal (close to elbow joint) pin is inserted in proximal fragments of fracture or dislocated wrist joint bone. Distal pin (close to fingers) is inserted in distal fragment of fractured radius or ulna bone or dislocated carpal bone of the wrist joint.
• External fixator holds the external end of the pins.
• External fixator can pull pins away from each other thus maintaining an alignment and separation of dislocated or fractured fragments.
• Wrist joint is placed in cast until dislocation or fracture of wrist joint is healed.
Advantages of Percutaneous Fixation
• Open Surgery is avoided.
• Better Joint Stability after Reduction of Dislocated or Fractured Wrist Joint than Close Reduction.
• Permanent Placement Of Hardware Is Avoided.
• Minimum Soft Tissue Injury.
• Less Painful Procedure Than Open Fixation.
• Scarring and Surgical Trauma is Avoided.
• Cast is Applied For 2 to 3 Weeks In Most Cases.
Disadvantage-
• Bulky instruments and frame around wrist joint and forearm.
• Inability to use injured hand and arm.
Complications-
• Fail to Reduce Or Maintain Dislocated Or Fractured Wrist Joint.
• Infection Caused By Internal Pins.
• Nerve Injury While Placing Pins.
• Bleeding and Hematoma Resulting From Laceration Of Blood Vessels While Placing Pins In Fractured Segments.
• Laceration or Tear Of Ligaments And Tendon By Pin.
Internal Fixation (Plates, Screws, Pins)
Indications for Internal Fixation-
• Displaced Fracture
• Unstable Fracture After Closed Reduction
• Compound Fracture
• Failed External Fixation
• Fracture or Dislocation Needs To Be Reduced Under Vision To Prevent Permanent Nerve Injury In Presence Of Symptoms Like Tingling, Numbness And Weakness
• Dislocation Associated With Fracture
Advantage of Internal Fixation Procedure-
• Internal Fixation Prevents Vascular and Nerve Injury.
• Cast Can Be Removed in 2 to 3 Weeks.
• Early Physical Therapy Prevents Long-Term Muscle Atrophy And Joint Stiffness.
• Increased Joint Stability.
Disadvantage of Internal Fixation Procedure-
• Procedure is Performed Under Anesthetics.
• Recovery Involving Wound Healing Can Be Prolonged If Followed By Infection.
• Infection May Need Long-Term Antibiotic Treatment.
Complications of Internal Fixation Surgery
• Inability to maintain normal alignment of fracture or dislocated wrist joint.
• Plate and screws may be misplaced.
• Joint infection may force to remove hardware.
• Surgical soft tissue injury may cause nerve damage, vascular tear or tendon rupture.
Internal fixation Surgery Options-
There are several surgical options for treatment of dislocation and fracture of wrist joints.
Surgical Options Are As Follows-
• "K" Wire Placement
• Screw and Plate
Procedure-
• Fracture and dislocation is identified with X-ray and image intensifier.
• Skin incision is made following general anesthesia or regional anesthesia.
• Fracture or dislocation is exposed with special equipment. Fracture or dislocation is reduced manually. Fracture and dislocation is fixed with following procedures.
Fixation of Fracture or Dislocation-
• "K" Wires- "K" wire is a stainless steel wire, which holds the fragments of fractured bones together. Surgery is indicated for carpal or metacarpal fracture. K wires are also used to maintain dislocated wrist joint bones in normal anatomical position.
• Plate and Screws- Fracture or dislocation is reduced manually or by using equipment during surgery. The dislocated or fractured fragments are anchored in normal anatomical position by using a metal plate, which is fastened to adjacent bone by screws. Plate and screws are made of stainless steel or titanium. Plates are shaped to maintain anatomical curves of wrist joint.
No comments:
Post a Comment