Ulnar-sided wrist pain, complex regional pain syndrome require prompt intervention
Surgeons offer insights for relieving the pain of these serious distal radius fracture complications.
After a distal radius fracture, orthopedic surgeons should be aware of symptoms like unexplained wrist pain or swelling, or a burning sensation in the hand, which could indicate complex regional pain syndrome or ulnar-sided wrist pain.
Images: Hastings H
Both conditions require prompt intervention, according to Richard H. Gelberman, MD, and Hill Hastings II, MD.
That may mean doing surgery to debride the area, decompress nerves, or using corticosteroids. Remember that re-establishing stability of the fracture itself is not a guaranteed home run, Hastings said.
He and Gelberman delivered their comments on complex regional pain syndrome (CRPS) and ulnar-sided wrist pain during a symposium on distal radius fracture complications at the American Academy of Orthopaedic Surgeons annual meeting.
In 1995, the American Pain Society (APS) re-established the term CRPS to describe conditions formerly called reflex sympathetic dystrophy (RSD), causalgia or algodystrophy.
Clinicians are just now figuring out why some patients develop the syndrome while others do not, Gelberman said.
Findings of this diagnosis are subtle and are not considered classic for carpal tunnel syndrome, he noted. To make the diagnosis requires a high index of suspicion in patients who present with some key findings.
According to the APS definition of CRPS, the syndrome typically occurs following a traumatic noxious event in the hand or arm. It is characterized by sensory changes, abnormal skin color and temperature, edema and abnormal sudomotor activity.
Two forms of CPRS
The APS classified CRPS into types I and II. Type I describes the form of the syndrome that develops just after an initial noxious event. Following compression or injury of the peripheral nerve, it is then classified as type II. However, It is difficult to distinguish types I and II CRPS, Gelberman noted.
He added that the median, ulnar or superficial radial nerves are frequently involved in Type II CRPS, as defined by a study by Monsivais.
Gelberman reviewed methods for quickly detecting nerve involvement problems. A positive Tinels sign at the wrist, persistent swelling or loss of finger flexion could signal a patient who has CRPS. In such cases, Prompt intervention is indicated, he said.
The underlying cause of type II CRPS in most patients with distal radius fractures is increased intracarpal canal interstitial fluid pressure. Keeping pressure below the critical pressure threshold is key, Gelberman said. One way to do that is to avoid flexing the wrist beyond 20· during nonoperative treatment of a distal radius fracture.
Lock that fracture reduction with pronation rather than flexion, Gelberman said.
Mean arterial pressure minus 45 mm Hg is the critical pressure threshold for neural viability. If you want a simpler method, [consider] diastolic blood pressure minus 30, he added.
Treatment of type II CRPS that occurs with distal radius fractures is carpal tunnel release. Gelberman recommended conducting electrophysiological studies first; however, he warned that the results can be negative in the early stages of CRPS but positive weeks later.
Gelberman suggested two references for those seeking more information on the subject: a 1994 study by Jupiter and a 2005 study by Placzek.
Hastings addressed management issues of ulnar-sided wrist pain subsequent to a distal radius fracture.
Distal radius fractures arent just fractures. Half the cases of extra-articular fracture will have injury to the triangular fibrocartilage complex, he said.
We know that some 21% of cases at least will have interosseous ligament injury to the scapholunate, and almost all because the hyperextension mechanism will have injury to the radioscapholunate ligament, Hastings added. This is one reason why our patients do not get better right away after a simple wrist fracture.
Hastings urged orthopedists to become familiar with the anatomy of the ulnar side of the wrist because it will help them better diagnose and treat lesions that develop there.
The TFCC is one of the major and most common sources of ulnar wrist pain, Hastings said. Debridement or repair when theres instability does deliver modest and predictable results with respect to pain relief.
Central or 1A-type tears in the TFCC are easiest to treat. Just debride them back to the stable margins without disrupting the ligaments dorsally or palmarly, he noted.
Partial- or full-thickness peripheral or 1B tears mainly involve the dorsomedial portion of the disc and can lead to partial or complete instability. If the distal radioulnar joint is stable, they may be treated arthroscopically via an outside-in suture passing system, which retensions the TFCC, relieves pain and re-establishes better load transmission on that side of the carpus. Peripheral 1B-type tears with instability are best treated by open repair that re-anchors the TFCC (with the palmar and dorsal distal radioulnar ligaments) back to the fovea of the ulna.
Complete tears oftentimes will lead to persistent instability if left untreated, Hastings said.
Lunotriquetral joint instability or tears may irritate the ulnar side of the wrist and cause pain. Most are amenable to simple arthroscopic debridement, but repair might be needed for excessive motion or instability, he said.
Because open surgery is predictable, it is indicated for rare traumatic palmar tears (type 1C), peripheral 1B tears and large basilar ulnar styloid fractures that involve ligamentous attachments.
Orthopedists should rule out other factors that produce pain or limit supination, such as radial shortening affecting the ulna or angular deformities that disrupt distal radioulnar joint mechanics or loading. Changes in inclination and shortening all disturb the mechanics and tensions about the distal radial ulnar joint, which give you problems on the ulnar side of the wrist, Hastings said.
After assessing the distal radius, he may perform a correctional osteotomy if the parameters of the distal radius are unacceptable or deformity is modest. He will shorten the ulna in a fairly deformity-free distal radioulnar joint with acceptable dorsal tilt (less than 10° to 20°) and acceptable radial inclination.
A distal radial ulnar joint destroyed or damaged by fracture can benefit from some kind of ablation or reconstructive procedure, Hastings said. Newer arthroplasty options allow replacing the distal ulna or entire distal radial ulnar joint.
For more information:
- Richard H. Gelberman, MD, professor and chair man of orthopedic surgery, Washington University, can be reached at 660 S. Euclid, Campus Box 8233, St. Louis, MO 63110; 314-747-2531; e-mail: email@example.com. He has direct financial interest in any of the products or companies mentioned in this article.
- Hill Hastings II, MD, can be reached at the Indiana Hand Center, 8501 Harcourt Road, P.O. Box 80434, Indianapolis, IN 46280-9105. 317-471-4338; firstname.lastname@example.org. He indicated he receives royalties from Biomet.
- Gelberman RH. Complex regional pain syndrome. Hastings, H. Ulnar-sided wrist pain. Both talks presented in Complications of distal radius fractures, Symposium Z at the American Academy of Orthopaedic Surgeons 74th Annual Meeting. Feb. 14-18, 2007. San Diego.
- Jupiter JB, Seiler JG, Zienowicz R. Sympathetic maintained pain (causalgia) associated with a demonstrable peripheral-nerve lesion. Operative treatment. J Bone Joint Surg. Amer. 1994;76A:1376-1384.
- Placzek JC, Boyer MI, Gelberman RH, et al. Nerve decompression for complex regional pain syndrome Type II following upper extremity surgery. J Hand Surg. 2005;30A:69-74.