What do you advise for a broken wrist that clunks and hurts?

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Q: About a year ago, I fell while skateboarding with my 10-year-old granddaughter. At age 67, I know it was a stupid thing to do. I broke my wrist during the fall and it still clunks and hurts. And I don't have the strength I need in that hand. What do you advise?

A: It sounds like there may be some instability in the wrist. That means some of the soft tissues (ligaments, cartilage) might have been injured at the same time as the bone fracture. There is one ligament in particular that could cause the kind of symptoms you have described if and when it is partially (or more likely) completely ruptured.

The triangular fibrocartilage complex (TFCC) suspends the ends of the radius and ulna bones over the wrist. It is triangular in shape and made up of several ligaments and cartilage. The TFCC makes it possible for the wrist to move in six different directions (bending, straightening, twisting, side-to-side).

Wrist fractures with associated soft tissue injuries can result in decreased grip strength, pain at rest, pain with activities, loss of wrist and hand function, and so on. Some patients report a feeling of instability, like the wrist is going to give out on them. You may feel as if something is catching inside the joint. There is usually tenderness along the ulnar (little finger) side of the wrist.

You will need a medical examination and diagnosis before the most appropriate treatment can be prescribed. Exactly what is damaged and how severe the damage is should be assessed. A hand surgeon will make the diagnosis through a series of steps starting with an interview about what happened and what symptoms you are experiencing now.

Special tests such as stress testing of the wrist joints help define specific areas of injury. An accurate diagnosis and grading of the injury (degree of severity) is important. Usually, the grade is based on how much disruption of the ligament has occurred (minimal, partial, or complete tear). There are two basic grades of triangular fibrocartilage complex injuries. Class 1 is for traumatic injuries. Class 2 is used to label or describe degenerative conditions.

Other tests may be done to provoke the symptoms and test for excess movement. X-rays with a dye injected is called a wrist arthrography can be used to look for specific soft tissue tears. Arthrography is positive for a TFCC tear if the dye leaks into any of the joints. There are three specific joint areas tested, so this test is called a triple injection wrist arthrogram.

If the dye moves from one joint compartment to another, a tear of the soft tissues is suspected. But studies show that almost half the patients with a true triangular fibrocartilage complex tear have normal arthrograms. So other tests may be needed such as wrist arthroscopy.

Wrist arthroscopy is really the best way to accurately assess the severity of damage. A tiny TV camera on the end of the instrument allows the surgeon to look directly at the ligaments. The surgeon can perform a special of the integrity of the soft tissues by inserting a long thin needle into the joint.

A special trampoline test can be done to see if the fibrocartilage disk is okay. The surgeon presses the center of the disk with the probe. Good tension and an ability to bounce back show that the disk is attached normally and is not torn or damaged. If the probe sinks as if on a feather bed, the test is positive (indicates a tear). One advantage of an arthroscopic exam is that treatment can be done at the same time.

You may be a good candidate for conservative (nonoperative) care. This usually involves spending some time with a hand therapist who will direct and guide you through a rehab program. Or you may be advised to have surgery to repair or reconstruct the soft tissue damage, especially if there is a complete rupture of the ligaments and joint instability. The specific surgical procedure recommended will depend on the damage present. So that brings us back to our original advice to see an orthopedic (hand) surgeon and get a proper diagnosis so that the appropriate treatment can be started.

Reference: Ante Mrkonjic, MD, et al. The Natural Course of Traumatic Triangular Fibrocartilage Complex Tears in Distal Radial Fractures: A 13-15 Year Follow-Up of Arthroscopically Diagnosed but Untreated Injuries. In The Journal of Hand Surgery. August 2012. Vol. 37A. No. 8. Pp. 1555-1560.

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