Wrist Wrist problems - should I do this?

[Dulcimer Diva]

Hi, everyone. Those of you who know me from the TKR forum (knees are doing just fine, 5 & 6 yrs. later) know that I am a musician--guitar & mountain (lap) dulcimer.

As the result of a fall (up my stairs) in Feb. and using my left hand to prop myself up in bed in April.In February I sustained what was thought to be a Triangular Fibrocartilage Complex (TFCC) and in April an ulnar tendinopathy. Got a cortisone shot. Wore a splint-brace 24/7 for 3 weeks.

Thereafter at night, played 3 gigs, each more painful than the last--can't pronate and can barely supinate. Saw ortho surgeon, who put me back into the brace 24/7, ordered the aforementioned MRI and a followup for another shot. MRI showed left TFCC disc central tear.

Last week, en route to getting that second cortisone shot, I fell in the hospital corridor (walking too fast, soft rubber sole stuck to hard terrazzo floor). Now I also have a left scaphoid fracture, a slight nick in my right elbow (radial head) and a hairline fracture in the distal end of the right radius. For the right hand injuries, I wore a sling for a week, but I rarely need it now--though pushing or pulling with my right hand hurts.

On June 10, I am scheduled for ORIF (tiny screw) of the left scaphoid, arthroscopic debridement of TFCC tear, and exploration to see if I messed up any other soft tissue in that second fall. But because I have a congenital 3-4mm "positive ulnar variance" (i.e., too long relative to radius), that TFCC will keep getting re-injured by the ulna. So I'm also getting an ulnar shortening osteotomy.

My surgeon will saw the ulna in two, remove a 3-4mm wafer from the bone, and screw & plate it back together. I will be in a Muenster cast for a week and either a Muenster or Sugar-Tong splint for at least 3 mos. (the first 6-8 wks. 24/7).

I am very, very nervous--I understand the ulnar hardware can be very painful (I still occasionally get spasms over the tibial hardware that pinned my shattered leg back together 22 yrs. ago). I cannot play again till at least mid-Sept. We're supposed to go to NYC for a mini-vacation the day after I swap the cast for a splint, and the surgeon says there's no reason I shouldn't (and I have a vocals-only gig the day after we return).

I worry I will never regain enough ROM to play effectively & comfortably again. And at 67, I will likely heal more slowly than I did for my TKRs at 61 & 62. But if I do nothing, my wrist won't heal (and the scaphoid might break all the way through).

Somebody talk me down off the ledge.

 

[Jaycey]

@Dulcimer Diva You will notice I moved your post to a thread of your own. You posted on an old thread that may not be seen by many members. I think you will get more input here.

Doesn't sound like you have much choice but to go ahead with this surgery. You need your wrist healed to get on with your life. If you trust your surgeon I would certainly go ahead with this surgery. You really can't predict how fast or slow you will heal.

I'm sure other members will be along soon to give you input.

 

[EmEm]

Hi @Dulcimer Diva I noticed your post on my thread earlier and I'm pleased to see now you have your own thread. You have had a very difficult time recently. You will have read that I have been offered ulnar shortening for my right wrist because the ulnar positivity has caused a bone cyst due to the repeated impact between the two bones. I had cortisone shots first to see if that helped. Six weeks afterwards the injection has proved to very helpful for my right wrist, less so for my fused left wrist so I might eventually have the ulnar excision that was offered for that hand.

You will have seen Josephine's comment on my thread about how successful the surgery is and like Jacey, I don't think you have a choice. I have a titanium plate where my wrist was fused and have had no problems with it other than a very small adhesion. It's 2.5 years since that surgery and I have never regretted it.

 

[Josephine]

I thought you might like to see these two casts which were designed for use on a forearm with multiple injuries.

Muenster cast

Sugar-Tong splint

I worry I will never regain enough ROM to play effectively & comfortably again.

Well sadly that is a possibility. Elbow and scaphoid injuries are notoriously bad to rehab but it has been done.

I wish you well with this.

 

[Dulcimer Diva]

Looking at the two cast-splints, I think what I'm getting is the Muenster. The elbow injury is to the R and does not affect my strumming or picking; it was the TFCC tear (even before I broke the scaphoid) that kept me from painlessly making certain chords on dulcimer & guitar (now, of course, I can't make them at all). My surgeon says that I may still end up with some residual stiffness & soreness, but no worse than before the TFCC strain morphed into a tear. He says I should be able to play again, but not at the virtuoso level (which I never was). I just want to be able to accompany my vocals.

Meanwhile, I am practicing retuning my dulcimer from DAD Mixolydian mode (which allowed me to make the chords that in turn gave me a large repertoire) to Ionian (DAA), which I can play with just a "noter" stick (sort of like a slide) in my splinted L hand--requiring neither wrist flexion nor rotation. It's how I first learned to play traditional Appalachian songs before I discovered what opportunities chording afforded.

 

[Dulcimer Diva]

Hmmm....just got my follow-up x-ray reports today. The first set (6/20) mentions "an irregularity in the L scaphoid waist concerning for nondisplaced fracture" and a "minimally depressed R radial head fracture with mild effusion." The followup (6/27) says about the R elbow "A subtle, intra-articular radial head fracture at the radial margin of the articular surface is again seen. No significant displacement identified. Mild marginal spurring at the elbow joint." As to the L wrist, "There is no acute fracture or subluxation." On 6/20 my ortho showed me on the monitor what he suspected was a L scaphoid fracture, and on 6/27 he pointed out the faint gray line had lengthened. He palpated the back of my hand and it was quite tender. He also said, on 6/27, that there appeared to be a faint hairline fracture at the edge of the articular surface of the R radius (i.e., thumb side of wrist); but the 6/27 report just mentioned "mild narrowing of the radial scaphoid joint on the right with subchondral sclerosis. There is mild narrowing of the triscaphe and first CMC joints bilaterally. There is no erosion. There is no chondrocalcinosis. There is no lytic or blastic lesion. There is no swelling." In other words, osteoarthritis.

Now, the caveat is that the x-rays were read and these reports were dictated by three different radiologists at two different branches of NorthShore Orthopedics. (The x-rays were taken at the branch where my ortho practices). My husband, who is a cardiologist, says that the opinion of the specialist who is actually treating the patient and knows her history is more reliable than that of a radiologist who's never examined nor even met the patient--his interpretation of, say, chest x-rays and echoes done outside his office is often far different from the radiologists', because he knows his patients and has seen, examined and talked to them (many over a few decades).

So whom do I believe? Should I ask for another L hand MRI before committing to an ORIF of the scaphoid? My surgeon had suggested it, but the first MRI was so traumatic (lying prone, feeling like my arm was being pulled out of its socket and my shoulder didn't work at all for over half an hour--the nurse had to dress me) that I didn't want to repeat the experience--I'd almost rather be waterboarded.

Josephine, do you often encounter such differences of opinion between those of the surgeon and those of radiologists? And if so, whose opinions usually control?

 

[sharonslp]

Oh Dulcimer Diva, I know absolutely nothing about your hand issues; I'm just terribly sad for you that your dulcimer playing is threatened. I do know this about loss though....there is a time to wallow in the pain of loss, and rant and rave about the unfairness. And then there's a time to set about finding new joys in life when the old ones are closed off to us. You may or may not lose your ability to play dulcimer. But you will not lose your love for music, and I am certain you will find other ways to make music, if and when it comes to that.

In the meantime, it seems to me that you have to come down off that ledge and keep moving forward, making the best informed decisions that you can, and hoping for the best.

And if I should ever need a cardiologist, your husband is the kind that I want.

 

[Celle]

Sandy, I'm really sorry to hear about your two falls and the damage they have done.

I'm glad that you are re-tuning your dulcimer, so that you will still be able to get music from it, even if you can't pronate or supinate your hand.
I don't think that anyone will be able to make long-term predictions at this (relatively) early stage.

My husband, who is a cardiologist, says that the opinion of the specialist who is actually treating the patient and knows her history is more reliable than that of a radiologist who's never examined nor even met the patient--his interpretation of, say, chest x-rays and echoes done outside his office is often far different from the radiologists', because he knows his patients and has seen, examined and talked to them (many over a few decades).

I agree with your husband. I've experienced something similar to what he says. Your surgeon has more practical experience and knowledge in this area than the radiologists. Remember that radiologists write reports on scans of the entire body, but the orthopaedic surgeon is an expert in the field of bones and joints.

 

[Dulcimer Diva]

Here I am after having had the "trifecta" (TFCC debridement, ORIF of scaphoid, and USO) early this afternoon. Been 12 hrs since the nerve block was administered--only now can I move my fingers--just flap them--but not feel them. (Typing one-handed). Beginning to get some sensation at the ulnar shortening hardware & incision, so taking one Norco 5/325 Q6h as directed (if it gets really bad, will double up and go Q4h if necessary).
Worried that I can't control the forearm itself--it still flops like a doll's arm. Because I couldn't get back into a bra, the "girls" don't sit high enough for the sling to elevate my arm & hand so I had to rig a travel beanbag neck pillow to prop it up. If I wake up and still can't move the arm w/o using my shoulder or grip or brace anything with my fingers, I will call--I hope an important nerve wasn't severed. (Josephine--how common is that)?

Didn't get my cast yet--in a hard splint with a pressure dressing over it. In 2 weeks I trade it in for a forearm cast (shorter than Muenster), then 2 weeks thereafter the plastic brace I'll wear till mid-Sept. Surgeon advised that if & when I begin playing again, to start with an electric guitar because I won't yet have the grip strength for acoustic, and short-scale dulcimer because of limited ROM (no gripping involved for dulcimer).

Will probably sleep downstairs tonight because I'm afraid of falling when descending because I can't grip the banister well enough with my R hand to steady myself. Bob will try to help me out of my shorts & tunic and into my nightie. He was a dear, and came home early to bring me dinner and feed the cats. Housekeeper coming in the a.m.--surgeon's NP will call too, and will discuss what kind of visiting evening & weekend help I might be able to get approved. It'd have to be from a regular home health agency, because insurance won't cover something like Visiting Angels; and Medicare won't approve inpatient rehab for upper-extremity surgery on one limb.

 

[Dulcimer Diva]

Oh, and acc. to my surgeon, there was almost nothing remaining of the center of the TFCC disc except the torn flap. The falls I took may have been the last straw, because the TFCC had been poked by the too-long ulna (>4mm) during years of overuse and aging. It'd have happened sooner or later anyway. Meanwhile, the R distal & radial hairlines aren't serious enough to treat, except night wrist bracing once I regain the strength in my L hand to apply & remove it.

Gonna try and see if I can sleep down here in the front room tonight--will have to displace my cat...

 

[Dulcimer Diva]

Hurting a lot this am, so nerves intact. Was told to ditch the sling, hold my arm up with its own muscles, and move fingers and do "tomahawk chops" to prevent frozen connective tissues and clots. Ice is doing squat, as bandages are so thick no cold is getting through--espec. since I can't get the Ace wrap wet. Been 4 hrs since the two 5mg Norco--I think he should have prescribed 10mg (like after the TKRS), but docs are getting really opoid-averse these days. Couldn't hold out even 5 hrs. since getting up at 8am. Since arriving home yesterday, I've taken 7 out of the 20. (Had I known the anesthesiologist would give me a 14-hr rather than 6-8-hr nerve block, I'd have waited till midnight to take that first pill--I was still numb). Per the surgi-center nurse's advice, I asked for a second Rx to get me into the weekend--I'll get a ride tomorrow to the hospital to pick it up and to the drugstore to fill it. (And go out for lunch--getting a bit stir-crazy already).

Turns out I will get my cast next week, not in 2 weeks. Will be a lot less bulky. Cast protector won't fit over the pressure dressing--opening too small, wrestling it on too painful--so it looks like sponge baths for awhile and maybe have my stylist come over; everyone has a price. Meanwhile, Medicare won't cover anyone other than a visiting nurse--and only to do bloodwork at that. Surgeon's NP says the first 3 days are the worst, so maybe I will be able to do more by the weekend.

Breakfast was "interesting:" planned on scrambling eggs because I could cook & eat them one-handed. I quickly learned that unlike chefs, I can't break eggs one-handed w/o destroying them and getting lots of bits of shell in the bowl. But was able to scramble them, get them on to the plate and make toast.

 

[Celle]

I can't offer any advice, but I just wanted you to know I'm thinking of you.

 

[Dulcimer Diva]

Thanks, Celie. I'm posting several times a day basically to share my experiences in case anyone else is faced with upper-body challenges, especially the little "hacks" & "kludges" (solutions for unforeseen problems & inconveniences) that I'm discovering as I go along. Of course, the biggest challenge (as I gather from your avatar) is keeping my kitties from knocking off my ice pack or bumping my arm!

Oh, and 5 yrs out (6 for the R) my knees are still going strong!

 

[EmEm]

I'm impressed that you are doing everything for yourself including breaking eggs! I hope you can get the pain under control. I only had Tylenol after my wrist fusion once I was home but made sure I took all the doses I was allowed.
I see the surgeon next week to discuss any future surgery on my wrists. I had a DIP finger joint cyst excision last week and now have an infection so really don't want any more surgery in the near future.

 

[Dulcimer Diva]

EmEm, hope you can beat that infection!

 

[EmEm]

Hi @Dulcimer Diva, I hope you are doing well and perfecting your one-handed technique! I didn't realise until the recent surgery how important the index finger on the dominant hand is. 10 days post surgery I still have a dressing on it but hopefully the infection is going.
I hope you get your cast next week and then can wear the shower sleeve. I have used one every day since surgery but was allowed to expose my finger to water today which meant a decent hair wash and shower.
When I see the surgeon on Wednesday I will postpone any ulnar shortening surgery until I can't bear the pain anymore. I had surgery in 2016 (wrist), 2017 (hip) and now 2018 (finger) and I think that's enough for me, and my long-suffering OH.

 

[Dulcimer Diva]

EmEm, I too had been in favor of postponing the osteotomy until the TFCC pain was unbearable, but two of my others docs (primary care & shrink) pointed out that the longer we wait, the older we get and the more "established" the disability from the injury becomes--and the less likely we will be to heal satisfactorily, much less optimally. My surgeon also told me that because of the positive ulnar variance (one of the longest he's seen), my TFCC damage was years in the making, and the fall pushed it over the edge. Without shortening my ulna, I would have kept abrading the disc till there would be no cushioning left--with a joint replacement or even fusion the only options. (And unlike knees, hips, ankles or even thumb joint replacements, wrist replacements tend to have short lifespans due to the constant stresses demanded of the joint).

Hope the antibiotic is knocking out that finger infection. I agree that we underestimate just how vital every digit & joint is until we lose the use of it. ("Don't it always seem to go that you don't know what you've got till it's gone?" Who knew Joni Mitchell was a philosopher)?

Progress report, post-op day 4. Began weaning down from 2 Norco q4h to 2 q6h to one q4h, with 400mg ibuprofen q6-8h. I let myself sleep in nearly 7 hrs from my last Norco, and was tempted to go on one q6h, but for the need to stay ahead of the pain--so sticking to one q4h for today. Maybe do one q6h along with an OTC extra strength Tylenol starting tomorrow, eventually switching to the ol' "Bonesmart cocktail."

Bob left early for work today and housekeeper doesn't work weekends, so will go braless today and hope that it's not too visible beneath a caftan. Got the hang of using dry shampoo & a styling iron one-handed, as well as putting on makeup, flossing & sponge-bathing. (Gotta bring the shower transfer chair up from the basement so I don't risk falling getting into & out of the tub). Bought a better cast protector with wide opening and velcro closure, so might try doing an actual shampoo. (Or bring my sulfate-and-salt-free shampoo & conditioner to a salon tomorrow and get a blowdry, style & bang trim. Had keratin straightening, so I have to be careful about what products I can use).

 

[Dulcimer Diva]

Major milestone today: just donned a front-hook bra unaided! Of course, in order to hold the L side against my chest I had to apply more tension than my surgeon would approve, and I didn't get all the hooks closed (there's a "cleavage keyhole") but the girls are satisfactorily contained.

 

[Dulcimer Diva]

Got the "arm mummy" removed today. Thought I was getting a cast (I'd requested pink), but the surgeon looked at my x-rays and decided on a molded plastic forearm brace instead--plastic foam heat-activated and molded to fit my arm & hand as it cooled. Removable for showering, so no need to keep my arm dry (and no need to carry plastic bags & rubber bands in my purse lest I get caught in the rain). Because the brace has a rigid thumb spica, though, I can't grip a bra to fasten in the front or back. (The padded splint allowed me to pinch thumb & forefinger together). So I will need help dressing or go braless under caftans. (Will message the NP to find out if it's ok to remove the brace for putting on & removing bras).

 

[EmEm]

I'm pleased to read your progression from the arm mummy! The new cast sounds like a really good idea especially being able to shower without it. I had my wrist fused in a small private hospital, after the first two weeks with a plaster slab and bandage, I had a lightweight fibreglass cast put on by the surgeon himself. No choice of colour, I wanted purple, but probably a textbook example of the technique. I have no ideas to offer about bra technique because my husband 'did me up' or I wore a close-fitting vest top underneath my shirt. It was also February and cold enough to cover up!