Dr. Richard Berger discusses a mysterious wrist injury and the innovative approach he's taken to discover the procedure that fixes it.
Utmost, elaborate on this tear in the ligament of the wrist. Why is this in the past been kind of a sneaky injury?
Dr. Berger: The ligament is in all probability one of the more exposed to examination. However, it’s one of those structures, or one of those conditions that has just escaped our attention. It’s unfortunate since a lot of people have this injury and they’ve had to put up with it. This may be a result of not having the information that’s available on this tear. Another reason could be or that a lot of their doctors don’t know what the nature of the ligament tear is and that there is ultimately a treatment. Basically, it’s one of the wrist ligaments. The wrist is supported and connected to the forearm by a series of ligaments that go from the two forearm bones, the radius, the ulna and out to the various wrist bones. This is a specific ligament that we call the ulnotriquetral ligament. That’s why we call it the "UT ligament." It’s a lot easier to say than ulnotriquetral.
When someone complains of severe wrist pain, you take scans or an MRI – can you see a tear there?
RICHARD BERGER: Now that we know what to look for, it's easier to see this on high resolution or high quality MRI. Alas, this doesn’t show up on a plain x-ray, CT scan or arthrograms. That’s really not how the diagnosis is made though. The diagnosis is made with something as straightforward as merely being with the patient, talking with them to get a good history of what their pain has been like in addition to the physical exam. The patients have always been telling me where the pain is and it was up to me to try and define what structure was associated with the pain that they were experiencing. Patients incessantly complained about pain deep inside the wrist with specific movements that result in piercing pain. Those specific movements are supination, which is a position in the forearm when the palm faces anteriorly, or faces up (when the arms are unbent and at the sides). Pain in this location is very much likely to be due to one of these UT split tears. It’s interesting because that’s possibly one of the reasons why the split tear occurs. Most of the ligaments that we have are fairly straight structures that are stressed in one direction. For example, as I bend my wrist forward, the ligaments that are on the back side of the wrist are simply stretched. That goes for the ligaments on the front of the wrist as well. The ligament on opposite side of the wrist is exactly on the axis of rotation of the forearm. As we turn our hand from palm down to palm up, this ligament undergoes a twisting action similar to someone wringing out a washcloth. Ultimately, that’s the method of failure of this ligament. When it fails, it doesn’t pull apart like a ruptured ligament. This is a situation where the ligament remains intact. It’s still connecting the ulna to the wrist bones, but it fails since its twisted and splits down the middle which basically opens like a book. I don’t know why it's painful since it’s still connecting the two bones, but it has something to do with the fact that the ligament is now filleted open. When you’re looking at the ligament through the wrist joint -- such as with an arthroscope -- instead of looking at the surface of the ligament, you’re now looking deep inside the ligament.
Is there specificity in the type of pain in terms of discomfort or duration that would separate this from any other wrist injury?
Dr. Berger: Whenever we do any type of assessment of a patient with a physical exam, it's imperative to make sure that when coming across something tender, the tenderness is precisely the same that they’re experiencing on their own during everyday activities. Most of the time, this is not painful unless they’re doing something which requires twisting or an extension of the wrist or more commonly both – and it could be an exceptionally sharp pain. It could be a pain that makes you stop in your tracks. That particular pain creates a sense of weakness and no matter how hard you try to overcome that weakness, your brain just won’t let you complete the task. That’s one of the more frustrating aspects, particularly for athletes, being that for 95 percent or so of their activities they’re fine, but when they’re supinating their forearm or extending their wrist or, they’re hit with a sudden shot of pain that’s localized right in that aforementioned soft spot. It’s different from other things that people associate with wrist pain. It’s different than carpel tunnel syndrome, which again is extraordinarily common and something physicians need to make sure to rule out when talking with their patient. With carpel tunnel syndrome, the pain associated is typically a nerve type of a pain involving numbness, tingling or a pins and needles sensation that radiates out to the fingers. Unlike tears in UT ligaments, it’s not well localized to the wrist. If you have arthritis in your wrist, it’s more than likely going to be found on the thumb side of the wrist. Arthritis pain can be more of a constant achiness, similar to a toothache. It can have sharp periods of pain, but it’s more constant and very often responds to changes in weather. It’s like having a built in barometer basically. The split tear is not the only thing that can cause pain in this location. There’s a situation where a complete rupture occurs of the ligaments that normally stabilizes the radius and ulna together. This is commonly referred to as a foveal dissociation. That too is tender in the same spot, but the difference is that I can demonstrate in the stability between the bones of the forearm with the foveal dissociation, whereas the split tear is completely stable. Now that’s something that most patients could not diagnose themselves. I could not diagnose that on my own – on my own wrist for that matter. I’d need to have a colleague actually exam – because it’s a two-handed exam.
In the past year, what has been done with patients who have this UT tear? Some of them have even had procedures done, right?
Dr. Berger: That’s right. It’s a bit frustrating, and it’s fully understandable because up until several years ago I didn’t know that this condition existed. So it’s fully understandable why patients and doctors alike are frustrated. Unfortunately, without recognizing the split tear, our options become limited. Many of them have gone from physician to physician hoping to an answer that resolves their pain. They typically don’t have swelling and their x-rays look normal. The patients begin to doubt themselves very often because there’s nothing external that shows what the problem is. So when there is something that we can put a diagnosis name to and have fairly high confidence that surgically we can correct, it’s quite remarkable to see that glimmer of hope coming back alive in these patients. A lot of these patients just coped with it. Honestly, I’m never going to claim that this is saving lives. This is isn’t a breakthrough in cancer nor is it as dramatic as bringing somebody back from cardiac arrest. I like to think of it as saving a lifestyle, and very often that lifestyle is somebody’s job. I'm not just referring to the elite athletes either; we’re talking about dairy farmers, brick layers, landscapers, people that use their hands – surgeons. I’ve had colleagues that are surgeons not be able to operate because of the pain that they have in the middle of an operation. So when we can save somebody’s career with a relatively straightforward procedure, we essentially give them back their lifestyle.
Barbara Metcalf said it gave her back her future retirement. That’s what she wants to be.
Dr. Berger: She’s not alone in people that have a passion which is interrupted by pain. We don’t have a cure for all aspects of pain in the wrist, but when something like this comes along, it’s just so gratifying to know that patients are going to get better and be able to return to a normal lifestyle. My goal with this treatment is to actually cure that pain; to actually have them return to essentially an unrestricted lifestyle where it’s as if this never happened before.
What exactly does the procedure involve?
Dr. Berger: The procedure is done with an arthroscope. It’s basically a telescope small enough in diameter – through very carefully positioned incisions that are usually 3 to 4 millimeters in length that we can actually – which is inserted into the end of the wrist joint. This renders us able to see the wrist joint from inside out. The wrist joint is so curved and there are so many tight spaces in there that even with surgical telescopes on, I would need to literally open up the wrist from end to end in order to be able to catch a glimmer of what the arthroscope allows me to see. It’s only through the arthroscope that I initially was able to even identify this as an actual diagnosis. What we see when a patient has a split tear is an area of irritation or inflammation in the joint that looks like bed sea anemones that are sort of waving in the current. There are little, tiny soft pillars that are loaded with blood vessels that look irritated. That’s what is covering the split tear – and that tells me that the body has been trying to heal this split tear, but couldn’t since its filleted open and can't span the gap between the edges of the ligament. The next thing we do is, with the scope still in the joint, make another incision in order to put in a little shaver that's about 3 millimeters in diameter. It has a little head that spins around and simply clips off the tissue that it encounters. Under direct vision with the arthroscope, we can shave this red tissue down until we actually see the substance and the ligament through this. That’s when we see the strands of collagen that form the ligament. For years I thought that the shaver had just simply taken off the outer surface of the ligament and that we were actually still looking at the surface. Eventually, I realized that what I was looking at was actually the inside of the ligament. That’s when the idea of putting some stitches across to try and close it up came to me. We do that through a third incision on the very ulnar side of the wrist, or the little finger side of the wrist. There’s an important nerve that we have to watch out for because the last thing we want to do is shish kabob a nerve with a needle to place some stitches. From there, we put a couple of stitches in, or what we call a mattress stitch. I can see the progress of the needle as it’s going through the substance of the ligament. Once we have those stitches in the ligament, we simply pull them tight so it folds the ligament back up into its normal position, tie them into a couple of knots, remove all the arthroscopic equipment and put some stitches in the skin. Then for six weeks we hold the forearm so it can’t rotate. We bring the cast up slightly above the elbow to keep the forearm from rotating because this ligament, again, is on the axis of rotation of the forearm. I’m concerned that if we allow the person to rotate their forearm, they’re going to get that same twisting motion back before the ligament’s healed and it will pull apart. So for six weeks – we find that that’s the magic number, that seems to be how long it takes for this ligament to heal – after six weeks is up they’re free to move the wrist.
What types of activities cause this injury in the first place?
Dr. Berger: We’ve found that about 50 percent of the patients who had this can recall some specific episode that makes them remember the pain. The other 50 percent just remember something sort of vaguely coming. They experience some pain and try to shake it off, but over a period of several months it just never went away. That’s why they go to see their doctors. Virtually 90-plus percent of these patients that can recall a specific event had some type of torsional accident or some type of a torsional event. That’s typically something that creates supination. A good portion of those also report having some extension of the wrist as well. So, for example, we’ll find that in most baseball players, when they’re batting, will find that it’s on their lead hand. In other words, a right hand batter follows through with their swing, thus they’re actually supinating that wrist. It’s the same thing with a golfer. When they’re coming through with a swing, on the follow through they're supinating their wrist. This goes for tennis players as well.
Jayson Werth of the Philadelphia Phillies has become the face of the UT injury and credits you with saving his career. How does that make you feel?
Dr. Berger: That’s a great example of how people start to doubt themselves. If you have people that don’t believe you, you can imagine how incredibly undermining that could be to your confidence. So when he got that back, there was such a bond that occurred that I’ll never forget it. He was letting me know at every step of the way when he was having success. When I started getting calls from owners and managers that were taking notice of him, it was fairly soon after his surgery that he was in the batting cage. He has done everything just perfectly – and it’s all him. What I did was about 40 minutes worth of surgery, everything after that has been Jayson doing his rehabilitation faithfully.