Getting a Handle on Hand and Wrist Injuries

Featuring: Stephen J. O'Connell, Jacob Bosley
Hands and wrists are intricate structures, made of many small bones, muscles and ligaments. Because we use these body parts in most daily activities, it's important to seek remedy for injuries.

Dr. Stephen O'Connell and Dr. Jacob Bosley, orthopedic surgeons, discuss hand and wrist injuries.


Stephen J. O'Connell, MD is a fellowship-trained, Board Certified orthopedic surgeon specializing in surgery of the hand, wrist and shoulder. He joined Desert Orthopedic Center in 1988 to establish and direct the Center's hand and upper extremity program.

Learn more about Stephen J. O'Connell, MD

Jacob R. Bosley, MD, is a fellowship-trained orthopedic surgeon. His training has included a focus on surgery of the hand, wrist and upper extremity. He has a particular interest in traumatic injuries of the upper extremity, as well as arthritic and nerve compression of the hand, wrist and elbow.

Learn more about Jacob Bosley, MD


Bill Klaproth (Bill Klaproth): There are 29 bones, 29 joints, 123 ligaments, 34 muscles, and 48 nerves in your hand. So, what could go wrong? Here to talk with us about getting a handle on hand and wrist injuries is Dr. Stephen O'Connell and Dr. Jacob Bosley, orthopedic surgeons with Eisenhower Desert Orthopedic Center. Both specializing in the hand, wrist and upper extremity and both fellowship-trained in hand and microsurgery. Dr. O'Connell and Dr. Bosley thank you so much for your time. We appreciate it. Dr. O'Connell let's start with you. So, hands and wrists are complex structures. Can you explain what hand surgery involves?

Stephen O'Connell, MD (Guest): Well you previously noted the hand is very, very complicated and the surgery for it very sophisticated and usually done by a fellowship-trained hand surgeon. And the reason for that is hand surgery has to combine the skills of orthopedic surgery, vascular surgery, neurosurgery as well as plastic surgeries. We tend to take care of bones, joints, ligaments, tendons, microsurgery of blood vessels and digital nerves as well as complex orthopedic injuries, fractures and ligament reconstructions. So, it's a combination of many surgical specialties that Dr. Bosley and I were fortunate enough to spend time and learn well and that's what we provide at Desert Orthopedic Center.

Bill Klaproth: Very complex, very involved. And Dr. O'Connell, let's stick with you. Many people may not realize that hand injuries are one of the most common injuries seen in emergency departments. Why is there such a high incidence of hand injuries and what are some of those, specifically?

Dr. O'Connell: Well actually 25% of athletic injuries involve the hand or wrist and about 40% of injuries in an emergency room typically involve hand and wrist injuries. But you think about it, the hand is our connection to the world. I mean it is part of our personality. We use it for communication, for discussion, for touching. So, putting our hands in positions to help us either working or in play and sports; so, hand injuries are very common whether they are lacerations or traumatic injuries with falls. But when we need our hands to provide the activities we do from day to day; they are really in danger of being injured and therefore, we end up seeing many, many hand injuries and fortunately, many can be reconstructed and get people back to their normal activity.

Bill Klaproth: And Dr. O'Connell you just mentioned wrist injuries. Dr. Bosley let's bring you in. Can you tell us about treating wrist fractures and what are the options and are there ways to prevent wrist fractures?

Jacob Bosley, MD (Guest): Sure, wrist fractures are a very common injury. Probably one of the most common injuries that Dr. O'Connell and myself see. And we see them from little tiny children all the way to very elderly patients. The most common thing that happens is just some type of a fall onto an outstretched wrist. It's pretty hard to prevent yourself from falling. Just because we encourage people to be active and do things. But the best thing we can do for prevention of wrist fractures is maintaining the bone health or maintaining our bone density. A lot of the fractures that Dr. O'Connell and I see are in patients that have osteoporosis. While we enjoy taking care of wrist fractures, preventing them is always helpful to the patients. Maintaining exercise is actually helpful for building the bone density as well as maintaining a healthy diet with calcium and vitamin D in them. We know that white females in particular, are particularly prone to osteoporosis and there are medications that could be taken in addition to vitamin D and calcium supplementation to help maintain the bone density.

Bill Klaproth: And Dr. Bosley a quick follow up. How do you treat most wrist injuries and how often do you need to perform surgery?

Dr. Bosley: So, it all depends upon how the fracture occurs, what the fracture pattern is. I would say that a lot of them can in fact be treated with casting and a time of immobilization. The bone is able to go andheal itself as long as it is in a good position. The ones that Dr. O'Connell and I need to get involved in with surgery are ones where there's a lot of angulation or else there's a lot of comminution meaning the bone is broken into several different pieces in which we need to go in and piece things back together to match the normal anatomy so that we can restore normal function to the wrist as well as to the hand.

Bill Klaproth: And Dr. O'Connell how important then is rehabilitation after treatment for a finger fracture or a wrist fracture? Are these the type of injuries people feel residual pain for years later or do they tend to heal and be a thing of the past?

Dr. O'Connell: Well, many times people will focus on the fracture itself. But what I like to tell them is you throw a rock in the pool and there's a big ripple away. There is a larger zone of injury than just the bone itself. So, the same energy that broke that bone had to go through the skin, and the subcutaneous tissue and the tendons and the nerves and the arteries; the soft tissue envelope absorbs the same force that bone did. So, if the bone is in good alignment; we may be able immobilize it briefly, then start therapy and exercises. If it's very displaced like Dr. Bosley is saying, we may put a plate and screws, get it aligned. A lot of times, the nice thing about fixing the fracture is with internal fixation, is it gives the fracture enough stability that we can start early motion and early rehabilitation of the soft tissues. Most of the time, the fracture heals in good position either if we fix it or if we chose to leave it in good position that it was initially. But the most important thing is rehabilitation; getting the soft tissue structures moving. The hand is so complicated, and everything is typically moving in a frictionless environment. When you break the bone, or you cut the tendon and there is bleeding; that will tend to scar and limit the excursion of the tendons and therefore the motion. So, we like to get people moving as quick as possible and it's usually under the guidance of a certified hand therapist. And fortunately, at Desert Orthopedic Center, we are very fortunate to have four certified hand therapists, three of which have been presidents of their societies here in California. So, we offer the surgical intervention or nonsurgical intervention and also really good rehabilitation for the total package of taking care of the hand and returning it back to its normal function. Most people will get good recovery with very limited residual function, most of the time. Obviously, in very severe injuries, there may be some limitation of function that could be permanent.

Bill Klaproth: Very good. And Dr. O'Connell how about arthritis then? Many people begin feeling some arthritis in their hands, particularly in the thumb joint as they age. Can you explain what's happening when arthritis develops? What is causing the pain and are there any easy stretches or other things people can do to help improve that pain?

Dr. O'Connell: Well arthritis in the base of the thumb occurs in women a little bit more than men, actually about three times as frequently. But it's interesting when you pinch the thumb against the index and you pinch twenty pounds per square inch, it translates to 240 pounds per square inch at the base of your thumb. Twelve times your pinch strength is the load at the base of your thumb. So, the base of the thumb has tremendous force across it when we are pinching, grabbing, opening jars. So, the joint tends to stretch out the ligaments that stabilize that joint as it becomes arthritic. So, when we load the joint, with tremendous force; frequently you have the typical dull aching pain like any arthritic joint, but specifically at the base of the thumb we tend to get some instability where the thumb loosens and is a little bit unstable and that gives people a lot of really sharp pain when they grab and pinch. And so, that's probably the most common area or arthritis that we see. Most of the time treated with splinting or anti-inflammatory medications, modifying the activity, corticosteroid injections. Sometimes we will do stem cell injections or PRP or amnion injections and if all else fails and people have intolerable discomfort; then we do a joint replacement at the base of the thumb which is a very successful operation. But it takes about three months to recover from. So, it's only used for the people with intolerable pain and dysfunction.

Bill Klaproth: Wow, that's very interesting. I never knew that type of force was put on the base of the thumb. And Dr. Bosley I know that you see many cases of carpal tunnel syndrome. How does it develop and how do you diagnose that to be sure that the pain isn't actually coming from the elbow joint since people often feel carpal tunnel in places other than their wrist or hand?

Dr. Bosley: Yes, carpal tunnel is a very common diagnosis that we treat. The carpal tunnel is actually a tunnel at the base of the wrist. I like to tell patients that it's where things bottleneck as the tendons and the median nerve are coming from your forearm and passing up and into your fingers to give sensation to the tips of your fingers. As those tendons become inflamed and sometimes that's from overuse, sometimes it's because the ligament that is the top of the tunnel can thicken. There are a variety of different conditions that can lead to compression of the nerve as it passes through that tunnel. Classically, that gives numbness and tingling into the thumb, the index finger and the long finger. Other classic symptoms are that it can wake you up at night. It can bother you more while you are driving or while you are pinching something for a prolonged period of time. Carpal tunnel syndrome can have a variety of different other appearances, but that's the classic and by knowing the classic ones are how we sort of solve out when that is in fact coming from carpal tunnel versus other locations in which a nerve can be pinched and give people pain into their hand.

Bill Klaproth: And Dr. Bosley then for people that are experiencing that pain; what are the conservative treatment options to address that?

Dr. Bosley: So, one of the first conservative things that we like to do for carpal tunnel syndrome are bracing at night. A lot of us sleep with out wrists in a flexed position or with our wrist extended and that has been shown to be a position in which the nerve gets pinched as it is coming through that tunnel at the base of our palm and leads to the numbness and tingling which then leads to folks waking up with those complaints of numbness and tingling into their fingers. If we brace the wrist at night; that helps hold it in a neutral position and keeps the nerve from getting pinched. If symptoms persist beyond that, oftentimes we will add a cortisone injection into the carpal tunnel which I would like to give the best analogy of that is like taking 100 Advil and putting them right into the spot where the inflammation is occurring, calming down inflammation within that carpal tunnel; which thereby gives more room for the nerve and calms down the swelling and gets the numbness and tingling to resolve.

Bill Klaproth: Alright, good to know. Hold the wrist in a neutral position when sleeping. I'm going to try that tonight. Great tip. And Dr. O'Connell when do you know it's time for surgery and what does that look like? Are there multiple approaches to surgically correct the condition?

Dr. O'Connell: Well it depends on how long the person has had the problems and also how severe they are. Most people that come in the office, they have had symptoms for less than a year, the typical waking up at night, when they drive a car or hold a book, talk on the phone; their hand falls asleep. If they have a normal exam, no evidence of wasting of the muscle at the base of the thumb, because not only does the nerve give sensation to the fingers; it powers the muscle at the bases of your thumbs, the thenar muscles. In the end-stages, you see those muscles are wasted away. There's a little test we do called two-point discrimination where we see the person's ability to tell one and two points at the end of the fingers. If people are unable to do that; we know that those people already have some permanent nerve damage. I usually move those people right to surgery. I say that's a minority of people that come in maybe 15-20%. Most people have the symptoms but a relatively normal examination; we like to treat them with splinting, anti-inflammatory medicines, particularly like a corticosteroid injection in the carpal tunnel. What that does is it shrinks the swollen tissue around the nerve and gives the nerve more room. If the pressure on the nerve is the problem; those people always get better. The interesting thing about it is it predicts your surgical outcome because the surgery cuts the ligament, opens the tunnel, gives the nerve more room. So, the anesthetic and corticosteroid does chemically what the surgery does mechanically and usually the corticosteroid injection is prognostic. So, I will inject those people, how them come back six to eight weeks later. If they say Steve, I was great for two months, now it's back. I can almost guarantee that person is going to do great with a surgery.

And now the surgery we do is both Dr. Bosley and I do a very minimally invasive technique. Either we can do it endoscopically in certain cases or we do a very mini open approach from the palm, about two stiches worth. We also frequently do carpal tunnels or trigger fingers and some of the minor surgeries in a technique called wide awake, local anesthetic with no tourniquet. Meaning we do local anesthetic with some epinephrine to shrink the blood vessels so that there's no bleeding involved, and the patient can be wide awake while we do the surgery. All these operations, carpal tunnels, trigger fingers, some of the basic operations; they are very brief operations, five, ten minutes. People go home the same day with a very short recovery period and a high success rate.

Bill Klaproth: Well that's good to know about being wide awake when doing the surgery and Dr. Bosley if you could wrap it up for us. Dr. O'Connell just mentioned trigger finger as well. Can you explain how someone might develop trigger finger? What are the risks for developing it and what does it look like? Is there a treatment that permanently resolves the issue or is surgery the only option?

Dr. Bosley: So, trigger finger is an inflammation of the tendon that flexes the finger and as the tendon gets inflamed; it has difficulty passing through a little tube or a sheath that's at the base of the finger that extends out the length of the finger. Classically, when people make a fist, and then go into bring their fingers out into extension; a finger will get stuck down in a flexed position and they have to kind of really focus on it and then the finger will pop or snap as it comes out into flexion. The biggest things associated with that are diabetes and rheumatoid arthritis. Diabetic patients are about four times more likely to develop trigger finger in comparison to the normal population. And trigger finger is fairly common even in just a general population. There are a number of different treatment options that we can do to keep people from needing surgery on this that we can actually - this is a problem that we often see in the office that can be solved with something even short or surgery and oftentimes get it to completely resolve. If we catch this early, sometimes anti-inflammatories or a brief period of bracing will get the tendon to - the swelling to come down and for the condition to resolve. Another treatment option that Steve and I both like is injecting the finger with cortisone. Injections are very successful at treating trigger fingers and it's about 70% of patients with one injection of cortisone into that sheath around the tendon, we usually can get the symptoms to completely resolve and subside completely.

Those folks that don't have complete resolution with cortisone injection or if they get injected and it resolves and then comes back; those are the ones that we are typically taking to surgery.

Bill Klaproth: Well this has been very, very informative. Wow the hand and wrist, very complex and the treatment and surgery options are varied and it's very interesting to hear both of you talk about hand and wrist injuries. So, thank you so much for spending some time with us and for more information about Eisenhower Desert Orthopedic Center or to make an appointment please visit, that's Or you can call 760-773-4545, that's 760-773-4545. This is Living Well with Eisenhower Health. I'm Bill Klaproth. Thanks for listening.