Carpel Boss

[lindajdunn]

I finally saw a hand specialist/sports medicine doctor today and he said what I have is not a gangalian cyst but a carpel boss. I think that roughly translates into "bump on back of hand." It's hard and it's in the wrong location for a cyst but otherwise the treatment appears to be roughly the same.

The recommendation was to live with it if it wasn't bothering me but I have reduced mobility. My blade control is not good. [Okay, it wasn't good before, but now the long term plans for improvement don't look good.]

I injured it fencing (a bad parry 5).

So I'm looking at options. Fencing won't make it worse and I could have surgery after the nationals. Surgery means 6 weeks of no fencing so waiting 11 months sounds like the best option thus far. [And yes, this also means 6 weeks of no functional right hand at work, which is another reason to wait.]

Suggestions? Warnings? Advice? Anyone been through this before?

[Lefty1]

Why don't you try fencing with your other hand, until you're healed?

[lindajdunn]

Why don't you try fencing with your other hand, until you're healed?

That's one of the options I'm considering for the time when I can't use my right hand. I just hate losing time. I'm old. I don't have that much time.

[mlr2fence]

If you have reduced mobility does it cause you to alter your hand/arm motions possibly causing other injuries? One way to look at it is to give up 6 weeks now might put you in better shape by summer than you would be just 'limping' along as is. On the other hand, post-surgical results/recovery is an unknown. Tough decision.

[Peach]

That's one of the options I'm considering for the time when I can't use my right hand. I just hate losing time. I'm old. I don't have that much time.

That time thing is a killer, isn't it? I fenced off-hand for a while when I hurt my elbow. I've also taken chair lessons for months, such as when I tore my calf and when my sciatica acted up. I don't like it.

As a veteran, I focus on:

(a) avoiding new injuries and treating new injuries with respect. I don't recover as fast any more, and often injuries end up permanent. They also screw up my technique. Rushing to recovery gets me hurt worse.
(b) taking the time necessary. I don't learn as fast any more, and I have more to unlearn.
(c) learning techniques and strategies that don't depend on speed, strength, or things that cause pain.
(d) taking the long view. Kids are in a big hurry, because they don't know how long life really is.
(e) doing what I really want to do. I've got a career, family, and other responsibilities. This is for me.

[lindajdunn]

If you have reduced mobility does it cause you to alter your hand/arm motions possibly causing other injuries? One way to look at it is to give up 6 weeks now might put you in better shape by summer than you would be just 'limping' along as is. On the other hand, post-surgical results/recovery is an unknown. Tough decision.

It's causing me to fence with wide, sweeping movements that take more time. I also have less blade control.

The doctors didn't seem too concerned (naturally, it's MY hand).

Hard decision. I'm still trying to line up all the possible options for consideration.

[Feltan]

(c) learning techniques and strategies that don't depend on speed, strength, or things that cause pain.

Peach,

Although I am sure it would be frowned upon at Nationals, I think this is why they originally invented guns to replace swords.

On a more serious note, and as a veteran, I appreciate your post. I am sure it must be monumentally frustrating to be 17, in superb shape, and to catch a reposte in the head from a person who is older, fatter and not as good looking nor as smart as they think they are.

Regards,
Feltan

[Peach]

I am sure it must be monumentally frustrating to be 17, in superb shape, and to catch a reposte in the head from a person who is older, fatter and not as good looking nor as smart as they think they are.

I relishthe memory of those occasions when I have made a teenaged hot-shot (one who doesn't know me) fall to her knees and weep with rage on the strip after the bout.

Generally they don't make that mistake twice, of course.

[TLH]

First of all, I'll admit I had to look it up. A BOSS is a "rounded or knoblike protuberance, as on the side of a bone or tumor." OK - Now a bunch of questions: How long has this been bothering you ?? Has it gotten worse or larger and over what period of time ?
Do you know which Carpal (wrist) bone is involved ?? What range of motion is effected and how does it make your motions bigger? How does it effect your point control ?? Does the doc think that it is a result of the injury you remember??
Do you know what the post-op bandaging/casting will entail ?? You said that continuing to fence won't make it worse, but did fencing create it or make something there previously worse ?? How will the additional offending bone be removed and that area treated to avoid recurrance ?? I assume, but must ask - does he understand how it is effecting you and how much fencing means to you??

My initial thought (as an almost 51 yr old MD that can't get enough of my newly found sport) is that the 6 weeks of "no fencing" doesn't mean you'll feel fine and be fencing as well as pre-op at 6 weeks post-op. you might be in for an extended healing and return to activity phase.

If you can give me a little more info, I'll run it by my hand specialist buddy here and see how his thoughts match up.

Later - TLH

[lindajdunn]

First of all, I'll admit I had to look it up. A BOSS is a "rounded or knoblike protuberance, as on the side of a bone or tumor." OK - Now a bunch of questions: How long has this been bothering you ?? Has it gotten worse or larger and over what period of time ?
Do you know which Carpal (wrist) bone is involved ?? What range of motion is effected and how does it make your motions bigger? How does it effect your point control ?? Does the doc think that it is a result of the injury you remember??
Do you know what the post-op bandaging/casting will entail ?? You said that continuing to fence won't make it worse, but did fencing create it or make something there previously worse ?? How will the additional offending bone be removed and that area treated to avoid recurrance ?? I assume, but must ask - does he understand how it is effecting you and how much fencing means to you??

My initial thought (as an almost 51 yr old MD that can't get enough of my newly found sport) is that the 6 weeks of "no fencing" doesn't mean you'll feel fine and be fencing as well as pre-op at 6 weeks post-op. you might be in for an extended healing and return to activity phase.

If you can give me a little more info, I'll run it by my hand specialist buddy here and see how his thoughts match up.

Later - TLH

I injured it in March and at that time, I could barely hold anything between thumb and forefinger. I wore those stupid icy hot bandages constantly for a week. Today, it's not noticeable except when I try to do things that I can't -- like pick up a notebook with thumb and finger. It slips through. So yes, it's gotten better. The bump is where the wrist bone connects to the forefinger bone. [Obviously, I do not remember my human anatomy.]

Since I don't have the ability to manuever with the thumb and forefinger, I've been manuevering with the entire hand/arm. Big motions. And bear in mind I'm a one-year-thus-far saber fencer learning late in life and thus much of my frustration may be interwoven with the learning process. I can't do this. Injury or learning process? My point control has never been good and when I try to work on that, I feel discomfort. [Note that this is one of the few times when discomfort rather than PAIN! is the correct term. It's not painful, but it sure as heck is uncomfortable and gives a slight twinge.]

I've no idea what post-op will involve. I'm 53 and in relatively good health. The doctor wasn't too impressed with my interest in fencing, imho. Busy day. New patient. Uninteresting. He DID read the X-rays that confirmed no injury.

The killer, however, was the warning that sanding down the bone to remove the spur [?] could be temporary and the spur could return. Then the bombshell: I'm developing a slight protrusion on the LEFT hand.

This is when I asked: You mean this may be AGE related?

He said he preferred to say it was something that eventually happened to some people. Gee, thanks. I get to be the first in my family.

I guess it's like my newly discovered tailor's bunions. I didn't know I had them until I injured my foot while fencing. THAT healed just fine. No pain or discomfort or reduced mobility. This hand thing is not healing.

I have a low tolerance for body parts that do not function properly and esp. so when surgery could fix it. Thus, the decision that I will probably have surgery next July.

I note that I'm an IT person and part-time writer so I'm hot on the keyboard. Repetitive stress injury could be a factor in this.

Any input would be greatly welcomed. I've been googling for weeks.

[TLH]

LJD - I don't have time to write a lot until next week. I have another question, especially with a twin coming up on your left wrist. Was there a lump there before your catastrophic parry-5, or has the lump developed since? I'm not trying to be pedantic, but there's a significant difference between there having been a lump there without any problems prior to the manuever that injured you - or that you have developed a lump de novo since the episode - or that there was a lump that has now gotten bigger.

I think it is very important for you that there has been partial resolution over the last 6 months and that you've decided to hold off on the knife, at least for now.

Also, do you get pain with any specific motions versus other motions that only cause discomfort, or are all of your symptoms at the level of discomfort only? Do you get pain when the notebook slips between your thumb and index finger, or just discomfort? And the twinge that you get - is it localized or does it feel like it "shoots" down your thumb or to another destination on your hand?

One last idea for tonite - if you could get a digital copy of the xray and send it to me, I can get really specific in a recommendation. You may well be helped by more intensive therapeutic measures on this end of things, rather than surgery that may not bring a permanent solution.

I'll be back to you later. - TLH

[lindajdunn]

LJD - I don't have time to write a lot until next week. I have another question, especially with a twin coming up on your left wrist. Was there a lump there before your catastrophic parry-5, or has the lump developed since? I'm not trying to be pedantic, but there's a significant difference between there having been a lump there without any problems prior to the manuever that injured you - or that you have developed a lump de novo since the episode - or that there was a lump that has now gotten bigger.

I think it is very important for you that there has been partial resolution over the last 6 months and that you've decided to hold off on the knife, at least for now.

Also, do you get pain with any specific motions versus other motions that only cause discomfort, or are all of your symptoms at the level of discomfort only? Do you get pain when the notebook slips between your thumb and index finger, or just discomfort? And the twinge that you get - is it localized or does it feel like it "shoots" down your thumb or to another destination on your hand?

One last idea for tonite - if you could get a digital copy of the xray and send it to me, I can get really specific in a recommendation. You may well be helped by more intensive therapeutic measures on this end of things, rather than surgery that may not bring a permanent solution.

I'll be back to you later. - TLH

If there was a bump on the right hand before the injury, it was so slight that I could not see it. I cannot see the one on my left hand that the doctor noted but I presume this is the difference between a trained observer and an untrained one. If I were to cut an almond in half and insert that half under my skin, that would be about the size of the bump on the right hand.

Discomfort is localized. No shooting pains up the arm (thank goodness!)

When I try to do something I can't, the main thing I feel is frustration rather than pain. I could not open a van door tonight because I could not depress the button with my thumb. Picking up a notebook between forefinger and thumb causes discomfort because I can almost do it. My hand simply wouldn't work the way I wanted on that stupid button tonight. No pain. No ability to perform the action desired.

Digital copy? Hmmm.... I'll have to check with the doctor's office on that one.

[DonnaP]

I wanted to share my two cents regarding carpal bosses. I have seen and treated many of them during my career. I am a hand therapist and these are not really that unusual or bizzare. A carpal boss is often misdiagnosed as a ganglion due to the lump and the location on the back of the wrist. Your doctor must be at least more intuned to subtle hand conditions if he/she picked up on this - that's a good first sign. It seems to me that by your screen name you may be female - a boss is 2:1 more common in women vs men and 2:1 more common in the right (probably dominant) hand.

What is a boss? It is an osteoarthritic spur that develops at the base of the metacarpal bone (where the finger bones attach to the wrist bones). By the way, a boss can co-exist with a wrist ganglion in about 30% of cases.
There is some information that the boss may also occur due to perostitis (swelling) where the wrist tendon (Extensor carpi radialis longus and/or brevis) attaches - incidentaly, this is the same location described above. The tendon would swell due to strain, injury or overuse most likely. So whether it is due to swelling from the tendon insertion or an osteoarthritic spur is up for debate. As a fencer - you likely use/over use the wrist muscles and therefore my suggestion for a conservative treatment would include anti-inflammatory measures (Medications as well as ice, maybe some therapy modalites - although I haven't seen much benefit from the ultrasounds, iotophoresis, laser treatments etc.) along with a custom removable wrist splint to rest the wrist. A few weeks of limited blade work wouldn't hurt. Spend the time working on footwork - we all need that anyway.

Now about the surgery option: Unless the patient comes in with complaints of significant paint or loss of function, the doctor will just recommend leaving it alone or conservative treatment as above. If surgery is indicated, the boss (osteophytes) are excised (removed) from an incision on the back of the wrist and the rough bone smoothed. If a ganglion is also present - it is excised as well. Due to the need to cut into the bone either way, these surgeries are often sore post-operatively. The typical treatment is to "cast" for 4 - 6 weeks to rest the ligaments. However, check with your surgeon about what his/her definition of casting is.... in our office this type of "cast" is actually a custom made plastic removable splint so that you can start exercising as early as 10 days after surgery and strengthening as early as 3 weeks after surgery so that by 6 weeks postop you're on you way and expected to use the hand normally. I would never expect a patient to be truly "immobilized" and not allowed to use the hand for 6 weeks unless there were other aspects or complications to the surgery. A common postop problem however is stiffness in the wrist - especially bending into flexion (forward direction - same direction as when you bend the fingers). This motion does typiclly come back, but can be annoyingly sore and take a few months to fully work through. Hope this info is helpful.

Sincerely,
Donna Pepe, OTR/L, CHT

[lindajdunn]

Wow! Thank you both for the wonderful wealth of information you've provided me.

Yes, I'm a female fencer (obvious by the name, as you said).

[smohrle]

Just an impressed observer, would ya'll mind keep posting updates on this? Both the two docs and the pateint ..
Thanks for the information, this is very interesting.
Sarah

[TLH]

Donna, my goddess. What a treatise. As I said in my first post on this - I had to look it up - and now some of you know why I've recommended physical therapists for evals of some of the finer points of diagnosis and treatment - there are multiple levels of expertise avilable in medicine and the "ancillary" providers. We are lucky to have you on the forum, Donna.

I'm going to need some time to digest this new info, and I'll get back with you soon. A friend of mine crashed his plane on take-off 2 weeks ago and I've been spending a bunch of time with his family at the ICU an hour away.

Everybody hug your loved ones and let them know how much you do. Sometimes life gets really short really quickly. Later - TLH

PS - my brother was an aviator in the navy, and in mission planning, the concept of pK (probability of kill) was used to calculate how much of what combination of weapons would be brought to bear to nullify a target objective. Certain munitions have higher pKs in certain conditions.

One of the aviators more sober sayings was that the ground has a pK of 1.0

[lindajdunn]

With an eye to readers, could someone answer these questions?

(1) What actions would help avoid carpal boss?
(2) In addition to reducing swordsplay, should one cut back on other activities such as Blackberrying, keyboarding, knitting?
(3) I'm a sabre fencer and one of the other fencers suggested I switch to epee on the grounds that re-injury/aggravation of the injury is less likely. I'm considering fencing left-handed for a while.

[DonnaP]

To TLH (aka the fencing doc) - thanks for the very kind words dear sir! And I send my prayers to your friend and his family.

To Linda - I'm not sure if you can modifiy your activities to "avoid" developing the boss as there isn't real clarity on what truly causes them to develop in the first place. However, once you have one, resting and avoiding overuse of the wrist may improve your symptoms. I would guess that the knitting could be an irritant due to the repetitive nature of the activity - especially since most people I know who knit - don't do it for short periods of time!! The key point is - do the activities you listed bother you when you do them? Generally, if they aren't causing you increased pain during or after the activity, I would not think they are a major problem, but again, adding up all of the things you do all day with your hands is what you have to consider. Try keeping a log of when you experience increased pain and what activities you've done in the previous 2 - 3 hours and look for trends. As far a switching from Saber to Epee - Eeeck Gads woman - what could you possibly be thinking!!! (does that subliminaly reveal what weapon I fence?) But seriously, you could/should certainly try it, but I doubt that the change of weapons is going to alleviate your symptoms.

I hope this continues to be helpful.
Donna

[lindajdunn]

I plea temporary insanity for considering switching from sabre to epee.

I now have a list of what movements hurt:

Picking up a binder with about 100 pages inside -- using thumb and forefinger.
Depressing a latch door handle.
Writing, but not typing.
Lifting a container of kitty litter (crystals) with palm spread around the container to get a good grip.
In fencing, mirror work doesn't hurt but warm up parries do. [Anything involving an impact and it is discomfort rather than shooting pain.]
Moving the car from park to reverse or drive. This requires me to press inward with the thumb.
Twisting open a container.
Pull starting the lawnmower
IOW, it seems to be the thumb pressure that causes slight discomfort.

I am not going to fencing practice again until Wed. and I'm going to work more on footwork and back off on the bladework.

OTOH, Mother is ill and we're working on her house, packing up stuff, moving furniture, etc. this weekend. Watch me do something else stupid.

[DonnaP]

I wanted to add one further piece of information regarding the surgery for a carpal boss. I was speaking with the surgeon in my office and he had stated that there is the possibility that to remove a boss they may need to cut into the wrist tendon which would then warrant a little longer rest period before you would be able to resume full use - the tough part is they may not always be able to tell if this will be necessary until they get in there to look. I am only adding this as I didn't want to leave you with too rosey of a picture - as I said earlier - there can always be complications to any surgery. Hope you're feeling better.