Diagnosis and Treatment of Wrist Injuries:

The wrist joint has multiple axes of movement: flexion-extension and radial ulnar deviation occur at the radiocarpal joints, and pronation-supination occurs at the distal and proximal radioulnar joints. These movements provide mobility for hand function. Injuries to the wrist often occur due to a fall on the outstretched hand. In sportspeople, the most common acute injuries are fractures of the distal radius or scaphoid, or damage to an intercarpal ligament. Intercarpal ligament injuries are becoming more frequently recognized and, if they are not treated appropriately (e.g. including surgical repair where indicated), may result in long-term disability. The anatomy of the wrist and hand is complex and therefore a thorough knowledge of this region is essential to diagnose and treat sports injuries accurately. The bony anatomy consists of a proximal row and a distal row, which are bridged by the scaphoid bone. Normally, the distal carpal row should be stable; thus, a ligamentous injury here can greatly impair the integrity of the wrist. Here a ligamentous injury disrupts important kinematics between the scaphoid, lunate, and triquetrum, resulting in carpal instability with potential weakness and impairment of hand function.

History:

It is essential to determine the mechanism of the injury causing wrist pain.  These injuries are commonly encountered in high-velocity activities such as snowboarding, rollerblading, or falling off a bike. A patient may fracture the hook of hamate while swinging a golf club, tennis racquet or bat and striking a hard object (e.g. the ground). It is very useful to determine the site of the pain; the causes of volar pain are different from those of dorsal wrist pain.

Other important aspects of the history may include:

• Hand dominance
• Occupation (computer related, manual labor, food service industry)
• History of past upper extremity fractures including childhood fractures/injuries
• History of osteoarthritis, rheumatoid arthritis, thyroid dysfunction, diabetes
• Any unusual sounds (e.g. clicks, clunks, snaps, etc.)
• recurrent wrist swelling raises the suspicion of wrist instability
• Musician (number of years playing, hours of practise per week, change in playing, complex piece, etc.)

Examination Involves:

1.    Observation

2.    Active movements

• Flexion/ extension
• Supination/pronation
• Radial/ulnar deviation

3.    Passive movements

• Extension
• Flexion

4.    Palpation

• Distal forearm
• Radial snuffbox
• Base of metacarpals
• Lunate
• Head of ulna
• Radioulnar joint

5.    Special tests

• Watson’s test for scapholunate injury
• Stress of triangular fibrocartilage complex
• Grip- Jamar dynamometer (may be contraindicated if a maximal effort is not permitted, e.g. after tendon repair)
• Dexterity- Moberg pick-up test
• Sensation- Semmes Weinstein monofilament testing
• Nerve entrapment- Tinel’s sign

6.    Standardized rating scales

• Several valid and reliable assessment scales can quantify function of the wrist specifically or the upper extremity after an Injury.

Diagnosis of Wrist Injuries:

• Plain Radiography

If ligament injury is suspected, also obtain a PA view with clenched fist. A straight lateral view of the wrist, with the dorsum of the distal forearm and the hand forming a straight line, permits assessment of the distal radius, the lunate, the scaphoid, and the capitate and may reveal subtle instability. The lateral radiograph of the normal wrist can be. These bones should be aligned with each other and with the base of the third metacarpal. A clenched fist PA view should be taken if scapholunate instability is suspected.

• Special Imaging Studies

The combination of the complex anatomy of the wrist and subtle wrist injuries that can cause substantial morbidity has led to development of specialized wrist imaging techniques. A carpal tunnel view with the wrist in dorsiflexion allows inspection of the hook of hamate and ridge of the trapezium. For suspected mechanical pathology, such as an occult ganglion, an occult fracture, non-union or bone necrosis, several modalities are useful (e.g. ultrasonography, radionuclide bone scan, CT scan or MRI). Ultrasonography is a quick and accessible way to assess soft tissue abnormalities such as tendon injury, synovial thickening, ganglions, and synovial cysts. Bone scans have high sensitivity and low specificity; thus, they can effectively rule out subtle fractures.

Treatment of Wrist Injuries:

Treatments for wrist problems vary greatly. Treatment for wrist injury may include first aid measures. Treatment depends on:

• The position, type, and seriousness of the injury.
• How long ago the injury happened.
• Your age, health problem and actions (such as work, sports, or hobbies).