Bone & Joint Expert Care
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Wrist Injuries
Often occur due to a fall on an outstretched hand. The most common acute injuries are fractures of the radius, ulna or scaphoid bone and damage to an inter-carpal ligament. If such injuries are not treated appropriately (including surgical repair where indicated), then long-term disability may result.
Fractures of the Radius / Ulna
These fractures are vary common. Initial treatment of the fracture is through immobilisation for up to 6 weeks in a cast. Should the bone be displaced and cannot be relocated then surgical fixation will be required.
Fracture of the Scaphoid
The usual mechanism for this fracture is a fall on an outstretched hand. The key examination finding is tenderness at the base of the thumb towards the wrist (anatomical snuffbox). This may be accompanied by swelling and loss of grip strength. Initial treatment consists of immobilisation in a specialised cast for 8 weeks. Due to an anatomically poor bllod supply to the scaphoid, a complication with a fracture is delayed healing / union. On cast removal and further x-ray, evidence of delayed healing should be treated with further immobilisation for 4-6 weeks and if this fails, surgical fixation.
Post-Immobilisation Treatment and Rehabilitation
Following cast removal, patients are invariably left with a stiff wrist joint and wasted, weakened muscles. At this stage, the physiotherapist will provide stretching and strengthening exercises for the wrist and hand. Treatment will also include mobilisation techniques to help regain the range of movement at the wrist.
Chronic Wrist Pain
Patients presenting with longstanding wrist pain will be assessed as to whether the symptoms are from a musculoskeletal origin or due to a manifestation of a systemic condition such as rheumatoid arthritis. Numerous conditions and structures within the wrist can cause longstanding pain and the physiotherapist will carry out a number of tests to ascertain where exactly the pain is coming from.
Potential Causes
Pain after repeated movements, with wrist stiffness after a period of rest, suggests an inflammatory condition such as tenosynovitis. Pain aggravated by weight-bearing activities, suggests bone or joint involvement and joint clicking may be associated with carpal bone instability. Characteristic night pain at the wrist, with or without pins and needles sensation, is found in carpal tunnel syndrome. Finally, neck or elbow conditions can also refer pain to the wrist and hand.
de Quervain’s Tenosynovitis
This is an inflammation of the synovium of the abductor pollicis longus and extensor pollicis brevis tendons as they pass through the medial aspect of the wrist at the base of the thumb. In athletes, it occurs principally in racquet sports, rowers and canoeists. The left thumb of a right handed golfer is particularly at risk because of the hyper-abduction required during a golf swing. The symptoms consist of local tenderness and swelling and in severe cases, crepitus may be felt. A positive Finkelstein’s test is usually diagnostically accurate.
Treatment includes splinting, electrotherapy modalities and graduated stretching and strengthening exercises. An injection of corticosteroid and local anaesthetic into the tendon sheath will usually prove helpful. A recent study showed that, injection alone cured 83% of cases, injection and splinting cured 61% and splinting alone cured 14%. It is noteworthy that no patients gained symptom reduction from rest and anti-inflammatory medication.
Ganglions
These occur in patients of any age. They are a synovial cyst and most often present as relatively painless swelling on either side of the wrist. The patients main complaint is of intermittent wrist pain and reduced movement. When symptoms persist, aspiration or a corticosteroid injection can be very effective. Some persistent symptomatic ganglions require surgery.
Triangular Fibrocartilage Complex Tear
The triangular fibrocartilage complex lies between the ulna and the carpal bones. This is a common site of lateral (outside) wrist pain. Sports involving racquets and golf can potentially tear the central portion of the cartilage. Examination reveals tenderness and swelling over the lateral dorsal aspect of the wrist, a clicking sensation on wrist movement and reduced grip strength. The ‘press test’ can be helpful with diagnosis whereby the patient attempts to lift his or her weight off a chair using the affected wrist.
Treatment may include the wearing of protective bracing, electrotherapy modalities for pain relief and strengthening exercises. Should the symptoms persist, the onward referral to a hand / wrist surgeon is appropriate.
Kienbock’s Disease
This condition is avascular necrosis of the lunate carpal bone, possibly because of repeated trauma. It presents as chronic dorsal wrist pain in athletes who undergo repeated impact on the wrist and is most common in those aged in their twenties. There is localised tenderness over the lunate bone and a loss of grip strength. In the acute stage, immobilisation may be therapeutic, whereas in chronic cases surgery is required.
Carpal Tunnel Syndrome
This condition is characterised by burning wrist pain, numbness and/or pins and needles of the hand. The median nerve may be compressed as it passes through the carpal tunnel along with the flexor tendons. The symptoms are more accurately located at the median nerve distribution (thumb, index finger, middle finger and radial side of the ring finger). Night-time pins and needles are also a characteristic.
On examination, Tinel’s sign may be elicited by tapping over the volar aspect of the wrist. Nerve conduction studies can also confirm a diagnosis. Diabetes mellitus should be excluded as it is a risk factor for carpal tunel syndrome.
In terms of treatment, mild cases may be treated conservatively with anti-inflammatory medication and splinting. A corticosteroid injection may also provide relief but persistent cases require surgical intervention.
Wrist Pain
1 What would cause you to suffer wrist pain?
Wrist pain is an extremely common complaint, and there are many common causes of this problem. If you have wrist pain, some common causes include:
Tendonitis is a common problem that can cause wrist pain and swelling. Wrist tendonitis is due to inflammation of the tendon sheath. Treatment of wrist pain caused by tendonitis usually does not require surgery.
Wrist sprains are common injuries to the ligaments around the wrist joint. Sprains can cause problems by limiting the use of our hands.
Carpal tunnel syndrome is the condition that results from dysfunction of one of the nerves in the wrist. In carpal tunnel syndrome the median nerve is compressed, or pinched off, as it passes through the wrist joint.
A ganglion cyst is a swelling that usually occurs over the back of the hand or wrist. These are benign, fluid-filled capsules. Ganglion cysts are not cancerous, will not spread, and while they may grow in size, they will not spread to other parts of your body.
Patients who sustain a broken wrist may be treated in a cast, or they may need surgery for the fracture.
Arthritis is a problem that can cause wrist pain and difficulty performing normal activities. There are several causes of arthritis, and fortunately there are a number of treatments for
2. How do you diagnose the cause of wrist pain?
Finding the cause of wrist pain begins with a detailed history, physical examination and the use of several diagnostic tests. These tests are used to find out the cause of your pain and not to make your pain better. X-rays of the wrist are usually a first step and will help determine if more tests are needed. An ultrasound scan can be used to diagnose tendon tears around the wrist. The MRI is commonly used to evaluate the wrist because it can show abnormal areas of the soft tissues. Blood tests are done to look for infection or arthritis.
3. When should you seek treatment?
History of fall and injury.
Inability to carry objects or use the wrist
Injury that causes deformity of the joint
Wrist pain that occurs at night or while resting
Wrist pain that persists beyond a few days
Inability to straighten or flex the joint
Swelling or significant bruising around the joint or forearm
Signs of an infection, including fever, redness, warmth
4. What are the treatments for wrist pain?
The treatment of wrist pain depends entirely on the cause of the problem.
Rest & Activity Modification: The first treatment for many common conditions that cause wrist pain is to rest the joint, and allow the acute inflammation to subside. It is important, however, to use caution when resting the joint, because prolonged immobilization can cause a stiff joint. Adjusting your activities so as not to irritate the joint can help prevent worsening of wrist pain.
Ice and Heat Application: Ice packs and heat pads are among the most commonly used treatments for wrist pain.
Wrist Support: Support braces can help patients who have either had a recent wrist sprain injury or those who tend to injure their wrists easily. These braces act as a gentle support to wrist movements. They will not prevent severe injuries, but may help you perform simple activities while rehabilitating from a wrist sprain.
Anti-Inflammatory Medication: Nonsteroidal anti-inflammatory pain medications, commonly referred to as NSAIDs, are some of the most commonly prescribed medications, especially for patients with wrist pain caused by problems such as arthritis and tendonitis.
Cortisone injections: Cortisone is a powerful medication that treats inflammation, and inflammation is a common problem in patients with wrist pain.
Arthroscopic Wrist Surgery: Some wrist conditions require a surgical procedure for diagnosis or treatment. Arthroscopic surgery is a treatment option available for some causes of wrist pain.
5. How do you take care of your wrist?
1 Stay Strong Keep your wrist, arm, hand and fingers strong. It is harder to overuse something if it is normally worked harder. Strengthen the muscles involved and increase flexibility through stretching. 2 Use Your Muscles
Control the movement of your hand and fingers through muscle use not tendon/ligament use.
3. Take Breaks
Take regular breaks to relieve stress. Take this opportunity to stretch and increase blood flow.
4. Change Positions
Change your position and posture regularly. Change of position will call in different muscles, kind of like a relief pitcher, letting the first group rest.
5. Get a Good Grip
Use a proper sized grip for your hand.
6. Maintain Your Distance
When working with your hands keep them in the middle ground, not too far, but not too close to your body. This allows muscles in your arms, shoulders and trunk to help share the load.It also keeps your joints in the middle of their range of motion, which increases blood flow and reduces the flex of tendons/ligaments/nerves over those leverage points at the joints.
Your pain may make it difficult for you to carry out your usual activities, and you might want to avoid using your wrist completely. However, it is important to resume normal activities as soon as possible. Staying active helps to prevent long-term problems.
You may need to use pain-relieving measures to help you return to your usual activity level. If you are working, the plan could include a programme of selected duties or reduced hours of work.
Unfortunately osteoarthritis is a problem we will all have to deal with at some point in our lives. But if you keep yourself fit and active, correct your posture and keep your shoulder strong and flexible you can help to alleviate and manage your shoulder symptoms