High Yield Topics

Wrist Sprain

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Wrist Sprain

Wrist Sprain
Peter R. Jay MD
Dawn M. LaPorte MD
Basics
Description
  • A wrist sprain is an injury to the bones and ligaments of the wrist that results in pain from an incomplete ligament tear.
    • No associated long-term disability
    • Because many serious injuries are easily
      confused with wrist sprains, the patient with substantial swelling or
      persistent pain should be suspected of having a more serious injury.
  • Classification:
    • Grade I: No ligament damage (stretch of the ligament without tearing)
    • Grade II: Partial tear
    • Grade III: Complete tear
Epidemiology
  • Wrist sprain occurs most commonly in adults; it is rare in children.
  • Suspect an injury to the growth plate if swelling and tenderness are seen.
  • Elderly persons are more likely to suffer a fracture.
  • Males and females are affected equally.
Incidence
This is a common injury because the wrist is part of the 1st reflexive defense against injury.
Risk Factors
  • Frequent falls
  • Overuse
Pathophysiology
Pathological Findings
  • A sprain of the wrist involves partial
    stretching or disruption of the ligaments holding the radius and the
    carpal bones in alignment.
  • No major interosseous ligament injury or fracture should be seen.
Etiology
  • This injury usually occurs from a fall on an outstretched hand.
  • It also may occur from a twisting injury as the hand is grasping an object.
  • Overuse or unusually heavy activity with wrist
Associated Conditions
  • A fall on an outstretched hand produces a
    continuum of injury from stretching and mild tearing of the ligament to
    fracture of the bones and dislocation of the articulation, such as the
    following:
    • Scaphoid fracture
    • Radial styloid fracture
    • Perilunate dislocation
Diagnosis
Signs and Symptoms
  • Signs: Swelling over the wrist joint
  • Symptoms:
    • Pain on ROM
    • Stiffness
    • Decreased grip strength
    • Little pain on axial loading
Physical Exam
  • Inspect the wrist for amount of swelling.
  • Carefully perform ROM.
    • It should be possible to achieve a complete range if done slowly.
    • Check pronation and supination of the wrist.
  • Palpate the structures on the dorsum of
    the wrist individually for tenderness and to focus the subsequent
    radiographic examination.
  • Palpate the volar part of the wrist; tenderness increases the likelihood of a serious injury.
  • Inspect the snuffbox for tenderness.
  • Palpate the wrist extensor tendons, both over and away from the wrist.
Tests
Lab
No serum tests
Imaging
  • Radiography:
    • Obtain AP, lateral, and oblique films of the wrist.
      • The oblique film (also termed the “navicular view”) is most useful to rule out an occult injury to this bone.
    • Order a clenched-fist view if scapholunate instability is suspected.
      • A positive view shows >3 mm of space between the scaphoid and lunate (1).
    • A coned (specially focused) lateral view
      of the wrist may be needed to rule out avulsion fractures of the
      triquetrum or of the lunate.
  • MRI or fluoroscopy may be used by the
    orthopaedist or hand surgeon in cases of an unclear diagnosis or to
    search for an occult injury.
  • If plain radiographs are normal, a bone scan may be ordered to rule out occult fracture (2).
Differential Diagnosis
  • The diagnosis of a wrist sprain is
    clinical and made primarily by palpation over the ligaments and by the
    exclusion of more serious injuries.
    • Navicular or scaphoid fracture:
      • This serious injury may progress to a painful nonunion if it is not immobilized.
      • Signaled by pain in the “snuffbox” area of the hand, between the extensor and abductor tendons to the thumb
      • A scaphoid radiographic view usually shows it.
      • If not, a bone scan may be ordered, or the wrist may be immobilized in a thumb spica cast for 2 weeks and then rechecked (2).
  • Scapholunate interosseous ligament injury:
    • This tear of the ligament that joins the
      lunate and scaphoid bones may result in late wrist instability,
      clicking, and degeneration.
    • The signs are a gap >3 mm between the
      scaphoid and lunate on plain posteroanterior radiograph or an angle of
      >60° between these bones on the lateral radiograph (1).
  • Avulsion or “chip” fracture of the lunate or triquetrum:
    • This injury, which may simulate a sprain, is best seen on coned or detailed lateral films of the wrist.
    • Longer immobilization is required.
  • De Quervain tenosynovitis:
    • This overuse injury of the
      extensor-abductor tendons of the thumb results in aching on the radial
      side of the wrist and a positive Finkelstein test (3).
  • TFCC tear:
    • This tear involves the distal radioulnocarpal joint and causes ulnar-sided wrist pain.
  • Distal radioulnar joint subluxation:
    • This injury is noted by a dorsal prominence over the distal ulna, especially in pronation (4).
  • Subluxation of the extensor carpi ulnaris tendon:
    • This injury usually occurs with pronation
      and supination of the wrist and causes pain that is frequently
      associated with “snapping.”
  • Lunate dislocations:
    • These serious injuries occur after falls and high-energy trauma to the wrist.
    • The lunate is completely dislocated on the radiographs.
    • This injury frequently is overlooked on initial plain radiographs.
Treatment
General Measures
  • Immobilization for comfort
  • Counseling to return to activity when symptoms subside
  • Specialist referral if symptoms persist
  • If a scaphoid fracture is suspected, the wrist should be immobilized in a thumb spica cast and re-examined in 2 weeks.
  • If carpal instability is suspected, refer patient to a specialist.
  • If a sprain is suspected, ice, immobilization, and analgesics are appropriate.
  • A wrist splint may be made of padded plaster or fiberglass or may be ready-made for easy removal and reapplication.
  • Remove the wrist splint when the pain subsides, usually in 5 days, at the most.
  • If pain persists >5 days and is not improving, referral to a specialist may be indicated.

P.487


Activity
  • When pain subsides, early return to activity should be encouraged.
  • If clicking or pain develops, the wrist should be re-evaluated.
Special Therapy
Physical Therapy
  • The patient may perform therapy at home with an exercise program or directly under the supervision of a therapist.
  • The goals of rehabilitation are return to preinjury ROM, strength, and dexterity.
Medication
First Line
NSAIDs are useful for patients with pain.
Surgery
  • Surgery is not indicated for simple wrist sprains.
  • Major ligament tears that result in
    instability often necessitate surgical repair (ligament reconstruction,
    or partial or complete wrist fusion) (1).
Follow-up
Prognosis
  • Full recovery is expected after a wrist sprain.
  • If it is not achieved, evaluate the patient for other conditions.
Complications
  • Reflex sympathetic dystrophy, a syndrome of sympathetically maintained pain resulting in exaggeration of the injury response
  • Ankylosis
Patient Monitoring
  • The patient should be seen 7–14 days after the injury.
  • If the pain has resolved, no additional evaluation is necessary.
  • If substantial pain is still present, radiographs and consultation with an orthopaedic or hand surgeon should be obtained.
References
1. Garcia-Elias
M, Geissler WB. Carpal instability. In: Green DP, Hotchkiss RN,
Pederson WC, et al., eds. Green’s Operative Hand Surgery, 5th ed.
Philadelphia: Elsevier Churchill Livingstone, 2005:535–604.
2. Amadio
PC, Moran SL. Fractures of the carpal bones. In: Green DP, Hotchkiss
RN, Pederson WC, et al., eds. Green’s Operative Hand Surgery, 5th ed.
Philadelphia: Elsevier Churchill Livingstone, 2005:711–768.
3. Wolfe
SW. Tenosynovitis. In: Green DP, Hotchkiss RN, Pederson WC, et al.,
eds. Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier
Churchill Livingstone, 2005:2137–2159.
4. Adams
BD. Distal radioulnar joint instability. In: Green DP, Hotchkiss RN,
Pederson WC, et al., ed. Green’s Operative Hand Surgery, 5th ed.
Philadelphia: Elsevier Churchill Livingstone, 2005:605–644.
Miscellaneous
Codes
ICD9-CM
842.00 Wrist pain
Patient Teaching
Instruct the patient to remove the splint in 5 days and to begin ROM and activities of daily living.
Prevention
If feasible, patients should avoid falling on the outstretched hand.
FAQ
Q: How is the diagnosis of wrist sprain made?
A:
The diagnosis is based on clinical examination and careful exclusion of
more serious injuries. The patient is tender to palpation over the
wrist ligaments.
Q: How should a wrist sprain be treated?
A:
The wrist should be immobilized in a splint for patient comfort.
Anti-inflammatory medication may be helpful initially. If the patient
is tender over the anatomic snuffbox, but no scaphoid fracture is seen,
the splint should be a below-the-elbow thumb spica, and the patient
should have a follow-up examination in 7–14 days for repeat
radiographic evaluation.

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