Wrist Sprain

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
  • 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
  • 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.
This is a common injury because the wrist is part of the 1st reflexive defense against injury.
Risk Factors
  • Frequent falls
  • Overuse
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.
  • 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
    • Scaphoid fracture
    • Radial styloid fracture
    • Perilunate dislocation
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.
No serum tests
  • 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.
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.


  • 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.
First Line
NSAIDs are useful for patients with pain.
  • 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).
  • Full recovery is expected after a wrist sprain.
  • If it is not achieved, evaluate the patient for other conditions.
  • 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.
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.
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.
If feasible, patients should avoid falling on the outstretched hand.
Q: How is the diagnosis of wrist sprain made?
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?
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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