Wrist Conditions

Guidelines below can be used to determine when to refer of a patient for hand & wrist therapy or surgery.

To make an appointment to see a hand therapist phone the Auckland Hand Institute on 09 444 9450

To make an appointment to see surgeon Dr Michael Boland phone (09) 443 3469


Wrist Sprain

Diagnosis: There are many structures that may be implicated in wrist pain following a fall, and diagnosis can be challenging. Commonly affected ligaments are the scapholunate and lunotriquetral ligaments, in addition to possible triangular fibrocartilage (TFC) tears. Plain x-rays are useful for ruling out distal radius and scaphoid fractures, with bilateral clenched fist views necessary for determining instability of the scapholunate interval. One should remain suspicious of an occult scaphoid fracture if there is continuing radial-sided pain and tenderness in the anatomical snuffbox following unremarkable initial x-rays.

Management: Grade I and II ligamentous injuries, and small peripheral TFC tears are treated conservatively with splinting for 6 weeks, with a possible initial period of casting. Following immobilisation, continuing pain and functional limitation is an indication for specialist review.

Surgery: Paragraph about surgical options.

Ganglia

Diagnosis: Ganglia are benign fluid-filled sacs typically found on the dorsal wrist, but do also occur volarly. They may be of idiopathic onset, or arise following trauma, typically to the scapholunate ligament. They present as tender, spongy growths, that often limit full range of motion at the wrist.

Management: If the ganglion can be clearly linked to a traumatic incident, and the patient presents within 3 months of the injury, fibreglass casting can be successful in achieving sound ligament healing, and resolving the growth. After this period immobilisation is unlikely to be successful. If functional impairment or pain are significant, surgical excision will be considered.

Surgery: Paragraph about surgical options.

Tendinopathy

Diagnosis: The most common tendon conditions of the wrist are tenosynovitis of the first extensor compartment (de Quervain’s syndrome) tenosynovitis of the first extensor compartment (de Quervain’s syndrome) and tendinosis or tenosynovitis of the sixth extensor compartment containing the extensor carpi ulnaris (ECU) tendon. Diagnosis of de Quervain’s is through clinical examination with tenderness of the first compartment and pain with active extension, and ulnar deviation of the wrist with the thumb flexed. It commonly affects new mothers, and may be associated with thumb overuse. ECU tendinopathy presents as ulnar-sided wrist pain, especially with resisted ulnar deviation. There may be history of a traumatic incident involving forceful radial deviation of the wrist, or sporting activity involving prolonged supination of the forearm, such as in carrying a rugby ball. Ultrasound imaging is useful in determining tearing or rupture of the tendon.

Management: Splinting and activity modification is essential to reduce forceful loading of the tendon, and friction between the tendon and sheath. If reduction in symptoms is not forthcoming corticosteroid injection may be beneficial. Surgical release of the tendon sheath may be considered if other treatment options are ineffective.

Surgery: Paragraph about surgical options.

Carpal Tunnel

Diagnosis: Compression of the median nerve in the carpal tunnel results in sensory disturbance in the first three and a half digits, and possible weakness in the thenar intrinsic muscles. Symptoms are reported at night and in the morning, and may be associated with gripping activities such as driving. Clinical testing is usually sufficient to diagnose the condition, with provocative tests such as the Phalen’s (sustained wrist flexion) and Tinel’s (percussion over flexor retinaculum) useful. The possibility of proximal nerve compression such as with thoracic outlet syndrome, or cervical nerve root pathology, needs to be considered, and nerve conduction studies may be useful.

Management: Wrist splinting at night to avoid provocative positions is beneficial, as well as specific nerve gliding exercises, and education on activity modification. Conservative management is usually sufficient for more mild cases, but more severe cases, especially those involving motor weakness, typically require surgical release.

Surgery: Paragraph about surgical options.

Distal Radius/Ulna Fractures

Management: Following casting or surgical fixation all wrist fracture patients benefit from hand therapy to help restore full range of motion, strength, and functional use of the hand, wrist, and forearm. Post-casting stiffness is common, especially in the older patient, as is weakness and proprioceptive deficits. Surgical patients may have additional complications such as tendon and nerve tethering beneath the scar, and will require guidance with scar management. A brief period of splinting is essential following cast removal as the wrist will feel vulnerable, with a pre-made splint normally being sufficient.