Injuries to the wrist & hand range from acute traumatic fractures, such as falling or playing sport to overuse conditions, which occur in racquet sports, golf and rock climbing activities. Various occupational activities such as typing or manual work can also predispose to such injuries, including carpal tunnel syndrome.
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 blood 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.
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.
Hand and Finger Injuries
The mechanism of injury is the most important component of the history of acute hand injuries. A direct, severe blow to the fingers may result in a fracture, whereas a blow to the point of the finger may produce an interphalangeal dislocation, joint sprain or tendon avulsion. A punching injury often results in a fracture at the base of the first metacarpal or to the neck of one of the other metacarpals, usually the fifth. An avulsion of a flexor tendon, usually to the fourth finger, is suggested by a history of a patient grabbing an opponents clothing while attempting a tackle.
Investigations
All traumatic finger injuries should be x-rayed, including fractures and dislocations. Once a diagnosis has been established, the principles of treatment are initially to control inflammation and swelling. This can be achieved through splinting, compression, ice, elevation and electrotherapy modalities. Once this is stabilised, range of motion and strengthening exercises can be commenced.
If one of the flexor or extensor tendons are ruptures, then surgical intervention is required, followed by personalised splinting and a structured, progressive rehabilitation exercise programme.
Mallet Finger
This is a flexion deformity resulting from avulsion of the extensor mechanism from the DIP joint. It commonly results from a ball striking the extended fingertip, forcing the DIP joint into flexion. This is seen in baseball catchers, cricketers and basketball players.
Examination reveals tenderness and an inability to actively extend the DIP joint from its resting flexed position.
If left untreated, a chronic mallet finger deformity develops.
Such injuries may require surgery, but treatment of uncomplicated mallet finger involves splinting the DIP joint into slight hyperextension for a period of up to 8 weeks. The splint is then worn for an additional 6-8 weeks while engaging in sporting activity and at night.
Boutonniere Deformity
This condition consists of hyperextension of the DIP joints with a flexion deformity of the PIP joint. Boutonniere deformity always follows a volar PIP dislocation.
Treatment is to splint the finger with the PIP joint in full extension while allowing active flexion of the DIP joint for 6 weeks. On return to sport, protective splinting is continued for a further 6-8 weeks or until a pain-free range of flexion and extension is present. In longstanding injuries, there may be a fixed flexion deformity of the PIP joint. This can be treated with a dynamic splint but if this is unsuccessful, surgery is indicated.
Jersey Finger
This injury is most commonly seen in the ring finger and may be caused by the sportsperson grabbing an opponents clothing, resulting in the distal phalanx being forcibly extended while the athlete is actively flexing. The patient often feels a ‘snap’.
Examination may reveal the finger assuming a position of extensionrelative to the other fingers. There is an inability to actively flex the DIP joint of the affected finger. A lump may be palpated more proximally in the finger corresponding to the avulsed tendon.
Treatment is urgent surgical repair with reattachment of the tendon to the distal phalanx. This must take place within 10 days of the injury as tendon ischaemia occurs when the tendon has retracted into the palm.
Trigger Finger
This is caused by tenosynovitis in the flexor tendon that is large enough to be impeded by the proximal A1 (annular) pulley located at the base of the finger. Conservative treatment involves splinting and local treatment to reduce the enlarged tendon. Corticosteroid injection is often advocated first, and then surgical release of the impeded A1 pulley.
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.
