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  Wrist 

Wrist  Sprain

A sprain results when the ligaments that connect bone to bone within the joint are stretched and perhaps torn. This can result when the wrist is bent forcefully backward, as can happen in a fall onto the palms of the hand.

Symptoms

Signs and symptoms of a wrist sprain may vary in intensity and location, depending on the degree of injury. Indications of a wrist sprain include:

Swelling in the wrist

Pain at the time of the injury

Persistent pain when the wrist is moved

Bruising or discoloration of the skin

Tenderness at the injury site

A feeling of popping or tearing inside the wrist

A warm or feverish feeling to the skin

Diagnosis

During the physical examination, the doctor will review how and when the injury happened. He or she will review all the symptoms, including asking about any numbness in the hand. Past medical history, especially any previous injuries to your hand or wrist, will also be reviewed.

The physician will examine the entire arm and hand, to ensure that there are no other injuries. Tenderness in certain areas may suggest a broken bone.

If a severe sprain is suspected, X-rays may be ordered. In some cases, a magnetic resonance image (MRI) or computed tomography (CT) scan also may be ordered. An arthrogram involves the injection of some liquid into the joint. This makes the joint show up more clearly on the X-ray. The liquid passes through an area where a ligament is torn, making it easier to identify injury.

Wrist sprains are graded, depending on the degree of injury to the tissues.

Grade 1, or mild, sprains occur when the ligaments are stretched, but not torn.

Grade 2, or moderate, sprains occur when some of the ligaments are torn. Grade 2 sprains may involve some loss of function.

Grade 3, or severe, sprains occur when the ligament is completely torn. These are significant injuries that require medical or surgical care. As the ligament tears away from the bone, it may also take a small chip of bone with it, called an avulsion fracture.

Sometimes, a sprain can show only mild swelling, but it still may be serious enough to require surgery. To avoid problems later, proper diagnosis and treatment is important.

An unrecognized (occult) fracture may be mistakenly diagnosed as a sprained wrist.

Treatment

Mild wrist sprains can usually be treated at home with the RICE protocol.

R Rest the joint for at least 48 hours. 

I Ice the injury to reduce swelling.

Do not apply ice directly to the skin. Use an ice pack or wrap a towel around the ice or a package of frozen vegetables. Apply ice for about 20 minutes at a time. 

C Compress the swelling with an elastic bandage. 

E Elevate the injury above the level of the heart. 

A pain reliever, such as aspirin or ibuprofen, may be helpful. If pain and swelling persist for more than 48 hours, however, see a doctor.

Moderate sprains may need to be immobilized with a wrist splint for 7 to 10 days.

Severe sprains may require surgery to repair the fully torn ligament. This would be followed by a period of rehabilitation and exercises to strengthen the wrist and restore motion. A wrist sprain can take anywhere from 2 to 10 weeks to heal completely, depending on the severity of the sprain.

Partial ligament tears are sometimes difficult to diagnose, but may cause re-occuring (chronic) disability if not treated surgically. Every effort should be made to properly diagnose the cause of a sprained wrist.

Prevention

Because wrist sprains usually result from a fall, be careful when walking in wet or slippery conditions. Wrist sprains also occur during sports, such as skating, skateboarding, and skiing. Wrist guard splints or protective tape can be used to support the wrist and prevent it from bending too far backward. When skiing, drop the poles during a fall to prevent wrist sprains

Scaphoid Fracture

Cause

Symptoms

Diagnosis

Treatment

Nonunions, Avascular Necrosis, and Arthritis

Rehabilitation n

Research on the Horizon The scaphoid is one of the small bones in the wrist. It is the wrist bone that is most likely to break.

Anatomy

The scaphoid is located on the thumb side of the wrist, in the area where the wrist bends.

Left:The scaphoid is located at the base of the thumb, just above the radius. Right: The scaphoid can be localized to just below the thumb tendons.

The image on the right was reproduced with permission from Cooney III WP: Scaphoid Fractures: Current Treatments and Techniques. Instr Course Lect 2003;52:197-208.

The scaphoid can be identified more easily when the thumb is held in a "hitch hiking" position. The scaphoid is at the base of the depression made by the thumb tendons. Pain or tenderness in this area can be a sign that the scaphoid is injured.

Cause

A fracture of the scaphoid usually happens from a fall on an outstretched hand, with the weight landing on the palm. The end of one of the forearm bones (the radius) may also break in this type of fall, depending on the position of the hand on landing. Pain and swelling in the wrist will usually cause a person with a scaphoid fracture to see a doctor.

Fractures of the scaphoid occur in people of all ages, including children. The injury often happens during sports activities or a motor vehicle accident. Men aged 20 to 30 years are most likely to experience this injury.

There are no specific risks or diseases that increase the chance of having a scaphoid fracture. Some studies have shown that use of wrist guards during activities like inline skating and snowboarding can decrease the chance of breaking a bone around the wrist.

Symptomsms

Unless the wrist is deformed, it might not be obvious that the scaphoid bone is broken. Sometimes, it might seem to be just a sprained wrist.

It is important to see a doctor if there is pain on the thumb side of the wrist that starts after a fall or accident and does not go away within a few days.

Scaphoid fractures usually cause pain in the base of the thumb, with swelling in the same area. The pain may be severe when the thumb or wrist is moved or the hand grips anything. In some cases, the pain is not severe, and may be mistaken for a sprain.

Diagnosis

This X-ray shows the location of the scaphoid and the surrounding bones of the hand and wrist.X-rays will be used to assess the bone. Sometimes, a broken scaphoid does not show up on an X-ray right away. If this is the case, the wrist might be put in a splint for a week or two. A new X-ray will be taken to see if the fracture will become visible. The splint should be worn during this waiting period, and heavy lifting should be avoided.

An MRI (magnetic resonance image) may be taken to visualize the bones and soft tissues. This sometimes shows a fracture of the scaphoid before it can be seen on an X-ray.

Treatment

Nonsurgical Treatment

Treatment of scaphoid fractures depends on the location of the break in the bone.

Fractures of the scaphoid at the end near the thumb usually heal in a matter of weeks with proper protection. This part of the bone has a good supply of blood. Most fractures here heal well when they are placed in a cast. The cast will usually be below the elbow. It may or may not include the thumb. The time frame for healing is best determined by X-rays or other imaging studies such as a computed tomography (CT) scan. These imaging studies are used to confirm that the bone has healed.

If the scaphoid is broken in the middle (waist) or at the part closer to the forearm (proximal pole), healing is more difficult. These areas of the scaphoid do not have very good blood supply. This makes it more difficult to heal. If a fracture of the scaphoid in these locations is treated in a cast, it will probably include the thumb. The cast will extend above the elbow.

Surgical Treatment

When the scaphoid is broken at the waist or proximal pole, surgery may be recommended. A screw or wire may be used to stabilize the scaphoid while the bone heals.

Where the incision is placed and how large it is depends on what part of the scaphoid is broken. The incision will be on the front or the back of the wrist. Sometimes the screw or wire can be placed in bone fragments with a small incision. In other cases, a larger incision is needed to ensure that the fragments of the scaphoid are aligned properly.

The X-ray on the left shows a scaphoid fracture treated with a screw. The screw was applied during surgery. The two fragments are held in alignment by the screw. The X-ray on the right was taken 4 months after surgery. The fracture of the scaphoid is healed.

After surgery, the wrist is usually placed in a cast. Even with surgery, fractures in this area can take a long time to heal. It is possible that the bone will not heal properly (nonunion) or that portions of the bone will die from a lack of a healthy blood supply (avascular necrosis).

If the scaphoid does not heal, the surgeon may consider using bone grafts to help the bone heal. The surgeon may order a magnetic resonance imaging (MRI) or CT scan to show more detail about position of the broken fragments of the scaphoid. These scans will help in planning the surgery. Many kinds of bone graft can be used. Bone grafts may be taken from a bone in the forearm or the pelvis, or it may be manufactured. Sometimes a special kind of bone graft with its own blood supply (vascularized graft) may be used.

Nonunions, Avascular Necrosis, and Arthritis

A bone that fails to heal is called a nonunion. Nonunions are more common after scaphoid fractures because blood supply to the scaphoid bone is poor. Blood supply to the bone is very important in its healing. Bones need blood to carry oxygen and nutrients to the site of the fracture.

When the scaphoid is broken, especially when the fragments have moved apart (displaced), the blood supply to those fragments may be disrupted. Sometimes, the blood supply to one of the fragments is so poor that the piece does not get enough nutrients and the cells in that fragment die. This is called avascular necrosis.

Over time, nonunion and avascular necrosis of the scaphoid can lead to arthritis of the wrist. Symptoms of arthritis in the wrist that results from scaphoid nonunion or avascular necrosis include:

Aching in the wrist

Decreased range of motion of the wrist

Pain with activities such as lifting or gripping

If X-rays show arthritis in the wrist as a result of an old break in the scaphoid, treatment focuses on improving the symptoms of arthritis. At first, this may include taking anti-inflammatory medicine and wearing a splint when the wrist is painful. Sometimes, the doctor may inject a steroid into the wrist to help to lessen wrist pain.

If this does not work, surgery may be recommended. Many types of operations can be performed for wrist arthritis.

Rehabilitation

A cast or splint will need to be worn while the scaphoid fracture is healing. This may be for as long as six months. During this period of healing,

Avoid heavy lifting, carrying, pushing, pulling or throwing with the injured arm

Do not participate in contact sports

Do not climb ladders or trees

Avoid activities with a risk of falling onto hand (for example, inline skating, jumping on a trampoline)

Some people have stiffness in the wrist after scaphoid fractures. This is more common when a cast was needed for a long time or when surgery was done through a long incision. Hand therapy may be recommended to help regain the motion and strength in the wrist. Even with therapy, some people do not recover the same motion and strength in their wrists that they had before the injury.

Research on the Horizon

Some orthopaedists are placing a screw in the scaphoid through a very small incision--about one-fourth to one-half inch. This may decrease the chances of long-term stiffness in the wrist by decreasing the time that a full-time cast needs to be worn. This is done using a special X-ray machine during surgery to help guide the placement of the screw. Some surgeons use this method even when the fragments of the scaphoid are out of place. By looking directly at the scaphoid with a tiny camera (an arthroscope), the surgeon can tell when the fragments are lined up.

There is a lot of research being done about the best way to treat fractures of the scaphoid that are not healing well. Some of this research looks at different types of bone graft, including vascularized grafts. New types of manufactured bone graft with special bone cell components to increase healing are now sometimes used

            
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