Wrist Sprain

Stretch or tear of one or more wrist ligaments, most often from a fall on the outstretched hand, forced hyperextension, or twisting. The injury ranges from microscopic fibre damage (grade 1) through partial tear (grade 2) to complete rupture (grade 3).

• The ligaments at risk are the dorsal and volar radiocarpal ligaments, the scapholunate interosseous ligament (the commonest important intrinsic ligament injury), the lunotriquetral ligament, the ulnocarpal complex, and the triangular fibrocartilage complex.
• It is a diagnosis of exclusion, because a missed scaphoid fracture or carpal ligament instability causes chronic pain, non-union, avascular necrosis and early osteoarthritis. About 10 to 20% of patients with a clinical scaphoid injury and a negative first X-ray have an occult fracture.
• Common in athletes (gymnasts, skaters, snowboarders, ball sports), cyclists, and in older adults falling on ice or stairs. Low bone density shifts the common injury to distal radius fracture.

• Wrist pain and swelling after injury, worse on loading and movement, with bruising, stiffness, reduced grip strength and tenderness over the injured ligament.
• Scapholunate injury: dorsal wrist pain just distal to the radial tubercle, pain on loading, and a positive scaphoid shift test, with a click.
• Triangular fibrocartilage complex injury: ulnar sided pain, clicking, and pain on ulnar deviation and forearm rotation.
• Red flags for fracture or instability: tenderness in the anatomical snuffbox, pain on axial loading of the thumb, tenderness over the scaphoid tubercle, deformity, severe swelling, numbness, inability to grip, and loss of rotation.
• Differential diagnosis: scaphoid fracture, distal radius fracture, hamate hook or triquetral fracture, perilunate dislocation, carpal instability, triangular fibrocartilage tear, De Quervain tenosynovitis, ganglion, avascular necrosis of the lunate or scaphoid, osteoarthritis, tendon rupture, and infection.
• Complications: chronic wrist pain and instability, post-traumatic osteoarthritis (scapholunate advanced collapse), stiffness, chronic regional pain syndrome, and missed fracture complications.

• Examination: inspect for swelling and deformity, palpate bony landmarks (snuffbox, scaphoid tubercle, distal radius, ulnar styloid, hamate hook), test range of movement, grip, and neurovascular status.
• X-ray: posteroanterior, lateral and scaphoid (ulnar deviation) views. Look for fracture, a scapholunate gap above 3 mm, and altered carpal alignment.
• If the clinical suspicion for scaphoid fracture persists with normal X-rays: immobilise in a thumb spica splint and repeat X-ray at 10 to 14 days, or arrange MRI (best) or CT within a few days.
• Stress views, ultrasound, MRI or MR arthrography for suspected ligament or triangular fibrocartilage tears. Wrist arthroscopy is the definitive test for persistent pain after 6 weeks of treatment.
• Examine the neck, elbow and the opposite wrist.

• Early care for the first 48 to 72 hours: protect the wrist in a removable splint or wrist brace, apply ice for 10 to 15 minutes 3 times daily, elevate the hand, and use compression for swelling.
• Analgesia: paracetamol 1 g orally 6 hourly, with ibuprofen 400 mg orally 8 hourly with food (or naproxen 500 mg 12 hourly) for up to 1 to 2 weeks if no contraindication. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily.
• Grade 1 and 2 sprains: splint for 1 to 2 weeks (up to 3 to 4 weeks for grade 2), with early gentle active movement as pain allows, then progressive range of motion, grip strengthening and proprioception exercises, usually with 4 to 8 weeks of recovery. Return to sport when pain free with full range and at least 90% grip strength compared with the other side. Tape or brace for sport for 6 to 12 weeks.
• Suspected scaphoid fracture: thumb spica splint or cast until fracture is confirmed or excluded. Undisplaced fractures need a cast for 6 to 12 weeks (waist fractures about 8 to 12 weeks, proximal pole longer), and displaced fractures, proximal pole fractures, or non-union need surgical fixation with a headless compression screw.
• Grade 3 sprains and ligament ruptures (scapholunate, lunotriquetral): cast for 4 to 6 weeks, then urgent hand surgery review. Acute repair with ligament reattachment or reconstruction within 3 to 6 weeks gives the best result. Later options include capsulodesis, tendon reconstruction, partial wrist fusion, proximal row carpectomy and wrist fusion for established arthritis.
• Triangular fibrocartilage tear: immobilise 4 to 6 weeks in a long arm or wrist splint, followed by therapy. Arthroscopic debridement or repair for persistent pain after 3 months.
• Corticosteroid injection is occasionally used for persistent synovitis (triamcinolone acetonide 10 to 20 mg with lidocaine 1% 1 to 2 mL), though it risks masking an unresolved ligament lesion.
• Special groups:
  • Children and adolescents: the growth plate is weaker than the ligament, so a "sprain" is often a physeal fracture. X-ray and splint, and refer if the physis is tender.
  • Elderly: distal radius fracture is more probable, and falls and bone health need evaluation.
  • Athletes: tape or brace for sport and graded return.
  • Pregnancy: splint, paracetamol, and ice. Avoid NSAIDs after 20 weeks.
• Follow up: review at 1 to 2 weeks to reassess and repeat imaging if indicated, and at 6 weeks for persisting pain. Refer to hand surgery or orthopaedics for persistent pain beyond 6 weeks, widened scapholunate gap, instability, missed fracture, or non-union.