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Wrist injuries in the gymnast are due to the transformation of the upper extremity into a weight bearing entity. Both acute and chronic disorders occur and are difficult to manage in these athletes because of the intensity of training and competition. Treatment is dependent on the injury as well as the expectations of the patient, coach, and family--a situation that at times may alter the usual management program.
The wrist is one of the most complex joints of the body. Wrist injuries are quite common, yet improper diagnosis of ligamentous injuries as simply 'sprains' often occurs. Understanding the functional anatomy and mechanics of the wrist is extremely important in appreciating the spectrum of injuries that occur there. A review of the analysis and detection of potential injuries is provided.
Patients with wrist injuries often present to primary care physicians. Many times, mild clinical injury involves significant damage to carpal bones and soft tissue elements. The long-term outcome of these injuries depends on prompt diagnosis and appropriate therapy. Familiarity with the functional anatomy and physical examination of the wrist, accompanied by radiologic evaluation, may aid the physician in differentiating simple sprains from potentially debilitating wrist injuries.
Hand and wrist injuries are common among athletes. Although the hand does not often bear weight and these injuries do not always sideline an athlete, careful attention must be paid when treating injuries of the hand and wrist. Rehabilitation is given for common injuries of the hand and wrist, including exercises and protective splints and braces. Details on how to fabricate a playing cast for athletes are also discussed.
Epidemiological data on wrist injuries in a population can be used for planning by applying them to criteria of care and thus deriving estimates of needs for care according to currently desirable standards. In a one-year study all patients 15 years or older with acute wrist trauma and treated at the emergency room were examined according to an algorithm until a diagnosis was established. The overall incidence of wrist trauma was 69 per 10,000 inhabitants per year. Incidence of wrist trauma requiring radiographic examination was 58 per 10,000 per year. The incidence of fractures of the distal radius was 27 per 10,000 per year (males, 16 per 10,000, females, 37 per 10,000 per year). In order to evaluate the completeness (defined as the proportion of patients with wrist injuries seen at the emergency room out of all patients with wrist injuries in the catchment area) of the hospital based data an analysis was performed using data from a population based study. A completeness rate of 0.56 (95% confidence interval 0.31-0.78) was found. A radiographic examination had been performed in all patients reporting a fracture, justifying the use of fractures as an incidence measure when comparing groups of patients with a wrist trauma.
Wrist injury is common and may significantly impair the overall function of the upper extremity unless properly managed. Fractures of the distal radius are particularly common among the aging population, accounting for nearly 1/6 of all fractures, often as a result of increased longevity with the subsequent underlying osteoporosis. New diagnostic tools, including wrist arthroscopy, magnetic resonance imaging, or computed tomography, are increasingly available in developed countries allowing accurate recognition and more effective resolution of lesions which would be otherwise missed using conventional methods. First world treatment standards, however, can scarcely be introduced in developing countries owing to, among other factors, different prevalence of problems, and the lack of resource to implement most modern technologies. If any program needs to be introduced that meets the demands of wrist injury management in the third world, aside from a better regionalisation of trauma care, it should emphasise adequate training of professionals in the use of more cost effective techniques of fracture reduction and stabilisation, applicable everywhere, with the minimum possible morbidity.
Hand and wrist injuries in children have steadily increased over the past decade as athletic participation by both boys and girls at an earlier age has been encouraged by parents and coaches. This article will cover the spectrum of hand and wrist injuries in children including ligamentous, tendinous, and bony injuries, as well as the increasing incidence of stress-related injuries in the upper extremities.
BACKGROUND: The benefits of sport are well recognized, but many activities carry a sport-specific injury risk. Snowboarding has become an increasingly popular winter sport in Austria in recent years, with an estimated 900,000 participants annually. Roughly 6,000 of these suffer from injury and up to 2,000 sustain moderate or severe wrist injuries (mainly fractures of the distal radius and epiphysiolyses). METHODS: We conducted a prospective, randomized, controlled trial to test the protective effect of a wrist protector, which differs in position, stiffness, length, and fixation from conventional protectors. Seven hundred twenty-one snowboarders were randomized into two groups. The risk factors and the injuries that occurred were registered by questionnaires and, in case of medical treatment, by medical reports. Time until injury (in half-days) was compared by the proportional hazards model. RESULTS: Nine severe wrist injuries were sustained in the unprotected control group and only one in the protected group (hazard ratio, 0.13; 95% confidence limits, 0.02, 1.04). Twelve snowboarders of the protector group secretly discarded their protectors during the trial (including the snowboarder who suffered the one and only severe wrist injury of this group). A per-protocol analysis was therefore performed, which demonstrated a more accentuated result (p = 0.003). There was no statistically significant increase in the incidence of other types of injury. Experience was shown to be a further protective factor. CONCLUSION: We recommend the use of a wrist protector, particularly for novices participating in this sport. As in other domains of medicine, preventive measures can decrease morbidity also in terms of sport injuries.
Wrist arthroscopy was done for one hundred nine patients with chronic wrist pain, averaging 22.8 months in duration. History regarding mechanism of injury, painful crepitus, pain with activity or at rest, localization of tenderness, visible swelling, and instability with examination was compared with arthroscopic findings of ligament damage, articular cartilage damage, and synovitis. Both pain at rest and swelling correlated significantly with synovitis. Tenderness did not correlate with specific ligament injury. Wrist ligament injuries and/or cartilage damage were noted in 96.3% of these wrists. Ligament injuries were frequently multiple, averaging 2.6 ligament injuries per wrist. No significant association was found between the presence of chondromalacia, synovitis, or specific ligament tears and the mechanism of injury, duration of symptoms, presence of clicking, or pain with activity.
OBJECTIVE: Fractures around the wrist are common in pediatric patients presenting to the emergency department (ED). This pilot study was aimed at identifying clinical variables that are most likely to be associated with a fracture. METHODS: This was a prospective blinded case series of patients 3-18 years of age presenting with an acute (<3 days) wrist injury, without obvious deformity. A team of five investigators blinded to the eventual radiographic findings evaluated patients. Physical examination variables included range of motion (ROM), site of maximal tenderness, and functional deficit. The latter was determined objectively, by recording any difference in grip strength between the injured and noninjured hands. Diagnostic radiographs were obtained for all patients. Univariate analysis using Wilks' log likelihood ratio test was performed to identify clinical variables associated with confirmed wrist fractures. Sample size was determined based on the ability to detect a difference of 15 degrees in the ROM variables, 20% point differences in grip strength, and 30% proportion differences in categorical variables using a power of 0.8 and a two-tailed of 0.05. RESULTS: The ROMs were not significantly different between the fracture (Fx) and nonfracture (NFx) group. There was significant change in the grip strength between the Fx and NFx groups (t = 3.3, p = 0.0019). Tenderness over the distal radius was also associated with a greater likelihood of a fracture (G(2) = 5.0, p = 0.02). Sensitivity of clinical prediction was found to be 79%, and specificity was 63%. The false-negative rate was 0.21 and the false-positive rate was 0.37, while the positive predictive value was found to be 0.68 and negative predictive value 0.75. CONCLUSIONS: Distal radius point tenderness and a 20% or more decrease in grip strength were predictive of fractures.
A system has been developed for the registration and combined display of the X-ray image and isotope bone scan. This system has been evaluated by prospectively studying 23 patients who were referred for suspected injury of the wrist. The registration system has an inherent precision for registration of about 1 mm. When patient positioning errors are included, this increases to about 4 mm. Two observers evaluated the sets of images prior to registration and after registration and combined display. They judged that in 16 out of 17 cases judged abnormal (observer 1) and 12 out of 18 cases judged abnormal (observer 2), the registration technique improved localization of a lesion. One case was rejected as registration was not possible due to incorrect positioning of the hand.
This article addresses the prevalence of various hand and wrist injuries in a variety of sports. Multiple resources and references have been utilized to draw a perception of the types of injuries and the sports with which they are most commonly associated. It is hoped that this article will give the physician a greater understanding of the types of hand and wrist injuries they may expect to encounter in athletes.
Fifty-two consecutive patients with acute scaphoid fractures were treated by closed reduction and percutaneous screw fixation. In addition, all underwent a wrist arthrogram and 22 patients also underwent a wrist arthroscopy. Eighteen patients (34%) had an associated carpal ligament injury (four scapholunate ligament, eight lunotriquetral ligament, two combined, three TFCC and one minor leak from the distal carpal row). These patients had worse Mayo wrist scores (no ligament injury median score=95: ligament injury median score=85) at a mean final follow-up of 61 weeks. We advocate that scaphoid fractures with associated carpal ligament injuries should be defined as a combined wrist injury.
The general principles of judging wrist injuries are discussed. Carefully made standard views will provide recognizable projections of carpal bones in order to judge abnormal positions. Additional views, conventional tomography and CT scans are, in some instances, necessary to diagnose fractures. For ligamentous damage resulting in carpal instability, fluoroscopy of the wrist and/or an arthrogram should be obtained. Examples of difficult pathology are shown and variations or more or less borderline pathology as coincidental findings are discussed. The main pitfalls are: wrong diagnosis made on inappropriately taken radiographs; misinterpretation of carpal bone relationships; and overestimation of some arthrographically found abnormalities.
A kinematic analysis of a progressive, ulnar-sided wrist injury was performed using a cadaver model to study the static and dynamic stabilizers of the distal radioulnar joint with a 3-dimensional motion tracking system. Anatomically based loads were applied to achieve pronation and supination and then the specimens were evaluated after serial transection of the triangular fibrocartilage, the extensor carpi ulnaris sheath, and the ulnocarpal ligaments. Statistically significant increases in translation of the radius relative to the ulna occurred with sectioning of both the triangular fibrocartilage proper and the extensor carpi ulnaris tendon sheath. No significant change in position of the forearm could be appreciated with subsequent sectioning of the ulnocarpal ligaments. Our observations support the idea that the ulnocarpal ligaments do not need to be surgically reconstructed when there are serious injuries to the triangular fibrocartilage complex.
In 1999, a study was done examining the injury risk and pattern in first time snowboarders versus first time skiers. Although these rates were similar, snowboarders sustained a higher percentage of injuries to the upper extremity, particularly wrist sprains and fractures. As an extension of this previous study, the protective value during snowboarding of an off-the-shelf wrist guard originally designed for inline skating was tested. Two thousand three hundred fifty-five first time snowboarders were evaluated at one northeastern ski resort. Five hundred fifty-one snowboarders wore wrist guards and a control group of more than 1800 snowboarders did not wear wrist guards. Forty wrist injuries were sustained in the control group (2.2%), compared with no injuries (0%) in the snowboarders who wore wrist guards. Importantly, there was no increase in more proximal or distal upper extremity injuries in the group of snowboarders who wore wrist guards.
The aim of the study was to assess acute-phase multidetector CT (MDCT) findings in wrist injuries. We retrieved all emergency room MDCT requests processed in the period from August 2000 to May 2003. All patients with a wrist injury who underwent MDCT initially were included. Imaging studies were evaluated in relation to injury mechanism, fracture location, and fracture type. A total of 6422 MDCT examinations were performed during this 34-month period, and 38 patients (24 male, 14 female, age range 21-73 years, mean age 40 years) met the inclusion criteria. MDCT revealed 56 fractures and 7 dislocations in 29 patients. In 9 patients (24%) MDCT findings were normal. Eleven patients (29%) underwent surgical procedures. The main injury mechanism was a fall (58%). In 33 cases the primary radiograph was available. Compared to primary radiographs, MDCT revealed 9 occult fractures, mainly in small carpal bones. In 14 cases a suspected fracture (of the scaphoid in 7 cases) was ruled out by MDCT. Due to high-quality two-dimensional reformatting, MDCT examinations were not dependent on the wrist's position in the CT gantry. In the comparison with radiography, MDCT detected occult fractures and ruled out suspected fractures, both mainly in the small carpal bones. High-quality two-dimensional reformats gave significant information about the fracture anatomy. MDCT provides fast and valuable information in assessing complex wrist fractures or when the primary radiograph is equivocal.