You might had wrist sprain at anytime in your life. It may be due to a sport or an accident. But the pain and immobility of the wrist surely has limited you from your daily tasks. The pain may had last even for several weeks. A wrist joint has a complex structure which help to move in full range. Even though it’s so common most of us didn’t know to identify and treat sprained wrist. Because of that pain may last longer period.
Sprained wrist typically shows signs of inflammation around the wrist joint. Those are redness, warmth, swelling, pain while moving. And the simple process of treatment is the PRICE protocol. Let’s discuss this further.
A little bit of Anatomy
Sprain is the stretching or tearing of one or more ligaments in a joint which can be caused by direct or indirect injury to affected joint. This happens in wrist joint when the wrist gets injured. Ligaments are fibrous tissues which bind the bones in a joint to keep it stable while maintaining the flexibility.
The wrist joint is made by distal ends of the long bones of forearm radius and ulna, eight carpal bones and proximal ends of five metacarpal bones. These bones are connected together by ligaments. The ligaments in the wrist joints are divided in to two as Intrinsic and extrinsic ligaments according to their location.
Intrinsic ligaments connect small carpal bones with each other. These include several proximal row ligaments, distal row ligaments and palmar midcarpal ligaments. Extrinsic ligaments connect carpal bones with metacarpal bones or with long bones in the forearm. These include several volar radiocarpal ligaments, volar ulnocarpal ligaments, and dorsal ligaments.
There are three grades according to severity of injury.
- GRADE 1 – Ligaments are stretched, microscopic tears can be there, but no major tears.
- GRADE 2 – Ligaments are partially torn. There can be some loss of function of the joint.
- GRADE 3 – Ligaments are fully torn or departed from the attachment to the bone.
Almost all cases of wrist sprain occur due to fall on outstretched hand (FOOSH). When someone is falling on ground, he/she reaches out with his/her hand unintentionally to break the fall. This causes wrist joint to bend backwards toward the forearm beyond its natural range of movement. This results in stretching and/or tearing of the ligaments of the joint.
This can happen in everyday activities, but more frequently this happens in sports like Baseball, Gymnastic, Skiing, Skating and Skateboarding. Road traffic accidents also can cause sprained wrist in drivers.
Other than this direct hit to the wrist joint and extreme pressure on wrist or twisting can give rise to sprained wrist.
- Pain – Pain can vary from mild intermittent aching pain to constant severe sharp pain. Pain usually subsides after several days, but activities like lifting weight and wrist twisting activities can give rise to pain until complete recovery occurs.
- Swelling – This is due to the inflammatory reaction and fluid collection in the joint space which occurs due to the injury. Usually the amount of swelling corresponds to the severity of the injury.
- Reduced movements – Joint stiffness occurs due to the inflammation and muscle spasm after the injury. Bending the wrist backwards extension and side to side movements are especially reduced.
- Weakness of the joint – You might feel the strength of the joint is reduced after the injury This is usually after moderate to severe injury to the joint.
Other symptoms are,
- Bruising – This is due to collection of blood in joint space and damage to the superficial blood vessels. The color of bruises may change with time after the injury
- Warmth – This is due to the inflammatory process going on after the injury and increased blood floor to the injured area.
- Numbness – Numbness of fingers can occur if one or more nerves are damaged by dislocated bone or directly from the impact.
- Feeling of tearing in the wrist – This happens in the time of the injury and with the movements of the injured wrist joint.
The duration of these symptoms depends on the severity of the injury and proper treatment.
Diagnosis of sprained wrist by a doctor is made with proper clinical history, Clinical examination and relevant investigations.
The doctor will ask about the pre-existing diseases, previous surgeries and previous injuries to the joint. The time and the nature of the injury and the severity of the symptoms will be inquired.
Doctor will try to see signs of injury like swelling, bruising, site of tenderness and loss of range of movements. He will see other injuries of hand, arm and fingers which might have occurred due to the trauma. Also the doctor will examine the sensations of the hand and the fingers and the presence of blood supply by assessing the pulse.
Investigations to diagnose sprained wrist are almost imaging modalities.
- X ray is the most commonly used and the primary investigation in a case of sprained wrist. Although X ray cannot visualize ligaments, it can suggest ligament injury if wrist bones are not in correct position, presence of gaps, overlapping and rotation of carpal bones. X ray also is helpful to exclude broken bones.
- Ultrasound scan is helpful in detecting joint and ligament inflammation, tears and damages to other structure like blood vessels and nerves.
- Magnetic Resonance Imaging (MRI) is useful to detect injuries to the soft tissues including ligaments, nerves and blood vessels.
Other than these non-invasive investigations; invasive investigations may be recommended by an orthopedic or hand surgeon for further evaluation if necessary. Those invasive investigations include Magnetic resonance arthrography (MRA), Multiple detector computed tomography (MDCT) arthrography and Wrist arthroscopy.
In the management it is important to make the diagnosis correctly because fractures of the bones of the wrist joint can happen due to the injury and they also present as the same way of the sprain. Most of the symptoms of a fracture are common to sprain, but in a fracture sometimes additional signs may be evident. The wrist joint may be deformed or the fractured bone may come out the skin. But these additional signs may not be presence in all the times of fractures. So, proper clinical evaluation and the investigations help to exclude a fracture. It is very important to exclude a fracture before diagnosing a sprain because missed and untreated fractures of wrist joint can result in worse outcome later.
In an injury the first aid should be given. It is known as the PRICE protocol.
- P > Protection – Move the injured person away from the danger area. Protect the wrist joint using a protective measure like a splint if possible.
- R > Rest – It is important to allow the joint to heal by resting the joint. Rest the injured wrist until the symptoms improve. It may take few days to few weeks. Most experts recommend “relative rest” that not too much. It says healing process is improved by gentle, pain free, slow movements. So complete immobility of the joint is not advised.
- I > Ice – Applying ice packs to the affected join immediately after the injury helps to reduce the pain and swelling. This should be done for 10 – 15 minutes at a time in every 1 – 2 hours for 1 – 3 days or until pain improves. The most convenient method is using a plastic bag with crushed ice and placing it over a paper towel. But some skins are sensitive and allergic to cold exposure. So it need to be concerned.
- C > Compression – Helps to keep the swelling minimum and provide a support. It can be done using an elastic bandage. It’s better not to tighten the bandage. If your hand cause numbness, tingling or color change quickly loosen the bandage. And it’s advisable to loosen the bandage at night and reapply in the morning.
- E > Elevation – By keeping the injured wrist above the level of the heart the blood flow to the injured site is reduced. So the inflammatory process is controlled and the swelling is reduced. But the patient must be comfortable with this. If the pain gets worse with elevation, it should be avoided.
PRICE protocol is a very effective method in trauma management. It shows better results than cryotherapy which is application of ice, a mostly practiced method earlier.
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and Aspirin can be used to reduce the pain and the swelling. But if the symptoms persist after about 48 hours, further evaluation by a doctor is recommended. Due to adverse effects of these drugs like bleeding and gastric ulceration; they should be taken only after prescribed by a doctor.
Moderate sprains can be managed with non-surgical treatments. The injured joint is kept immobilized using a wrist splint for about a week. Because immobilization causes joint stiffness it is important to do stretching exercises according to the doctor’s recommendation.
Severe sprains need surgical management to reconstruct the torn or avulsed ligament. Surgical options include reconnecting the ligament to the bone or using tendon graft to reconstruct the injured ligament. The surgeon discusses the possible options with the patient before the surgery and the patient can decide the way of treatment. However rehabilitation of the joint is done after the surgery to strengthen wrist and restore range of motion. Depending on the severity the time for the full recovery can vary from eight weeks to one year.
You should be careful while walking or running especially in a slippery ground because most of the cases of wrist sprain are due to falls. Players who are vulnerable to get wrist injuries can reduce the chance of getting injured by using wrist guards or protective tapes. Elders are more prone to injuries because they tend to fall. So it’s better use good light source, avoid wet floors.
Dr. Aruna Padmasiri ( MBBS )
He is a medical graduate from Faculty of Medicine – University of Peradeniya, currently working as a temporary lecturer in Faculty of Allied Health Sciences – University of Peradeniya. He is a medical researcher and a passionate writer.