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Injury of the Wrist Ligaments

    Injury of the Wrist Ligaments

    There are three main ligaments of the wrist. These are the SCAPHO-LUNATE LIGAMENT, the LUNO-TRIQUETRAL LIGAMENT and the TRIANGULAR FIBROCARTILAGE (TFCC).        

    The scapho-lunate ligament is a key ligament on the radial side of the wrist (thumb side).  Injury of this ligament is usually the result of a fall onto the outstretched hand and causes RADIAL WRIST PAIN.  Often the pain of the initial injury resolves and it seems the injury has healed.  Unfortunately the ligament has not healed and the wrist bones begin to shift out of place leading to early onset of arthritis.  By the time the wrist pain returns the arthritis is advanced and treatment options may be limited.
     
    The luno-triquetral ligament is on the ulnar side (pinky finger side) of the wrist and causes ULNAR WRIST PAIN.  Injury of this ligament can also cause the wrist bones to shift out of position but rarely causes arthritic changes.
     
    The triangular fibrocartilage is a combination of ligament and cartilage on the ulnar side of the wrist.  It can be torn in an acute injury such as a fall or worn out by repetitive activity.  Injuries of the Triangular fibrocatilage are the most common cause of ULNAR WRIST PAIN.

    What is it?

    The diagram below shows the location of these three ligaments.

     wrist.jpg
    Figure 1:  The wrist is a complex joint made up of many bones and ligaments, which hold the bones together.


    © 2011 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee

    Treatment

    Diagnosis is made by a combination of history, examination by the physician and MRI.  MRI studies are unfortunately only 80% accurate for ligament injuries in the wrist.  If the examination suggests an injury and the MRI fails to show an injury an ARTHROSCOPY may be needed.  Arthroscopy is a surgical procedure requiring regional (putting the arm to sleep) or general anesthesia.  The arthroscope is a small tube fitted with a lens and connected to a television monitor that is placed into the wrist through a small incision allowing the surgeon to look directly at the ligaments.  Some injuries can be treated through the arthroscope, others may require a larger procedure.

    Nerve Lacerations and Injuries

    Nerve lacerations can occur with lacerations of the hand or arm.  Most lacerations occur in the fingers and result in laceration of the DIGITAL NERVES.  These injuries produce numbness in the injured digit.  In the hand or forearm the MEDIAN NERVE, the ULNAR NERVE or the RADIAL NERVE  may be injured.  These injuries produce numbness and loss of muscle function.

    How is it treated

    Nerve lacerations can be repaired using MICROSURGERY.   Under a microscope the outer layer of the nerve is sutured together allowing the individual nerve fibers to grow back across the nerves pathway.  Unfortunately nerves grow back slowly and it may take many months for the nerve to recover. 

    Osteoarthritis of the thumb

    The most common location for arthritis in the hand is the base of the thumb.  Also called BASAL JOINT ARTHRITIS  or CMC ARHTRITIS it causes WRIST PAIN  and /or thumb pain at the base of the thumb.  The pain can be a dull aching sensation or sudden sharp pain with use of the thumb.   Symptoms are often brought on by activities such as opening jars or turning a key.

    What is it?

    The joint between the thumb metacarpal and the trapezium is the connection between the thumb and the wrist.  Over time the cartilage of the joint wears out.  As it does so the joint becomes swollen and painful.  As the process continues the ligaments holding the joint together become loose and the thumb metacarpal can begin to slip resulting in the typical “shoulder deformity” at the base of the thumb.

    Treatment options

    Treatment for the arthritis includes avoiding strenuous grasping activities.  This can include simple home aids including can openers with large handles and aids for opening jars.  Anti-inflammatory medications (NSAIDS) can help relieve the pain.  Topical agents such as asperin cream, ibuprofen cream, Capsacin C cream may be of some benefit.  At this time evidence for chondroitin sulfate, glucosamine and other supplements is lacking. 

    Steroid injections can produce short term pain relief, usually 2 or 3 months.  Unlike some of the larger joints there are no approved cartilage injections and no technology for replacing the cartilage in the joint.

    Surgical options include replacing the joint.  Numerous artificial implants for joint replacement exist but seem to develop problems over time.  Soft tissue interpositional arthroplasty has been successfully used for 60 years.  This involves removing the trapezium bone and replacing it with a tendon from the forearm of the patient.  The procedure provides most patients with excellent pain reduction while preserving motion and strength.

    Scaphoid Fracture

    The scaphoid is the most commonly fractured bone in the wrist.  Scaphoid fractures are usually the result of a fall onto the out-stretched hand and present as PAIN IN THE WRIST at the base of the thumb.   Often patients do not perceive the injury as being severe or the pain as being severe enough to represent a fracture. Only 80% 0f scaphoid fractures are detectable on x-ray and an MRI may be required to confirm the fracture. 

    Without treatment many times the acute pain of the injury resolves with the time but the fracture persists and over time causes irreversible arthritic changes of the wrist.

    Treatment

    If there is pain or tenderness at the base of the thumb after a fall a fracture of the scaphoid should be suspected.  If initial x-rays do not show a fracture a MRI can be obtained or a cast may be applied for 2 weeks and then the wrist re-examined.  If the pain has resolved completely then a fracture is very unlikely.  If pain persists then casting for 8 weeks or an MRI need to be considered.

    Non-displaced fractures of the scaphoid (with certain exceptions) will heal with casting about 95% of the time.  If the fracture is displaced, then surgery is required.  Some surgeons advocate surgery for all scaphoid fractures to shorten the time in a cast and reduce the chance of the fracture not healing.  Even with surgery the scaphoid may fail to heal and require additional procedures.