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The Wrist
30April/2015

The Wrist

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The Wrist

Wrist injuries make up approximately a quarter of all general sports injuries1. The high prevalence of wrist injuries relates to the requirement of wrist involvement in most sporting activities, for example, holding a barbell during bench press, hanging from a chin-up bar and, holding a tennis racquet. All these activities and many more use the wrist as a means of performing a particular action.

By Dr. Matthew Davidson B.Sc., M.Chiro. Director, Hope Island Chiropractic Centre Certified Active Release Technique Provider Member, Chiropractic Association of Australia Member, Sports Chiropractic Australia

 

Anatomy and basic biomechanics 

The wrist comprises eight carpal bones and their corresponding joints with one another, as well as the distal radius and ulna bones of the forearm, and metacarpals. The wrist can move in a number of directions due to the orientation of these eight bones. These bones collectively are the hamate, scaphoid, triquetrum, trapezoid, trapezium, lunate, pisiform and the capitate2. These bones are arranged in rows proximal and distal (distal meaning further toward the fingers).

The proximal row, closest to the elbow, is made up of the scaphoid, lunate, triquetrum and pisiform. Each of the carpal bones has a ligamentous attachment to the adjacent bone within its row. All outside wrist ligaments are thickenings of the joint capsule, which emphasises the complexity of providing stability while at the same time allowing free movement of the wrist2.

Strengthening

The wrist can be strengthened in a number of ways, from using weights, isometric exercises to therabands. Your standard wrist curls with the palm up and palm down are the most popular exercises. These can be done with a
barbell or dumbbell. Also, squeezing a tennis ball or squeezing hand grips are another way to strengthen the wrists - with high reps being the key. Radial deviation is another often forgotten option for strengthening the wrist. Begin this exercise with a resistance band around your fingers, your thumb facing up, or using a hammer or one-sided dumbbell
with the thumb-side up. Your elbow should be at your side and bent to 90 degrees, your forearm supported by your other hand. Slowly curl your wrist up against the resistance band, dumbbell or hammer, tightening your forearm muscles. Perform three sets of 10 repetitions as far as possible and comfortable without pain.

WHAT CAN GO WRONG?

Triangular Fibrocartilage Injury: Falling on an outstretched hand or a compression injury to the wrist from a heavy bench press can cause damage to the fibrocartilage structure at the distal ulna. The person complains of pain on the ulna side of the wrist. The triangular fibrocartilage or TFC is injured through traumatic avulsions or degeneration. The diagnosis of a TFC tear is usually by arthrogram or an MRI. Management is initially by immobilisation of the wrist in a
neutral position for 4-6 weeks. Failure to resolve requires arthroscopic or full open surgery with recovery anywhere
from six to 18 months3.

DeQuervains Tenosynovitis: DeQuervains Tenosynovitis is a condition that affects the abductor pollicus longus and the extensor pollicus brevis muscles. It is usually caused by repetitive microtrauma. The person usually presents with radial-sided wrist pain, with a history of repetitive gripping with ulnar deviation of the hand and wrist or continuous use of the thumb. Treatment usually involves nonsteroidal anti-inflammatories, ice and rest from the inciting activity. Graston technique and Active Release Techniques® are usually successful at treating this condition. Failure of conservative treatment after four weeks requires immobilisation with a brace for a further three weeks3.

Intersection syndrome: A syndrome that can affect weightlifters, tennis players and office works is intersection syndrome. The person usually complains of pain and "clicking" about four centimetres above the back of the wrist more
toward the radius bone. The patient is usually an athlete who has a history of repetitive flexion and extension movements of the wrist associated with their sport. Again, treatment usually involves non-steroidal antiinflammatories, ice and rest from the inciting activity. Graston technique and Active Release Techniques® are usually successful at treating this condition. If conservative management is unsuccessful, bracing for 2 -3 weeks may be necessary to enforce a rest period3.

Carpal Tunnel Syndrome: Carpal tunnel syndrome affects a large range of individuals, from mechanics, office workers, and generally people who work with their hands. Repetitive prolonged  flexion and extension at the wrist is a common cause. Other causes include pregnancy (water retention), rheumatoid arthritis, ganglions, fractures and dislocations. By far the most common is the use of a computer and computer mouse for extended periods of time3,4. The patient usually
presents with a history of numbness and tingling in the thumb, index finger, middle finger and half of the ring finger. This may either be intermittent, or constant depending on severity and can be diagnostically present at night when the person is trying to sleep3,4. In later stages, if severity increases, weakness can occur and is noted by the person
becoming clumsy with items such as putting a key in a door, or opening jars and using tools. Conservative treatment
may include physiotherapy, chiropractic manipulation/mobilisation of the joint, Active Release Techniques®, ultrasound, the use of vitamin B6, and splinting. Tendon gliding exercises may also be given by the practitioner. Failure of conservative management includes orthopaedic surgery where they cut the transverse carpal ligament, reducing pressure on the median nerve as it pierces the carpal tunnel.3,4

Tunnel of Guyon: Most people are familiar with the term carpal tunnel but rarely have people heard of the tunnel of Guyon. The tunnel is formed by the groove between the pisiform bone and the hook that is present on the hamate bone.
The patient presents to their health care provider with numbness and tingling in their fourth and fifth fingers. This is a common compression injury in cyclists, and ironman distance triathletes due to compression on handle bars or tri bars.3
Treatment usually involves modification of activity, using some form of padding to reduce pressure on the area. Active Release Techniques® tunnel of Guyon protocols are usually successful at treating this condition. If a neural deficit occurs at the ulnar nerve (signs of ulnar nerve damage) referral to a specialist is usually necessary. This can be either an orthopaedic or a neurosurgeon.

Kienbock's disease: Kienbock's disease affects the lunate bone of the wrist. It occurs due to repetitive microtrauma or from a stress fracture to the bone. What generally happens is there is compromise of the blood supply to the lunate bone and the bone begins to die. This is called avascular necrosis.3 The patient usually complains of stiffness and pain
at the wrist with no history of trauma. Treatment of this condition usually requires cast mobilisation for 8-10 weeks to help re-establish the blood supply. When this fails, surgery with an orthopaedic specialist to decompress the area is essential to prevent collapse.

Scaphoid Fracture: The scaphoid bone can be fractured by a fall on an outstretched hand. This can occur commonly during snow skiing or snowboarding, and particularly in older individuals more prone to falls. The patient will present
with a pain around the base of the thumb usually in an acute situation where it has just occurred or up to 3 months
later. Due to the vascular blood supply only coming into the bone at one end, this bone has a 20% risk of not healing with a consequence of avascular necrosis or bone death due to lack of blood supply.3 Treatment of this fracture is an immobilisation cast that includes the wrist and thumb, provided the fracture is not displaced (misaligned). This process is an 8-12 week process and failure to heal requires intervention from an orthopaedic specialist.

References
1. Hyde TE, Gengenbach MS. Conservative Management of Sports Injuries. 2nd Edition. USA: Jones and Bartlett;2007.
2. Millar, M.D, and Thompson, S.R. DeLee & Drez's Orthopaedic Sports Medicine. Principles and Practice. 4th Edition Vol 1, USA: 2015.
3. Souza, TA. Differential Diagnosis and Management For the Chiropractor: Protocols and Algorithms. 4th Edition. USA: Jones and Bartlett; 2009.
4. Barsten, G., McCarthy, K. Conservative Chiropractic Approaches to Carpal Tunnel Syndrome. Top Clin Chiropr 1999: 6(4): 62-72.

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