What should I do next if my wrist has not recovered completely after a fall?Orthopaedic Surgery Hand Surgery
A Fall On an OutStretched Hand (FOOSH) can cause significant injury to the wrist. These injuries can cause radial-sided (the side nearer the thumb) and/or ulnar-sided (the side nearer the little finger) wrist pain.
Causes of persistent radial-sided wrist pain after a FOOSH include:
- Scaphoid fracture or scaphoid non-union
- Fracture of the distal radius
- Scapholunate intercarpal ligament (SLIL) injury
- Thumb carpometacarpal joint injury including fractures or ligament injuries
- Tendinosis of the flexor carpi radialis (FCR) tendon
- Uncommonly, perilunate injury
Causes of persistent ulnar-sided wrist pain after a FOOSH include:
- Ulnar styloid, ulnar head or neck fractures
- Injury to the triangular fibrocartilaginous complex (TFCC)
- Lunotriquetral (LT) ligament injury
- Tendinosis of the extensor carpi ulnaris (ECU) or flexor carpi ulnaris (FCU) tendons
- Uncommonly, complex ligament injuries resulting in midcarpal instability
A hand & wrist specialist will evaluate your wrist through detailed history taking to determine the mechanism of injury. Meanwhile, clinical examination is used to determine the location of the injury and order investigations such as:
- X-rays with special views,
- CT scans or
- MRI scans.
The relevant treatment and management plan will then be compiled, tailoring to the patient's individual needs (a professional athlete will have a higher demand in function as compared to a sedentary retiree). The hand occupational therapist working with the hand & wrist surgeon will also be briefed on the post-treatment therapy protocol to meet these individual demands.
Fortunately, with early diagnosis and treatment, one can regain full function and strength in the hand and wrist without pain. One should consider seeking a consultation with a hand & wrist specialist to achieve this restoration and elimination of pain and prevent future complications such as secondary osteoarthritis and permanent joint deformity.
Sorry to hear about your wrist. Having had various injuries from falls of bikes and such, I know that they can be quite painful and sore for some time.
Sometimes, your initial X-ray might appear normal, but later images may demonstrate subtle breaks in bones such as a the scaphoid. The doctor that you spoke to is also correct in that you may have sustained a ligament injury, but there might also be an element of bone bruising (swelling in the bones themselves) - from experience with other patients, this can take several months to settle.
If you are having pain and limitation in movement, it may be worthwhile considering further clinical assessment. Depending on the assessment, it maybe that a repeat X-ray or ultrasound examination of the wrist is required. Treatments could include splinting, oral analgesia, prolotherapy injections (for ligament injuries) or surgical intervention for fractures.
I would suggest visiting a Sports/MSK physician in the first instance for a more thorough clinical assessment/further investigations, but if you happen to know a physiotherapist, this might also be an option.
Sorry to hear about your wrist and I hope things improve soon.
The wrist, while small and compact, is a complicated joint connecting 2 forearm bones with 9 small carpal bones to 5 hand bones. It is a complex system of articulating surfaces, supported by a network of restraining ligaments. It is a masterpiece of evolutionary development that has given humans unsurpassed manual dexterity and the ability to use tools.
On the clinical front, chronic wrist pain is often liken to chronic back pain; that is to say that even amongst doctors, the accurate diagnosis of wrist pain and its appropriate management remains challenging.
A visit to a specialist experienced in dealing with wrist injuries, and a detailed physical examination can put things into perspective very quickly, and decide which course of action is required.
During such a consultation, I would consider various key factors such as:
1. A detailed history of how the injury occurred
- Whether it was a high energy trauma (eg. A fall from a moving vehicle, mountain bike or from a flight of stairs) or a low energy trauma (like falling on a slippery bathroom floor, in your case).
- Presence of significant pain, swelling or bruising (internal bleeding suggestive of a fracture of bone or tears in the supporting soft tissues like ligaments) following the injury.
2. Background Medical History
- History of pre-existing injuries to the area (sometimes as long ago as childhood)
- Gender (eg. older post-menopausal women are more prone to fractures of the wrist even with lower energy trauma).
3. The actual site of the pain
Hand Surgeons generally categorise wrist pain into radial sided (thumb side) or ulnar sided (little finger side) to cone down on the suspected structures that could be damaged.
4. The type of wrist actions that cause the most discomfort.
As an example, if the pain is most acute during prono-supination activities (e.g. turning the wrist to twist a door knob, or turning a steering wheel) or ulnar deviation activities (like chopping vegetables) and the pain is located on the ulnar side of the wrist, then injuries such as the triangular fibrocartilage complex (TFCC) tear or radio-ulnar ligament tears are considered.
Whereas, if the pain were on the radial side of the wrist, and exacerbated by thumb extension and radial deviation activities (e.g. pulling up trousers or reaching behind to a bra strap), then a diagnosis such as DeQuervain’s Tendonitis could be considered.
And there are many other variations, permutations and possible diagnoses depending on the pattern of symptoms displayed.
5. Duration of your symptoms
I am often asked by patients how soon they should seek treatment for their injuries, and which injuries are likely to heal by themselves. As a very rough guide, I often offer this guide to patients – 3 days, 3 weeks or 3 months - How long have you had your pain and symptoms?
- Naturally, if pain and symptoms resolve in 3 days, these are usually not an issue.
- Pain that persists for more than 3 weeks certainly should receive medical attention, as these are clearly not healing well and are still problematic. These may require further imaging (e.g. X-rays or MRIs) or other diagnostic tests (e.g a keyhole wrist scope called Arthroscopy for direct visualisation of internal structures), and will need active intervention ranging from protection/immobilization (splinting or brace for example) to occupational and physical therapy. Early intervention in these cases can speed recovery and prevent it worsening.
- Pain that still persists for more than 3 months (usually affecting your ability to perform daily tasks or participate in sports), are often a result of established instability, and are usually very significant. These should definitely be attended to, and will most likely require an aggressive diagnostic process and intervention (sometimes surgery) to restore stability, minimise long-term damage, and restore function.
Considering all these factors and clinical clues, together with a thorough physical examination will allow your doctor to counsel you appropriately, identify any major injuries requiring urgent care, and advise the best way forward.
Often this may avoid you having excessive tests (such as the claustrophobic experience of an unnecessary MRI), and get you on the road to recovery, while avoiding the possible worsening of your condition.
Best regards and get well soon,
Dr. Jonathan Y. Lee
Consultant Surgeon, Hand Wrist and Reconstructive Microsurgery
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Yes, what Dr Dinesh said holds true. I think if you have persistent wrist pain despite a “normal” X-ray, we have to consider other potential problems.
1. Sometime very small minute cracks/ microfractures may not be seen on a standard X-ray. It may be necessary to do a more detailed radiological investigation - an MRI. This can pick up hairline fractures or bony oedema (swelling).
2. Injury to other hand/ carpal bones. Like the scaphoid bone. We usually order specific scaphoid X-ray views to look for a scaphoid fracture. A wrist X-ray may not be adequate.
3. Injury to soft tissue. Ligaments, tendons, TFCC (triangular fibro cartilage complex) injuries are also other potential injuries in the wrist.
If your symptoms are persistent, my advice would be to visit a doctor/Orthopaedic surgeon. He would then examine your hand/ wrist thoroughly, and determine what should next be done. This could be further supplemented with radiological investigations, medications, splinting etc
I hope you recover soon.
Dr Sean Ng
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