Wrist Ligament Injuries
Contrary to the common perception, ligamentous injuries of the wrist (similar to other joints in the body) are often more difficult to treat successfully then bone fractures. Damage to few particularly important ligaments, may have devastating consequences for the long term function of the hand, especially if not recognized early.
Facts and comments in this handout relate to major ligament disruptions (thankfully rare), not minor wrist sprains which are very common and usually resolve spontaneously within 4-6 weeks.
The wrist is made up of eight separate small bones, called the carpal bones (Picture 1). In simple terms, wrist represents a skeletal connection between the hand and forearm, but it’s anatomy is very complex and designed for extreme mobility of our hands. Each carpal bone forms a joint with the bone next to it. Glistening, smooth articular cartilage, which wraps each of these bones, allows gliding between them, whilst ligaments restrain their motion ensuring synchonised movements and ‘harmony’ within the joint itself. When one (or more) of these ligaments is injured, the way bones move is changed – bones do not move and act together as a unit any more and joint is likely to become unstable. Bones normally held in oplace by ligaments between them, become unrestrained and ‘allowed’ to rotate abnormaly often leading to arthritis in the long term (Pictures 2a/b – illustrate displacement and malrotation of scaphoid and lunate bones once the ligament between them (scapho-lunate) is torn.
Sophisticated anatomical and biomechanical arrangement found in the normal wrist is often impossible to restore after injury. This is why ligament disruptions are particularly challenging to treat successfully.
Not all ligaments are of equal anatomical and clinical importance. As a matter of fact, injuries to only few of those might require medical input and treatment. Particularly important joint stabilisers are: scapho-lunate, luno-triquetral, radio-scapho-capitate and ulno-carpal ligaments (names indicate which particular two bones are connected).
The most common way the wrist is injured is, by far by a fall on an outstretched hand. When we slip or trip against something, we automatically extend our upper limb to support the body before hitting the ground. Sport injuries are another common cause for wrist ligament sprains and tears. Whether the wrist bone gets broken or ligament gets torn during such accidents depends on many things: how the wrist is positioned during the impact, density and strength of the bones, how much force is transmitted etc. Either way, a significant load/force/power across the wrist joint (like falls, sport injuries, forceful punches, mighty racquet hits) is usually required to rupture the most important internal wrist ligaments.
It is not uncommon that after clinical examination and investigations for a trivial accident, a significant, pre-existing ligament injury is discovered, almost coincidently. In such cases, either an awkward recent trauma triggers a flare of pre-existing, but dormant arthritis or previously partially torn structure ultimately fails with the new injury. Naturally, treatment plan will vary pending on how old ligament injury is this is why the focused and detailed consultation is paramount in successful clinical management. This might sound paradoxical, but sometimes, injury of an important stabilizing wrist ligament might remain clinically dormant (unnoticeable) for several years.
When a wrist ligament injury occurs, pain and swelling are the main symptoms. With significant tears, patients are usually able to recall an incident or a specific movement which triggered “click” or ‘memorable pain’ in the wrist. There are no specific symptoms to indicate weather ligament injury has occurred as opposed to fracture and/or joint sprain. Once the initial pain of the injury subsides, the wrist may remain painful for several weeks, but most innocuous sprains usually settle with rest and avoidance of strenuous hand activities within 4-6 weeks.
Disabling pain beyond 6-8 weeks might be due to the instability of the ligaments and therefore, require further investigations. If the ligaments have been damaged and/or have not healed properly, the bones do not slide against one another correctly when the wrist is moved. This can result in pain, clicking or snapping sensation as the wrist is used for gripping activities.
Over the years, repetitive abnormal motion of the carpal bones will lead to predictable pattern of wrist osteoarthritis. Rate of deterioration is impossible to predict with accuracy, but in general, more the wrist is used and strained, quicker the wear and tear changes will be incurred. Since worn articular cartilage cannot heal itself, the damage becomes irreversible and slowly adds up. Finally, the joint can no longer compensate for the damage, and the wrist begins to hurt most of the time, not only during motion and activity.
As mentioned above, the diagnosis of ligament injuries of the wrist begins with a medical history and joint examination. Usually a lot can be concluded from just these two diagnostic modalities, but pending exact individual circumstances, plain radiograph (X-rays), magnetic resonance imaging (MRI) or arthrogram (X rays taken after injection of dye into the wrist) of the wrist might need to be done too. Each one of these investigations has its own advantages and diagnostic specificity. Which particular one is ordered is determined during consultation depending on clinical evidence as to which particular tissue and structure appears to have been affected.
Finally, for cases in which it is not possible to establish the diagnosis by any of the means above, arthroscopy of the wrist joint may be the only way to determine whether a ligament injury is causing the continued symptoms. The arthroscope is a miniature TV camera that is inserted into the wrist joint to allow the surgeon to see the ligaments that may be torn. In some cases, the arthroscope may also be used to assist with repair of the ligaments at the same time. Wrist arthroscopy is carried out under regional or general anaesthesia, usually on a day care basis.
The first challenge in treating a ligament injury of the wrist is recognizing that it exists. Many ligament injuries go unrecognized until much later. Usually patients fall and injure their wrist, but assume they have sustained a sprain only. Whilst vast majority of patients will improve with simple rest for few weeks, few people will unfortunately acquire more serious injury.
The treatment of a ligament injury depends on whether it is an acute injury (just happened within weeks) or a chronic injury (something that happened months ago).
A wrist injury that causes a partial injury to a ligament, a true wrist sprain, may simply be treated with a cast or splint for 3-6 weeks to facilitate healing.
In cases where the ligaments are completely torn and the carpal bones are no longer lined up well, surgery may be recommended.
Direct Ligament repair and Bone Pinning (suitable only within the first 4-6 weeks from injury)
Direct ligament repair gives the best chances for functional recovery, This procedure is however, feasible only within a first few weeks after injury, whilst ligament still possesses a healing potential. Ligament is repaired with special sutures whilst neighboring bones are fixed and held in place with metal pins allowing ligament to heal. The longer the surgery is done after the initial injury, less likely it is that the bones can be repositioned properly and less likely that torn ligaments will heal once scar tissue has developed over the ends. The pins are usually removed 4-6 weeks later.
In most cases, patient presents much later (often even many years after the actual accident), when ligament repair is not possible, so one of reconstructive options become indicated.
There are several reconstructive options. In principle, they are based on passing a sling of one of the neigbouring tendons through and around the carpal bones restraining their movements and acting as a ligament. The tendon graft is usually borrowed from one of the forearm tendons (flexor carpi radialis, palmaris longus or extensor carpi radialis). One of the most popular (also my preferred choice) is called tri-ligament tenodesis. Its most crucial steps are illustated in Picture 3. Sling of flexor carpi radialis (forearm tendon – Picture 3a) is tunneled through the scaphoid bone (3b) and secured against the ligaments on the opposite side of the wrist (3c). Such manouvering aims to prevent abnormal malrotation of the bones and to some extent, limit harmful extremes of wrist movement. Similar to direct repair, metal pins are used to hold the bones stationary while the tendon graft heals. The pins are removed 6-8 weeks after the surgery. In addition, the wrist has to be immobilised with external splint for up to 8-10 weeks after surgery.
Sometimes abnormal bone movements and rotation can be controlled and prevented by attaching/anchoring a piece of wrist watertight sac (capsule) into the carpal bone. This reduces the mobility of the bone which has otherwise become too loose following ligament disruption. This method is less invasive and less robust then formal ligament reconstruction (as described above), but can halt progression of arthritis. It can also be very useful in partial ligament tears which are very symptomatic, but do not require for complex reconstruction.
When the ligament instability is discovered long after the injury and arthritis is present in the joints between the unstable bones ligament reconstruction becomes pointless and joints should better be fused (bones permanently fixed against each other). Two or more bones are fused by removing the cartilage between them. When the raw bone surfaces are placed together they will heal together like any fracture so two bones fuse into one. This stabilizes the motion between the bones (some stiffness is inevitable), but it reduces pain that occurs when the arthritic joint surfaces rub against each other. In order words, pain is exchanged for some stiffness. Fusion in the wrist can be performed against only two bones (partial wrist fusion) or more including all of them (total wrist fusion) if the whole wrist becomes affected with longstanding arthritis.
Rehabilitation protocols are used to help you regain wrist range of motion, strength, and function after injury and during healing.
If the injury has been treated conservatively i.e. only with the cast, a hand therapist or occupational therapist will start mobilising fingers early to prevent stiffness of its small joint. Wrist movements will be initiated either during splintage (for few hours a day under the supervision) or after the splint is removed. Exact rehabilitation protocol depends on the nature of your injury.
If you have surgery, your hand and wrist will be bandaged with a well-padded dressing and a splint for support. Physical or occupational therapy sessions may be needed for up to 6 months after surgery. The first few sessions focus on controlling the pain and swelling after surgery. Patients then begin to do exercises that help strengthen and stabilize the muscles around the wrist joint. Other exercises are also used to improve the fine motor control and dexterity of the hand. The therapist suggests ways to do activities without straining the wrist joint.
Beware that recovery following surgery for disrupted wrist ligaments is often protracted and rarely complete in less then 12, sometimes even 18 months after operation. Ligaments have poor blood supply, yet have to regain great strength. That simply takes time so patience is essential.
Risks and side effects of surgery:
Complications are rare, but as with any surgical procedure, there are general and carpal tunnel release -specific risks which patients should be aware of:
- Skin/wound infection
- Painful scars
- Hypertrophic (lumpy and itchy) scarring
- Tendon / nerve injury (< 1%)
- Joint infection
- tendon rupture
- Failure of treatment
- Reflex Sympathetic Dystrophy – RSD (bad reaction to surgery seen in 5% of patients: hand may become very swollen and painful – this can occur with any hand surgery from a minor procedure to a complex reconstruction. This problem cannot be predicted but will be watched for afterwards and can be treated with medication and hand therapy
- Repeated or additional surgery
Things to look out for
- Disproportionate swelling and pain in your hand
- Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
- Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
- Increased temperature in the area
- Strange smells coming from the wounds.
If you notice any of above symptoms in the first few days, feel free to contact the team on numbers below.
This leaflet provides only basic and generic information, but full details and explanations are provided at the consultation as no two patients are the same and each person’s circumstances are highly individual.
If you have any concerns following your surgery please contact:
|Hospital stay||Day care|
|Anaesthetic||General or Regional Anaesthesia|
|Surgery time||60-90 minutes|
|Healing||Skin = 2 weeks; Ligaments= 8-12 weeks|
|Splintage||finger splint for 1-2 weeks|
|Hand therapy||8-12 weeks|
|Washing||from week 3|
|Time off work||2 weeks for office based work; 8 weeks for manual work|
|Sports and exercise||from week 12|
|Driving||The hand needs to have full control of the vehicle and you should be able to make an emergency stop. This is usually between 5-8 weeks. Please check details with your insurance company|
|Full recovery||8-12 weeks|
2bPicture 2a/b: When Scapho-Lunate ligament is disrupted, gap between corresponding bones widens and they become unstable and/or malrotated Picture 3: Tri-ligament tenodesis - one of the most commonly performed operations for reconstruction of torn scapho-lunate ligament