Wrist Injuries Part 2

For basic anatomy and stats, as well as info on wrist injuries:

• Carpal Tunnel syndrome
• Stress fracture to the hook of hamate

see Wrist Injuries Part 1

This part will discuss Triangular Fibro-Cartilage Complex (TFCC) injuries, and scapholunate ligament injuries, as well as some preventative measures.

TFCC Anatomy

The Triangular Fibro-Cartilage Complex (TFCC) connects ulnar and radius, that is involved in stabilizing the ulnar-radial joint.

It is also sometimes referred to as the “wrist meniscus” as it acts like the meniscus in the knee by forming a congruent surface for the carpal bones to move more easily on the ulnar and radius

Symptoms

• Clicking
• Popping
• Pain on the little finger side
• Weakness
• Swelling
• Tenderness

Diagnosis is normally based on the area of tenderness and special provocation tests, as well as other investigations such as x-rays.

Causes

• Falls onto pronated hyperextended wrist
• Power-drill injuries in which the drill binds and rotates the wrist instead of the bit (obviously not climbing related!)
• Distraction force applied to the palm side of the forearm or wrist (for instance, when open-handing big slopers)
• Distal radius fractures
  

Treatment

Treatments obviously depend on the extent of the injury.

• POLICE principles
• Avoiding aggravating factors
• NSAIDs
• Immobilization in a cast for up to 6 weeks

This is because, like other ligaments, the TFCC has quite a poor blood supply and so this means that the healing process is slow.

If a cast is required, then remember to keep finger and thumb movements within the limits of the cast

Then, once out of the cast, normal rehab resumes, beginning with passive movements, then active assisted range of movements (ROM), active ROM (including stretches of the flexor and extensors), isometric strengthening, resistive strengthening (this includes eccentric movements)

Eccentric wrist strengthening

Wrist extension strengthening

Wrist flexion strengthening

N.B. It can take up to 12 weeks before progressing to strengthening work, so don't rush your rehab!

If a cast is not required, then the normal rehab described above can be implemented straight away, if deemed necessary by a professional.

A TFCC injury could mean up to 3-4 months off climbing

Surgery may be required, such as an arthroscopic repair, depending on the extent of the injury.

A lot more on TFCC can be read here: http://triangularfibrocartilagecomplextear.blogspot.com

Scapho-lunate ligament tear

Anatomy

The scapholunate ligament connects the scaphoid to the lunate. It's an important stabiliser of the wrist to control the movements between the bones. If this ligament is torn there is a loss of the balance of the wrist, and causes abnormal wrist movements.

Symptoms

• pain in the center or on the thumb side of the wrist, worsened with activities such as push-ups, or other activities that load the wrist
• grip weakness,
• snapping, or popping of the wrist
• swelling
• tender and specific swelling over the gap between the scaphoid and lunate

Causes

Large stress on extension and ulnar deviation, normally a fall on an outstretched hand – e.g. falling off when bouldering, and spraining your wrist

Treatment

Initially, immobilization up to 8 weeks or more

Then progress to increasing the range of movement and gentle strengthening/loading activities

Timing and progression of the exercises depend on many factors, such as the type of injury, and the healing process.

A surgical option may be required.

Avoidance/prevention

The obvious prevention is to avoid movements that cause the issues, however, this is always not easy to do. Therefore, if a wrist injury does occur, take notice in the early stages and do something about it, rather than continue to climb on it and make it worse.

Safer bouldering:

Learning how to properly fall sideways or backwards with fingers pointing safely towards the body (thumbs to the bum) would be a beneficial technique to learn, especially for the boulderer, to try and reduce wrist injuries. It is worth emphasizing that these techniques are not instinctive and need to be learned in a safe environment

References

Bourdon M, Thompson J 2013 Safer Bouldering http://www.mec.ca/AST/ContentPrimary/Learn/Climbing/IntroToClimbing/SaferBouldering.jsp

Bissell B, Bedi A 2011 Scapholunate Ligament Tear http://www.sportsmd.com/Articles/id/14/n/scapholunate_ligament_tear_.aspx

Palmer AK, Werner FW 1981 The triangular fibrocartilage complex of the wrist--anatomy and function. J Hand Surg Am 6(2):153-62.

McNamara MG, Carino BB, Thomas R 2012 Diagnosis: TFCC Tear http://www.akhanddoc.com/TFCC.htm

http://www.shoulderelbowhand.co.uk/wrist_ligament_injuries.html

Verheyden JR 2012 Triangular Fibrocartilage Complex Injuries  http://emedicine.medscape.com/article/1240789-overview

http://triangularfibrocartilagecomplextear.blogspot.com/2010/04/how-can-physiotherapy-help.html

http://ih-voc.eznetpublish.ihealthspot.com/tabid/14407/mid/24836/ContentPubID/113/ContentClassificationGroupID/-1/Default.aspx

Roux A 2010 Scaphoid and Scapholunate Ligament Injuries: The Achilles' heel of the wrist http://occupational-therapy.advanceweb.com/Archives/Article-Archives/Scaphoid-and-Scapholunate-Ligament-Injuries.aspx