WRIST PAIN

Symptoms, Causes, Risk Factors, Tests and diagnosis , Complications, Treatments and drugs AND Prevention

Definition

Chopping vegetables, angling for trout, falling during an athletic activity — there's practically no end to the ways you can hurt your wrists. In fact, hand pain and wrist pain are among the most common musculoskeletal complaints that doctors see.

The causes of wrist pain can range from repetitive stress injuries to sprains, fractures and diseases such as arthritis. Because so many factors can lead to wrist pain, and because the wrist is a complex structure, diagnosing the exact cause of long-standing wrist pain can be difficult.

For most people, wrist pain can be diagnosed and treated. The type of care depends on the cause and severity of the wrist pain.

Symptoms

The signs and symptoms of wrist pain vary by the type of wrist pain you have.

Ligament sprains and tears

A sprain is an injury to a ligament — the fibrous tissue that connects bones. Ligaments are composed of a number of individual fibers, and the degree of injury depends on how many of the fibers are damaged and whether they're completely torn or just pulled apart. A mild sprain will generally cause minor discomfort and swelling, whereas a severe injury or complete tear can lead to:

• Significant pain and swelling that becomes worse with use
  
• Bruising
  
• Inability to use your wrist normally
  
• A painful popping or clicking

Tendinitis

Tendons are thick, fibrous cords that attach muscles to bone. Tendinitis, which occurs when tendons become inflamed or irritated, can cause the following symptoms just outside the affected joint:

• Pain
  
• Mild swelling

Though tendinitis is most common in your shoulders, elbows and knees, it can also affect your hips and wrists.

Fractures

Because the bones in the wrist are small and intricately arranged, they're prone to fractures. Though a broken wrist bone is usually quite painful, it's possible to have a fracture and not realize it. In addition to pain, symptoms may include:

• Swelling
  
• Discolored skin
  
• Limited ability to move your wrist
  
• A deformed or crooked wrist, sometimes with the bone protruding through the skin

Repetitive strain injuries

Any repetitive motion can stress and inflame your joints or worsen an existing injury, especially when done forcefully and for long periods of time without rest. Such motions can range from assembly line work to hitting a golf or tennis ball or typing on a computer. Repetitive strain injuries cause the following symptoms in muscles, joints, tendons and nerves:

• Pain
  
• Inflammation
  
• Dysfunction (sometimes)

Carpal tunnel syndrome

One of the most highly publicized wrist injuries, carpal tunnel syndrome occurs when the median nerve is compressed as it passes through a narrow passageway (carpal tunnel) in your wrist. Symptoms may include:

• Tingling or numbness in your hand or fingers, especially when you're holding a cup, driving a car or reading a newspaper
  
• Pain radiating or extending from your wrist up your arm to your shoulder or down into your palm or fingers, particularly after forceful or repetitive use
  
• A sense of weakness in your hands and a tendency to drop objects
  
• Chronic loss of feeling in some fingers in advanced cases

Osteoarthritis

Osteoarthritis is the breakdown of cartilage that cushions the bones in your joints. Over time, the loss of cartilage can cause:

• Joint pain, swelling and stiffness
  
• Limited motion and weakness in your wrist joint

Rheumatoid arthritis

Unlike osteoarthritis, rheumatoid arthritis is a systemic disease that can cause problems throughout your body. It usually starts in small joints in your hand and wrist, leading to:

• Joint pain and swelling
  
• Loss of motion and strength in the affected joint
  
• Joint deformity
  
• Fatigue and a general feeling of being unwell

Causes

Your wrist is a complex joint made up of eight small bones (carpal bones) arranged in two rows between the bones in your forearm (radius and ulna) and the metacarpal bones in your hand. Tough bands of ligament connect the carpal bones to each other and to the forearm bones and metacarpals. Damage to your ligaments, bones or the cartilage that cushions your joints can cause pain and affect your ability to use your wrist and hand.

Common causes of wrist injury and pain include:

• Ligament sprains and tears. Most ligament sprains or tears result from the kind of high-impact injuries that happen when you fall forward onto your outstretched hand. They can also occur when you push a heavy object or brace yourself against the car dashboard during a sudden stop or collision. The ligament that's most often torn is the scapholunate ligament, which connects the scaphoid bone, on the thumb side of your wrist, to the neighboring lunate bone.

• Cartilage tears. The triangular fibrocartilage complex (TFCC) is a small piece of cartilage and ligaments on the small-finger side of your wrist, just below the ulna. The TFCC can tear when you fall on your outstretched hand, swing a bat or racket, or twist your wrist sharply.

• Fractures. The bones in your wrist can break for many reasons, but they're most likely to fracture when you land on your outstretched hand in an accident; fall from a roof or ladder; are in a car collision; or receive a direct blow to your wrist. But the same injury may not break the same bone in every person. For instance, teens tend to have growth plate fractures — a break in a part of the bone that's still growing — whereas adults who fall the same way might break the scaphoid bone on the thumb side of the wrist.

• Repetitive strain injuries. Any activity that involves a repetitive motion — from hitting a tennis ball or bowing a cello to driving cross-country — can inflame the joints in your wrist, especially when you perform the movement for hours on end without a break.

• Carpal tunnel syndrome. Carpal tunnel syndrome develops when there's increased pressure on the median nerve, which passes through the carpal tunnel, a passageway in your wrist. Studies have failed to pinpoint the exact cause of carpal tunnel syndrome, though they have ruled out the commonly held notion that typing on a computer is to blame. Several studies have found no relationship between using a computer up to seven hours a day and a risk of carpal tunnel.

• Osteoarthritis. In osteoarthritis, the problem lies in the cartilage that cushions the ends of bones in your joints. Over time, the cartilage deteriorates and its smooth surface roughens. If the cartilage wears down completely, you may be left with bone rubbing on bone — damaging the ends of the bones and causing pain in the joint. Arthritis that affects the metacarpal-carpal joint in the thumb is particularly common.

• Rheumatoid arthritis. Some researchers suspect that rheumatoid arthritis is triggered by an infection — possibly a virus or bacterium — in people with an inherited susceptibility. Although the disease itself is not inherited, certain genes that create an increased susceptibility are. People who have inherited these genes won't necessarily develop rheumatoid arthritis. But they may have more of a tendency to do so than others. The severity of their disease may also depend on the genes inherited. Some researchers also believe that hormones may be involved in the development of rheumatoid arthritis.

• Kienbock's disease. Like all living tissues, your bones require a constant supply of blood for nourishment. In Kienbock's disease, the blood supply to the lunate bone is cut off, and the bone slowly dies. The exact cause isn't known, though it may begin with a fall or a series of injuries to the hand or wrist. Kienbock's is often overlooked because its initial symptoms resemble those of a ligament strain. Untreated Kienbock's can lead to arthritis and disability.

• Other diseases. Most wrist pain comes from arthritis or an injury to your wrist joint, but certain systemic diseases can also affect the bones and tissues in your wrist. These include diabetes, gout, Paget's disease, leukemia, scleroderma and lupus erythematosus.

Risk factors

You're a candidate for wrist pain whether you're very sedentary, very active or fall somewhere in between. Still, certain factors can make you more prone to wrist problems, including:

• Certain sports. Professional and amateur athletes of all sorts — basketball, football, hockey and tennis players, pitchers, and golfers — are prone to wrist injuries. But wrist problems are also showing up in more children and teens, especially those who snowboard, rollerblade and skateboard. According to some estimates, nearly 80 percent of young gymnasts have chronic wrist pain.

• Age. Older adults are more likely to have osteoporosis, which makes bones brittle and more susceptible to fractures, than younger people are. They're also more likely to fall and to develop arthritis.

• Repetitive work. Almost any activity that involves your hands and wrists — even knitting and cutting hair — if performed forcefully enough and often enough can lead to disabling wrist pain.

• Pregnancy. Some women develop carpal tunnel in the second and third trimesters of pregnancy because of hormonal changes. Shifts in the balance of estrogen and progesterone cause the body to retain more fluid, which increases swelling in the carpal tunnel.

When to seek medical advice

Not all wrist pain requires medical care. Minor strains, for instance, usually respond to ice, rest and over-the-counter anti-inflammatory medications. But if pain and swelling last longer than a few days or become worse, see your doctor. Delays in diagnosis and treatment can lead to poor healing, reduced range of motion and long-term disability.

Get emergency care if your pain is severe, your wrist looks misshapen or bone protrudes through your skin. An exposed bone can lead to a life-threatening infection if not treated promptly.

Tests and diagnosis

Some wrist injuries can be diagnosed with a medical history and careful examination of the painful area. For example, your doctor can often detect an injury to a ligament simply by examining your hand. Ligament injuries don't always show up on imaging tests.

In other cases, though, you may need further tests. These may include X-rays, sometimes using a contrast material (arthrogram) , or more detailed images from a computerized tomography (CT) scan or magnetic resonance imaging (MRI). If the results are still inconclusive, your doctor may perform an arthroscopy, a procedure used both to diagnose and treat joint problems.

Different tests may be needed to evaluate the degree of carpal tunnel syndrome, including:

• Electromyogram. This test measures the tiny electrical discharges produced in your muscles. A needle-thin electrode is inserted into the muscle, and its electrical activity is recorded when you're at rest and when the muscle is contracted.

• Nerve conduction study. In this variation of electromyography, a small shock is passed through the median nerve to see if electrical impulses are slowed in the region of the carpal tunnel.

Complications

Wrist injuries can sometimes lead to long-term problems, including:

• Ongoing stiffness, aching, numbness or disability. You may have ongoing stiffness, pain or aching even after your injury has healed. These problems sometimes go away, but they may be permanent if your injury was severe. You may also have some deformity in your wrist or limited range of motion. Be sure to talk to your doctor about exercises that might help prevent some of these problems.

• Arthritis. Fractures that extend into the joint can cause arthritis years later. If your wrist or hand starts to hurt long after a break, see your doctor for an evaluation.

• Poor healing. Some wrist fractures — such as scaphoid fractures — may take longer to heal because of poor blood supply to this part of your body or because treatment wasn't started quickly enough. Not immobilizing the fracture properly can also delay healing. And fractures are less likely to heal if you smoke.

• Bone death. Because the scaphoid and capitate bones both have poor blood supplies, they're especially prone to avascular necrosis, which occurs when a lack of blood causes the bone to deteriorate and die.

• Nerve or blood vessel damage. Trauma to your wrist can injure adjacent nerves and blood vessels. Seek immediate care if you notice any numbness or circulation problems.

Treatments and drugs

Treatments for wrist problems vary greatly, depending on the type, location and severity of the injury, as well as on your age and overall health.

Ligament sprains and tears

Minor sprains generally heal on their own with ice, rest and anti-inflammatory medications. More severe sprains or ligament tears may need:

• Splinting. Torn ligaments may be splinted for three to six weeks to allow them time to heal.
  
• 
  
  Surgery. When the ligament is torn and the joints no longer line up, your doctor may suggest surgery to either repair the ligament or pin the bones together to improve alignment while the ligament heals.
  
  
  If a great deal of time has passed since the initial injury, the ligament may need to be replaced with a tendon graft that's usually taken from the same wrist. In cases of long-standing instability or arthritis, two or more wrist bones may be fused together to stabilize the motion between the bones and reduce pain.

Cartilage tears

You can treat some cartilage injuries yourself with rest, ice and anti-inflammatory drugs, but complete tears may need to be surgically repaired. This can usually be done using local anesthetics, small incisions and a fiberoptic scope fitted with a tiny camera and surgical instruments.

Fractures

If you have a broken wrist bone that's properly aligned, you may wear a cast for six weeks to three months or more. You'll have regular X-rays to monitor your progress. If the bone doesn't seem to be healing, your doctor may recommend wearing an electrical stimulator, which looks something like a large bracelet, to encourage the bone to heal.

Other options include:

• Screw fixation. In this procedure, a screw is inserted through the broken bone to help hold it in place. Your doctor may suggest screw fixation instead of a cast because it can lead to a faster recovery and less downtime.

• Removal of dead tissue (debridement) . If your bone doesn't heal even after casting and electrical stimulation, your doctor is likely to suggest surgery. One approach is to remove the old scar tissue between the two halves of the broken bone — a procedure called debridement — which allows the fresh surfaces to try healing again.

• Bone graft. A graft involves using bone tissue from another site in your body or a graft substitute and placing it in the fracture to stimulate healing. A metal pin or screw may be inserted to hold the graft in place. Though minimally invasive procedures can hasten healing and minimize scarring, they still pose certain risks, such as damage to nearby blood vessels.

Repetitive strain injuries

For mild to moderate symptoms of carpal tunnel syndrome and other repetitive strain injuries, your doctor may suggest:

• Wrist splinting. A splint that immobilizes your wrist while you sleep may relieve minor numbness and tingling.

• Nonsteroidal anti-inflammatory drugs (NSAIDS). Over-the-counter pain relievers such as ibuprofen (Motrin, Advil, others) and acetaminophen (Tylenol, others) may help reduce pain from repetitive strain injuries caused by inflammation.

• Corticosteroids. Your doctor may inject the carpal tunnel with cortisone to relieve the pressure on the median nerve.

When pain and numbness are more severe and splinting doesn't reduce your symptoms, surgery may be the best option. Several procedures are used, but all involve cutting the transverse carpal ligament (flexor retinaculum) that's compressing the nerve.

Surgery usually causes marked improvement, but it can take several weeks or months until you have full use of your hand and wrist, and you may have residual numbness, pain, stiffness or weakness. Be sure to discuss all possible outcomes with your doctor before your surgery.

Prevention

It's impossible to prevent the unforeseen events that often cause wrist injuries, but these basic tips may offer some protection:

• Build bone strength. Getting adequate amounts of calcium — at least 1,500 milligrams a day for adults — and vitamin D can help prevent fractures.

• Prevent falls. Falling forward onto an outstretched hand is the main cause of most wrist injuries. To help prevent falls, wear sensible shoes. Remove home hazards. Light up your living space. And install grab bars in your bathroom and handrails on your stairways, if necessary.

• Use protective gear for athletic activities. Wear wrist guards for high-risk activities, such as football, snowboarding and rollerblading. If you're new to extreme sports, consider getting professional instruction, and know your limits.

• Pay attention to ergonomics. The market is flooded with devices such as ergonomic chairs, keyboards and mice that claim to take the stress off your wrists when you're at the office. Using some of these devices, taking regular breaks, keeping your wrists in a relaxed, middle position when you type, and improving your posture can make you more comfortable and help protect your wrists.