The wrist is a complex structure bound proximally by the distal radioulnar joint and distally by the base of each metacarpal bone. Hand fractures account for approximately 19% of all fractures, with 8% occurring in the carpal bones (38). Maintaining a high index of suspicion for traumatic injuries to the wrist is important because disruption of the elaborate structures in the wrist may cause chronic disability if unrecognized. An understanding of complex potential pathologies of the wrist is essential in treatment plan development and avoiding morbidity in athletes.
The anatomic segment between the distal radius and articular disc overlying the ulna and the base of the five metacarpal bones defines the wrist. The eight carpal bones form a kinematic chain, which transmits forces through interosseous articulations from the hand to the radius and ulna. Intrinsic and extrinsic ligaments support unique biomechanical interactions of the wrist. Multiple ligamentous injuries can occur during traumatic injuries to the carpal bones. Two of the most common causes of carpal instability are scapholunate and lunotriquetral ligamentous injuries. A high index of suspicion for ligamentous injuries must be maintained because these injuries can result in chronic morbidities.
The proximal carpal bones lie deep to the distal wrist crease and include the scaphoid, lunate, triquetrum, and pisiform (from the radial to the ulnar side of the wrist). The scaphoid spans the proximal and distal row of carpal bones and has significant pathoanatomical consequences. The proximal row also forms a tendon-free intercalated segment making movement dependent on external forces (12). The distal row of carpal bones is tightly interconnected to the base of the five metacarpal bones, forming the carpometacarpal joints, including the trapezium, trapezoid, capitate, and hamate (from the radial to the ulnar side of the wrist).
Examination of the Wrist
The evaluation of a traumatic injury to the wrist is not unique to this specific joint. However, physicians can overlook injuries without an organized approach. An understanding of the distinct anatomy and pathology of the wrist can help differentiate injury patterns.
Examination begins with a thorough history with strict attention to the injury, chronicity and evolution of symptoms, and activities causing symptoms. Followed by a thorough examination, the differential can be significantly narrowed. A proposed assessment sequence of the wrist is: inspection, palpation, ranges of motion, muscle strength, neurovascular testing, and provocative testing. The appearance of deformity and color changes may warrant urgent assessment and a high index of suspicion for a vascular injury, but these injuries are rare. Precision palpation with knowledge of the underlying anatomy can assist in quick decisions on positioning for x-rays. The normal ranges of motion at the wrist are approximately 68 degrees of palmar flexion and dorsiflexion, with 20 degrees of radial deviation and 26 degrees of ulnar deviation (36). However, the range of motion and muscle strength can be difficult to assess in acute trauma, pain, or deformity and are more helpful in subacute or chronic conditions. Evaluating the circulation of the radial and ulnar arteries is essential for traumatic wrist and hand injuries. An Allen test provides a more accurate evaluation of the patency of the ulnar and radial arteries, in which a normal test is less than five seconds. During the assessment of an injury, the provider should assess the hand for sensory deficits due to the proximity of underlying nerves to ligamentous and bony structures. One modality for assessing the sensation of the hand is the two-point discrimination test. It should be used as a component of the neurological testing in the hand, but has low sensitivity and variability among different age groups (37). Provocative testing is another element that helps to elucidate the injury; the specific testing will be included within the respective fracture type.
Presentation and Examination
The scaphoid is the most common carpal bone fracture through a direct or indirect force and has an incidence of approximately 40% to 70% of all wrist fractures (15,29,32,38). Scaphoid fractures have a higher incidence in the second decade of life and an increased relative risk in males (40). The scaphoid is particularly vulnerable to fracture during a fall on an outstretched hand with dorsiflexion, radial deviation, and pronation of the hand causing forcible loading of the scaphoid. One study found that 34% of all scaphoid fractures in the United States were related to injuries during high-risk sports, including contact sports, and those that are a high risk for a fall, such as basketball, skateboarding, cycling, football, snowboarding, and soccer (39).
Careful examination of an athlete can aid in narrowing the diagnosis. However, scaphoid fractures can be difficult to diagnose by either physical examination or diagnostic imaging. The athlete can present with varying levels of pain, range of motion limitations, tenderness, swelling, and ecchymosis of the wrist and hand. Special tests have variable sensitivities and specificities. Anatomic snuffbox tenderness to palpation has a sensitivity of 85% to 90%, but a specificity of only 29% to 40% for fracture (8,11). Scaphoid tubercle tenderness has a sensitivity of 87% to 95% and specificity of 57% to 74% for fracture (8,11). A scaphoid longitudinal compression test, performed by axially loading the thumb to compress the scaphoid against the radius, has a sensitivity of 42% to 70% and specificity of 21% to 29% for fracture (7,8). One prospective study stated that patients evaluated within 24 h of a scaphoid fracture and found to be positive for all three provocative tests had a combined 100% sensitivity and 74% specificity for fracture (30). Given the high variability of patient presentation and among the studies of the types and timing of provocative examinations, the evaluation of the scaphoid through history and physical alone is not adequate in ruling-in or ruling-out a scaphoid fracture.
There is not currently a consensus for the optimal imaging modality or specific views to diagnose a scaphoid fracture. The standard wrist x-rays include a posterior-anterior (PA) and lateral views (23). Additional recommendations suggest that at least two more scaphoid views, including semipronated 45 degrees PA oblique and semisupinated 45 degrees PA oblique be obtained (6,23).
If an occult scaphoid fracture is suspected despite negative x-rays, computed tomography (CT) or magnetic resonance imaging (MRI) should be considered because both have high sensitivities and specificities for a scaphoid fracture (2). Jorgsholm et al. (17) recommend advanced imaging, such as MRI, in patients with traumatic radial sided wrist pain younger than 18 y because they found that only 45% of the radiographs detected carpal fractures in this age group. CT remains the gold standard for classifying the fracture and planning for surgery because of the limitation of MRI in differentiating cortical versus trabecular fractures (2). The Herbert classification of scaphoid fractures divides acute fractures into two types, A and B, based on CT findings to develop further treatment and management strategies: A1, stable tuberosity fractures; A2, stable undisplaced fracture of the waist; B1, unstable oblique fracture of the distal third; B2, unstable displaced or mobile fracture of the waist; B3, unstable proximal pole fracture; B4, unstable fracture dislocation of the carpus; and B5, unstable comminuted fracture (21).
It is crucial to distinguish the location of the scaphoid fracture due to the precarious blood supply and high risk of avascular necrosis. Avascular necrosis of the scaphoid is attributed to the retrograde blood supply from the distal to proximal scaphoid. Branches of the radial artery along the dorsal ridge of the scaphoid largely supply the proximal scaphoid. This unique blood supply leaves the proximal pole of the scaphoid tenuously supplied by retrograde blood flow (10). As a result, fractures of the scaphoid can disrupt the blood supply to the proximal bone, causing avascular necrosis. The length of time to nonunion in the distal and proximal segments of the fracture has been correlated to the degree of long-term complications, such as scaphoid nonunion advanced collapse (SNAC) (31). The incidence of scaphoid nonunion among scaphoid fractures that present to a medical provider is about 5% and found to be the highest among patients with delayed presentation or diagnosis (31).
Conventionally, management of an athlete with a suspected occult scaphoid fracture has been accomplished by thumb spica splint immobilization with repeat radiographs in 2 wk (2,5). Herbert type A fractures are managed conservatively through a short arm thumb spica cast for 6 to 8 wk with repeat imaging to demonstrate healing (2,21). An alternative approach to a Hebert type A2 fracture is screw fixation, allowing early mobilization with follow-up in 6 to 8 wk for repeat imaging (2,21). If an injury meets nonoperative guidelines with an acute nondisplaced fracture of the scaphoid waist, Halim and Weiss (13) suggest if the athlete has a strong desire, they can return to both contact and noncontact athletics immediately in a playing cast with close follow-up. However, they suggest more commonly that these athletes can return to play safely with a playing cast in 4 wk (13). The athlete needs careful monitoring and follow-up to identify complications, demonstrate clinical and radiological healing, and perform frequent cast changes. Type B fractures are recommended to be managed with screw fixation and repeat imaging to demonstrate healing in 6 to 8 wk (2,21). Belsky et al. recommend an open reduction internal fixation (ORIF) for elite athletes with scaphoid fractures, which allows for earliest return to play because of faster healing times and earlier rehabilitation (4). However, after ORIF of the scaphoid, the recommendations for return to play are highly variable and based on multiple factors to include sport, position, and postsurgical progress. Treatment recommendations can span 2 to 12 wk of immobilization with healing demonstrated on a CT scan before return to sport is recommended, especially in sports with increased wrist strain such as wrestling (13). In determining return to play, the provider should consider working in conjunction with the athlete and hand surgeon. The multidisciplinary team's recommendations should consider the injury type, the demand of the sport, the desires and goals of the athlete, and the safety requirements of the sport (3).
Presentation and Examination
The lunate is a well-protected carpal bone in the center of the proximal carpal row, with articulations distally with the capitate and proximally within the lunate fossa of the radius (24,29). This protection leads to a modest 0.5% to 1% incidence of acute lunate fractures among carpal fractures (24,29). The mechanism of injury for an isolated lunate fracture is described as an indirect force experienced during a fall on outstretched hand with ulnar deviation and hyperextension of the wrist or through a direct blow to the hand while aligned with the forearm (24,29). The symptomology of this fracture can be nondescript with a painful range of motion of the wrist, decreased or painful grip strength, and central wrist pain (24). If there is a high suspicion for an isolated lunate fracture, the examiner should immobilize the injury and pursue further imaging.
Lunate fractures are classified into five groups based on the vascularity to the bone, including dorsal and volar pole, transverse and sagittal planes within the body, and chip fractures (35). The recommended initial radiographs of the lunate include standard PA, lateral, and oblique wrist views (34). Complete x-ray visualization of a lunate fracture can be difficult due to overlapping carpal bones; consequently, to exclude occult fractures or ligamentous injury, advanced imaging with CT or MRI is recommended if an occult fracture or ligamentous injury is suspected (24,28). Causality has not been established between lunate fractures and Kienbock disease (24,28,29). However, if wrist pain persists in an athlete after a lunate fracture, MRI is recommended to further assess for avascular necrosis (24,28,29).
To initiate a treatment protocol, a meticulous approach to a physical evaluation is needed due to the complications that can ensue if carpal instability or a nonunion occurs. Traumatic nondisplaced or small marginal chip fractures are treated with cast immobilization for 4 to 6 wk with reexamination and reimaging to demonstrate healing and appropriate carpal alignment (24,29,34). Referral to a hand surgeon for further evaluation is recommended for comminuted fractures, fractures through the body, articular surface fractures, nonunions, avascular necrosis of the lunate, malalignment of the carpal bones, palmar chip fracture with volar intercalated segment instability (VISI), or dorsal chip with dorsal intercalated segment instability (DISI) (24,29,34).
Presentation and Examination
The incidence of triquetrum fractures has been reported from 4% to 18% among carpal bone fractures (14,24,29). Despite being the second most common carpal bone fracture, the triquetrum is well protected proximally by the triangular fibrocartilage complex (TFCC), and distally where it articulates with the hamate (14,24,29). The most common mechanism of injury for a triquetrum fracture is the indirect force applied on the triquetrum through an extended hand in ulnar deviation (14,24,29). Rarely, the mechanism of injury is a direct blow to the dorsal aspect of the triquetrum because of support from surrounding structures (14). The clinical examination of an athlete with a triquetrum fracture can elicit point tenderness over the triquetrum, hypothenar swelling, and pain with wrist palmar flexion and dorsiflexion (14,24).
Greater than 90% of triquetrum fractures are avulsions along the dorsal ridge, with the remaining fractures occurring within the body and on the volar surface of the triquetrum (14,27,29). The recommended initial radiographic evaluation of the triquetrum includes PA, lateral, and 45 degrees pronated oblique views (24,34). Additional imaging with a CT or MRI is recommended if occult fractures or concomitant ligamentous injuries are suspected (28). Marchessault et al. (24) recommend an MRI to evaluate for concomitant injuries in an athlete with significant soft tissue swelling that would slow their return to play.
Treatment of traumatic isolated nondisplaced body fractures or dorsal avulsion fractures is short arm cast immobilization for 3 to 6 wk, with reexamination and reimaging to demonstrate healing and appropriate carpal alignment (28,33). Marchessault et al. recommend cast immobilization in nonoperable cases where wrist motion is not required, with regular follow-ups every 1 to 2 wk to reevaluate the injury for an option of return to play (24). Referral to a hand surgeon is recommended for large avulsion fractures, greater than 1 mm of displacement in a body fracture, nonunion, malalignment of carpal bones, or any fracture accompanied by intercarpal ligament instability (28,29,33).
Presentation and Examination
Pisiform fractures account for about 1% of carpal bone fractures (16,24,26,29). Athletes typically present with pinpoint tenderness to palpation of the pisiform with ulnar-sided wrist pain exacerbated by resisted palmar wrist flexion (16,24,29). The mechanism of injury is usually a direct impact on the volar aspect of the wrist (16,24,26,29). As with all wrist examinations, a thorough nerve evaluation must be performed. Specifically, in pisiform fractures, careful completion and documentation of ulnar nerve function is crucial given its proximity to the pisiform within Guyon canal (16,24,29).
Initial imaging of the pisiform should include PA and lateral wrist x-rays, but standard radiographs miss fractures of the pisiform (19,24,29). Differentiating fractures from normal ossification centers in pediatric radiographs before or around the 12th year of life can be difficult to distinguish (19,29). Therefore, additional imaging could include a carpal tunnel view, an oblique x-ray at 30 to 45 degrees of supination, or CT scan (19,24,26,29).
One treatment technique for a traumatic nondisplaced or avulsion fracture of the pisiform is immobilization of the wrist with a splint or a brace for 3 to 6 wk with reexamination and reimaging to demonstrate healing (9,16,24,28,33). Another treatment method is pisiformectomy, which has demonstrated safe and rapid return to play (24). Referral to a hand surgeon is recommended for displaced fractures, posttraumatic arthritis, refractory pain, ulnar neuropathy, or nonunions (9,16,28,29,33).
Presentation and Examination
Hook of hamate fractures account for about 2% of carpal bone fractures (16,24,26). Athletes usually present with tenderness over the ulnar side of the wrist that is increased with ulnar deviation of the wrist, gripping objects, and resisted flexion of the fourth and fifth fingers (16,24,26,29). The mechanism of injury commonly involves a direct or indirect blow to the hamate. High-risk activities include tennis, golf, baseball, hockey, and climbing sports (16,24,26,29). As with the pisiform, the ulnar nerve passes through the Guyon canal rendering it susceptible to injury with hamate fractures; thus, a thorough nerve evaluation and documentation with hamate fractures is critical (16,24,26,29).
Initial radiographic evaluation of suspected hook of hamate fracture includes PA, lateral, and oblique views (29). According to Norman et al. (25), a hamate fracture can be identified on PA radiograph by evaluating for three signs: “absence of the hook of the hamate, sclerosis of the hook, and lack of cortical density of the hamulus.” Standard radiographs have been found to be unreliable for the detection of acute fractures and lead to misdiagnosis or delayed diagnosis. Additional views include carpal tunnel view with 40% to 50% sensitivity, supinated oblique with the wrist dorsiflexed, and 30 degrees tilted lateral view with the thumb abducted, which has a sensitivity of 5% to 100% (1,20,24). CT or MRI can help elucidate occult fractures with a combined sensitivity for a hook of hamate fracture between 53% and 90% (20,34).
Acutely traumatic hook of hamate fractures have been treated with cast immobilization and close follow-up for 6 to 12 wk to identify fracture nonunion; one study demonstrates up to 19 wk for healing (9,13,20,28,29,33). To allow athletes to return safely and rapidly within 4 to 10 wk after surgery, excision is recommended for acute displaced, nondisplaced, or symptomatic nonunion hook of hamate fracture (3,9,13,24). The surgical scar can remain sensitive for months after surgery; therefore, postoperative therapy with scar desensitization can help decrease incision sensitivity (13,24). Referral to a hand surgeon is recommended for hook of hamate nonunions and displaced fractures (20,28,29,33).
Presentation and Examination
Capitate fractures account for about 1% of carpal bone fractures (24,29). The capitate is the largest of the carpal bones and is well protected by surrounding structures (24,29). The mechanism of injury can be a direct blow or an indirect fall with axial loading through the third metacarpal while the wrist is in hyperextension (24,29). The athlete usually presents with tenderness over the capitate at the base of the third metacarpal exacerbated by wrist motion. However, a capitate fracture is rarely an isolated fracture and more commonly occurs with concomitant injuries to the scaphoid or lunate (24,29).
The capitate is the first bone in the wrist to ossify (18). Consequently, early rigidity can lead to an increase in its susceptibility to a fracture in the pediatric population (18). The most common fractures of the capitate occur in the body or as distal dorsal avulsion fractures (18,28). Isolated capitate fractures are often misdiagnosed with routine radiographs of the wrist (28). If there is a high suspicion of a capitate fracture, CT or MRI is recommended to further evaluate for occult fractures or concomitant injuries (18,28).
A treatment approach to acutely diagnosed traumatic, nondisplaced, isolated capitate fractures is cast immobilization with reexamination and reimaging to demonstrate healing (28,29,33). Marchessault et al. (24) recommend cast immobilization for nondisplaced capitate neck fracture. Suh et al. (34) recommend internal fixation of a capitate neck fracture to allow for early immobilization and decrease wrist stiffness associated with cast immobilization. Capitate fractures can be complicated by painful nonunion, arthritis, avascular necrosis of the proximal pole, and concomitant injuries, such as scaphoid fractures or scapholunate ligamentous injuries. As a result, recovery of an athlete is performed in close consultation with a hand surgeon (24). Referral to a hand surgeon is recommended for displaced fractures, nonunions, avascular necrosis, symptomatic arthrosis, instability, or concomitant injuries (24,28,29,33,34).
Presentation and Examination
Trapezoid fractures are the rarest carpal bone fracture with an incidence of 0.4% to 1% (24,29). It is well protected by the trapezium, scaphoid, capitate, second metacarpal, and the surrounding intercarpal ligaments. The mechanism of injury has been described as an axial loading force through the second metacarpal with a flexed finger (24,29). On clinical examination, the athlete has pain elicited by palpation of the trapezoid, and motion in the wrist or the second metacarpal (24).
Trapezoid fractures can be complicated by fracture-dislocation of the trapeziometacarpal joint (24). PA, lateral, and oblique radiographs of the wrist may demonstrate a fracture and dislocation of the trapezoid (24). If an occult fracture or dislocation is suspected, CT or MRI of the wrist should be obtained (24,33).
Acute, traumatic, nondisplaced, isolated trapezoid fractures are treated with 4 to 6 wk of short cast immobilization with reexamination and reimaging to demonstrate healing (24,28,29,33,34). Closed reduction can be attempted with cast immobilization for a trapeziometacarpal dislocation, but if it remains unstable, referral is recommended for open reduction (24,28). Return to play for an athlete with an uncomplicated ORIF of a trapezoid fracture is typically 12 wk (24). Referral to a hand surgeon is recommended for unstable or displaced fractures and subluxed or displaced first carpometacarpal joint, concomitant injuries, symptomatic chronic injuries, malunion or nonunion (24,28,29,33,34).
Presentation and Examination
The incidence of a trapezium fracture is reported as 4% to 5% of all carpal fractures (24,29). The trapezium articulates with the scaphoid proximally in the anatomic snuffbox and distally with the first metacarpal. A fracture to the trapezium is rarely due to a direct blow, usually a fracture results from indirect force through an axial load through the first metacarpal or a fall on an outstretched hand with a dorsiflexed wrist in radial deviation (24,29). On clinical examination, the athlete can present with direct tenderness to palpation of the trapezium, pain upon palmar flexion of the wrist or with a pinching motion, and swelling over the dorsum of the hand in the anatomic snuffbox (24).
The most common fractures of the trapezium are along the dorsal ridge or within the body of the trapezium (22,24,33). PA, lateral, and oblique x-rays of the wrist may demonstrate a fracture in the body of the trapezium (24). A carpal tunnel view and a pronated anterior-posterior view (Bett view), can improve identification of a trapezial fracture (24,33,34). If standard x-rays are negative and there is a high suspicion for a trapezial fracture, CT can be useful to identify occult fractures (24,33,34).
Acutely diagnosed traumatic trapezial ridge fractures or nondisplaced trapezial body fractures are treated with 4 to 6 wk of thumb-spica splint or cast immobilization with reexamination and reimaging to demonstrate healing (24,28,33). Referral to a hand surgeon for further evaluation is recommended for trapezial body fractures with 2 mm of intra-articular displacement of the first carpometacarpal joint, misaligned joint, or symptomatic nonunion of the trapezium (24,28,29,33).
Overall incidence of wrist injuries among athletes is high and can have a significant impact on return to play. If misdiagnosed, they can result in long-term comorbidities. Therefore, a keen knowledge of wrist anatomy and pathology along with how they relate to an athlete’s sport can help team physicians develop effective treatment plans and return to play timelines.
The views and opinions expressed in this article are those of the authors alone as individuals and do not reflect those of the Department of Defense, the Army, the Air Force, or the Uniformed Services University of the Health Sciences.
The authors declare no conflict of interest and do not have any financial disclosures.
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