Wrist Injury

[Captain127]

I play rugby and I injured my wrist round about start of October. My wrist is still sore. It was a hyperextension as I blocked a kick with my hands and afterwards for 2 weeks I could not really move it nor use it at all. I continued rugby with extreme pain and without the use of my right side.

It may of been slightly cracked but it is probably gone now. Physio suggested it could be tendons being pulled due to hyperextension. Its more of an area of injury I say. Its half of the wrist below the thumb muscle. I cannot do press ups and bench pressing with the curved motion which causes you to bend your wrist at the bottom, that is very sore/agony to do but i persevere. I stretch my wrist forwards and backwards with pain and use a dumbell to try and strengthen it and do fist press ups but there has been no improvement! I rest my arm on my leg and keep my forearm horizontal then I bend my wrist backwards and downwards because its suppose to be bit stuff it hurts quite a lot doing it and it hurts to move the thumb after the pulling back of the hand stretch. I do the downwards and upwards motions with a dumbell with pain. Movement and usuage of the thumb causes pain. It hurts if I press and rub my wrist - more specifically the small gap between the wrist and forearm area.

Its been several months, a hospital diagnosed it as a fracture due to a small chip but bone specialist clinic said its nothing. Should I see an orthopedics? Stretching my wrist (with pain) and trying to strengthen it has done nothing much. There has been improvement during the first 1-2 months then it just stayed the same condition.

(I do quite a lot of weightlifting and I'm a second row in rugby as well and naturally I can barely tackle using my arms or throwing people. Sorry for the long typing but half the seasons over and I really want to play with my friends before I graduate school and I'm fighting for my position)

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[sarahkelly]

Hi there
I suggest you use pain as a guide and damped down the activities that you suggest are aggravating it. There is a small bone in the wrist (scaphoid) which fractures sometimes when ppl fall on outstretched arms) this rarely shows up on x-ray and sometimes gets a bit better after a few weeks then worse again (seems to follow that pattern). On the other hand if it is tendons then putting your entire body weight through them may not help much either, You'll need instead to stretch them eccentrically over a long period of time, don't start with the dumbells introduce them gradually.
What movement is the most painful? Have you noticed after all this time anything that eases your pain?
STUDENT PHYSIO

[Captain127]

well impact on the hand hurts as we did some core where my friend did sit ups and when he did 1 he had to punch sideways and when he hit my right hand it was agony so any impact on it, if i do a lot of stretching it hurts quite a lot and sometimes the wrist cracks and feels as if its clicking back in when i stretch it extensively

i can do benching now only a bit of pain so long as i do stretches, physio was telling me about that few months ago and checked it out saying my scaphoid is fine since i just had an x-ray so she suggested it must be tendons but she also had no idea of my left wrist pain but ill ignore it till my right wrist is better

all movements of the wrist hurts but i do it to stretch it and get it working as in bending it forwards, backwards, moving it sideways with my left hand.

also if i were to isolate the thumb and use it alone to push downwards it hurts a lot in the wrist area where my thumb joins on and so does pushing my thumb in any direction causes the pain. do you think theres a chance of this being tendonitis? as i have researched a lot in the internet and i can only conclude it being tendonitis

i am considering seeing an osteopath and maybe get an x-ray again and perhaps see a different physio if nothing changes

[gcoe]

What SarahKelley is saying about a possible scaphoid fracture is absolutely right (well done Sarah!) The mechanism of injury you describe could cause such an injury and all the pain provoking movements you desribe fit the picture. Furthermore schaphoid fractures are common

It is folly to go on self diagnosing and considering going to an osteopath. Scaphoid fractures are difficult to diagnose and manage and mismanaged fractures can go on to sustained disability and pain so neglect can make matters worse not better. You should get it seen again by an orthopedic surgeon and ensure you have it really checked out and ruled out before carrying on. Fractures that are missed early on by imaging are often picked up later due to displacement of the bone fragments due to lack of immbilisation, or due to death of part of the bone

Have a read about scaphoid fractures:

http://emedicine.medscape.com/article/328658-overview

[sarahkelly]

does applying upward pressure on the thumb as the patient described usually bring-on scaphoid fracture pain, it sounds like it woud lmake sense to do so but it is nto mentioned in the literature as a possible indicator like anatomical snuff box sensitivity etc. is/
I don't know much about scaphoid fractures but am about ot start a placement where I will be dealign with them no doubt,
are they usually pinned if found or treated conservatively,
I have a feelign that scaphoid # patients are divided into 2 groups, those who pick up on it straight away and those who start to improve, then get better then worse again, then come back 4 treatment.
How are these patients typically treated and is there usually a difference in how they progress, if scaphoid #'s are treated conservatively shodu lwe as physio's treat them differntly then the pinned ones?
what are the main issues to address, it sounds like (from the case below) these patients are more limited by pain than range, are mobs the kep to easign their pain? or does one strenghten the joint?
Sorry for all the questions, but this is quite new to me,
sarah

[Captain127]

that would make sense since i cannot do press ups on my palm of my hand really i have to lean further forward to apply pressure on the upper hand where the fingers meet and had to gradually increase my wrist strength by benching (because of the motion of bending ur wrist) and also suddenly grabbing a railing when stumbling on a bus and sticking an arm out in rugby and someone running into my forearm/wrist invokes a lot of pain and lifting from behind in the line outs

never occured to me there was a possibility because when i saw a physio they checked me out and said it does not seem to be any injury releated to the scaphoid therefore it seems to be the tendons... im not too knowledgable in orthopedics so i just go visit an orthopedics and ask them about the possibility of a scaphoid fracture? i guess its a possibility that the physio may of not recognise it yet? within 1-2 months of injury although the inital injury my parents told me my thumb muscle area was extremely swollen and i could not move the wrist lol but i thought it was a normal sprain... i am so confused i hate to be stuck with a long term injury because i have suffered so many injuries due to not seeing a specialist until its gotten in a bad state and now the physio i saw ages ago is clueless in what to do

[gcoe]

Hi Captain 127

I am not saying this is what you have and one should take into account that you have had it investigated. However scaphoid fractures are notorious for being missed.

[Captain127]

ok thanks i will see an osteopath soon and ask about scaphoid fractures and tendonitis thanks

[gcoe]

does applying upward pressure on the thumb as the patient described usually bring-on scaphoid fracture pain, it sounds like it woud lmake sense to do so but it is nto mentioned in the literature as a possible indicator like anatomical snuff box sensitivity etc

Yes you are right that this is not a formal test but painful thumb movements can and do go with scaphoid # Why don't you review the diagnostic accuracy of various clinical tests. I have put a ref for you to look at below but there may be better ones. My understanding is that clinical pain provoking tests are for scaphoid are highly sensitive particularly when combined, but that they have poor specificity - so good for picking up suspected fractures but lousy at ruling out non scaphoid #s. So get familiar with the tests available.

I don't know much about scaphoid fractures but am about ot start a placement where I will be dealign with them no doubt,
are they usually pinned if found or treated conservatively,

conservative management is the first choice. the problem is when it has been missed (so no immobilisation) and/or one of the three main complications arise - malunion, nonunion and avascular necrosis. When this happens I understand the two main surgical approaches is internal fixation, or bone chip implants

I have a feelign that scaphoid # patients are divided into 2 groups, those who pick up on it straight away and those who start to improve, then get better then worse again, then come back 4 treatment.
How are these patients typically treated and is there usually a difference in how they progress, if scaphoid #'s are treated conservatively shodu lwe as physio's treat them differntly then the pinned ones?

If the patient is treated conservatively and pain then increases it may well be that the management has failed and one of the complications has set in. Likewise those who are missed and not treated who get better for a bit then get worse - same scenario with the development of complications. The physiotherapy is based on the method of orthopaedic management - so generally I would be guided by the surgeon. On the whole the management is pretty straight forward and doesn't vary from any standard post fracture situation - increasing ROM and strength etc. Obviously a good assessment before starting will identify the main impairments that are present. But we do play an important role in picking up an occult fracture and referring on[/QUOTE]

what are the main issues to address, it sounds like (from the case below) these patients are more limited by pain than range, are mobs the kep to easign their pain? or does one strenghten the joint?

The key thing is to do know harm by neglect. So not going on treating a wrist injury if you suspect it needs an orthopaedic review. Localised mobilisations - again depends on what you are dealing with but I would be very careful and seek supervision if you think mobilisations are warranted for stiffness or painful stiffness
Also there is an article that reviews the management of scaphoid fractures which might be worth reading. All the best with your studies

Diagnosis and Management of Scaphoid Fractures - September 1, 2004 - American Family Physician

ScienceDirect - The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand : Combining the clinical signs improves diagnosis of scaphoid fractures : : A prospective study with follow-up

[crystal2]

When I tore my wrist ligament (slip and fall on the ice - OUCH), i went to physical therapy and they used an ultrasound on it - it really helped so i bought my own. There are a few home-use/portable ultrasounds, but I used Sonic Relief and was very pleased with it. The cost was reasonable and my PT liked that I used it at home. It's worth a try esp. for someone who is susceptible to regular injury (athletes, seniors, laborers). Hope this helps!

[gcoe]

Ultrasound is able to give temporary relief but that is all it does. It has found to have no value in healing. It also carries a small risk of causing a deep burn - not a pleasant side effect. There are cheaper and safer ways of giving yourself a bit of pain relief.

Captain 127 - an osteopath is not going to help you sought out a scaphoid fracture. In the UK oteopaths are alternative therapists. I m not saying don't try it but they can't really do a better diagnosis if that s what is needed

[Captain127]

really? i just saw that they deal with sports injuries and various other things and assumed they can diagnose the wrist, alternatively i should just go see a physio to checkup on my wrist again? as various other problems are developing as my middle and the other part of the wrist is beginning to cause even more pain than it used to now? I'm frankly just confused in seeking help from a different physio again or to seek out an osteopath to get an opinion from like a different perspective or just going to a hospital to get an x-ray again because a 4 month injured wrist is bad and with exams coming up i hate to break my wrist in rugby

[gcoe]

Hi captain127

4 months is a long time and I gather it is causing you significant pain and restriction in what you can do. It doesn't sound to me like it is healing up so it is time to really have it checked out. So what i am suggesting is not seek more treatment till you know what is going on. I would get it reviewed by an orthopaefic surgeon.

I take it you had a plain xray last time? Do you know which bone showed a crack? Plain xrays often fail to pick up scaphoid fractures. You often need to have a special image: MRI, scintograph or ultrasound. I don't think another physical examination is going to shed light on what is going on

Ifbyou really have had it checked out and no bone probs found then obviously you can choose the treatment of your choice. But neglecting a potential problem and really letting it get chronic is a bad idea.

[Captain127]

i believe so it was my first time having an x-ray it was just a hospital just an accident area i popped by got an x-ray seemed rather normal just laid my hand on the machine and a red light shined on my wrist and scanned it in angles, they showed me i believe it was the radius bone that there was a wee chip in it and i think it was towards the end of the radius (close to the wrist anyways) and it was below the thumb so i think thats the radius bone. I said that was just a wee chip no problem it'll just heal but they were adamant in having me in a splint and not to use my wrist too much saying that even if its just a small chip its still classified as a fracture. until i saw a bone specialist clinic in another hospital which they just went alright its nothing no fracture just a small problem just do what you can according to the pain and i went right ok bye because i was keen in playing rugby and continued my training. i only sought out a physio at that time for only 3 sessions was because my dad mentioned it to his physio and she told me to stretch it and i decided to actually see the physio myself.

but yeah i had an ordinary x-ray after like a month and this morning when i begun stretching a lot of pain sparked in the middle of my wrist that felt like it was spreading and intenisfying and gave a funny painful feeling that you cant contiunue although its worn off throughout the day but it could just be cause i hurt it a bit from training the day before but it does seems the other side of my wrist is getting worse.

It seems weird to see a surgeon and ask them to check it out since i thought you get some other specialist to diagnose you and if you need an operation to fix whatever you get refered over to a surgeon. I am a modest guy and do not like bothering/taking up professionals time which often leads me to forget to mention half the things i wanted to beforehand

[gcoe]

Hi captain 123

Thanks for the additional info. A small chip on the radius may be nothong but that doesn't rule out ligamentous injury or an an "occult scaphoid fracture" -ie one that was just not visble at the initial xray or the followup.

I am not trying to force you to see an orthoaedic surgeon and I can understand you reticence. The whole medical scene can be a bit intimidating and if ypu havealready seen a specialist you may feel a bit stupid going back or finding another for a further opinion. But if it is such a fracture it will not heal itself now - you may have a problem there.

However what I advised before - still stand by it. 4 months is too long. If you had fronted up to my clinic I would most probably get on the phone to a surgeon for you and organise it. However obviously I can't since you are not my patient.

So....I would look at it like this: you only get 1 body. Ther are no bionic wrists on the market - not since i looked lately anyway. So you will be living with that wrist for the rest of your life. Any physio, osteopath, or orthopaedic surgeon you visit won't be. You are lucky in that you live in a country where getting high quality help is won't necessarily cost you. You now know a bit more about what could be going on so I would suggest you stand up for yourself and insist on getting it properly investgated and don't take no for an answer.

But that is juat my opinion.

[Captain127]

okay thanks ill go and check if i can rule out the possibility of a scaphoid fracture. to arrange an appointment for an orthopaedic surgeon i presume its private and if its not scaphoid ill see what the surgeon recommends and see a physio or an osteopath for further diagnosis and see what'll happen.

Thanks a lot you have been extremely useful! This injury has just been causing nothing but a nuisance!

[gcoe]

Don't know if you can get it on the NHS. Cananyone from the ?UK advise captain 127?

[Captain127]

thanks a lot mate but ill just go get it checked by various specialists and see, seek an osteopath and see what they say and if its not helpful ill go get an x-ray from the injury department in a hospital again and if not ill see if i can get a referal from a different GP this time for an ultrasound hopefully that will find a problem and if not i will seek out an ostepathic surgeon somewhere

[Captain127]

Thanks mate it seems i have fractured my scaphoid bone and it also seems that i must of sustained it within the time between my 1st x-ray and my 2nd x-ray but i think that it started off as a crack then developed into a fracture in my opinion but anyways ill be seeing a hand specialist. You have been very helpful! thanks a lot!

[dano75]

Hi Captain127,

I know this thread is a month old, but I wanted to know how you are getting on. I read your original post and it was scarily similar to what happened to me. I hope you have had it checked out now.

In 1993 I was playing rugby when I charged down a kick from the opposition scrum half at the back of a maul. Unfortunatley he kicked my hand in the process. It hurt like hell but I ignored it and weeks later it seemed to have got better. Fast forward to the end of 2009. My wrist was hurting more and more with loss of strength and movement. I had it x-rayed and was told that I had suffered a proximal pole fracture of the scaphoid and was also suffering arthritis due to the change in the joint.
May 2010 I had a radialstyloidectomy with a bone graft of the scaphoid. Unfortunately it failed. In December 2010 the scaphoid pole that was floating around was removed. I am still in considerable pain and can hardly move my wrist now. I suspect what will happen next is a fusion of the wrist. I am only 36 years old.

I strongly reccommend if you havn't done so already to have it fully investigated otherwise you could pay for it in the future.

I'm sure lots of people on here will tell you that a scaphiod fracture may not show up on an xray until a few weeks after the injury. Good luck!

[Captain127]

thanks and sorry to hear about that. luckily it was somewhat bad as it affected my daily routines and i am into rugby and gym a lot that i just had to get it checked on continuously. it is indeed a proximal pole fracture of the scaphoid for me which is about 5-6 months old so im having an operation for a wire/screw in it. hopefully i will be back within 2 months to play the very last game and to continue my work outs! best of luck for you! they should make scaphoid injuries more known in rugby as we tend to ignore any niggles or pain and let it get worse as time progresses!

[gcoe]

Yes good thing you did get it checked Captain127 and although neglected fractures don't all go as bad as is the case with dano 75 (worst case scenario, but not uncommon), he gives good advice. Yes better awareness in football would be good it is an injury that isn't confined to one contact sport. Any younger person who has sustained a hyperextension injury to the wrist such as a high impact fall on an oustretched hand should be screened for a scaphoid fracture from the start and certainly investigated further whn symptoms persist. So thanks Dano

Finally we should thank our physio student here for having the knowlwdge and doing the homework for raising it with you on the first place. Well done Sarah Kelly!

[Captain127]

yes thank you very much everyone. never suspected a scaphoid fracture since i saw a private physio but ive grown a bit more sceptical in what im told. i guess when you cant move something in your body and seems swollen you ought to go give a hospital a visit immediately!