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Wrist trauma: Wrist Injuries | Wrist Disorders


It’s All In The Wrist: Common Wrist Injuries And When To Get Help

The wrist has 15 bones, 17 ligaments, 24 tendons, three nerves, two major arteries — and numerous possibilities for injury.

This complex part of the body is prone to both traumatic and non-traumatic injury. Henry Ford hand surgeon Charles Day, M.D. covers common wrist injuries and what to do if you find yourself up to your wrist in pain.

Traumatic Wrist Injuries

“The majority of wrist injuries are traumatic,” says Dr. Day. “They encompass wrist fractures and damage to the ligaments.”

Fractures And FOOSH

FOOSH stands for “fall on outstretched hand.” As Dr. Day explains, “Although FOOSH isn’t the only reason for wrist fractures, it’s the major one.” Common wrist fractures include:

  • Distal radius fracture: The most common type of wrist fracture, distal radius fractures occur at the end of the forearm near the wrist.
  • Scaphoid fracture: Another frequent FOOSH injury — and the second-most common wrist fracture — scaphoid fractures also affect athletes. In a scaphoid fracture, one of the small bones of the wrist is fractured, causing pain below the base of the thumb. It also happens to be the one bone in the wrist that is hardest to heal after a fracture.
  • Chauffeur’s fracture: Also known as radial styloid fractures, chauffeur’s fractures typically result from a hit to the radius bone near the base of the thumb.
  • Ulnar styloid fracture: The ulnar styloid process is the bony projection at the end of your arm near your wrist. Symptoms of ulnar styloid fracture include pain and swelling near the outside of the wrist.

Ligament Injuries

Wrist ligament injuries can also be caused by trauma — FOOSH and otherwise. Wrist sprains are traumatic injuries to the wrist ligament. Sprains can range from a minor ligament tear that almost always heals, to a complete rupture that rarely heals without surgery. There are a number of different traumatic ligament injuries, including:

  • Scapholunate ligament injury: Essential for full wrist motion, the scapholunate ligament can be stretched or torn partially or completely in a fall or if the wrist is bent backwards.
  • Triangular Fibro Cartilage Complex (TFCC) injury: This structure, which stabilizes the forearm bones as the hand grasps and the arm rotates, can be injured or torn with FOOSH and wrist hyperextension.
  • Lunotriquetral ligament injury: This often difficult-to-diagnose (and pronounce) injury may result from hyperextension of the wrist and FOOSH.

Non-Traumatic Injuries

Trauma isn’t the only way to injure your wrist. “Non-traumatic injuries are often due to overuse, although sometimes a medical condition may be involved,” says Dr. Day. Non-traumatic wrist injuries include:

  • Carpal tunnel syndrome: This is the most common non-traumatic injury and can affect up to 10 percent of people who work in administration and manufacturing. Carpal tunnel syndrome is usually due to increased pressure in the carpal tunnel that presses on a nerve, resulting in pain, numbness and weakness.
  • De Quervain’s tenosynovitis: Also known as “Mommy’s Thumb,” this type of tendonitis causes pain in the thumb, wrist and forearm. It can be the result of — you guessed it — picking up a baby. “That’s not the only cause of De Quervain’s tenosynovitis, of course,” says Dr. Day. “De Quervain’s can also occur with repetitive movements of the thumb.”
  • Ganglion cyst: Ganglion cysts are more unsightly and annoying than painful or dangerous. They form when fluid leaks from a joint and the body forms a wall around it. “Ganglion cysts can be effectively, and usually permanently, removed with outpatient surgery under local anesthesia,” says Dr. Day. “However, patients can also simply live with a ganglion cyst since it is not harmful.”
  • Arthritis: Arthritis causes inflammation and swelling of the body’s joints. Since the wrist is comprised of a number of joints, it’s especially vulnerable to arthritis due to a previous injury. The base of the thumb is the part of the hand most commonly affected by arthritis. Base of the thumb arthritis affects 16 percent of all women and 8 percent of all men over the age of 45. “There are a number of different types of arthritis that may affect the wrist,” remarks Dr. Day.

What To Do If You Have Wrist Pain

Your wrist is sore, difficult to move or swollen. Now what? According to Dr. Day, the first step to wrist injury treatment is likely immobilization, preventing the wrist from moving. “Unless the wrist is obviously fractured, you can begin by splinting it with a brace,” he says. “Preventing the thumb and wrist from moving will help the body begin to heal and reduce swelling. Just keep in mind that fractures and torn ligaments take six to eight weeks to heal.”

For traumatic injuries, Dr. Day recommends a spica splint, which comes up the thumb. Spica splints are particularly effective for injuries that involve the thumb or the part of the wrist closer to the thumb. For non-traumatic injuries, including tendonitis, carpal tunnel syndrome and arthritis, a wrist brace or Ace-type bandage can provide relief.

When To Seek Help

“If you have symptoms after wearing a brace for four or five days after an injury, you need professional wrist injury treatment,” Dr. Day advises. “You likely have something other than a sprain or a bruise.” For non-traumatic injuries, Dr. Day recommends making an appointment if wearing a brace doesn’t provide relief over two weeks or if pain wakes you at night.

“Continued pain, swelling, lack of mobility and other symptoms mean something is wrong,” remarks Dr. Day. “In some cases, wrist injury treatment doesn’t just provide relief. It can help you avoid permanent damage.”

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To find an orthopedic surgeon at Henry Ford, visit henryford.com or call 1-800-HENRYFORD (436-7936). 

Dr. Charles Day is an orthopedic surgeon who specializes in hand and wrist surgery. He sees patients at Henry Ford Hospital in Detroit and Henry Ford Medical Center Bloomfield Township.

Tags: Charles Day, Orthopedics

Hand and Wrist Injuries: Part I.

Nonemergent Evaluation

JAMES M. DANIELS II, M.D., M.P.H., Southern Illinois University School of Medicine, Quincy, Illinois

ELVIN G. ZOOK, M.D., Southern Illinois University School of Medicine, Springfield, Illinois

JAMES M. LYNCH, M.D., Florida Southern College, Lakeland, Florida

Am Fam Physician. 2004 Apr 15;69(8):1941-1948.

This is part I of a two-part article on hand injuries. Part II, “Emergent Evaluation,” appears in this issue on page 1949 (Am Fam Physician 2004; 69:1949–56).

Diagnosis of upper extremity injuries depends on knowledge of basic anatomy and biomechanics of the hand and wrist. The wrist is composed of two rows of carpal bones. Flexor and extensor tendons cross the wrist to allow function of the hand and digits. The ulnar, median, and radial nerves provide innervation of the hand and wrist. A systematic primary and secondary examination of the hand and wrist includes assessment of active and passive range of motion of the wrist and digits, and dynamic stability testing. The most commonly fractured bone of the wrist is the scaphoid, and the most common ligamentous instability involves the scaphoid and lunate.

Whether a physician is working in a rural clinic or an urban academic center, or is attending a high school football game, acute injuries of the hand and wrist will be encountered. Patients may not appreciate the severity of these injuries and are as likely to present in a clinic as in the emergency department. Timely diagnosis and treatment of upper extremity injuries are of paramount importance. Failure to diagnose, manage, and rehabilitate upper extremity injuries has the potential to result in permanent disability.1

Part one of this two-part article reviews an anatomic-based examination of the hand and wrist, allowing the physician to quickly evaluate a patient in a nonemergent setting. Part two2 focuses on the emergent evaluation of hand and wrist injuries.


The bones of the wrist.


Many injuries of the hand and wrist are obvious, but subtle injuries can be missed without a systematic primary and secondary examination. There are eight carpal bones in the wrist, five metacarpals, and 14 nonsesamoid bones that comprise the phalanges. These 27 bones act dynamically to allow oppositional grip.3 The proximal row of carpal bones includes the scaphoid (i.e., carpal navicular bone), lunate, triquetrum, and pisiform, which are closely approximated to the distal radius (Figure 1). The triangular fibrocartilage complex, an articular disk located between the proximal row of carpals and the ulna, completes the concave surface on which the carpals move (Figure 2). The distal row of carpals includes the hamate, capitate, trapezium, and trapezoid, which are closely approximated to the metacarpals. The scaphoid links the two rows of carpals.

Each digit has two neurovascular bundles near the palmar aspect of the finger—one located radially and the other ulnarly. The neurovascular bundle includes the digital artery, vein, and nerve.4


The dorsum of the hand.

Twelve extensor tendons of the wrist are arranged in six compartments along the dorsum of the wrist. There are multiple slips of the abductor pollicis longus and two slips of the extensor digiti quinti. The extensors originate in the lateral and dorsal forearm, inserting on the dorsal aspect of the hand. Twelve flexor tendons of the wrist originate in the medial part of the forearm and insert on the palmar aspect of the hand and wrist.5


The tendons of the finger.

Each phalanx has a superficial flexor tendon that inserts at the base of the middle phalanx and a profundus flexor tendon that inserts at the base of the distal phalanx. Consequently, injuries of the flexor tendons are more complicated to evaluate and repair than injuries of the extensor tendons.

The extrinsic extensor tendon attaches to the base of the dorsum of the middle phalanx, and bands from the intrinsic hand muscles attach to the distal phalanx. The tendons are connected by fibers that form a hood over the proximal interphalangeal (IP) joint6 (Figure 3).

In general, the radial nerve accounts for wrist and finger extension, the ulnar nerve provides power grip, the median nerve allows for fine control of the pincer grip, and the median and ulnar nerves supply sensation to the palmar surface. However, to truly place the hand in a functioning position, the entire upper extremity must be involved. The ulnar nerve enters the hand alongside the ulnar artery through Guyon’s canal, located between the pisiform and the hook of the hamate and covered by the pisohamate ligament (Figure 4). The ulnar nerve supplies the intrinsic muscles of the hand as well as the extrinsic muscles for flexion of the fourth and fifth fingers to provide power grip. The ulnar nerve also innervates the adductor pollicis and first dorsal interosseous muscles, which allow pinch. The median nerve passes into the hand via the carpal tunnel of the volar aspect of the wrist. The median nerve supplies the thenar compartment, providing opposition and circumduction for fine control. The radial nerve extends the fingers to enhance grasp with the ulnar nerve.


The palm of the hand.


An efficient method for evaluating the hand is to begin with a primary survey, then perform a secondary survey. Summaries of each examination are given in Tables 1 and 2.

View/Print Table


Primary Physical Examination of the Hand and Wrist
Examination technique Abnormal result Possible pathology

While the patient’s hand is in the resting position look for fingers that are flexed or extended

Flexed finger

Disrupted extensor tendon (see Figure 6 right)

Extended finger

Disrupted flexor tendon (see Figure 6 left)

While patient flexes fingers toward the palm, check that tips of fingers point toward the scaphoid (see Figure 7)

Fingers extend normally but overlap when flexed

Fracture with rotational deformity of finger

Check for changes in skin color or ability to sweat

Part or all of finger has a different skin color (blanched or hyperemic) or lacks ability to sweat

Digital nerve injury

Check capillary refill after applying pressure to distal fingertip or nail bed

Blanching lasts more than two seconds

Microvascular compromise

Check two-point discrimination in distal fingertip using blunt calipers or a paper clip

Patient cannot distinguish two points at least 5 mm apart

Neurologic compromise


Primary Physical Examination of the Hand and Wrist
Examination technique Abnormal result Possible pathology

While the patient’s hand is in the resting position look for fingers that are flexed or extended

Flexed finger

Disrupted extensor tendon (see Figure 6 right)

Extended finger

Disrupted flexor tendon (see Figure 6 left)

While patient flexes fingers toward the palm, check that tips of fingers point toward the scaphoid (see Figure 7)

Fingers extend normally but overlap when flexed

Fracture with rotational deformity of finger

Check for changes in skin color or ability to sweat

Part or all of finger has a different skin color (blanched or hyperemic) or lacks ability to sweat

Digital nerve injury

Check capillary refill after applying pressure to distal fingertip or nail bed

Blanching lasts more than two seconds

Microvascular compromise

Check two-point discrimination in distal fingertip using blunt calipers or a paper clip

Patient cannot distinguish two points at least 5 mm apart

Neurologic compromise


The primary survey includes evaluation of passive and active range of motion of the fingers and wrist while noting the resting position of the hand. Manipulation is not always necessary; much can be noted about the hand and fingers with simple observation.

View/Print Table


Secondary Physical Examination of the Hand and Wrist
Examination technique Abnormal result Possible pathology

The patient flexes the proximal IP joint of the affected finger while the other fingers are kept extended.

Patient cannot flex joint

Disrupted flexor digitorum superficialis

The patient extends the distal IP joint of the affected finger while the other fingers are kept extended.

Patient cannot flex joint

Disrupted flexor digitorum profundus (i.e., jersey finger)

The patient extends the distal IP joint of the affected finger.

Patient cannot extend joint or lacks complete joint extension

Fracture of distal phalanx or rupture of extensor tendon (i.e., mallet finger)

The patient shakes hands with the examiner, then attempts to pronate and supinate the wrist while the examiner resists movement.

Patient has pain or cannot complete the movement

Pathology of distal ulnar joint or triangular fibrocartilage complex (in the absence of radiographic findings)

Locate the small, bony prominence on the ulnar aspect of the palm in the area of the palmar crease.


Trauma to pisiform

After pisiform is located, the physician’s thumb IP joint is placed on the pisiform, and the thumb is directed toward the patient’s index finger. When the patient flexes the wrist, the hook of the hamate can be felt with the tip of the thumb.


Fracture of hook of the hamate

Follow the extensor carpi radialis tendon distally where it intersects the palmar crease, then palpate the small protuberance.


Fracture of scaphoid tubercle

Locate the extensor pollicis longus and abductor pollicis longus, then palpate the depression between them (the anatomical snuff-box).


Fracture of distal pole

Physician’s thumb is placed on scaphoid tubercle while thewrist is held in ulnar deviation, then the patient actively radially deviates the wrist while the physician exerts pressure on the tubercle (see Figure 8)


Fractured scaphoid

Pain with clunk

Scapholunate instability

Patient’s wrist is held in flexion while the physician resists active finger extension (see Figure 9)


Parascaphoid inflammation, radiocarpal instability, midcarpal instability


Secondary Physical Examination of the Hand and Wrist
Examination technique Abnormal result Possible pathology

The patient flexes the proximal IP joint of the affected finger while the other fingers are kept extended.

Patient cannot flex joint

Disrupted flexor digitorum superficialis

The patient extends the distal IP joint of the affected finger while the other fingers are kept extended.

Patient cannot flex joint

Disrupted flexor digitorum profundus (i.e., jersey finger)

The patient extends the distal IP joint of the affected finger.

Patient cannot extend joint or lacks complete joint extension

Fracture of distal phalanx or rupture of extensor tendon (i.e., mallet finger)

The patient shakes hands with the examiner, then attempts to pronate and supinate the wrist while the examiner resists movement.

Patient has pain or cannot complete the movement

Pathology of distal ulnar joint or triangular fibrocartilage complex (in the absence of radiographic findings)

Locate the small, bony prominence on the ulnar aspect of the palm in the area of the palmar crease.


Trauma to pisiform

After pisiform is located, the physician’s thumb IP joint is placed on the pisiform, and the thumb is directed toward the patient’s index finger. When the patient flexes the wrist, the hook of the hamate can be felt with the tip of the thumb.


Fracture of hook of the hamate

Follow the extensor carpi radialis tendon distally where it intersects the palmar crease, then palpate the small protuberance.


Fracture of scaphoid tubercle

Locate the extensor pollicis longus and abductor pollicis longus, then palpate the depression between them (the anatomical snuff-box).


Fracture of distal pole

Physician’s thumb is placed on scaphoid tubercle while thewrist is held in ulnar deviation, then the patient actively radially deviates the wrist while the physician exerts pressure on the tubercle (see Figure 8)


Fractured scaphoid

Pain with clunk

Scapholunate instability

Patient’s wrist is held in flexion while the physician resists active finger extension (see Figure 9)


Parascaphoid inflammation, radiocarpal instability, midcarpal instability

A patient’s inability to assume the “safe hand” position (Figure 5) may suggest a tendon or nerve disruption. 7 If the hand is immobilized in the safe hand position, extension contractures of the metacarpophalangeal (MCP) joint and flexion contractures of the IP joints can be avoided. In normal anatomic position, the thumb is slightly abducted, the MCP joint is at 45 to 70 degrees, and each of the IP joints is slightly flexed at 10 degrees. Physicians should be alerted to the possibility of tendon disruption if any of the fingers are not maintained in the position8 (Figure 6). As the hand is closed, fingers should point toward the base of the scaphoid (Figure 7). The distal nail tips should align when the fingers are partially flexed.

Subtle skin changes can alert the physician to possible nerve injury. The hand normally has moisture on it; absence of moisture on the distal phalanx may indicate a digital nerve injury. The vascular status of the finger is evaluated by blanching the fingertip; capillaries should refill within two seconds. Sensory nerve function of the digits can be evaluated with two-point discrimination using a paper clip or blunt calipers. The patient should be able to distinguish two points about 5 mm apart.3

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Normal anatomic position of the hand (the “safe hand” position).


Normal anatomic position of the hand (the “safe hand” position).


The secondary survey should include tests of the superficialis and profundus flexor tendon of each finger.1 With practice, each of the flexor tendons of the fingers can be evaluated. Each digit should flex independently. The patient should be able to actively flex the distal IP joint, indicating an intact profundus flexor tendon. The superficialis tendon is evaluated by having the patient flex the proximal joint of the finger while the remaining fingers are extended. If there is any question of tendon disruption, a simple test can be performed. In this test, the physician grasps the patient’s forearm approximately 6 to 7 cm from the proximal palmar crease of the wrist and squeezes the forearm. 9 As the forearm is grasped, each of the flexor tendons can be identified by passive flexion of the patient’s corresponding digit. Range of motion of the wrist, as well as any deformity or swelling, should be noted. Full forced pronation and supination of the hand without pain virtually eliminates pathology of the distal radioulnar joint or triangular fibro-cartilage complex from consideration.10

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Signs of tendon injuries. (Left) Flexor tendon disruption. (Right) Extensor tendon disruption.


Signs of tendon injuries. (Left) Flexor tendon disruption. (Right) Extensor tendon disruption.

Palpation of the hand usually starts on the ulnar side. The pisiform can be palpated easily in the hypothenar eminence just distal to the distal wrist crease on the palmar ulnar aspect of the hand. To locate the hook of the hamate, the physician places his or her thumb’s IP joint on the patient’s pisiform and directs the distal aspect of his or her thumb toward the patient’s index finger. When the patient’s wrist is flexed, the hook of the hamate can be felt with the tip of the physician’s thumb. A fracture of the hook of the hamate usually is not apparent on typical radiographic images of the hand; a carpal tunnel view or computed tomographic scan sometimes is necessary.11

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Approximate location of the scaphoid bone. In the flexed position, all fingers should point to the scaphoid.


Approximate location of the scaphoid bone. In the flexed position, all fingers should point to the scaphoid.

The flexor carpi ulnaris, the flexor carpi radialis, and the palmaris longus tendons usually can be observed by having the patient oppose the thumb and fifth finger while flexing the wrist. The flexor carpi ulnaris inserts on the pisiform. Because 12 to 15 percent of people lack a palmaris longus tendon, care must be taken not to confuse the flexor carpi radialis for the missing tendon. The flexor carpi radialis can be seen distally on the volar radial aspect of the wrist as it crosses the distal palmar crease. In this area, the proximal tubercle of the scaphoid is a prominence that can be palpated easily. If the thumb is placed on the scaphoid tubercle, four fingers can wrap around the distal radius while the wrist is held in ulnar deviation. As the patient radially deviates the wrist, the scaphoid tubercle will volarflex into the physician’s thumb. If pressure is directed dorsally with the thumb, pain may be elicited. This reaction may indicate a fractured scaphoid, or a scapholunate instability if an associated “clunk” is noted. This maneuver is termed the Watson or Scaphoid Shift Test12 (Figure 8).

On the dorsum of the wrist, the anatomical snuff-box can be identified easily as the patient abducts and extends the thumb. The extensor pollicis longus tendon can be identified on the radial aspect of the wrist by having the patient raise the thumb with the palm pronated on a surface. The waist of the scaphoid is located just radial in a depression in the wrist. Pain in this area can be an indication of a scaphoid fracture.13 The patient’s wrist is then held in flexion, and active finger extension with resistance is tested. Significant parascaphoid inflammation, radial carpal, or midcarpal instability will cause considerable pain with this maneuver, known as the Shuck Test1 (Figure 9).

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The Watson or Scaphoid Shift Test. (Left) The physician’s thumb is placed on the scaphoid tubercle while the patient’s wrist is in ulnar deviation. Pressure is applied dorsally. (Right) The patient radially deviates the wrist. Great pain indicates ligamentous instability of the wrist between the scaphoid and the lunate.


The Watson or Scaphoid Shift Test. (Left) The physician’s thumb is placed on the scaphoid tubercle while the patient’s wrist is in ulnar deviation. Pressure is applied dorsally. (Right) The patient radially deviates the wrist. Great pain indicates ligamentous instability of the wrist between the scaphoid and the lunate.

The triscaphe joint is located by following the dorsal side of the second finger proximally; the physician’s thumb will fall into a recess. The scapholunate joint can be palpated by following the third finger proximally until the thumb falls into a recess, just distal to Lister’s tubercle dorsally. Lister’s tubercle is a small, mast-like protuberance in the center of the distal radius that is identified by palpating the distal radius while the patient flexes the wrist. The lunate is the most prominent area on the dorsum of a flexed wrist. Kienböck’s disease, a post-traumatic avascular necrosis of the lunate, is present in up to 20 percent of patients with lunate fractures.

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The Shuck Test for perilunate instability. (Left) The wrist is held in flexion by the physician, and the patient extends his or her fingers. (Right) The physician resists this movement. Significant parascaphoid inflammation, radial carpal, or mid-carpal instability may cause considerable pain with this maneuver.


The Shuck Test for perilunate instability. (Left) The wrist is held in flexion by the physician, and the patient extends his or her fingers. (Right) The physician resists this movement. Significant parascaphoid inflammation, radial carpal, or mid-carpal instability may cause considerable pain with this maneuver.


Understanding the surface anatomy of the hand and wrist allows the physician to evaluate common injuries and appreciate less common injuries that might be overlooked on examination.

The scaphoid is the most commonly fractured bone of the wrist. Most of these fractures are caused by falling on an outstretched hand. Depending on the patient’s age, bone density, and reaction time, this type of fall can result in a fractured scaphoid, scapholunate dislocation, or distal radius fracture. 14

Patients with pain over the anatomical snuff-box should be treated for a possible scaphoid fracture, and a radiograph in what is called the “stretch or navicular view” should be obtained. This type of fracture carries a high likelihood of nonunion. To prevent supination and pronation of the wrist, the patient should be put into a long arm cast, or a short arm thumb spica splint or cast and shoulder sling; a simple palmar splint or “sugar-tong” splint is inadequate.

Patients with negative radiographs should be put into a temporary thumb spica splint for two weeks. When they are reexamined, another radiograph should be taken. If the patient’s wrist is not tender and the second A gap of more than 3 mm in the scapholunate joint in a symptomatic patient should alert the physician to consider scapholunate instability until proven otherwise. radiograph is negative, the patient can be instructed to return only if symptoms recur. If the wrist is still tender, further evaluation and a surgical consultation are warranted even if the second radiograph is negative. 15

A fractured hook of the hamate is a less common injury of the wrist that often is not diagnosed because it is not apparent on standard radiographic views. This injury may occur when a patient falls while holding an object, and the object lands between the ground and the ulnar side of the palm. It also may be caused when a bat hits a ball or a golf club catches the ground, and the hypothenar eminence is struck. Standard radiographs and a “carpal tunnel” view should be obtained in patients with tenderness over the hook of the hamate, and the ulnar nerve should be tested. These patients can be put in an ulnar gutter splint or simple volar splint and referred to a surgeon, because treatment often requires removal of a bone chip.10

The most common ligamentous instability of the wrist occurs between the scaphoid and the lunate. Patients with injuries of these ligaments often have a high degree of pain even though initial radiographs may appear normal. A gap of more than 3 mm in the scapholunate joint is considered abnormal, and a comparison radiograph of the opposite wrist should be obtained. Physicians should suspect this type of injury if a patient has wrist effusion and pain that is seemingly out of proportion to the injury. Patients with this type of injury often will not tolerate a Watson test. These injuries require an immediate consultation but can be stabilized with a thumb spica splint.16

Wrist Fracture – StatPearls – NCBI Bookshelf

Continuing Education Activity

Distal radius fractures, commonly known as a wrist fracture, are defined by the involvement of the metaphysis of the distal radius. In younger patients, they are commonly associated with high-energy mechanisms, and in older patients, they more frequently occur with lower energy mechanisms or falls. They can result in significant morbidity if left untreated. Treatment can involve both non-operative and operative management and ultimately depends on several factors. This activity illustrates the evaluation and management of the wrist fractures and stresses the role of the interprofessional team in improving care for patients with this condition.


  • Summarize the epidemiology of wrist fractures.

  • Describe the typical imaging findings associated with wrist fractures.

  • Explain the criteria for non-surgical management of wrist fractures.

  • Outline the importance of collaboration among the interprofessional team in the evaluation of wrist fractures and the care of affected patients.

Access free multiple choice questions on this topic.


A distal radius fracture, commonly known as a wrist fracture, is defined by the involvement of the metaphysis of the distal radius. The fracture may or may not involve the radiocarpal joint, distal radioulnar joint, and/or the distal ulna.[1] This injury is commonly associated with high-energy mechanisms in younger patients and lower energy mechanisms or falls in older patients.[2] The fracture results in acute wrist pain and swelling, and if left untreated, it can result in significant morbidity. Treatment can involve both non-operative and operative management and ultimately depends on multiple factors.[3]


The mechanism of injury in a distal radius fracture is an axial force across the wrist with the pattern of injury determined by bone density, the position of the wrist, and the magnitude and direction of the force. Most distal radius fractures result from falls with the wrist extended and pronated.[1] This action places a dorsal bending moment across the distal radius. This type of injury is often referred to as a “fall onto an outstretched hand” or FOOSH. The relatively weaker, thinner dorsal bone collapses under compression; whereas, the stronger volar bone fails under tension resulting in a characteristic “triangle” of bone comminution with the apex volar and greater comminution dorsal. Cancellous impaction of the metaphysis compromises dorsal stability, and shearing forces impact the injury pattern, which often involves the articular surface.[4] High-energy injuries may result in significantly displaced or highly comminuted unstable fractures to the distal radius.

Common mechanisms in younger individuals

Common mechanisms in elderly individuals


A distal radius fracture is the most common fracture of the upper extremity.[1] These fractures happen in all patient populations and are the most common orthopedic injury with a bimodal distribution. More than 450,000 fractures occur annually in the United States, and that number continues to rise. Fractures of the distal radius represent approximately one-sixth of all fractures treated in emergency departments. Younger patients tend to be involved in higher energy trauma mechanisms, whereas older patients tend to be involved with lower energy falls. The incidence in the elderly population correlates with osteopenia and rises in incidence with increasing age which corresponds to the increased incidence of hip fractures.[5]

Risk factors in the elderly


Wrist fractures are common in patients with osteoporosis. Almost any type of fall on the hand is associated with a risk of wrist fracture.

History and Physical

Patients will typically present with variable wrist deformity and displacement of the hand relative to the wrist. The wrist usually swells, with ecchymosis, tenderness, and painful range of motion. The mechanism of injury should be investigated to assist in assessing the energy and level of destruction. It is essential to establish the patient’s functional status before the injury as well as occupational demands as these may aid in determining treatment direction. Document co-existing medical conditions that may affect healing such as osteoporosis, diabetes, and/or tobacco use.

The physical examination should include careful attention to the following:

  • Condition of the surrounding skin and soft tissue

  • Quality of vascular perfusion and pulses

  • The integrity of nerve function

  • Sensory 2-point discrimination

  • Motor function of intrinsic, thenar, and hypothenar muscles of the hand

  • Careful attention to median nerve function as acute carpal tunnel syndrome can occur up to 20% of the time[6]
  • The integrity of the median nerve requires assessment and documentation

Associated injuries include:


Imaging confirms fracture severity, determines stability, and guides the treatment approach. Plain radiographs should be obtained before and after reduction, if necessary. The standard radiographs include posteroanterior and lateral views of the wrist, as well as oblique views for further fracture definition. Oblique views are useful to help evaluate articular involvement, particularly the lunate fossa fragment. Contralateral wrist views may evaluate the patient’s normal ulnar variance and scapholunate angle. Computed tomography scan may demonstrate the extent of intraarticular involvement. It is important to know normal radiographic measurements of the distal radius because it is useful in identifying distal radius fractures. These measurements are also useful in determining treatment.

Important normal radiographic relationships include[7][8]:

  • Radial inclination: Average of 23 degrees

  • Radial height: Average of 11 mm

  • Volar tilt: Average of 11 degrees

Treatment / Management

Distal radius fractures may have either surgical or non-surgical treatment. Non-surgical treatment necessitates acceptable fracture displacement, angulation, and shortening. Should these criteria not be met, surgical treatment is the recommended approach.

Acceptable criteria for distal radius fractures include:

  • Radial height: Less than 5 mm shortening

  • Radial inclination: Less than 5-degree change

  • Articular step off: Less than 2 mm

  • Volar tilt: Dorsal angulation less than 5 degrees or within 20 degrees of the contralateral distal radius

Displaced fractures must undergo a closed reduction in an attempt to achieve an anatomic or acceptable reduction. Adequate anesthesia or analgesia, such as conscious sedation or hematoma block, are necessary for closed reduction.[9] Following the closed reduction, the arm should be immobilized in a long-arm, sugar-tong splint acutely, as opposed to a cast. A long-arm, sugar-tong splint prevents pronation, supination, and elbow flexion, thereby eliminating the brachioradialis as a deforming force. The splint will allow for swelling as opposed to a cast.[10] Post-reduction radiographs must be obtained to evaluate the quality of the reduction. If the fracture reduction meets the acceptable criteria, the patient may remain in the splint and follow up with an orthopedic surgeon where weekly radiographs will be obtained for the first 2 weeks. If the reduction is not maintained and is no longer acceptable, surgical intervention should be recommended. If the reduction is maintained, the splint may be converted to a cast and immobilized for a total of 6 weeks.

Non-displaced fractures are treated without surgery in a long-arm splint acutely and transitioned to a short-arm cast in the office for a total of 6 weeks with serial radiographs to monitor for fracture displacement and healing.

For fractures that do not meet acceptable alignment, surgical intervention is recommended.[3] The goal of surgical treatment is to achieve acceptable alignment and stable fixation for early motion. There are various methods of fixation, including pins, external fixators, dorsal plates, and a volar plate. Percutaneous pinning is useful in maintaining sagittal length and alignment in extra-articular fractures with a stable volar cortex. It is unacceptable when the volar cortex is comminuted, and therefore unstable, as there is not enough bony fixation to maintain reduction. Good outcomes have been reported up to 90% of the time if used appropriately. External fixation is often used in conjunction with percutaneous pin or plate fixation as it does not reliably restore the volar tilt on its own. This technique relies on ligamentotaxis to maintain fracture reduction. It is essential to limit the duration of external fixation to a maximum of 8 weeks and to perform aggressive hand therapy to maintain range of motion of the hand. Good outcomes have been reported up to 90% of the time if used appropriately. Open-reduction internal fixation with volar plating is much more common than dorsal plating. Volar plating is associated with irritation of both flexor and extensor tendons, and flexor pollicus longus tendon rupture may have occurred.[11][12] Volar plating offers support to the subchondral bone to help maintain fracture reduction. Dorsal plating is associated with extensor tendon irritation and rupture. It is typically necessary for displaced intra-articular fractures with dorsal comminution.

Differential Diagnosis

Radiographs confirm the diagnosis; however, the following must merit consideration:


Multiple Classification Systems of Distal Radius Fractures

Frykman Classification 

Based on the pattern of intraarticular involvement

  1. Extraarticular distal radius fracture

  2. 1 + distal ulna fracture

  3. Intraarticular distal radius fracture involving radiocarpal joint

  4. 3 + distal ulna fracture

  5. Intraarticular distal radius fracture involving distal radioulnar joint

  6. 5 + distal ulnar fracture

  7. Intraarticular distal radius fracture involving radiocarpal and distal radioulnar joint

  8. 7 + distal ulna fracture

Fernandez Classification

Based on the mechanism of injury

  1. Metaphyseal bending fracture with the inherent problems of loss of volar tilt and radial shortening relative to the ulna

  2. Shearing fracture requiring reduction and often buttressing of the articular segment

  3. Compression of the articular surface without the characteristic fragmentation; also the potential for significant interosseous ligament injury

  4. Avulsion fracture or radiocarpal fracture-dislocation

  5. Combined injury with significant soft tissue involvement owing to high-energy injury

Common Eponyms for Distal Radius Fractures

Colles fracture

  • Low energy, intraarticular and extraarticular distal radius fracture demonstrating dorsal angulation, dorsal displacement, and radial shortening

  • Clinically, described as a “dinner fork” deformity

Smith fracture

Barton fracture

  • Fracture-dislocation or subluxation of the wrist. The dorsal or volar rim of the distal radius gets displaced with the hand and carpus

  • Volar involvement is more common

Chauffeur’s fracture

Die-punch fracture


Overall good to excellent results can be expected in over 80% of patients regarding a range of motion, strength, and outcomes scoring with open-reduction internal fixation and volar plating. Studies comparing volar fixation to other forms of fixation have revealed similar if not superior results. Results appear to be superior in the early recovery period with the outcome yielding equivalent results among all fixation groups. Some studies suggest better maintenance with volar plating in overall reduction compared to other forms of fixation.[1]


Median Nerve Neuropathy (Carpal Tunnel Syndrome)[6]

  • Most frequent neurologic complication

  • One percent to 12% of low-energy fractures and up to 30% of high-energy fractures

  • Treat with acute carpal tunnel release in progressive paresthesias, weakness in thumb opposition if symptoms do not respond to closed reduction, and if they last greater than 24 to 48 hours

Extensor Pollicus Longus Tendon Rupture[11][12]

Radiocarpal Arthrosis

  • The reported incidence of up to 30%

  • Ninety percent of young adults will develop symptomatic arthrosis if articular step-off is greater than 1 to 2 mm

  • May also be asymptomatic

  • Malunion and nonunion

Compartment Syndrome

Complex Regional Pain Syndrome

Postoperative and Rehabilitation Care

Postoperative care for open-reduction internal fixation with volar plating includes immediate volar splinting following surgery. The patient is instructed to perform active range of motion exercises for the digits and elevate their wrist above heart level to prevent stiffness and aid in edema control. The splint is removed 1 to 2 weeks after surgery for a wound check. A removable splint should be fabricated by a hand therapist to help with edema and worn at all times to protect fracture fixation. The patient should remain non-weight bearing of the upper extremity but may begin active range of motion exercises of the wrist after the first post-operative visit. At 4 to 6 weeks putty and grip exercises may be added. At 6 to 8 weeks, the splint is discontinued, and progressive strengthening exercises are advanced. The patient will typically be discharged to activities as tolerated at the 10 to 12-week mark.

Enhancing Healthcare Team Outcomes

Wrist fractures are complex because of the number of anatomical structures that may be involved. The majority of these patients have their initial encounter with the nurse practitioner or emergency department physician. Once the diagnosis of wrist fracture is made, an orthopedic or hand surgery consult is usually the next step. Poorly managed wrist fractures demonstrate enormous morbidity and often lead to limited use of the hand. Asides from pain control and stabilization, these patients should receive a referral to a hand or orthopedic surgeon. Mild fractures may undergo management with closed reduction, but severely displaced fractures may require ORIF.

Once the wrist fracture is managed, the primary care clinicians should follow the patient for pain management, which can be significant. Before recommending the patient back to work, the orthopedic surgeon should re-examine the patient. Long term monitoring is necessary because even surgery has its complications, and not everyone obtains the desired result. Communication between the team members should be open to ensure that the patient receives the optimal level of care. Nursing will play a pivotal role in either surgical or conservative management, but monitoring on followup visits, checking progress and coordinating with any physical or occupational therapy. This type of interprofessional coordination is necessary to achieve optimal outcomes and minimize morbidity.

The outlook for most patients is fair, but a significant number do have chronic pain and limited range of motion after treatment. Physical therapy is a must to regain muscle function and strength.[13][14]


CT versus plain film x-ray wrist fracture. Contributed by John Copeland, DO


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Distal Radius Fracture (Wrist Fracture)

What is a distal radius fracture?

The radius is one of two forearm bones and is located on the thumb side. The part of the radius connected to the wrist joint is called the distal radius. When the radius breaks near the wrist, it is called a distal radius fracture.

The break usually happens due to falling on an outstretched or flexed hand. It can also happen in a car accident, a bike accident, a skiing accident or another sports activity.

A distal radius fracture can be isolated, which means no other fractures are involved. It can also occur along with a fracture of the distal ulna (the forearm bone on the small finger side). In these cases, the injury is called a distal radius and ulna fracture.

Depending on the angle of the distal radius as it breaks, the fracture is called a Colles or Smith fracture.

  • A Colles fracture may result from direct impact to the palm, like if you use your hands to break up a fall and land on the palms. The side view of a wrist after a Colles fracture is sometimes compared to the shape of a fork facing down. There is a distinct “bump” in the wrist similar to the neck of the fork. It happens because the broken end of the distal radius shifts up toward the back of the hand.
  • A Smith fracture is the less common of the two. It may result from an impact to the back of the wrist, such as falling on a bent wrist. The end of the distal radius typically shifts down toward the palm side in this type of fracture. This usually makes for a distinct drop in the wrist where the longer part of the radius ends.

What are the symptoms of a distal radius fracture?

  • Immediate pain with tenderness when touched
  • Bruising and swelling around the wrist
  • Deformity — the wrist being in an odd position

What is the treatment for a distal radius fracture?

Decisions on how to treat a distal radius fracture may depend on many factors, including:

  • Fracture displacement (whether the broken bones shifted)
  • Comminution (whether there are fractures in multiple places)
  • Joint involvement
  • Associated ulna fracture and injury to the median nerve
  • Whether it is the dominant hand
  • Your occupation and activity level

In any case, the immediate fracture treatment is the application of a splint for comfort and pain control. If the fracture is displaced, it is reduced (put back into the correct position) before it is placed in a splint. Fracture reduction is performed under local anesthesia, which means only the painful area is numbed.

Nonsurgical Treatment

If the distal radius fracture is in a good position, a splint or cast is applied. It often serves as a final treatment until the bone heals. Usually a cast will remain on for up to six weeks. Then you will be given a removable wrist splint to wear for comfort and support. Once the cast is removed, you can start physical therapy to regain proper wrist function and strength.

X-rays may be taken at three weeks and then at six weeks if the fracture was reduced or thought to be unstable. They may be taken less often if the fracture was not reduced and thought to be stable.

A displaced fracture needs to be corrected first. Once it is anatomically aligned, a plaster splint or cast is applied. The reduction (closed reduction) is usually performed with local anesthesia. Your orthopaedic surgeon will evaluate the fracture and decide whether you will need surgery or if the fracture can be treated with a cast for six weeks.

Surgery for Distal Radius Fractures

This option is usually for fractures that are considered unstable or can’t be treated with a cast. Surgery is typically performed through an incision over the volar aspect of your wrist (where you feel your pulse). This allows full access to the break. The pieces are put together and held in place with one or more plates and screws.

In certain cases, a second incision is required on the back side of your wrist to re-establish the anatomy. Plates and screws will be used to hold the pieces in place. If there are multiple bone pieces, fixation with plates and screws may not be possible. In these cases, an external fixator with or without additional wires may be used to secure the fracture. With an external fixator, most of the hardware remains outside of the body.

After the surgery, a splint will be placed for two weeks until your first follow-up visit. At that time, the splint will be removed and exchanged with a removable wrist splint. You will have to wear it for four weeks. You will start your physical therapy to regain wrist function and strength after your first clinic visit. Six weeks after your surgery, you may stop wearing the removable splint. You should continue the exercises prescribed by your surgeon and therapist. Early motion is key to achieving the best recovery after surgery.

Sports-related wrist and hand injuries: a review | Journal of Orthopaedic Surgery and Research

Approximately 25 % of all sports-related injuries involve the hand or wrist [1, 2], and incidence is growing not only due to the competitive level of high school and collegiate athletes but also due to the activity level of the general population [3]. While the shoulder and knee are the commonly thought of in athletic injury, hand and wrist injuries are common and can have a significant impact especially if initially disregarded with a resultant delay to treatment.

Due to the high level of physical demand for function, athletes represent a unique subset of the population. Injury time can have a significant impact on scholarship opportunities or jeopardize professional aspirations with direct financial impact. Knowledge of common sports-related injuries and therapeutic strategies can help the physician effectively treat the athlete considering their sports, position, and timing during season. The following is an overview of hand and wrist injuries commonly seen in athletics. Information regarding evaluation, diagnosis, conservative measures, and surgical treatment are provided.

Radial-sided wrist injuries

Scaphoid fracture

Scaphoid fractures are the most commonly injured carpal bone [4] with a high incidence in college football players [5] and an increasing incidence in female athletes [6]. This hyperextension wrist injury tends to occur in a pronated, radially deviated hand. Presentation can range from disabling wrist pain to mild swelling and decreased range of motion. It is not uncommon to find a scaphoid nonunion with a remote history of a wrist sprain.

Located at the radial side of the carpus, athletes will complain of radial-sided wrist pain with exquisite tenderness in the anatomical snuff box, axial loading of the thumb, or pincer grasp. Radiographic assessment of the wrist should include a posteroanterior (PA), lateral, and ulnar deviated view. Unfortunately, due to subtle fracture lines and the irregular contour of the scaphoid, nondisplaced fractures can be missed on radiographs and advanced imaging with computed tomography (CT) scan for fracture identification or alignment. Additionally, magnetic resonance imaging (MRI) or bone scintigraphy for occult fracture may be needed to confirm the diagnosis [7, 8].

Treatment decisions depend upon fracture location and displacement, with strong surgical consideration being given to scaphoid fractures which are displaced and/or proximal. Whether treatment affects the athlete’s continued participation in his or her sports within the context of the status of the season may also play a role in determining whether or not to operate. Due to retrograde blood supply, distal pole scaphoid fractures can effectively be treated nonsurgically. Proximal pole fractures are prone to avascular necrosis and necessitate stronger surgical consideration [9, 10]. Likewise, displacement carries a relatively increased risk of nonunion and we would recommend surgical fixation. Operative management, mostly commonly in the form of headless compression screw fixation, often offers the fastest return to sports [11]. Cast immobilization may provide appropriate definitive treatment in a nondisplaced fracture or a temporizing measure for return to play. Return to athletic participation is based upon the athlete’s handedness, his or her specific sports’ requirements, and negotiating the bulk or restriction of the cast with respect to dexterity and/or strength [12] (Fig. 1).

Fig. 1

a PA radiograph of a nondisplaced proximal pole scaphoid fracture in a recreational hockey player. b PA radiograph of a nondisplaced scaphoid waist fracture in a high school soccer player treated with headless compression screw fixation

Scapholunate ligament tears

Wrist instability commonly occurs in a spectrum of severity in hyperextension injuries. Contact sports such as football or rugby commonly place the athlete in a position of impact with hyperextension, ulnar deviation, and supination of the wrist that can lead to these injuries.

Because of the proximity of structures in the wrist, diagnosis of these injuries can be challenging. Pain in a loaded, extended wrist with tenderness in the dorsal wrist at the interval between the third and fourth extensor compartments suggests possible scapholunate (SL) interosseous ligament injury. Standard radiographic assessment with PA and lateral views may appear normal only showing increased flexion of the scaphoid (a signet ring sign on the PA view as in Fig. 2a). A PA clenched fist view may show greater than 5 mm of widening between the scaphoid and lunate (Terry Thomas sign) is diagnostic of a complete SL ligament tear [13]. Chronic tears may demonstrate a static SL gap on the PA film and an increased SL angle on the lateral consistent with dorsal intercalated segmental instability (DISI). Advanced imaging is commonly needed in the form of MRI with or without contrast arthrography [14].

Fig. 2

a PA radiograph showing a flexed scaphoid (signet ring sign). b Intraoperative finding of a complete SL interosseous ligament tear with the tip of the probe on the scaphoid (yellow arrow). c Open reduction of the SL interval (blue arrow) prior to ligament repair

Suspected tears or partial tears can respond to immobilization allowing the participant to still compete. Those with continued pain and dysfunction that interferes with their level of play will require wrist arthroscopy. Geissler et. al. [15] developed an arthroscopic grading system which helps guide management that ranges from immobilization for attenuation of an intact ligament to open reduction and repair for gross instability.

Radial-sided tendinopathies

Radial-sided wrist pain from overuse injuries requires careful evaluation. Accurate diagnosis using provocative maneuvers and identifying the precise location of maximal tenderness are paramount. Radiographic assessment can be indicated for ruling out fracture depending on the patient’s history. Advanced imaging, such as MRI, is not routinely used.

The most common tendinopathy in the athlete is de Quervain’s tenosynovitis [16]. Repetitive thumb extension and abduction can lead to a thickening of the abductor pollicis longus and extensor pollicis brevis tendons as they pass under the first extensor compartment retinaculum. Tenderness to palpation is approximately 2 cm proximal to the radial styloid and exacerbated by tucking the thumb under the other fingers while ulnarly deviating the wrist (a positive Finkelstein’s sign) [17, 18].

Intersection syndrome, also called Oarsman’s wrist, is caused by friction at the crossing of the tendons of the first extensor compartment as they pass over the tendons of the second extensor compartment (extensor carpi radialis longus and brevis) or a stenosing tenosynovitis within the second extensor compartment itself [19]. Pain is elicited with extension and radial deviation approximately 4–8 cm proximal to the radial styloid. Without careful attention to the location of pain, this can be misdiagnosed as de Quervain’s tenosynovitis.

Tendonitis of the flexor carpi radialis is due to repetitive wrist flexion or acute overstretching of the wrist as can be seen in volleyball or water polo [20]. Pain develops from tendon thickening as it runs in its tunnel adjacent to the carpal tunnel. Pain typically courses from the radial palmar wrist crease towards the base of the second metacarpal made worse by resisted wrist flexion.

Conservative treatment for these tendinopathies begins by avoiding inciting events. Immobilization, stretching techniques, ice, and nonsteroidal anti-inflammatory medications can effectively diminish symptoms. Should symptoms persist, anesthetic/corticosteroid injections into the responsible tendon sheaths at the point of maximal tenderness can be of diagnostic and of therapeutic benefit. When recalcitrant to conservative measures, surgical release of the respective tunnel or compartment may be warranted.

Ulnar-sided wrist injuries

Extensor carpi ulnaris injury

Abnormalities of the extensor carpi ulnaris (ECU) covers an array of pathologies seen in golf, baseball, hockey, tennis players, and other racquet sports. Injury may present as acute or chronic encompassing tendinosis, subluxation, dislocation, or rupture causing pain with or without mechanical symptoms on the ulnar side of the wrist. The pathophysiology involves repetitive microtrauma or a sudden traumatic episode during wrist flexion, supination, and ulnar deviation such as the nondominant hand in a double-handed backhand in tennis or the leading hand in the downward phase of a golf stroke.

Injury to the ECU will typically present with pain over the ulnar aspect of the wrist. Tenderness to palpation in the ECU groove and pain with resisted extension and ulnar deviation are hallmarks of tendinopathy. Subluxation will give the sensation of snapping with supination and ulnar deviation of the wrist. The physician should also evaluate the triangular fibrocartilage complex (TFCC) as a peripheral tear can lead to ECU tendonitis. Radiographic assessment is not routinely required unless needed to rule out other causes of ulnar-sided wrist pain. Ultrasound (US) can be useful in identifying inflammatory changes or using a dynamic assessment to look for tendon subluxation or dislocation [21]. MRI can be helpful to assess other structures such as the TFCC.

Acute or chronic ECU tendinopathy can be managed with immobilization in wrist extension and ulnar deviation with progression to isometric and eccentric exercises. In cases of acute dislocation, reduction and immobilization with the forearm in pronation and the wrist in radial deviation for 4 months can be successful but not conducive to athletic participation [22]. Nonanatomic reconstruction of the subsheath with extensor retinaculum [23, 24] or, preferably, anatomic repair (Fig. 3) with reduction of the periosteum and subsheath back in the ulnar groove [25] are successful options to return to sports.

Fig. 3

a Intraoperative finding of a volarly subluxed ECU tendon (between yellow lines) in a recreational tennis player. b The ECU tendon back in its reduced position (red lines) after an anatomic repair of the subsheath

Ulnar abutment

The majority of load absorbed at the wrist is through the radiocarpal joint. In the ulnar neutral wrist, the distal ulna bears approximately 20 % of forces. As the wrist becomes more ulnar positive, the ulnocarpal joint experiences increased forces leading to ulnar-sided wrist pain. Ulnar positivity can be a normal anatomic variant, the result of distal radius physeal arrest (so-called gymnast’s wrist), or as a dynamic condition with grip and pronation [26, 27].

Rarely presenting after an acute injury, symptoms from ulnar abutment typically manifest as an insidious onset of pain with repetitive activities of pronation, gripping, ulnar deviation, axial loading, or combinations thereof which begin to affect the athlete’s level of play. Tenderness to palpation at the prestyloid recess of the ulna and pain with wrist ulnar deviation as moved through a full arc of pronosupination (ulnocarpal stress test) [28] is characteristic of the exam. Standard PA radiograph may reveal ulnar positivity but when dynamic ulnar positivity is suspected, a pronated/maximum grip PA view may be helpful in making the diagnosis [27]. MRI is not always necessary but may be helpful in evaluating the TFCC, early chondral changes in the distal ulna and/or the ulnar lunate, or lunotriquetral interosseous ligament tears.

As a slowly progressive condition, acute surgical treatment is rarely warranted. Conservative measures to decrease symptoms and avoid provocative activities can allow continued participation. Immobilization between practices with or without nonsteroidal anti-inflammatories can decrease pain. Corticosteroid injections as a diagnostic and therapeutic tool can be used in the more chronic setting [29]. If conservative measures fail to allow continued level of play or timing is optimal, surgical treatment can be used to halt the progression by decreasing ulnar positivity and debriding the degenerative TFCC tear. Arthroscopic debridement and ulnar shortening are the mainstays of treatment. While arthroscopic wafer resection enjoys the benefit of shorter recovery times [30–32], the gold standard is diaphyseal ulnar shortening osteotomy (Fig. 4) and has shown improvement in pain, motion, and function [33–35].

Fig. 4

a PA radiograph of a patient with ulnar abutment revealing both 6 mm of ulnar-positive variance and incidentally an ulnar styloid nonunion. b Neutral to −1 mm of ulnar variance after a diaphyseal ulnar shortening osteotomy is performed

Triangular fibrocartilage complex tears

Another cause of ulnar-sided wrist pain, particularly in those athletes who grip and rotate baseball bats, racquets, or golf clubs, is injury to the TFCC. The TFCC is a soft tissue complex that supports the distal radioulnar joint. It also acts as an extension of the radial articular surface serving as a load-bearing structure of the carpus on the distal ulna [3, 36]. In the acute setting, tears of the TFCC can occur with hyperextension and pronation of the axially loaded, ulnar deviated wrist. However, micro- or repetitive trauma can cause peripheral tears to the TFCC with rapid supination-pronation of the ulnar deviated wrist as seen with swinging a baseball bat.

Deep aching pain, pain with gripping, and occasionally mechanical symptoms of clicking with pronation-supination can be experienced. Tenderness at the prestyloid recess that is accentuated with extremes of rotation or translation of the ulna, anterior to posterior, is characteristic of the exam. Standard radiographic evaluation typically appears normal. MRI or MRA are commonly used to confirm the diagnosis (Fig. 5a) [37].

Fig. 5

a A T2-weighted coronal sequence of a wrist MRI revealing an ulnar-sided peripheral tear of the TFCC (yellow arrow). b Arthroscopy view from the three to four portal showing the peripheral tear (red arrow). c Intraoperative arthrosopic image during an arthroscopic-assisted outside-in repair using PDS suture (blue arrow)

As repetitive trauma is more common in athletes, conservative treatment is typically employed if symptoms arise during season. Immobilization, with or without physical therapy if ECU irritation is involved, for a period of 3 months can be helpful at alleviating symptoms [38]. Recalcitrant or recurring symptoms require arthroscopy for definitive classification as set forth by Palmer [36]. Symptomatic peripheral TFCC tears should be repaired either open or with arthroscopic assistance (Fig. 5b, c) [39–43] and typically require 3 months before return to play. Symptomatic tears of the central articular disk which fail conservative management can be treated with arthroscopic debridement (with or without a concomitant ulnar shortening osteotomy if indicated), but are not amenable to repair.

Hook of the hamate fractures

Direct blows from a golf club with the ground or from a baseball bat while “checking” a swing can result in hook of the hamate fractures. Infrequently, repeated lesser impacts from the same can result in stress fractures.

Hypothenar pain is present with palpation or with forceful grip. A pull test is performed by flexing the ring and small finger in the ulnar deviated wrist which produces pain by the deforming force of the flexors. Because the hook makes up one border of Guyon’s canal, dysesthesias in the ulnar nerve distribution or weak grip may be present. A carpal tunnel radiograph, in addition to standard PA and lateral views, is needed to make an accurate diagnosis. If radiographs are negative, a CT scan can be most helpful in defining the bony injury (Fig. 6).

Fig. 6

Axial CT image demonstrating a hook of the hamate fracture (red arrow) in a college hockey player

Most fractures on presentation are subacute or chronic making definitive treatment with immobilization difficult. Whalen et. al. [44] reported healing of all six fractures they treated with immobilization, but other reports have showed less success and may risk flexor digitorum profundus (FDP) tendon injury [45, 46]. Biomechanical studies have suggested a possible decrease in flexion force with hook of the hamate excision lending consideration for open reduction and internal fixation [47, 48]. Nonetheless, excision of the hook of the hamate fragment is currently the standard of care and has produced successful results with return to play in 6 weeks [49–53].

Hand/finger injuries

Thumb ulnar collateral ligament tears

Ulnar collateral ligament (UCL) injuries of the thumb are extremely common [54, 55] and often seen in skiing, basketball, and football. Injury occurs from an abduction moment at the thumb metacarpophalangeal joint (MCPJ) such as a fall onto an outstretched hand with the thumb abducted. An acute thumb UCL injury has been dubbed a skier’s thumb [56], in contrast to chronic attritional insufficiency of the ligament which is referred to as a gamekeeper’s thumb [57].

Acute injuries often present with pain, ecchymosis, and swelling on the ulnar aspect of the thumb MCPJ. Stress examination with the thumb in extension and 30° of flexion is the most important aspect of the physical exam [58]. Laxity of 30° total, greater than 15° to the contralateral, or lack of endpoint (Fig. 7a) are all strongly suggestive of ligament injury [59, 60]. The thumb UCL has two portions, the proper (more dorsally located) and the accessory (more volar) ligaments. Laxity at 30° of MCPJ flexion and at full MCPJ extension is suggestive of injury to both the proper and the accessory components, respectively. Radiographic assessment is important for excluding bony fragments but US or MRI (Fig. 7b) is often used to confirm the diagnosis. A Stener lesion refers to interposition of the adductor aponeurosis in between the torn off UCL and its proximal phalanx insertion, making healing impossible.

Fig. 7

a Preoperative photograph demonstrating a patient with no endpoint to valgus stress testing of the thumb MCP joint. b A T2-weighted coronal sequence demonstrating a complete tear of the UCL which is detached from the proximal phalanx (yellow arrow)

Immobilization with a hand-based thumb spica splint or a cast with the interphalangeal (IP) joint free is appropriate for treating UCL partial tears with a firm endpoint to valgus stress testing at the MCPJ. For complete tears without an endpoint, surgery is recommended. Most UCL injuries are amenable to direct repair using either transosseous sutures or a suture anchor, although more chronic tears may require reconstruction with a variety techniques available [61–63]. Both UCL repair and reconstruction have shown satisfactory results with decreased pain and increased function [64].

Metacarpal/phalangeal fractures

Accounting for 10 % of all fractures presenting to the emergency department, metacarpal and phalangeal fractures are common injuries [65–67]. Injuries occur from falls, direct blows, or crush during sporting activity, although stress fractures have rarely been noted in racquet sports [68, 69]. Incidence is highest in contact sports such as football, lacrosse, and hockey [2, 70–72].

While swelling, ecchymosis, and deformity can be present, not all fractures lead to obvious deformity. For those with obvious deformity, a reduction maneuver should not be attempted without radiographic or fluoroscopic examination first in order to ensure appropriate treatment of the specific fracture, dislocation, or fracture dislocation [73]. In less obvious injuries, careful clinical examination of the hand with respect to digital range of motion (ROM), the finger cascade, and comparison of any subtle malrotation to the contralateral hand might point to an occult injury. Radiographic assessment with anteroposterior (AP), oblique, and lateral views are standard. Training rooms have been increasingly outfitted with mini-fluoroscopy units for rapid evaluation, although their sensitivity in detecting fractures of the smaller bones with possible intra-articular involvement has been questioned [74]. If further imaging for fracture characteristics is needed, a CT scan may be indicated.

Many fractures can be treated nonoperatively if acceptable alignment can be maintained with immobilization. When conservative treatment is inadequate, operative fixation is indicated. In the athlete, operative fixation may be sought to allow faster return to play.

Metacarpal fractures

Metacarpal base fractures occur from an axial load with the wrist in flexion. Eponyms such as Bennett and reverse-Bennett fractures are used to describe the characteristic fractures of the thumb and small finger metacarpal. Bennett fractures are sometimes associated with significant displacement as strong muscular forces tend to pull the base of shaft in abduction and proximally. As an intra-articular fracture, acceptable alignment to decrease the chance of symptomatic, posttraumatic arthritis is desirable [75]. If there is more than 25 % articular involvement or more than 1 mm of articular step-off or gapping between fracture fragments, operative fixation is usually indicated. Closed or open reduction of the fracture stabilized with Kirschner wires (K-wires) or screws is frequently needed.

Metacarpal shaft fractures are typically stable due to the intermetacarpal ligaments, although the net flexion moment at the distal segment pulls these fractures into a classic apex dorsal position. Acceptable angulation depends on the metacarpal involved with no greater than 10° tolerated in the index and up to 30° in the small finger [76]. Shortening of greater than 2 mm is generally not well tolerated as it leads to an extensor lag that can eventually not be compensated for by the hyperextensible MCPJ [77]. Careful clinical exam should assess not only for the finger cascade but also for the rotational deformity. Mild rotation in the metacarpal can lead to significant finger overlap [76]. Immobilization of isolated fractures in acceptable alignment is usually possible but the type of sports and position can limit tolerability. Multiple forms of fixation are possible each with its own relative advantages and disadvantages. K-wire fixation offers a soft tissue friendly form of fixation, adequate in maintaining alignment but protruding pins risk infection and pin migration/breakage and preclude further participation with exposed hardware in gripping athletics (i.e., tennis, basketball, golf). Lag screw fixation (Fig. 8a, b), indicated in long oblique fractures, offers minimal dissection and an anatomic reduction, but stability may not allow an expedited return to play. Plate and screw fixation (Fig. 8c, d) offers the stability of a relatively quicker return to play [78], but may expose the player to an increased risk of infection, tendon irritation, extensor adhesions, and the need for future hardware removal. Which treatment is selected should be a collaboration between the surgeon, the athlete, and the training staff.

Fig. 8

a Intraoperative and b fluoroscopic images of a long oblique metacarpal shaft fracture secured with three lag screws. c Intraoperative and d fluoroscopic images of a transverse shaft fracture secured with a plate and screws

Metacarpal neck fractures are the most common metacarpal fracture as they occur at the metadiaphyseal junction at the area of the weakest bone. The so-called Boxer’s fracture is an eponym referring to metacarpal neck fractures of the small finger which result from an impact punching with a closed fist. Immobilization is typically adequate. Various forms of immobilization with the hand in intrinsic plus position or buddy taping with a short arm cast do not show any functional difference in outcome [79]. Acceptable alignment follows the same principles as for metacarpal shaft fractures with apex dorsal angulation being the most obvious deformity and increasing in toleration as the injury moves from the index to the small finger, with approximately 40°–50° of apex dorsal angulation well tolerated in the small finger. When acceptable alignment cannot be achieved or immobilization cannot be tolerated for the athlete, operative fixation is occasionally considered. Both K-wire and plate (Fig. 9) fixation have produced reasonably good outcomes, each with its own inherent risk/benefit profile as previously discussed.

Fig. 9

Plate and screw fixation of an angulated fifth metacarpal neck fracture in a high school running back

Phalangeal fractures

Shaft fractures of the proximal and middle phalanges can occur in a variety of patterns, but buddy taping and/or protective splint wear in acceptable alignment can allow fast return to play. Extra-articular fractures without rotational malalignment, less than 15°of angulation, and less than 6 mm of shortening are indicated for conservative treatment [80]. Operative fixation with open versus closed reduction using either K-wires (Fig. 10), screws, or plate and screws as fixation is sometimes required, especially when there is digital malrotation [81]. The athlete’s demands, the status of the season, and the fracture’s characteristics combine to dictate the optimal form of treatment.

Fig. 10

A PA radiograph of a small finger transverse proximal phalanx fracture with clinical malrotation which was treated with closed reduction and crossed K-wires

When fractures enter the articular surface of the phalangeal base or condyle, operative fixation should be sought unless less than 1 mm of gap or step-off is present. Fractures can range from simple articular fractures, fixed with K-wires or screws, to comminuted pilon-type fractures which may require a distraction fixator in order to restore articular alignment through ligamentotaxis [82–84].

Distal phalanx fractures, due to crush mechanisms, are typically stable with surrounding soft tissue and the overlying nail plate. The vast majority of these are treated nonoperatively; however, careful attention should be paid to those distal phalanx fractures with associated nail bed trauma, such as displaced physeal (Seymour type) fractures in children.

Dislocations or fracture dislocations, particularly those that spontaneously reduce on the field, can often be overlooked in athletics. These comprise a spectrum of hyperextension jamming-type injuries from pure dorsal proximal interphalangeal (PIP) joint dislocations, to dorsal dislocations with volar plate avulsion fractures, to fracture dislocations involving a significant portion of the middle phalangeal articular surface. Radiographic assessment should be performed after every apparent dislocation to assess the percentage of articular surface involvement. In the setting of an acute PIP dislocation, with or without a volar plate avulsion fleck of bone, the PIP joint is most likely stable and early flexion ROM rehabilitation with buddy taping is appropriate. Fracture dislocations of the PIP joint which involve more than 30 % of the middle phalangeal articular surface may be unstable and should be treated much more cautiously, often requiring surgery. Those PIP fractures which involve more than 50 % of the PIP joint surface (Fig. 11) are clearly unstable and require surgical management.

Fig. 11

Lateral radiograph of a dorsal fracture dislocation of the PIP joint with 50 % articular involvement of the middle phalanx

Sagittal band rupture

A Boxer’s knuckle refers to an injury of the sagittal band, which is the structure that normally keeps the extensor digitorum communis (EDC) tendon centralized over the metacarpal head at the level of the MCP joint [85]. The sagittal bands are composed of transverse, sagittal, and oblique fibers that can be injured by blunt trauma over the MCPJ with a clenched fist impact [86, 87]. Painful EDC tendon subluxation can ensue causing an inability to achieve active extension of the finger at the MCP joint (cannot obtain, but can maintain extension).

Athletes can present with an acute or chronic injury. The central rays are more often affected due to more prominent bony structure, thinner superficial tissue, longer radial fibers, and single extensor tendons [86, 88]. Weakness of MCPJ extension in the affected digit, painful tendon subluxation usually in an ulnar direction, and tenderness over the injured sagittal band are evident on exam.

Sagittal band injury without subluxation or dislocation can be treated with MCPJ extension splinting with the PIP joint free. When there is frank EDC subluxation or dislocation, a trial of conservative treatment can still be attempted, although results in the literature have been mixed [89–91] which have lead most surgeons to treat these injuries operatively (Fig. 12b, c) [87, 92]. MCPJ immobilization after repair or reconstruction is required to allow adequate healing after which aggressive ROM can be initiated. Athletes should be cautioned about returning to sports too quickly to prevent wound complications and recurrence [91, 92].

Fig. 12

a Intraoperative findings of a patient with a torn radial sagittal band and ulnarly subluxed EDC tendon before repair b and after repair

Central slip ruptures

Volar dislocation or forced flexion at the PIP joint can lead to acute rupture or chronic attenuation of the triangular ligament at the distal end of the central slip. These injuries are seen more commonly in basketball and volleyball players [93]. Injury leads to the lateral bands migrating volarly with resultant PIP joint flexion and hyperextension at the distal interphalangeal (DIP) joint known as a boutonniere deformity. As chronicity sets in, progressive loss of motion is seen at the PIP and DIP joints.

Evaluation with history and physical examination should elicit any history of volar PIP joint dislocation and try to isolate pain to the central slip insertion. Assessing DIP flexibility with the PIP joint resisted in extension (Elson’s test) is a helpful method for assessing the central slip [94]. An intact central slip would have a flexible DIP while an incompetent central slip would have a rigid DIP. Radiographs should be obtained with or without a history of dislocation to assess for bony avulsion of the central slip and PIP joint alignment.

Splinting of the affected digit with the PIP joint in extension and PIP free is appropriate in order to allow the central slip tendon to heal in as closed to an anatomic position as possible. Leaving the DIP joint free for flexion assists in pulling the lateral bands into normal alignment and decreases stiffness [95]. Athletes close to season completion can be allowed to continue competition as long as their participation is not hindered by the splint [96]. Rarely do acute injuries require operative treatment unless a displaced bony fragment is identified and requires screw fixation versus excision with repair [97] after which early rehabilitation can begin [97, 98].

Chronic central slip injuries with a fixed Boutonniere deformity create a challenging situation for the treating surgeon. Treatment begins by attempting to obtain a passively correctable deformity by using an extension splint, serial casting, or a dynamic external fixator [99–101] to stretch the contracted volar structures. Once a supple deformity is achieved, reconstruction can be attempted with a variety of techniques such as extensor tenolysis and transverse retinacular ligament mobilization or release, terminal extensor tenotomy with lateral band lengthening, and central slip reconstruction [102–104]. Because treatment of a chronic deformity results in much worse outcomes [97, 105, 106], athletes should be strongly encouraged to seek treatment in the acute period.

Pulley ruptures

Closed annular pulley ruptures occur most commonly in rock climbers due to the high demand placed on the flexor tendon system in the hanging and crimping positions [107, 108]. Pulley ruptures typically involve the A2 or A4 pulleys and occur most often in the middle and ring fingers. Previous work has evaluated the force required to produce an A2 pulley tear and loads experienced during these vulnerable maneuvers finding they are at particular risk for climbers [109–112].

Athletes present with the acute onset of pain over the volar aspect of the affected digit which may exhibit swelling and ecchymosis. They can usually isolate the event to a particular movement or slip leading to a forceful digital contraction and feeling a pop. Tenderness to palpation can usually be localized over the affected pulley but diffuse swelling of the entire flexor tendon sheath may cause pain with passive extension. While rupture of the A2 and A4 pulley are generally required to show significant bowstringing, relative bowstringing may be appreciated or a flexion lag may be evident on exam. Applying external pressure over the affected area and asking the patient to flex the digit may reduce his or her pain further supporting the diagnosis. While pulley ruptures are not evident on plain radiographs, MRI or US may be helpful in confirming the diagnosis [113–116].

Isolated pulley ruptures can be effectively treated nonoperatively with taping or pulley rings that externally provide support for the flexor tendon. However, in the case of multiple pulley ruptures, or failed nonoperative treatment, reconstruction is indicated [117]. A variety of graft sources such as palmaris longus tendon, extensor retinaculum, or an excised flexor digitorum superficialis (FDS) slip are available. Early ROM to facilitate tendon gliding is encouraged with higher loading not allowed until 6 months postoperatively.

Jersey finger

Forceful hyperextension of the DIP joint leading to FDP avulsion, as seen with a jersey tearing away from a finger, is most commonly seen in football and rugby players. Eccentric loading of the FDP has shown the ring finger to be most susceptible to injury due to its position in power grip, decreased independent motion, and failure strength compared to other digits [118–122].

The athlete may or may not recall the moment of injury to the digit. Swelling is commonly present which may cause the athlete to not seek attention assuming that the lack of DIP flexion is simply a fingertip sprain. Commonly, they present with complaints of decreased motion or stiffness and lack of strength. Continuity of the flexor system can be assessed passively by tenodesis effect or by holding the MCPJ and PIP joints extended and asking the athlete to flex the DIP in isolation. In cases of a bony avulsion (Fig. 13) in which the trapped fragment cannot migrate proximally through the A4 or A5 pulley, some flexion may actually be possible but decreased and painful. Radiographic assessment can be helpful at identifying a bony avulsion with amount of retraction. For pure tendon failures, MRI can provide information about continuity and retraction of the tendon [123, 124], but is not usually necessary.

Fig. 13

Lateral radiograph of a ring finger of a patient whose finger got caught on a basketball net showing an FDP bony avulsion fracture with the fragment caught up distal to the A4 pulley level (yellow arrow)

Further migration or retraction of the tendon can compromise the nutritional supply to the flexor tendon. Therefore, operative intervention is warranted as soon as possible. Various methods for repair have been described, but they all involve advancement of the intact, viable tendon to the base of the distal phalanx, often using transosseous sutures tied over a dorsal button or suture anchors [125–129]. Chronic injuries may require primary or staged flexor tendon reconstruction with a tendon graft, or in the case of an intact FDS, a DIP joint arthrodesis could be considered [121].

Mallet finger

Mallet finger injuries refer to the disruption of the terminal extensor tendon from the distal phalanx, with or without an avulsed bony fragment. Its occurrence most commonly in baseball has lead to the eponym “baseball finger” [130], but is also seen in football, basketball, and rugby [131]. Its mechanism of injury involves forceful flexion of an extended DIP joint.

The hallmark of physical exam for mallet fingers is a fingertip that is “drooped” in flexion with the inability to extend at the DIP joint. Dorsal DIP swelling and ecchymosis are commonly seen but in cases without bony involvement are often surprisingly painless [132]. Evaluation should include assessment for swan neck deformity (flexed DIP with extended PIP) as this may cause more functional deficit than a DIP flexion deformity. Radiographic assessment is necessary to assess for a bony mallet avulsion fragment (Fig. 14) and alignment of the DIP joint.

Fig. 14

Lateral radiograph of a mallet finger with a bony avulsion fragment (red arrow)

Conservative treatment with extension splinting of the DIP joint is appropriate for almost all mallet fingers, including those with bony fragments as long as there is no significant joint subluxation [133–135]. Full-time DIP splinting with the PIP joint free is recommended for 6 weeks around the clock oftentimes with an additional 6 weeks of nighttime splinting [136–141]. For athletes experiencing splint complications such as dorsal skin maceration or difficulty with the compliance of full-time splinting, buried K-wire immobilization of the DIP joint offers an alternative treatment path with possible return to sports albeit with relatively high inherent risks [142].

Global trends of hand and wrist trauma: a systematic analysis of fracture and digit amputation using the Global Burden of Disease 2017 Study


As global rates of mortality decline, rates of non-fatal injury have increased, particularly in lower Socio-demographic Index (SDI) nations.1 Hand trauma occurs with considerable frequency,2 representing a significant proportion of non-fatal injuries requiring medical attention.3 Even seemingly minor hand and wrist injuries have the potential to result in chronic pain, lost productivity and decreased quality of life without proper management.4 Prompt and thorough evaluation by a hand specialist is often necessary to provide an optimal functional outcome, regardless of the injury pattern. Furthermore, rehabilitation of the injured hand is of great importance outside the acute period of injury.5 While expedient diagnosis, proper management (surgical or non-surgical) and long-term rehabilitation (eg, structured hand therapy to improve motion, strength, adaptive function, and so on) may be standard treatment protocol in high SDI regions, lower SDI countries likely do not have accessibility to such care.6

The Global Burden of Disease (GBD) study represents the most exhaustive estimation and review regarding trends of disease and injury worldwide.7–10 This study provides a comprehensive assessment of 354 diseases and injuries in 195 countries and territories from 1990 to 2017. Included in the current GBD analyses are estimates of prevalence, incidence, mortality, risk factors and disability-related health outcomes (eg, years lived with disability (YLD) and disability-adjusted life years). For non-fatal trauma, such as hand and wrist injuries, the GBD study has established a method for comparing these measures over time and by region. Estimates for non-fatal injury represent a new feature of the GBD study and were previously incorporated into measurements of disability.

Central to understanding the global burden of hand and wrist trauma is determining where these injuries and healthcare resources are most imbalanced.11 12 There has not yet been a systematic appraisal of the global burden of hand and wrist trauma for all countries, age groups and sexes. Current reviews of upper extremity injuries have instead focused on single institution or country-wide estimates, and thus are not generalisable to regions of different socioeconomic development.13–16 Given this relative paucity of data regarding the global pattern of these injuries, there is considerable value in estimating the burden of hand and wrist trauma. Since the burden of injury can be high in areas of the world that lack health data, there is also interest in estimating the incidence and prevalence of these conditions in all countries over a time period to provide information regarding the trends of hand injury. These estimates will likely influence future resource allocation and health system planning.


Results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) study were used; these are described in greater detail in the GBD summary publications17–21 (online supplementary appendix 1). The GBD 2017 results are publicly available via the GBD Results Tool (http://ghdx.healthdata.org/gbd-results-tool) and GBD Compare (https://vizhub.healthdata.org/gbd-compare/). All incorporated data sources meet minimum inclusion criteria as outlined by previously established guidelines. Notably, the GBD study complies with the Guidelines for Accurate and Transparent Health Estimates Reporting recommendations22 (online supplementary appendix 2). A brief description of the GBD study methods as they apply to this analysis is provided below.

First, in the hierarchy of causes and injuries, GBD 2017 differentiates injury cause from injury nature. The cause of injury designation includes causes such as road injury, falls, and fires, heat and hot substances. While cause of injury determines the cause of death in the event of fatality, the nature of injury that results from a cause determines the actual disability experienced in the event of a non-fatal injury. For example, if a fall occurs that leads to a hand fracture, the fall would be the cause of injury and the hand fracture would be the nature of injury. For GBD 2017, 30 mutually exclusive, collectively exhaustive causes of injuries were designated, with 47 natures of injury that could result from each cause.

In order to comprehensively measure the global burden of hand trauma, GBD 2017 first estimated the incidence of 30 different causes of injury. This list includes road injuries and their subtypes; falls; fires, heat and hot substances; interpersonal violence; self-harm; and others. GBD 2017 uses a wide array of incidence data for each cause of injury, which are documented and catalogued in detail in GBD literature and in the Global Health Data Exchange (http://ghdx.healthdata.org). Incidence data included literature studies, survey data, surveillance data, outpatient (clinic) data, hospital data and insurance claims data. Each data source used was extracted, processed, reviewed and analysed as part of the GBD 2017 study. Once data for each cause of injury were available, GBD 2017 modelled the incidence of each injury cause using DisMod-MR V.2.1—a Bayesian meta-regression tool that uses a compartmental model framework to reconcile incidence, cause-specific mortality and remission.23 Further details regarding the modelling approach for each cause of injury are available in previous GBD publications.1

After each cause of injury was modelled, the incidence of each cause was split into incidence of each cause–nature combination. This process is based on clinical data where both cause and nature of injury were coded. The clinical sources and analytical method used for this process are described in more detail elsewhere.24 In this manner, GBD 2017 measured the proportion of each cause of injury that would lead to a hand or wrist fracture, thumb amputation or finger amputation when it was the most disabling injury sustained in a given case. Each nature of injury is assigned to a GBD disability weight to measure YLDs. Finally, the rates are summed across causes such that the overall incidence, prevalence and YLDs for each nature of injury (including hand and wrist fractures, thumb amputations and finger amputations) can be computed. The final results from this process were obtained, reported and described for this research study.

Socio-demographic Index (SDI) is a marker of development status used by the GBD study and for this analysis. In brief, it is calculated using the total fertility rate under the age of 25, mean education for those aged 15 and older and lag distributed income per capita. An SDI of 0 and 1 would reflect a minimum and maximum level of development relevant to health, respectively.

Similar to other GBD analyses,1 7–9 uncertainty is measured at various steps of the analytical process using the sample size, SE or original uncertainty interval (UI). Uncertainty is maintained in a distribution of 1000 draws and is then propagated in draw space through each analytical step. The 95% UIs reported in this study are the 25th and 975th values of the ordered 1000 values across draws.

The analytical processes were conducted in Python V.2.7, Stata V.13.1 or R V.3.3. The statistical code used in steps of this analytical process is available online (http://www.ghdx.healthdata.org). Results with additional detail by age, sex, year and location can be downloaded at ghdx.healthdata.org.


Global rates of bony hand trauma have decreased slightly over the last 27 years (table 1). In 2017, an estimated 178.9 (95% UI 145.8 to 216.8) age-standardised hand and wrist fractures per 100 000 individuals occurred worldwide, representing a 2.6% decrease from 1990. Furthermore, there were 24.1 thumb (95% UI 17.4 to 33.9) and 56.0 (95% UI 43.4 to 74.0) non-thumb digit amputations per 100 000. Males comprise the majority of those who sustain hand and wrist fractures (1.8:1 male-to-female incidence ratio), thumb amputations (1.9:1 incidence ratio) and non-thumb digit amputations (2.3:1 incidence ratio). Males, however, have experienced a greater reduction in the incidence of these injuries since 1990 compared with females.

Table 1

Global incidence of hand and wrist trauma and digit amputations

The highest overall number of hand and wrist fractures in 2017 was observed in South and East Asia; however, the age-standardised rate of this injury was highest in Central Europe, Australasia and Eastern Europe, corresponding to 666.8 (95% UI 511.2 to 865.3), 652.6 (95% UI 506.7 to 819.9) and 544.7 (95% UI 427.6 to 691.2) injuries per 100 000, respectively (figure 1). Within these regions, New Zealand, Czech Republic, Slovenia, Slovakia, Poland and Australia had the highest age-standardised rates of hand and wrist fractures. Incidence was lowest in Southeast Asia and Tropical and Central Latin America, corresponding to 71.2 (95% UI 59.8 to 84.9), 104.5 (95% UI 81.8 to 135.3) and 106.1 (95% UI 84.5 to 131.1) injuries per 100 000, respectively. The countries Timor-Leste, Laos, Mauritius, Indonesia and Philippines had the lowest incidence overall (online supplementary table 1).

Figure 1

Age-standardised incidence rate of hand and wrist fractures in 2017 (A) and percentage change in hand and wrist fracture incidence rate from 1990 to 2017 (B).

The highest overall number of digit amputations was reported in high-income North America and Western and Eastern Europe. The highest incidence of thumb amputation was again observed in Australasia, followed by Central and Eastern Europe, corresponding to 74.2 (95% UI 48.7 to 112.2), 68.8 (95% UI 43.5 to 112.8) and 57.3 (95% UI 37.9 to 90.2) injuries per 100 000, respectively (figure 2). The highest incidence of non-thumb digit amputation was observed in Australasia, followed by Eastern and Central Europe. This corresponded to 207.5 (95% UI 149.4 to 286.0), 184.3 (95% UI 131.6 to 260.4) and 154.1 (95% UI 113.4 to 215.2) injuries per 100 000, respectively (figure 3). The incidence of digit amputations (thumb and non-thumb) was lowest in Oceania, Andean Latin America and the Caribbean. The countries Timor-Leste, Laos, Philippines and Mauritius had the lowest incidence of thumb amputation, while Indonesia, Timor-Leste, Laos and Mauritius had the lowest incidence of non-thumb amputation.

Figure 2

Age-standardised incidence rate of thumb amputations in 2017 (A) and percentage change in thumb amputation incidence rate from 1990 to 2017 (B).

Figure 3

Age-standardised incidence rate of non-thumb digit amputations in 2017 (A) and percentage change in non-thumb digit amputation incidence rate from 1990 to 2017 (B).

The most significant increase in injury incidence by region since 1990 was noted in East Asia—with a 63%, 47% and 57% increase in the age-standardised rate of fracture, thumb amputation and non-thumb digit amputation, respectively. China and North Korea make up the majority of these increases. Other regions with increases (eg, Oceania, Caribbean, Tropical and Southern Latin America) were substantial, but not to the same magnitude as East Asia. Variable patterns of change were seen in sub-Saharan Africa and the Middle East. High-income North America, however, experienced a substantial reduction in the rates of fracture, thumb amputation and non-thumb digit amputation.

Over the study period, high SDI countries had the highest reported age-standardised incidence of hand and wrist fracture, thumb amputation and non-thumb digit amputation, corresponding to 297.8 (95% UI 237.2 to 366.0), 44.0 (95% UI 30.2 to 64.7) and 85.1 (95% UI 63.0 to 114.5) injuries per 100 000, respectively (figure 4). Middle SDI countries had the lowest age-standardised incidence of hand and wrist trauma, corresponding to 115.2 (95% UI 96.1 to 140.0) hand and wrist fractures, 18.5 (95% UI 13.5 to 25.4) thumb amputations and 36.8 (95% UI 28.4 to 48.3) non-thumb digit amputations per 100 000, respectively.

Figure 4

Age-standardised incidence of hand and wrist trauma by Socio-demographic Index (SDI).

Paralleling the reduction in high-income North America, the high SDI country group experienced a substantial decrease in the rates of these injuries over the last 27 years, with an estimated 9% decrease in hand and wrist fractures, 12% decrease in thumb amputation and 9% decrease in non-thumb digit amputation. During the same period, however, hand and wrist fractures increased by 16% and 26%, thumb amputations by 15% and 20% and non-thumb digit amputations by 16% and 23% in low-middle and middle SDI groups, respectively.

The greatest proportion of hand and wrist fractures occurred secondary to falls, followed by other exposures to mechanical forces and unintentional injuries (figure 5). Causes of hand and wrist fracture are overall similar in Central and Eastern Europe and Australasia. The greatest proportion of digit amputations is due to exposures to otherwise unspecified mechanical forces, which likely represents industrial injuries. Notably, conflict and terrorism account for a greater number of all bony hand injuries in North Africa and the Middle East.

Figure 5

Causes of hand and wrist fracture (A), thumb amputation (B) and non-thumb digit amputation (C) by region.

Trends of disability, specifically YLDs, parallel trends of the incidence of hand trauma (table 2). Thumb amputation accounts for the greatest burden of disability globally at 10.5 (5.0–19.7) per 100 000, as compared with hand and wrist fracture at 4.1 (2.1–7.3) and non-thumb digit amputation at 9.4 (3.5–19.9) YLDs per 100 000, respectively. As before, the highest rate of YLDs was observed in Australasia and Central and Eastern Europe. The high SDI group had the greatest observed burden of disability related to hand trauma overall; however, the low-middle and middle SDI groups experienced increases in YLDs over the last 27 years, paralleling the rising reported incidence in these regions.

Table 2

Global disability of hand and wrist trauma and digit amputations


Hand and wrist injury has the potential to result in significant impairment, affecting both social and vocational activities.4 Unfortunately, these injuries are overwhelmingly common, affecting all ages, sexes and geographic regions. Prior descriptions of the epidemiology of hand and wrist injuries have focused on isolated data sets, and have not compared the frequency and effect of these injuries by geography and income group worldwide. This is the first study that aims to measure the global incidence and resultant disability of hand and wrist fracture, thumb amputation and non-thumb digit amputation using data collected between 1990 and 2017 as part of the GBD 2017 study.

Although hand trauma is frequent and affects all demographic groups, these injuries are not equally distributed and significant variation by region and SDI group exists. The first discernible pattern is that fractures and amputations appear to be most concentrated in high-middle and high SDI groups. This trend is consistent with other forms of non-fatal trauma as estimated in the GBD 2017 study,25 but may be related to the more comprehensive reporting of injuries. In particular, Australasia and Central and Eastern Europe were observed to have the highest incidence of hand and wrist trauma per capita, while East and South Asia had the highest total number of hand and wrist injuries overall. The rates of fracture and digit amputation in sub-Saharan Africa and the Middle East were lower than expected, and are likely greater than estimated secondary to a paucity of medical data collection and poor access to medical care.

The inequitable distribution of fatal and non-fatal traumatic injuries has been well studied in Europe.26–28 While some European countries fall into the high SDI group and have similar rates of trauma relative to high-income Asian and North American countries, others are relatively low income. Research has suggested that additional sources of trauma in Europe are secondary to military conflict, which has taken place every year prior to and during the 27-year study period.29 Other studies have demonstrated a strong association between alcohol use and mortality, specifically in Central and Eastern Europe.30 31 Furthermore, there has also been a significant influx of migrant populations, with approximately 76 million international immigrants residing in Europe in 201532 and many of those individuals migrating from conflict zones.33 This may skew the rate of injuries documented in Central and Eastern Europe.34

Although the burden of traumatic injuries is documented in Australia and New Zealand,35 the specific reason for why rates of hand trauma are observed to be comparatively high in the Australasian region remains unclear. One study comparing injury patterns between the USA and New Zealand found that rates of fatal and severe non-fatal injuries were higher in New Zealand.36 Explanations for this disparity included higher populations in rural environments, road design, differences in trauma system implementation and differences in legislation and public policy.

The second pattern noted in this study is that bony hand and wrist trauma appears to be increasing at a significant rate in the low-middle and middle SDI groups, whereas it is observed to be decreasing in the higher SDI groups. This phenomenon may be due to a number of different causes. As access to healthcare improves, more individuals may seek medical care than previously, and thus an increasing number of injuries are recorded as a result. Another explanation is that industrial job availability may predispose individuals to occupational hand and wrist trauma that may have not been possible previously. Similarly, the so-called ‘motorization’ of lower SDI countries may also affect rates of trauma. For instance, the growing proportion of individuals operating personal vehicles in low-income countries37 combined with poor traffic safety standards likely results in more collisions.38 Another cause may be the improved survivability of traumatic injuries in these countries stemming from implementation of health safety measures and development of trauma systems. As trauma victims survive what may have otherwise been fatal injuries, increasing rates of non-fatal polytrauma may be noted. Lastly, medical record keeping may also be improving in these regions, now reflecting an estimate closer to the true number of hand injuries.

The third pattern of hand injury is the distribution of hand injury by sex. Females represented approximately one-third of all hand injuries captured in this study. Global reductions in age-standardised incidence over the 27-year period were approximately 50% of their male counterparts. When divided by age group, male injuries demonstrated a bimodal distribution across all SDI groups with one peak occurring between 15 and 40 years of age, and another peak after 80 years of age.25 We speculate that the first group captures occupational hand injuries and also corresponds to increased rates of trauma in general for younger men.39 This peak becomes more pronounced from 1990 to 2017 for low-middle and middle SDI countries, but is reduced in the high SDI group over that time period. For females, this first peak does not exist no matter the SDI group or year. Although speculative, this may relate to the different occupational hazards to which men and women are exposed. Males may demonstrate a greater reduction because males tend to make up a majority of hand injuries in the workplace.40 41

Regardless of the underlying cause, bony injuries of the hand follow universal principles of fracture management—establish anatomic reduction, maintain immobilisation for adequate bony healing and subsequently mobilise the joints to prevent stiffness.42 43 The technologies available to achieve reduction and immobilisation will vary widely based on the medical resources and capabilities of the country or region in question. Lower SDI countries will not have access to proper diagnostic equipment and a trained surgical workforce, thus placing the populations they serve at greater risk of experiencing the long-term sequelae of these injuries. Estimates of surgical workforce and unmet surgical need, as expected, show that low-income countries have the greatest unmet need.44 Based on this analysis, 93% of the people living in sub-Saharan Africa and 97% of those in South Asia are without access to safe and affordable surgical care, as compared with 3.6% of the population in higher income regions. This undoubtedly signals an imbalance in the rate of hand injuries and the specific resources needed to adequately diagnose and treat those injuries.

Despite the lesser frequency of digit amputations as compared with fracture, loss of a finger, and more notably a thumb, has the potential to result in more impairment and subsequent disability. Fractures can go on to heal with little permanent deficit or deformity, depending on the degree of comminution and displacement of fracture pieces. Loss of a digit, however, will often result in at least some degree of permanent functional deficit (eg, range of motion, fine pinch, power grasp, strength, sensibility).45 This is well illustrated by the higher disability weight and years lived with disability (YLD) for thumb amputations globally. Optimal management after a digit amputation considerably depends on the mechanism of injury and level of amputation. Even in high-resource areas, a digit replantation may not be ideal, and thus ensuring good postinjury hand function relies on a well-planned revision amputation. Secondary reconstructive modalities (eg, osteoplastic lengthening, free tissue transfer, ray resection) following a digit amputation require a high level of expertise. Furthermore, access to specialised occupational and physical therapists, as well as prosthetists, may not be possible in lower income regions.

Improving the burden of hand injuries, like all disease states, depends both on prevention of the injury and reduction of associated impairment when it occurs. One study of risk factors of work-related acute hand injuries in the USA found that malfunctioning or incorrectly used equipment, in addition to subjective factors such as being distracted or rushed, contributed to occupational hand trauma.46 Policy mandating the implantation of industrial and occupational safety protocols—including the use of protective equipment—is critical for reducing the number of workplace incidents. Similarly, the introduction of safety devices for heavy machinery and occupational equipment would help prevent high-energy and mangling hand injuries, which can have devastating consequences for patients.47 Targeted safety campaigns and education regarding the use of protective vocational and recreational gear could also be promoted at a number of levels.48 The primary impediment for these efforts is the cost associated with their implementation, which may be prohibitive in lower SDI countries.

After an injury occurs, expedient diagnosis and proper management mitigates the long-term sequelae of bony hand trauma. Primary care providers, who will see the majority of bony hand injuries, should receive adequate education regarding management of hand and wrist fractures. Thus, outreach missions should focus on providing clinical services for those in need, and educating local practitioners—particularly non-specialists. In addition, emergency response systems should also be designed in such a way that hospitals with specialised hand and microsurgical services are prioritised in instances of digit amputation. Uncertainty regarding where a patient should be taken initially may cause untoward delays in care. Lastly, the impact of trained physical and occupational therapists following injury should never be underestimated. Global outreach should prioritise acute management of the fracture, and focus on the aftercare and rehabilitation of these injuries.

There are several limitations inherent in this study. First, this analysis only allows estimation for bony injuries of the hand, which represent a subset of the total hand trauma incurred globally. Soft tissue injuries, including acute burns, skin laceration, tendon laceration, vascular injury and nerve damage, will not be captured in an isolated manner. Additionally, hand burn contractures also make up a substantial burden of hand disability and are not estimated in this study.49–51 The sequelae of burn injury, especially in the upper extremity, require the expertise of a reconstructive surgeon to treat. These soft tissue injuries make up a substantial proportion of the overall burden of hand trauma, and thus actual rates of hand and wrist trauma will be far greater when all types of trauma are considered.

Furthermore, estimates rely on the availability of clinical and hospital data, which may be lacking in lower income regions and conflict zones. In these circumstances, estimation models rely more heavily on covariates. The current GBD method for estimating the cause–nature relationships of hand and wrist injuries (ie, hand and wrist fractures and digital amputations) depends on dual-coded hospital data, which are not always available in every country.

Next, due to data constraints in GBD 2017, disability weights may not accurately reflect specific outcomes for specific types of injury. For instance, a non-displaced fracture of the fifth metacarpal will not experience the same degree of disability compared with someone who sustains a comminuted distal radius fracture, and these outcomes may vary even within a specific patient population receiving care at the same facility. This level of detail is difficult to capture at the population level. As previously noted, the current GBD study design uses an injury severity hierarchy model, which is determined by the most severe nature of injury sustained for a given cause. Therefore, the model will ignore certain injuries in instances of polytrauma. For example, in circumstances in which an individual sustains a hand injury in conjunction with a more serious injury such as an intracranial bleed, the hand injury will not be accounted for. Lastly, a considerable limitation of the current investigation is that assumptions regarding the exact cause and mechanism of injury were made as a result of restrictions within the available data set. This limitation will be addressed with further iterations of the GBD study.


High rates of bony hand and wrist injuries are noted in Central Europe, Eastern Europe and Australasia, which are consistent with patterns found in other anatomic zones of injury (eg, facial fracture, traumatic brain injury and spinal cord injury).38 In low-middle and middle SDI countries, increasing rates of fracture and amputation are observed over the 27-year study period. Patients in these countries are less likely to have access to quality and subspecialised surgical hand care.

The comparative reporting of hand and wrist injuries by region and SDI will allow for design and implementation of preventative measures and effective management strategies. We anticipate that future GBD studies will provide more granular data to gauge the effectiveness of these efforts over time.

What is already known on the subject

  • Fractures of the hand and wrist, as well as digit amputations, are debilitating injuries that occur in all regions and income groups, and occur by a variety of mechanisms.

  • Bony hand trauma occurs globally with high incidence; however, the resulting impairment and disability depends on the severity of injury, prompt diagnosis and proper treatment.

What this study adds

  • In 2017, there were approximately 18 million hand and wrist fractures, 2 million thumb amputations and 4 million non-thumb digit amputations worldwide.

  • Bony hand injuries, including digit amputation, occur in greatest number in South and East Asia, but appear to be most concentrated (per capita) in Central Europe, Eastern Europe and Australasia.

  • Whereas the rate of these hand injuries is decreasing in the higher Socio-demographic Index (SDI) countries, low-middle and middle SDI regions have experienced an increasing rate of hand injuries over the past 27 years.


MDN acknowledges support from the Government of the Russian Federation (Agreement № 075-02-2019-967). AMS acknowledges support from a fellowship from the Egyptian Fulbright Mission Program.

Wrist Injury – an overview

Rehabilitation Principles and Considerations for Wrist Injuries

Rehabilitation of wrist injuries requires an understanding of carpal anatomy, force distribution, and wrist kinematics.194 An optimally aligned, stable but mobile wrist is capable of the precise interaction needed between bone and soft tissues to produce pain-free, functional motion. Restoration of alignment, stability, and pain-free motion poses a challenge to the treating clinician.

Key Therapeutic Considerations in Management of Wrist Injuries

Soft tissue injury accompanies bony injury140

Disruption of ligaments can lead to altered mechanics, instability, degenerative changes, and pain140,186,187

Nerve irritation or injury contributes to pain syndromes195–199

Motor and sensory loss can occur as a result of nerve injury

Distal Radial Fractures

Understanding normal force distributions at the wrist and the impact of altered mechanics is essential in initiating therapy regimens. When the distal ulna is equal in length to the distal radius, this is termed ulnar neutral variance. Changes from ulnar neutral variance can occur as a result of injury, and they alter the mechanics of the wrist joint (Figure 10-83). Shortening of the distal radius during fracture healing, with no change in the position of the ulna, results in ulnar positive variance. This change increases the force distributed to the ulna and potentially results in ulnar-sided wrist pain.175,200–203

In a typical ulnar neutral wrist, 80% of the force is borne by the radius, with only 20% through the ulnocarpal joint. However, even a small change in height results in the ulna absorbing 40% of the load if the ulna is 2 mm ulnar positive or 4% of the load if it is 2 mm ulnar negative.139,175,203–205 Loading the wrist, which occurs during weight bearing and gripping, places stress on the primary ligamentous stabilizers of the wrist. Evaluation for ligamentous injury should be considered in the event of persistent pain with loading of the wrist.206 The push-off test measures upper extremity weight bearing, using a grip dynamometer, and may be useful to measure progress as patients recover strength and heal from their wrist injuries.207

For the clinician charged with the rehabilitative management of a patient with a wrist injury and pain, the key considerations regarding force distribution at the wrist are summarized below.

Key Therapeutic Considerations in Force Distribution at the Wrist

Ulnar-sided wrist pain may result from a change in mechanics and may not be limited to a healing ulnar styloid fracture. For example, a radial compression fracture that shortens the radius changes the relationship between the radius and the ulna, causing ulnar-sided wrist pain from ulnar positive variance.

Care must be taken when loading the wrist to protect healing structures on the radial side of the wrist (e.g., with scaphoid fractures) or the ulnar side of the wrist (e.g., with tears in the triangular fibrocartilage complex).

Loading the wrist stresses many of the carpal ligaments. Care must be taken when loading a wrist known to have or suspected of having a ligament tear. Wrist and grip strengthening may not be appropriate in patients with ligamentous instability. Appropriate diagnosis of the source of wrist pain is paramount in preventing further injury or degenerative changes of the carpus.

Forearm position affects force distribution at the wrist. Activity modification, taking into account forearm position, should be considered in patients with persistent ulnar-sided wrist pain. Pronation shortens the radius and increases ulnar variance; this can increase ulnar-sided wrist pain.

The dynamics of wrist motion are important for the rehabilitation strategy. Wrist kinematics is described by the direction in which the proximal carpal row moves.208,209 Normal kinematics and wrist motion are detailed in Table 10-18. Normal values for AROM at the wrist compared with what is needed for light activities of daily living (ADL) tasks are presented in Table 10-19. Of note, 40% to 60% of wrist flexion and extension occurs at the radiocarpal joint, and the remaining motion occurs at the midcarpal joint. As well, 60% of radial and ulnar deviation occurs at the midcarpal joint and 40% at the radiocarpal joint.210,211

Key Therapeutic Considerations for Wrist Kinematics and Wrist Motion

Optimization of motion depends on restoration of wrist kinematics. Specific joint mobilization techniques can be used to improve wrist kinematics.214

Surgical procedures or conditions in which the midcarpal joint is fused or significantly limited reduce motion 40% to 60% (except pronation/supination, which remains unaffected).

Light activities of daily living can be performed without restoration of full motion.

Optimization of pain-free motion is essential and should be based on individual activity requirements and realistic goals. The goals should consider the status of the joints comprising the wrist, including alignment.

In a postoperative or postinjury therapy regimen, the clinician should consider the ultimate goals for motion and strength. Joint mobilization should focus on restoring normal kinematics.214,215 Surgical procedures with any partial fusion of the wrist reduce motion 40% to 60%. However, most ADLs can be completed without full motion. Optimizing pain-free motion is essential. The clinician must perform a realistic evaluation of the patient’s needs and expectations.

Newer philosophies for therapeutic intervention consist of an accelerated rehabilitation program. A recent study has reported that patients who underwent ORIF of a distal radius fracture, with stable fixation, had better mobility, strength, and DASH scores in the early postoperative period, after engaging in a rehabilitation protocol that emphasized early motion and strengthening.216 Another newer philosophy is that there may be a role for wrist proprioception reeducation in the therapeutic plan for recovering wrist function and stability and preventing further injury.217 The literature in this field is growing, and early success is promising.

Although some literature fails to support a therapist-governed exercise program as being more beneficial than a home exercise program,218 it is clear that some patients benefit from having the motivation and supervision of a trained therapist.

In summary, the wrist is a complex structure with key specific considerations for the treating clinician. Direct communication between the surgeon and the therapist is essential. The overall rehabilitation strategy must account for the type and location of injury, possible concomitant ligament disruption, fixation methods used for fracture stabilization, overall fracture stability, and joint alignment (Figure 10-84). Table 10-20 presents rehabilitation strategies the clinician can use with patients who have suffered a wrist injury. Successful therapeutic intervention and its progression must incorporate all stages of the healing process.

Scaphoid Fractures

Rehabilitation of scaphoid fractures depends on the location and healing of the fracture. General casting guidelines for nondisplaced fractures at the distal pole is 4 to 8 weeks in a thumb spica cast. Midscaphoid (waist) fractures are immobilized longer (6 to 12 weeks). Proximal pole fractures are protected the longest (12 to 20 weeks).152 During the casting phase, emphasis is placed on maintaining normal ROM of the fingers. After the cast is removed, the goals of therapy are joint mobilization and strengthening at the wrist and fingers.

Compression screw fixation of scaphoid fractures allows for earlier motion and return to activities. Generally, the thumb and wrist are immobilized for 1 to 4 weeks after compression screw fixation of minimally displaced fractures. After the cast has been removed, gentle motion is initiated. Weight bearing, gripping, and loading of the wrist should be avoided for the first 3 weeks. Between weeks 3 and 6, return to sports with casting or splinting is possible. Strengthening is initiated at week 8, after fracture healing allows for an increased demand. After 8 weeks, return to normal activities generally is permissible.

Displaced fractures that require ORIF are immobilized for 4 to 12 weeks, depending on the type of fixation. After the cast has been removed, active motion begins. If the scaphoid vascular supply is a concern, no weight bearing or strengthening can begin until CT scanning has confirmed fracture healing. Return to sports usually begins at 4 to 6 months.

Complications from scaphoid fractures include nonunion and malunion. Either of these causes kinematic disturbance within the wrist that can cause pain, instability, loss of motion, and eventually arthritic degeneration.152,222,226–228

Triangular Fibrocartilage Complex (TFCC) Injuries

Splinting in an ulnar gutter splint for stable TFCC sprains and strains to prevent ulnar deviation can be helpful for reducing inflammation and preventing repetitive stress to the region. Activity modification is essential. Activities that require ulnar deviation or forceful gripping should be avoided. Splinting during these activities prevents the incriminating wrist motions of ulnar deviation with or without terminal wrist flexion and extension. The splint often acts as a reminder to the patient to avoid the positions or activities that irritate the TFCC. Weight bearing, such as yoga or cycling, should be avoided regardless of the wrist position used. A splinting approach is used until the pain diminishes (approximately 4 to 6 weeks), at which time a strengthening to tolerance regimen can be initiated in all wrist positions. As previously mentioned, if pain persists after a 4-week period of splinting and activity modification, the patient should return to the referring physician.

Cast immobilization in a long arm cast as an initial treatment for peripheral and central tears has been reviewed previously and is used for 4 to 6 weeks. After cast immobilization, the goal of therapeutic strategies is restoration of pain-free motion and function. Strengthening is initiated when full AROM has returned. Weight bearing is avoided for 6 to 12 weeks and should be pain free before the patient returns to aggressive weight-bearing activities. If pain limits progression of the rehabilitation course, further evaluation is required.

Debridement of the central portion of the TFCC requires little or no immobilization. The patient wears a wrist or ulnar gutter splint for 1 week when not exercising. Occasionally, the splint time is extended to respect patient comfort. AROM is initiated during the first week to pain tolerance. At 2 to 4 weeks, light functional tasks can be resumed with limited ulnar deviation and weight bearing. Strengthening and functional progression begin at 6 to 8 weeks, during which a gradual return of ulnar deviation and weight-bearing activities is initiated. If pain limits progression of the therapeutic intervention, a mechanical issue (e.g., positive ulnar variance) may be contributing to the patient’s pain and TFCC irritation.

Repair of the peripheral portion of the TFCC is treated with an initial casting period of 3 to 4 weeks in a long arm cast, followed by a short arm cast for an additional 2 to 3 weeks. Casting times can vary. At 6 to 8 weeks, restoration of motion begins with the initiation of AROM. Ulnar deviation and forearm rotation are avoided. A wrist or ulnar gutter splint is worn between exercises and at night for comfort. Progression of motion, including forearm rotation and ulnar deviation, occurs between 8 and 12 weeks. Strengthening is initiated at week 12, with a gradual return to sports and weight-bearing activities as tolerated.229,230

Scapholunate Dissociation

As noted, surgical solutions for scapholunate dissociation include both soft tissue repairs or reconstructions and fusions. The period of cast immobilization after soft tissue repairs or reconstructions varies and can last up to 12 weeks.210

After cast immobilization, an AROM program is initiated, as well as scar management, edema control, and activity modification, avoiding weight bearing and gripping. At 12 weeks, gentle stretching and strengthening and functional progression are begun. A wrist splint can be worn for comfort. Taking care to avoid stretching out the repair is a prime postoperative concern. Motion limitations of approximately 30° of flexion and 50° of extension are to be expected in procedures such as the Blatt technique,231 in which a portion of the dorsal wrist capsule is used to correct the rotation and flexion deformity of the scaphoid (Figure 10-85). Return to high-demand activities and/or competitive sports occurs at 6 to 9 months after surgery.210,231

The surgical fusion procedures (proximal row carpectomy, STT fusion, and four-corner fusion) follow a similar rehabilitative course (Figure 10-86). The wrist is immobilized for up to 6 to 12 weeks. After immobilization, AROM is initiated, along with scar management, edema control, and activity modification and splinting for comfort. At 12 weeks, stretching, strengthening, and functional progression begin. A reduction in motion is to be expected. Return to high-demand function and competitive sports may occur at 6 to 9 months after surgery. Persistent problems with scapholunate dissociation can include wrist pain despite surgical intervention to correct the instability.

90,000 fracture, dislocation, sprain, inflammation, arthritis / arthrosis, hygroma – Treatment and recovery

Wrist joint injuries: fracture, dislocation, sprain, inflammation, arthritis / arthrosis, hygroma – Treatment and recovery


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Orthopedic traumatologist, head of the department of traumatology and orthopedics

Wrist joint is a bony articulation that forms the radius and three bones of the wrist: lunate, scaphoid and triangular.This joint connects the hand and forearm. From the outside, the joint is covered with a strong shell (joint capsule). The articular bag with the help of ligaments is attached on one side to the bones of the hand, and on the other to the radius and articular disc. The wrist joint is a particularly mobile connection of the bones of the upper limb: the forearm and hand of a person. This joint is complex in the composition of the bones included in it, is responsible for the variety of actions in the hand (rotational function of the hand, for flexion, extension, abduction and adduction of the hand) and takes on various power loads, therefore this area is very vulnerable.

Types of damage

Frequent injuries of the wrist joint include the following types:

  • Fractures. The radius is especially often injured. There are two types of fractures of the radius in the wrist joint:
    • Smith fracture (flexion fracture). The cause of injury is a fall on an outstretched arm, on its back side. The bone breaks and thus the bone fragments are displaced towards the palm.
    • Kolles Fracture (extensor fracture). Damage occurs when a person falls on the palm, there is a displacement of bone fragments towards the thumb and the back of the hand.

  • Ligament sprain. When stretching, the fibers of the ligaments are damaged as a result of their excessive tension, the tissues remain intact, but for a certain time the joint performance is lost.
  • Dislocations. With dislocations in the area of ​​the wrist joint, the articular ends are displaced, as a result of which they completely lose contact with each other. Dislocations are pathological (due to diseases of the bones and joints) and traumatic (due to trauma).
  • Inflammatory diseases . They can occur against the background of previous injuries, hormonal disorders, excessive joint stress, infections, etc.
    • Tendovaginitis is an inflammatory lesion of the tendons and surrounding membranes in the wrist.
    • Styloiditis – inflammation of the ligaments attached to the styloid processes of the radius or ulna.
    • Synovitis is an inflammatory lesion of the synovial membrane of the joint.
    • Bursitis is an inflammatory disease of the synovial bags with the formation and accumulation of fluid in its cavity.
  • Arthritis is an inflammatory pathological disease of the joints (leading to their destruction) and the whole organism as a whole. There are the following main types of the disease (depending on the cause): rheumatoid arthritis, osteoarthritis, psoriatic, gouty, infectious and reactive arthritis.Inflammation in arthritis extends to all elements of the wrist joint (begins in the synovial membrane of the joint, then spreads to the cartilage, joint capsule, tendon ligaments and bursa).
  • Osteoarthritis is an age-related degenerative chronic disease in which joints are deformed or worn out. Most often, there are post-traumatic arthrosis, which form after dislocations and fractures of the wrist bones. As a rule, arthrosis is an isolated pathology that affects only the wrist joint.
  • Hygroma (ganglion) of the wrist joint is a tumor-like neoplasm in the form of a cyst on the wrist, containing a fluid of a serous-mucous or serous-fibrinous nature. Hygromas most often form and develop on joints that experience regular monotonous physical exertion, friction and squeezing. Hygroma is not a malignant tumor. Hygromas can occur at any age, including the elderly and children.

Symptoms and pain location

For each type of the above injuries, there are characteristic symptoms, based on which a qualified specialist will establish an accurate diagnosis and prescribe the necessary treatment.The main signs of damage to the wrist joint include:

  • Joint pain of varying intensity and localization
  • Edema and swelling of the injured area
  • Changing the appearance of the hand and wrist
  • Redness of the skin in the damaged area
  • Hemorrhage at the site of injury
  • Contracture of the joint (severe limitation of joint mobility)
  • Total temperature rise
  • Weakness, malaise, chills
  • The appearance of cones (with hygromas)

Which doctor should I contact

Depending on the signs of the onset of the disease, you should seek help and advice from the following specialists:

  • Traumatologist, surgeon (for fractures, bruises, dislocations, sprains, hygromas, synovitis)
  • Rheumatologist, therapist, dermatologist, urologist (for various types of arthritis, arthrosis, bursitis).


Diagnosis of various types of diseases of the wrist joint mainly includes:

  • Initial inspection by a specialist
  • Urine and blood tests
  • ultrasound
  • CT or MRI
  • X-ray of the hand
  • Referral for consultations to specialized specialists (with the appointment of the necessary additional examination)


Treatment depends on the severity of the disease (there are two options: conservative or surgical).According to the testimony of the attending physician, the treatment option necessary in each specific case is prescribed (restoration of the damaged joint with the help of medications, physiotherapy, physiotherapy exercises or performing a surgical operation). With any treatment option, the patient needs subsequent rehabilitation for a speedy recovery and return to working capacity.


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90,000 treatment for sprains, dislocations, bruises, fractures

Injuries to the wrist account for about 40% of the total statistics of injuries to the upper extremities, with 50% of them leading to life-long loss of hand functionality or even disability.

In most cases, wrist injuries are treated according to the general principles of injury management, which will be discussed in more detail below. The high level of post-traumatic complications is explained, first of all, by the peculiarities of the anatomical structure of the wrist zone, which leaves little chance of mild fractures, dislocations or sprains of the wrist.

Anatomy of the wrist at a glance

The wrist is the section of the hand located between the metacarpus (metacarpals) and the forearm (ulna and radius).The wrist is formed by eight cancellous bones arranged in two rows: capitate, pisiform, hook-shaped, scaphoid, lunate, trapezoid, trapezoidal and trihedral.

The bones of the wrist are firmly fastened by ligaments, so that the energy of a blow struck on one of the bones is evenly distributed throughout the wrist. This serves as a kind of protection system, primarily from fractures. At the same time, if a fracture or dislocation of the wrist does occur, then due to the large crowding of bones and, accordingly, ligaments, the injury is always more extensive than, for example, with a simple fracture of the radius.

Types of injuries

Mechanical wrist injuries are classified by the nature of the damage:

  • fracture – violation of the integrity of the bone;
  • dislocation – displacement of the ends of the bones of the joint relative to each other;
  • sprain and rupture of ligaments – partial or complete violation of the integrity of the ligaments;
  • contusion – damage to soft tissues without violating the integrity of the skin;
  • wound – damage to soft tissues with violation of the integrity of the skin;
  • crush injury – destruction of tissues, leading to a complete loss of their vitality.

General principles of treatment

For any wrist injuries, therapeutic and therapeutic measures are carried out in the following sequence:

  1. Stopping bleeding . Depending on the intensity of bleeding, the wound is sutured with vascular coagulation, or a tight bandage is simply applied. Required for open fractures, wounds and crush injuries of the wrist.
  2. Reposition . Fragments of broken bones are connected, dislocated joints are repositioned, or torn ligaments are sutured.
  3. Immobilization . To fix the performed reduction, the wrist is partially or completely immobilized with the help of orthopedic braces or orthoses, less often with plaster casts.
  4. Decongestant therapy . To relieve pain, inflammatory and edema syndrome, nonsteroidal anti-inflammatory drugs are prescribed, with severe edema – diuretics. To eliminate hematomas, warming ointments are used.
  5. Rehabilitation .Restoration of muscle tone and functional usefulness of the wrist with the help of exercise therapy (exercise therapy), massage and physiotherapy (magnetotherapy, electrophoresis, etc.).

In case of crushing of tissues, the question of endoprosthetics (replacement of a bone with an implant) or amputation with subsequent prosthetics of a limb may be raised.

The role of braces and orthoses

The main condition for the restoration of damaged tissues of the wrist is to reduce the load on the specified area or to completely immobilize it.Modern traumatology solves both of these problems with the help of special orthopedic products – bandages and orthoses.


Soft or semi-rigid products that allow you to stabilize the wrist in the anatomically correct position and restrict the movement of the hand, without its complete immobilization. The main task of the wrist bandage is to maximize the unloading of the muscles and the articular-ligamentous apparatus of the wrist, so as not to interfere with the regeneration of damaged tissues.

Wearing bandages on the hand is indicated for severe wrist bruises, partial ruptures of the ligaments, mild forms of dislocations and subluxations without damaging the joint capsule, as well as late stages of rehabilitation after fractures.

  • Reducing the risk of secondary injury due to sudden movement or high stress;
  • reducing the load on the damaged area during the recovery period improves the rehabilitation prognosis;
  • Prevention of swelling due to compression compression.


Semi-rigid or rigid products that guarantee complete immobilization of the hand to provide damaged tissues with maximum rest for the entire rehabilitation period. The need to wear orthoses arises in case of fractures, irreducible forms of dislocation of the wrist, or complete rupture of the ligaments.

The issue of fixing the thumb is considered separately. The need to limit his mobility does not always arise, and therefore not all models of orthoses allow doing this.

  • delivers less inconvenience (in comparison with a plaster cast), without compromising the rigidity of fixation;
  • the ability to easily remove and put on the orthosis if necessary for medical and diagnostic or hygienic procedures;
  • Possibility of adjusting the amount of permissible movements (in some models).

First aid rules

In case of injury, the wrist should be immobilized as much as possible, cold should be applied to the damaged area and the patient should be taken to the emergency room as soon as possible.If there is severe bleeding, a tourniquet is applied above the level of the wound.

Strongly not recommended:

  • check flexion-extension functions of the arm for self-diagnosis of a fracture – this can lead to displacement of bone fragments;
  • independently adjust the dislocation – with a probability of 99.9% this will lead to a worsening of the situation;
  • to postpone an appeal to a traumatologist, otherwise the developed swelling and hematoma will complicate the provision of medical care.

And of course, the purchase of an orthosis or a bandage, with all the advantages of these orthopedic products, cannot serve as an alternative to visiting a doctor, since effective treatment of injuries to the hand, and wrist in particular, requires accurate diagnosis and complex therapy.

Effective treatment of wrist and hand injuries on DocDoc.ru

Traumatologists of Moscow – latest reviews

I chose a specialist based on reviews.Vladimir Ilyich is a good and attentive doctor. The doctor asked questions, gave recommendations and explained everything. We will also have an online consultation. I would recommend this specialist.


07 December 2021

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06 December 2021

Thank you doctor for being there! An incredible doctor.He very carefully examined his sore hand and immediately said what was wrong with me. I did not appoint any expensive examinations, I just talked, felt and voiced the problem. Prescribed a treatment plan and, most importantly, that it is correct! At the first visit I made a blockade, the pain went away immediately. According to the results of the treatment, it is clear that the inflammation goes away.


05 December 2021

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03 December 2021

The doctor is very good.We have the most favorable impressions. Alexey Mikhailovich determined the reason for our complaint, explained everything in detail, and drew up a plan for further actions. He revealed deviations in the test results and advised him to contact a rheumatologist. Now we are acting on his recommendations. Thank you very much.


November 30, 2021

I found this specialist from work experience and reviews.Polite, competent doctor. The reception went well. Alexey Valerievich listened to my complaints, studied the MRI results and issued a referral for an additional examination. I was satisfied.


November 30, 2021

The reception went well.The doctor is adequate, normal, one hundred percent explains everything. The appointment lasted about thirty minutes, the doctor explained all his recommendations. As a result of the reception, Maria Vladimirovna gave recommendations on my further actions.


November 29, 2021

Everything went well.The doctor listened. I gave a diagnosis, prescribed an analysis. Received treatment. From the reception I got an understanding of what the problem is and a treatment plan for the next month. I chose the clinic based on the proximity to home and the doctor’s rating.


November 26, 2021

There was a house call.Very professional doctor, delicate. The review is very good. I left good impressions about myself. Gave good advice. Nikolai Nikolayevich told how to be treated, what to do, at the moment, what is in the future. I stayed in touch with him, said if you call. There are not many such doctors now.


04 October 2021

A competent doctor, he explained everything in an accessible way.Andrey Sergeevich performed an examination, prescribed procedures and prescribed treatment. I was satisfied, the specialist helped me.


September 12, 2021

Show 10 reviews of 9,520 90,000 Hand Surgery Center

In the Filatov Children’s Hospital, since 2016, Hand Surgery Center has been opened.

The center specializes in the diagnosis and treatment of a wide range of injuries and hand defects, including those requiring inpatient treatment using micro- and reconstructive surgery methods.

Children under 18 with developmental anomalies and diseases of the hand are sent to the Center for Hand Surgery.

Hospitalization at the Center is carried out through several channels:

  • Emergency hospitalization (by the ambulance team and by self-referral to the emergency department)
  • Planned hospitalization (in the direction of outpatient departments and CDC)

Hospital.NF Filatova possesses all the necessary arsenal of modern therapeutic and diagnostic measures and treatment methods to provide highly qualified assistance to children with hand diseases.

We provide assistance to children with the following pathology:

  • Congenital malformations and malformations of the hand, fingers and forearm

    Injury to hand

    • fractures of the bones of the fingers, bones of the wrist, radius and ulna;
    • dislocation of fingers
    • damage to the flexor and extensor tendons of the hand pathology
    • gunshot and explosive wounds
  • Consequences of injuries

    • consequences of pathological changes in peripheral nerves
    • old dislocations
    • old lesions of the flexor and extensor tendons of the hand
    • post-traumatic joint contractures
    • incorrectly fused bone fractures
    • false joints of bones
  • Planned surgical interventions

    • degenerative-dystrophic lesions of the hand
    • benign bone tumors and tumor-like formations
    • soft tissue benign neoplasms of the hand
    • neuropathies of the hand
    • radioulnar synostosis

Center for Hand Surgery includes subdivisions:

  • Department of Reconstructive and Plastic Microsurgery
  • Department of Traumatology and Orthopedics
  • Department of purulent surgery
  • Department of Medical Rehabilitation


Alexandrov Alexander Vladimirovich

Head of the Department of Plastic and Reconstructive Microsurgery

Tarasov Nikolay Ivanovich

Head of the Department of Traumatology and Orthopedics

Rybchenok Vsevolod Vitalievich

Professor of the Department of Plastic and Reconstructive Microsurgery

Krestyashin Vladimir Mikhailovich

Professor of the Department of Traumatology and Orthopedics

Khan Maya Alekseevna

Head of the Department of Medical Rehabilitation

Doctor of Medical Sciences, Professor

Smirnov Alexey Nikolaevich

Head of the Department of Purulent Surgery

Doctor of Medical Sciences, Professor

Lviv Nikolay Vasilievich

Head of the Center for Hand Surgery

Nike Air Max 270

90,000 The Ministry of Foreign Affairs clarified the nature of S.Lavrova – RBK

Russian Foreign Minister Sergei Lavrov received not a broken arm, as the media reported, but a sprained wrist. Izvestia writes about this with reference to the press service of the Foreign Ministry.


According to the newspaper, the incident took place the day before, on December 3, at a hotel in Istanbul, where the Russian delegation was staying.S. Lavrov slipped on the stairs and, in order not to fall, leaned on his left hand, as a result injuring his wrist.

The minister was immediately taken to a local hospital, where he spent about half an hour. He underwent an X-ray and a retainer was placed on his injured arm, after which he was released.

The Foreign Ministry called Lavrov’s injury insignificant. This incident will not affect the minister’s busy work schedule.

Earlier, Turkish media reported that the Russian Foreign Minister broke his arm in Istanbul under unknown circumstances.Then there was information that S. Lavrov received a minor sports injury.

We will remind that earlier the Western press also wrote about serious health problems of the President of the Russian Federation Vladimir Putin, who allegedly needs surgery due to a sore back. However, the presidential press secretary Dmitry Peskov denied these rumors, explaining that V. Putin only has a minor sports injury.

Hand surgery – online appointment in the network of clinics MEDSI

The hand has 27 bones, several dozen muscles, and more than 50 tendons.All these structures must be anatomically preserved and ideally interact in the course of performing their functions in order to provide gross and fine motor skills. In the event of an illness or injury to the hand, it is imperative to obtain the highest quality specialized medical care. Only this will help restore or maintain its full function.

The center of competence “Surgery of the foot and hand” operates on the basis of MEDSI. The operating rooms are equipped with the latest medical technology, state-of-the-art equipment and leading surgeons are employed.

Areas of activity

Even patients with difficult clinical cases can get help from us: modern technologies, a full cycle of treatment and rehabilitation services and an individual approach ensure a high percentage of success even with serious problems.

24/7 Acute Trauma Service works for patients who were injured within 24 hours before seeking help. Our emergency surgeons treat:

  • Acute injuries of fingers, palm, wrist, forearm with violation of the integrity of tendons, muscles, blood vessels and nerves
  • Hand fractures (closed reduction, osteosynthesis)
  • Soft-tissue defects

Within the framework of the direction “Treatment of the consequences of injuries” are carried out:

  • Tendon plastics
  • Combined interventions after improper healing
  • Elimination of post-traumatic contractures and deformities
  • Neurolysis
  • Restoration of damaged nerve integrity
  • Skin plastics
  • Treatment of false joints
  • Bone graft transplant
  • Prosthetics of the hand

Direction “Sports trauma” consists in performing operations for sports and ballet trauma, followed by rehabilitation.

Direction “Treatment of hand diseases” includes:

  • Restoration of hand function with Dupuytren’s contracture
  • Elimination of the manifestations of the tunnel syndrome
  • Treatment of benign, malignant tumors of the tissues of the hand (hygroma, synovioma)
  • Elimination of deformities of the rheumatoid hand

Methods and possibilities

  • In their practice, MEDSI specialists prefer minimally invasive surgical techniques.Whenever possible, operations are performed arthroscopically
  • Doctors are fluent in the techniques of bone and skin grafting, revascularization, osteosynthesis, chondroplasty
  • In cases of large-scale damage to the hand, it is possible to carry out multi-stage interventions according to individually planned tactics
  • For prosthetics, modern foreign-made prostheses are used, printed on a 3D printer
  • Joint-saving methods of operations are used


MEDSI specialists strive to provide patients with the fullest and fastest possible rehabilitation.Rehabilitation measures and procedures begin from the first hours after the operation. The rehabilitation program is drawn up in advance, even before the operation, during the consultation with the participation of the attending physician (surgeon), physiotherapy doctor, rehabilitation therapist, neurologist and other doctors whose participation may be required in a particular case.

If necessary, patients will be able to undergo specialized rehabilitation at the MEDSI Otradnoye sanatorium. The sanatorium is equipped with modern rehabilitation equipment.In 2018, additional devices were purchased for neurological rehabilitation after surgical treatment of the hand, operating on the basis of biofeedback.

Benefits of treatment at MEDSI

The best proof of our high competence is the constant flow of patients: from Moscow, regions and even from other countries.

  • Doctors implement patented author’s methods of treating diseases and injuries of the hand, which have no analogues in the world
  • Treatment is carried out according to the principle of “fast path surgery”: we provide the most effective assistance aimed at the speedy recovery and recovery of the patient
  • We take into account all the factors of the disease and prescribe the most personalized treatment, because we understand: each injury or disease of the hand is individual and has many subtle features
  • It is possible to undergo treatment and rehabilitation under the compulsory medical insurance policy *

* The possibility of receiving treatment under the compulsory medical insurance policy, the list of diagnoses and the number of quotas, check with your doctor.