Contrary to the common perception, ligamentous injuries of the wrist (similar to other joints in the body) are often more difficult to treat successfully then bone fractures. Damage to few of particularly important ligaments, may have devastating consequences for the long term function of the hand, especially if not recognized and treated early and adequately.

Facts and comments on this page relate to the major ligament disruptions which are thankfully rare.

The wrist joint represents a skeletal connection between the hand and forearm, with complex anatomy designed for extreme mobility of our hands. Restoration of sophisticated anatomical and biomechanical arrangement after ligament trauma, is one of the most challenging in wrist surgery.

The joint is made up of 8 separate small (carpal) bones (Pictures 1,2; Gallery below). Each bone forms a joint with the bone next to it. Glistening, smooth articular cartilage, which wraps each of these bones, allows gliding between them. Nearby ligaments restrain extreme, uncontrolled motion of individual bones, ensuring synchonised movements and ‘harmony’ of the wrist joint as a whole (Picture 1). Not all ligaments are of equal anatomical and clinical importance. Only few are crucial stabilisers: the scapho-lunate, luno-triquetral, radio-scapho-capitate and ulno-carpal ligaments (names indicate which particular two bones are connected).

When one (or more) of these ligaments is injured, the individual bone may start to rotate abnormally, as if being ‘unleashed'(Picture 2). Over time, abnormal alignment may lead to wrist arthritis in the long term (Picture 3,4).

Fall on outstretched hand is by far, the commonest mechanism of wrist ligament disruptions. When we slip or trip against something, we automatically extend our upper limb to support the body before hitting the ground. Sport injuries are another common cause for wrist ligament sprains and tears. Whether the wrist bone gets broken or ligament gets torn during such accidents, depends on many factors: how the wrist is positioned during the impact, density and strength of the bones, how much force is transmitted etc. Either way, a significant load/force/power across the wrist joint (like falls, sport injuries, forceful punches, mighty racquet hits) is usually required to rupture the most important internal wrist ligaments.

It is not uncommon that after clinical examination and investigations for a trivial accident, a significant, pre-existing ligament injury is discovered, almost coincidently. In such cases, either an awkward recent trauma triggers a flare of pre-existing, but dormant arthritis or previously partially torn structure, ultimately fails with the new injury. Naturally, treatment plan will vary pending on how old ligament injury is this is why the focused and detailed consultation is paramount in successful clinical management. This might sound paradoxical, but sometimes, injury of an important stabilizing wrist ligament might remain clinically dormant (unnoticeable) for several years.

When a wrist ligament injury occurs, pain and swelling are the main symptoms. With significant tears, patients are usually able to recall an incident or a specific movement which triggered “click” or ‘memorable pain’ in the wrist. There are no specific symptoms to indicate whether ligament injury has occurred as opposed to fracture and/or joint sprain. Once the initial pain of the injury subsides, the wrist may remain painful for several weeks, but most innocuous sprains usually settle with rest and avoidance of strenuous hand activities within 4-6 weeks.

Over the years, repetitive abnormal motion of the carpal bones will lead to predictable pattern of wrist osteoarthritis, easily recognisable on X rays and MRI scanning (Pictures 3,4; Gallery below). Rate of deterioration is impossible to predict with accuracy, but in general, more the wrist is used and strained, quicker the wear and tear changes will be incurred. The damage slowly adds up and with time, becomes irreversible. Finally, the joint can no longer compensate for the damage, and the wrist begins to hurt most of the time, not only during motion and activity.

As mentioned above, the diagnosis of ligament injuries of the wrist begins with a medical history and joint examination. Usually a lot can be concluded from just these two diagnostic modalities, but pending exact individual circumstances, plain radiograph (X-rays), magnetic resonance imaging (MRI) or arthrogram (X rays taken after injection of dye into the wrist) of the wrist might need to be done too. Each one of these investigations has its own advantages and diagnostic specificity. Which particular one is ordered is determined during consultation depending on clinical evidence as to which particular tissue and structure appears to have been affected.

Finally, for cases in which it is not possible to establish the diagnosis by any of the means above, arthroscopy of the wrist joint may be the only way to determine whether a ligament injury is causing the continued symptoms. The arthroscope is a miniature TV camera that is inserted into the wrist joint to allow the surgeon to see the ligaments that may be torn. In some cases, the arthroscope may also be used to assist with repair of the ligaments at the same time. Wrist arthroscopy is carried out under regional or general anaesthesia, usually on a day care basis.

It always helps to plan things in advance of surgery and adjust work and life activities accordingly. Therefore, please consider the following issues prior to your operation:

• Anticoagulation medication (Aspirin, Brufen, Warfarin, Clopidrogel, etc.) should ideally be stopped few days before the operation to reduce the risk of bleeding, but advise from the clinician who prescribed them is wise beforehand. I would strongly advise you to stop smoking prior to surgery as this can badly affect the outcome of surgery and increase complication rates.
• Please make sure that you arrange to be collected from the hospital as you will not be able to drive after the surgery
• Plan your time off school / work / sports
• Allow at least few weeks after surgery before considering holiday

The first challenge in treating a ligament injury of the wrist is recognizing that it exists. Many ligament injuries go unrecognized until much later. Usually patients fall and injure their wrist, but assume they have sustained a sprain only. Whilst vast majority of patients will improve with simple rest for few weeks, few people will unfortunately acquire more serious injury.

The treatment of a ligament injury depends on whether it is an acute injury (just happened within weeks) or a chronic injury (something that happened months ago).

Non-surgical Treatment

A wrist injury that causes a partial injury to a ligament, a true wrist sprain, may simply be treated with a cast or splint for 3-6 weeks to facilitate healing. Pain killers, hand therapy, steroid injections, warmth etc. can all be helpful in reducing symptoms.

Modifications of daily living mean that you might need to amend your life style, avoid hobbies and activities that predictably precipitate pain and discomfort in the wrist.

In cases where the ligaments are completely torn and the carpal bones are no longer lined up well, surgery may be recommended.

Direct Ligament repair and Bone Pinning (suitable only within the first 4-6 weeks from injury)
Direct ligament repair gives the best chances for functional recovery, This procedure is however, feasible only within the first few weeks after injury, whilst ligament still possesses healing potential. Ligament is repaired with special sutures whilst neighboring bones are fixed and held in place with metal pins supporting ligament repair through immobilisation. The pins are usually removed 4-6 weeks later.

Later surgery is accomplished from initial injury, less likely it is that the bones can be repositioned properly and less likely it is that torn ligaments will heal as useless scar tissue develops between torn ligament ends with time. In most cases, patient presents late (often even many years after the actual accident), when direct ligament repair is not possible, so one of reconstructive options (to imitate ligament function) becomes indicated.

Ligament Reconstruction
There are several reconstructive options. In principle, they are based on passing a sling of one of the neigbouring tendons through and around the carpal bones restraining their movements and acting as a ligament. The tendon graft is usually borrowed from one of the forearm tendons (flexor carpi radialis, palmaris longus or extensor carpi radialis). One of the most popular (also my preferred choice) is called tri-ligament tenodesis. Its concept is schematically presented in Picture 5, Gallery below.  Tendon sling is tunneled through the scaphoid bone and secured against the ligaments on the opposite side of the wrist. Such manouvering aims to prevent abnormal malrotation of the bones and to some extent, limit harmful extremes of wrist movement. Similar to direct repair, metal pins are used to hold the bones stationary while the tendon graft heals. The pins are removed 6-8 weeks after the surgery. In addition, the wrist has to be immobilised with external splint for up to 8-10 weeks after surgery.

Capsulodesis

Sometimes abnormal bone movements and rotation can be controlled and prevented by attaching/anchoring a piece of wrist watertight sac (capsule) into the carpal bone. This reduces the mobility of the bone which has otherwise become too loose following ligament disruption. This method is less invasive and less robust then formal ligament reconstruction (as described above), but can halt progression of arthritis. It can also be very useful in partial ligament tears which are very symptomatic, but do not require for complex reconstruction.

Fusion

When the ligament instability is discovered long after the injury and arthritis develops in the joint between loose bones, ligament reconstruction becomes pointless: the joint should better be fused i.e. bones permanently fixed after cartilage between them is removed. This stabilizes the motion between the bones (some stiffness is inevitable), but it reduces pain that occurs when the arthritic joint surfaces rub against each other. In order words, pain is exchanged for some stiffness. Fusion in the wrist can be performed against only two bones (partial wrist fusion) or more bones, including all of them (total wrist fusion) if the whole wrist becomes affected with longstanding arthritis.

Rehabilitation protocols are used to help you regain wrist range of motion, strength, and function after injury and during healing.

Nonsurgical Rehabilitation
If the injury has been treated conservatively i.e. only with the cast, a hand therapist or occupational therapist will start mobilising fingers early to prevent stiffness of its small joint. Wrist movements will be initiated either during splintage (for few hours a day under the supervision) or after the splint is removed. Exact rehabilitation protocol depends on the nature of your injury.

After Surgery
If you have surgery, your hand and wrist will be bandaged with a well-padded dressing and a splint for support. Physical or occupational therapy sessions may be needed for up to 6 months after surgery. The first few sessions focus on controlling the pain and swelling after surgery. Patients then begin to do exercises that help strengthen and stabilize the muscles around the wrist joint. Other exercises are also used to improve the fine motor control and dexterity of the hand. The therapist suggests ways to do activities without straining the wrist joint.

Beware that recovery following surgery for disrupted wrist ligaments is often protracted and rarely complete in less then 12, sometimes even 18 months after operation. Ligaments have poor blood supply, yet have to regain great strength. That simply takes time so patience is essential.

Things to look out for after operation and contact us earlier than planned:

• Disproportionate swelling and pain in your hand
• Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
• Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
• Increased skin temperature in the scar area
• Offensive wound smell

Wrist ligaments repair/reconstruction are technically demanding procedures and associated with various risks. Complications are common and divided into general and procedure – specific risks which patients should be aware of:

General complications:

• Skin/wound infection
• Painful scars
• Hypertrophic (lumpy and itchy) scarring
• Numbness
• Stiffness

Specific complications:

• Tendon / nerve injury (< 1%)
• Joint infection
• tendon rupture
• Failure of treatment
• Reflex Sympathetic Dystrophy – RSD (bad reaction to surgery seen in 5% of patients: hand may become very swollen and painful – this can occur with any hand surgery from a minor procedure to a complex reconstruction. This problem cannot be predicted but will be watched for afterwards and can be treated with medication and hand therapy
• Repeated / additional surgery