indirect repair (capsulodesis) is needed. Results of repair are unpredictable and often disappointing if delayed months after the initial injury. If left for too long, then irreversible deformity and osteoarthritis can develop. Over time, the abnormal position of the scaphoid and lunate results in degenerative changes at the radio-scaphoid, mid- carpal and then radio-lunate joints and are referred to as scapho-lunate advanced collapse (“SLAC wrist”). Salvage procedures include, among others, proximal row carpectomy, scaphoid excision with mid-carpal fusion, and full wrist fusion.

Fracture of hook of hamate The hook of the hamate lies distally and radial to the pisiform and forms the lateral border of the canal of Guyon, through which the ulnar artery and nerve run. Fracture of the hook is classically from either a direct blow or blocked swing of a club or racquet. Most patients have pain and tenderness on the ulnar side of the palm, with pain increased by gripping and reduced grip strength. There may also be ulnar nerve paraesthesia and mild carpal tunnel syndrome signs and symptoms. In delayed cases, the FDP tendon to the little finger, which runs alongside the hook, may rupture.

The fracture cannot be diagnosed on simple anteroposterior and lateral X-rays. It can sometimes be seen on a carpal tunnel view. If there is still diagnostic doubt, a CT scan is the definitive test (Fig. 5).

If diagnosed in the first 2–3

weeks (unusual), then treatment is by immobilisation in a cast. If the patient presents later, then surgical excision of the hook produces very good results.

CHRONIC WRIST PAIN Excluding missed acute injuries, causes include: n Tendinopathies n Ganglion and dorsal impingement n TFCC injuries n Neuropathy n Arthritis n Kienbock’s disease n Piso-triquetral pain n Snapping ECU.

General assessment History The affected part of the wrist may

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Intersection syndrome This is actually a frictional bursitis where the APL and EPL tendons cross over the ECR. There is tenderness and crepitus just proximal and radial to Lister’s tubercle. This is a relatively common condition in rowers, canoeists and racquet sportspeople. The diagnosis, usually made clinically, can be confirmed on either ultrasound or MRI. Treatment consists of physiotherapy, non-steroidal anti- inflammatory drugs (NSAIDs), relative rest and correction of any technique errors. If this fails, a cortisone injection into the area is often effective.

Other tendinitides These are common in endurance sports with repetitive wrist movement,

indicate the problem (eg. dorsal may be intersection syndrome). Stiffness at rest may indicate a tendinopathy or arthritis, whereas pain on loading (eg. in gymnastics) may be due to a bony or joint problem. Neural symptoms may be due to a local entrapment, but if the symptoms extend above the wrist, then it is important to exclude pathology in the elbow or neck.

Examination

The wrist should be examined systematically: look, feel, move.

Investigation

Depending on the likely diagnosis, there is a role for X-rays, MRI, ultrasound, nerve conduction studies and arthroscopy.

Tendinopathy De Quervain’s tenosynovitis This is an inflammation of the APL and EPL tendon in the synovial sheath and is more common in gripping sports such as rowing and canoeing. There is tenderness and swelling over the radial styloid and a positive Finklestein’s test (closing the fingers over the thumb and then ulnar deviation of the wrist produces pain over the radial styloid). The tenosynovitis can be detected on ultrasound scan. The most effective primary treatment is an injection of cortisone into the tendon sheath (Fig. 6). Splinting or strapping to immobilise the wrist and physiotherapy (ultrasound, massage, stretches) are adjuncts. Surgical decompression of the tendon is usually curative but rarely necessary.

Figure 5: CT scan of fractured hook of hamate

Figure 6: Injection for de Quervain’s

Figure 7: Volar ganglion

Figure 8: Ulno- carpal impaction

such as rowing and canoeing. Increased risks in these sports include blade design, poor grip and poor technique, possibly from fatigue. Relative rest, physiotherapy and strapping, as well as correcting any causative factors, are usually successful. An accurate cortisone injection is very helpful in more significant cases. Surgery is rarely required.

sportEX medicine 2009;41(Jul):21-26