changes, a gadolinium-enhanced MRI scan is diagnostic. Treatment consists of

immobilisation in early cases. The natural history is often benign. Some cases need surgery to decompress or revascularise the lunate.

Piso-triquetral pain Figure 10: Keinbock’s disease

grip. Severe and persistent cases may need surgical decompression. However, scar tenderness can be an issue.

Osteoarthritis The wrist can develop arthritis spontaneously as part of an individual’s genetic programme. The demands of sport may expose symptoms (although there is no evidence that sport causes arthritis, unless there is a predisposing sporting injury). Previous sporting injury can cause arthritis in specific patterns (eg. scaphoid fracture, scapho-lunate injury, pisiform fracture, intra-articular radius fracture). Initial treatment is conservative – modifying the technique and tempering sporting ambitions. Splinting and an occasional cortisone injection can help. There is no role for physiotherapy. Some patients require surgery for intrusive symptoms; if possible, total wrist fusion is avoided. Some part of the complex articulation can be preserved in order to maintain some movement (partial wrist fusion). However, loss of wrist movement and coordination from surgery is likely to reduce sporting performance considerably. Modern wrist replacements, although increasingly trusted for low-demand individuals, are unlikely to withstand the demands of an athlete.

Keinbock’s disease This is an avascular necrosis of the lunate (Fig. 10). The aetiology is unclear but is possibly from repeated trauma. There is chronic mid-dorsal and volar wrist pain. It is more common in athletes in their twenties. Diagnosis is made by X-ray, which shows sclerosis of the lunate and, in later cases, crumbling of the lunate, with altered alignment of the other carpal bone and arthritis. If suspected before plain X-ray

26

Piso-triquetral arthritis is unusual, but it can follow a fracture or can develop spontaneously. Pain is located on the palmar-ulnar corner of the wrist, aggravated by flexion in ulnar deviation (eg. tennis, golf). A special supinated lateral X-ray is needed to show this joint. Treatment is by cortisone injection or excision.

Piso-triquetral instability can occur in patients with lax joints or with a previous injury that has damaged the ligaments that support this joint. Again, there is pain in the ulnar-palmar corner, aggravated by grip in flexion and ulnar deviation. On examination, the joint can be balloted laterally. Treatment is by amending sporting posture or, occasionally for troublesome symptoms, pisiform excision.

Snapping ECU This may follow an acute injury, usually a poorly executed tennis shot, or it may be exposed as a chronically developing condition. In normal rotation, the ECU passes across the back of

the ulnar head, restrained in a groove. If the restraints tear or gradually fail, then the ECU snaps across the back of the ulna head in rotation. An acute tear (very rarely diagnosed) is treated in an above-elbow cast. A chronic injury needs surgical reconstruction of the ECU sheath.

Clinical Sports Medicine (revised

2nd edn) by Peter Bruckner and Karim Khan was used as a template for this article.

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THE AUTHORS David Warwick, MD BM FRCS FRCS(Orth) European Diploma of Hand Surgery is a consultant hand surgeon at Southampton University Hospitals NHS Trust. He is also Reader in Orthopaedic Surgery at the University of Southampton. His elective and trauma practice is confined to conditions of the hands, wrists, elbows and nerves. He provides a tertiary referral service for the States of Jersey, the Isle of Wight and the British army (training and recruitment). He looks after many sportspeople, including four gold medal Olympians and two silver medal Olympians. He has looked after national-level rugby, diving, hockey, cricket and soccer players. He is club surgeon to Southampton Football Club and Hampshire County Cricket Club. He has admitting rights at Wessex Nuffield Hospital, BUPA Southampton Hospital and Jersey General Hospital. He has written many articles and book chapters; most recently, he edited and authored the Oxford Handbook of Hand Surgery.

Mike Rossiter, MB BS MSc (SEM) FFSEM (UK) MRCGP is a sports physician at the English Institute of Sport, Bisham Abbey and an associate specialist in orthopaedics and sports and exercise medicine at the North Hampshire Hospital Basingstoke. He also has sports clinics in Basingstoke and Parkside Hospital. He is an honorary senior lecturer and examiner in sports and exercise medicine at the University of Bath. He is club doctor at London Irish Rugby Club and chief medical officer for England and Great Britain Hockey and also for the Great Britain Synchronised Swimming Team. He was team doctor for both the men’s and women’s hockey teams at the Commonwealth Games in 2006 and the Beijing Olympics in 2008. He was one of the club doctors at Southampton Football Club until 2008.

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