Chapter 269: Wrist Injuries

INTRODUCTION AND EPIDEMIOLOGY

The wrist is the area from the distal radius and ulna to the carpometacarpal joints. Wrist injuries are common, accounting for 2.5% of ED visits annually, and up to 25% of all sports injuries include the hand or wrist.^1-3 Clinical diagnosis is often difficult, and even subtle injuries may lead to significant impairment if not properly diagnosed and treated. Management options vary from conservative to surgical, so an understanding of the functional anatomy, mechanisms of injury, and clinical evaluation is needed for proper diagnosis and treatment.

ANATOMY

The wrist is a complex unit with articulations among the eight carpal bones and the distal radius and ulna that allows for flexion, extension, and radial/ulnar deviation.^4,5 Not only does it consist of the carpal bones, radius, and ulna, but it also contains distal radioulnar joint, triangular fibrocartilage complex (TFCC), and thumb radial and ulnar collateral ligaments. The wrist has dual blood supply, although most carpal bones do not. The radial nerve provides dorsal sensation and wrist/finger extension, the median nerve volar sensation to the first three digits and wrist/finger flexion, and the ulnar nerve sensation to the palm and last two digits and hypothenar and fourth/fifth digit lumbrical movement.^4,5

DISTAL RADIUS AND ULNA

The distal radius is the only forearm bone that articulates directly with the carpal bones (scaphoid and lunate). The distal radius has three articular surfaces: radiocarpal, distal radioulnar, and the triangular fibrocartilage complex. The radiocarpal surface is concave and tilted in two planes. It has an ulnar inclination, or tilt, of 15 to 25 degrees in the frontal plane, and a volar tilt of 10 to 15 degrees in the sagittal plane (Figure 269-1).^4,5 The ulna is separated from the carpal bones by the triangular fibrocartilage complex, the main stabilizer of the distal radioulnar joint, on its distal end. The triangular fibrocartilage complex forms a smooth, continuous, ulnarly directed extension of the distal radial surface, and supports the lunate and triquetrum on the distal ulna. The distal radius has a concave sigmoid notch at its ulnar aspect that articulates with the curvature of the ulnar head, which permits wrist rotation during pronation/supination of the forearm.⁶ The distal radioulnar joint is also supported by dorsal and volar radioulnar ligaments that merge with the triangular fibrocartilage complex.⁷