What is the treatment plan for wrist instability?

Treatment Plan for Wrist Instability

The treatment of wrist instability requires a structured approach beginning with proper diagnostic imaging followed by appropriate stabilization techniques, with surgical intervention reserved for cases that fail conservative management.

Diagnostic Approach

Initial Imaging

• Start with standard radiographs as the first-line imaging modality 1
  • Posterior-anterior and lateral views in neutral position
  • Supplemented by oblique views
  • Stress positions/maneuvers to detect dynamic instability not visible on standard views

Advanced Imaging (when radiographs are inconclusive)

• MRI with dedicated wrist coil for accurate assessment of:
  • Intrinsic and extrinsic ligaments
  • Triangular fibrocartilage complex (TFCC)
  • Bone marrow abnormalities 1
• MR arthrography for better visualization of:
  • Scapholunate ligament tears (sensitivity 65-89% at 3T)
  • Lunotriquetral ligament tears (sensitivity 60-82% at 3T) 1
• CT for distal radioulnar joint stability assessment 1
• Wrist arthroscopy as the "gold standard" for definitive diagnosis 2

Treatment Algorithm

1. Conservative Management (First-Line)

• Immobilization

  • Splinting or casting for 4-6 weeks to allow ligament healing
  • Limit duration of external fixation when used to prevent finger stiffness 1

• Pain Management

  • NSAIDs for pain and inflammation
  • Consider vitamin C supplementation to prevent disproportionate pain 1
  • Ice therapy in acute phase (shown to be beneficial at 3 and 5 days post-injury) 1

• Rehabilitation Protocol

  • Active finger motion exercises should be started immediately following diagnosis to prevent stiffness 1
  • Wrist stability training combined with grip-strengthening exercises (20 min/day, twice weekly for 4 weeks) 3
  • Home exercise program is an acceptable option for patients without complications 1
  • Early wrist motion is NOT routinely needed following stable fracture fixation 1

2. Surgical Management (for failed conservative treatment)

• Arthroscopic Techniques

  • Diagnostic arthroscopy to confirm diagnosis and assess extent of damage 2
  • Débridement of damaged tissue
  • Acute repair of ligamentous structures, especially for TFCC injuries 4

• Open Procedures

  • Limited wrist arthrodesis for persistent instability 5
  • Open ligament repair for distal radioulnar joint instability 4
  • Ligamentous reconstruction for chronic cases

Special Considerations

TFCC Injuries

• Critical to differentiate injuries that produce distal radioulnar joint instability from those that do not 4
• Acute repair is indicated for unstable TFCC tears with distal radioulnar joint instability 4

Chronic Instability

• Limited wrist arthrodesis is preferred over ligamentous reconstruction for chronic instability 5, 6
• Partial arthrodesis aims to transfer load from the capitate to the radius while preserving functional motion 5

Monitoring and Follow-up

• Patients with unremitting pain during follow-up should be reevaluated 1
• Assess for development of degenerative changes, which are common in untreated or inadequately treated carpal instability 6

Pitfalls and Caveats

• Late presentation of ligamentous injuries often results in osteoarthritic changes and cartilage destruction 6
• Ligamentous reconstructions for chronic instability have shown disappointing long-term results 6
• Dynamic instability may be missed on static imaging; stress views or dynamic examination techniques are essential 1
• Partial arthrodesis can lead to pathologic wrist movements, impingement syndromes, and stress reactions in neighboring joints 6