Wrist Injury

January 1, 2002
John F. Connolly, MD

The goal in managing manymusculoskeletal injuries isnow early mobilization-notimmobilization. This shift inemphasis encompasses injuriesranging from a strained backto a sprained ankle. Patients withsciatica who previously might havebeen kept at bed rest for severalweeks are now encouraged to avoidbed rest and to alleviate nerve irrita-tion with positional exercises. Similarly,patients with ankle sprainsgain faster pain relief and recoverfunction more rapidly when cast orsplint immobilization is avoided.Early mobilization is appropriate formany acute injuries without riskof significant bone or joint instability.Its advantages have emerged asthe many detriments or hazards ofeven brief periods of immobilizingmuscles, joints, and bones havebecome apparent.

The goal in managing manymusculoskeletal injuries isnow early mobilization-notimmobilization. This shift inemphasis encompasses injuriesranging from a strained backto a sprained ankle. Patients withsciatica who previously might havebeen kept at bed rest for severalweeks are now encouraged to avoidbed rest and to alleviate nerve irrita-tion with positional exercises. Similarly,patients with ankle sprainsgain faster pain relief and recoverfunction more rapidly when cast orsplint immobilization is avoided.Early mobilization is appropriate formany acute injuries without riskof significant bone or joint instability.Its advantages have emerged asthe many detriments or hazards ofeven brief periods of immobilizingmuscles, joints, and bones havebecome apparent.In the following pages, I presentcases that clearly demonstrate therisks of immobilization. Several ofthese cases underscore the dangersof immobilizing injured soft tissue,which continues to swell after a castor splint has been applied. Wrist InjuryProblems in the wrist can occur when a displaced distal radial fracture orColles fracture is treated in a cast with the wrist in maximum flexion to holdthe reduction. As the photograph shows, this can cause both compressionof the median nerve that leads to carpal tunnel syndrome and, occasionally, acompartment syndrome with subsequent impairment of the intrinsic musculatureof the hand. Immobilization of this patient's wrist in a hyperflexed positionfor a Colles fracture resulted in atrophy of the thenar muscles, with some lossof hand function.The acutely fractured distal radius is best immobilized in a temporarysplint with minimal wrist flexion until the acute swelling subsides. At thatpoint, you can safely apply a circular cast that maintains reduction withouthyperflexing the wrist and risking nerve or muscle damage.