• Work Loss Data Institute. Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss Data Institute; 2008. 128 p. [148 references]

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute. Forearm, wrist, and hand (acute & chronic), not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss Data Institute; 2007 May 16. 113 p.

The Official Disability Guidelines product line, including ODG Treatment in Workers Comp, is updated annually, as it has been since the first release in 1996.

Initial Diagnosis

1. Determine the type of injury or contributing factors (direct trauma, fall, repetitive motion, twisting incident, animal bite, etc.)
2. Determine whether the problem is acute, subacute, chronic, or of insidious onset.
3. Record the severity and specific anatomic location of the pain asserted.
4. Assess the ability of the patient to use the fingers, forearm, wrist, or hand, from no to full ability.
5. Search for any evidence of an open or penetrating wound.
6. Search for any evidence of deformity (anterior/posterior or lateral/medial) of the wrist or phalanges.
7. Test the range-of-motion of the joint (normal, mild restriction, severe restriction, or complete restriction).
8. Record any present medication.
9. Elicit any previous medical history, history of systemic disease, or previous wrist or hand injury or disability.

Presumptive Diagnosis

• Fracture or Dislocation (see original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)
• Other diagnoses:
  • Sprain, sprain-fracture or contusion, excluding carpal tunnel syndrome (see separate chapter)
  • Laceration
  • Tenosynovitis
  • Hand tendon injuries
  • Superficial injury

Fracture or Dislocation of Wrist

1. Definitive Evaluation
   • Record a history of the cause of injury.
   • Search for any evidence of an open wound in the vicinity of the injury.
   • Perform a clinical examination for deformity, tenderness, or ecchymosis, or associated nerve, neurovascular, or tendon injury.
   • Check for snuff box tenderness.
   • Search for any evidence of dislocation or arterial vascular compromise (cold, dusky hand with loss of sensation). If found, an immediate reduction should take place (prior to x-rays, if necessary, or proper consultations).
   • Perform an evaluation for an associated injury of the wrist or fingers.
   • X-ray the wrist. Include a scaphoid view.
   • Consider the easily missed scapholunate dissociation, or scaphoid fracture.

2. Initial Therapy
   1. Simple, undisplaced, stable fractures of the wrist can be treated by the primary care physician.
      1. Place the wrist in a plaster or sugar tong splint for seven to ten days, and then change to a short arm cast.
      2. Ice prior to application of cast, if applicable, and elevate for 4 to 7 days to prevent or reduce swelling (Hand Higher than Heart - HHH).
      3. Give the patient instructions to prevent tight cast problems.
      4. Analgesics and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for up to two weeks may be appropriate.
      5. Recheck at seven days and then at two-week intervals until healed. Repeat x-rays at seven days and at two weeks to assure that the fracture has not slipped. X-ray again at five weeks; in most cases, the cast can be removed at that time.
      6. Estimate a return-to-work date for temporary transitional and regular work at each visit.
      7. Prescribe temporary transitional and job modifications at each visit.
   2. Undisplaced scaphoid fractures can be treated by the primary care physician. The average time for a fracture of the waist of the scaphoid of a bone that is not displaced is three months in a cast. A careful discussion with an orthopedic surgeon may result in a decision to operate and stabilize the bone with a special screw. These patients usually are allowed out of a cast within three weeks to begin flexibility exercises.
      1. With a negative x-ray but clinical suspicion of a scaphoid fracture (i.e., localized pain at snuff box following fall/trauma), a short arm thumb spica cast is used for seven to ten days. Then a repeat x-ray out of plaster is obtained to clarify the diagnosis. Rarely is a bone scan useful to confirm a suspected diagnosis of scaphoid fracture.
      2. Confirmed scaphoid fractures should be immobilized in a short arm thumb spica cast for 10 to 12 weeks until healed by x-ray examination.
      3. Analgesics and/or nonsteroidal anti-inflammatory drugs for up to two weeks may be appropriate.
      4. Recheck at seven days and then at two-week intervals until healed. Treatment may be as long as 12 to 36 weeks.
      5. Wrist x-rays should be taken at four to six weeks. It is often necessary to remove the cast to obtain the quality of x-rays necessary to determine healing status. Persistent fracture line on the x-ray and continued clinical tenderness over the scaphoid suggest delayed union that should prompt referral.
      6. Estimate a return-to-work date for temporary transitional and regular work at each visit.
      7. Prescribe temporary transitional and job modifications at each visit, and maybe a brace to prevent re-injury.
   3. Minimally displaced fractures can be reduced and treated by a primary care physician with proper training.
      1. Patients with minimally displaced fractures and no loss of length can have local anesthesia injected into the fracture; then the physician can perform a reduction. Parenteral analgesic will facilitate the reduction.
      2. Ice prior to application of cast, if applicable, and elevate for up to seven days is appropriate to prevent or reduce swelling.
      3. Apply a sugar tong splint with an ace bandage. Replace with a short arm cast after seven days or when swelling has subsided.
      4. Give the patient instructions to prevent tight cast problems.
      5. Analgesics and/or nonsteroidal anti-inflammatory drugs for up to two weeks may be appropriate.
      6. Recheck at seven days and then at two-week intervals until healed.
      7. Obtain x-rays after reduction, seven to ten days, and at four weeks.
      8. Physical therapy (three to four visits) to teach patient range-of-motion and muscle-strengthening exercises is appropriate following removal of cast.
      9. Estimate a return-to-work date for temporary transitional and regular work at each visit.
      10. Prescribe temporary transitional and job modifications at each visit.

      Wrist fractures with any question of non-union and all other wrist fractures not described above should be referred to an orthopedic surgeon for care.

      Evaluate for delayed union, malalignment, or signs of associated tendon or nerve injury.

      Promptly refer to an orthopedic surgeon if one of these conditions is found, otherwise continue therapy.

Other Diagnoses

Record a history including the onset of symptoms, limitations of present activity, and history of previous episodes, including type of treatment and results.

The history should include the nature of symptoms (numbness, pain, tingling), the time of day symptoms are experienced, and how the pain is relieved.

Separate cases of true nerve root impairment from those that mimic carpal tunnel syndrome (CTS). These include sprains, tenosynovitis, contusions, and hand arm vibration syndrome (HAV).

X-rays are not usually needed, unless local pathology or referred pain in the wrist from cervical spine pathology is suspected or the case is persistent. In such cases, wrist or cervical spine x-rays are appropriate.

Order laboratory studies including glycohemoglobin, sedimentation rate, thyroid-stimulating hormone (TSH), and a Rheumatoid Factor, if appropriate.

• The initial evaluation of the wrist needs to include a careful history for type of injury and the possibility of both repetitive and vibration type injuries. It is extremely important to make sure that any painful injury of the wrist does not have its origin in the upper extremity or the neck. It is also important to evaluate the patient's history for avocational activities that may be the cause of or be aggravating the problem, as it is necessary to have the patient modify these activities if one is to successfully treat the problem.
• The presumptive diagnosis is used to classify the type of problem prior to a thorough evaluation. Subsequent to a thorough evaluation, the diagnosis may change (e.g., if the physician classifies a patient with a sprain and the x-rays subsequently show a fracture). In such a case, therapy should follow the subsequent rather than the initial diagnosis.
• An open wound in the vicinity of a fracture makes it a compound fracture, even if no clear connection to the fracture site is apparent. All compound fractures should be referred to an orthopedic surgeon for care.
• Snuff box tenderness is often a sign of injury to the scaphoid bone. If symptoms persist for seven days or longer, repeated scaphoid view x-rays should be taken.
• Trans-scaphoid perilunar dislocation is a rare, severe injury which should be referred to an orthopedic surgeon.
• Scapholunate dissociation is the most frequent serious ligamentous injury of the wrist and is diagnosed by the "Terry Thomas sign" on wrist x-rays. There is a widening of the space between the lunate and the scaphoid on the anteroposterior view.
• Magnetic resonance imaging (MRI) of the wrist shows:
  • 82% of triangular fibrocartilage (TFC) tears confirmed by arthroscopy (Injuries to the triangular fibrocartilage complex are a frequent cause of ulnar-sided wrist pain. The TFC is a complex structure that involves the central fibrocartilage articular disc, merging with the volar edge of the ulnocarpal ligaments and, at its dorsal edge, with the floors of the extensor carpi ulnaris and extensor digiti minimi.)
  • 50% of scapholunate ligament tears
  • 40% of intercarpal dorsal ligament tears
• Arthroscopy is thought to be superior to arthrograms in delineating ligament tears.
• Fluoroscopy exam is helpful in diagnosing tears and abnormal motion.
• Undisplaced scaphoid fractures can be treated by the primary care physician. Those scaphoid fractures that are displaced or have a wide gap between the fragments should be immediately referred to an orthopedic surgeon, as they have a significant increased incidence of nonunion.
• Wrist sprains are common industrial injuries, and must be differentiated from carpal tunnel syndrome and tendonitis.
• Tendon injuries are not common with sprains, but it is important to check for such injuries as they require different therapy than a simple sprain.
• Grade III sprains involve tears of the carpal ligaments and are impairing injuries. Clinically they have significant swelling, ecchymosis, and an unstable joint. These are the sprains that are more likely to have associated injury of tendons or nerves. Injuries to the triangular fibrocartilage complex (TFCC) may have pain and stiffness as the only relevant findings. These injuries should be referred to an orthopedic surgeon or hand surgeon for evaluation and treatment.
• A wrist splint or short arm cast is sometimes necessary for the initial treatment of sprains which are very tender, swollen, and painful with motion. Splinting is continued until symptoms abate. An early nonresisted exercise program is indicated.
• The Terry Thomas sign refers to the x-ray appearance of a widening gap between the two carpal bones of the wrist in patients with scapholunate dissociation. (Terry Thomas's teeth were apart when he smiled).
• Imaging procedures are appropriate for sprains that have been treated for six weeks with little or no improvement in the patient's complaints or physical findings. Repeat x-rays with scaphoid views are indicated, since routine anteroposterior and lateral x-rays generally fail to demonstrate scaphoid fractures. Additionally, an arthrogram may be of value to demonstrate carpal ligament tears and help determine the necessity of surgical therapy, but should be obtained only after a consultation with an orthopedic surgeon.
• A laceration produced by crush injury needs an x-ray to rule out any underlying fracture and to answer any question of penetration of the joint or a foreign body in the wound.
• Neurovascular and tendon function need evaluation with any laceration around a joint. No anesthesia should be used in the wound until the sensation has been checked distal to the laceration and the function of the tendons has been identified as intact.
• Antibiotic therapy for contaminated lacerations should include both anti-staphylococcal and broad-spectrum coverage.
• Tenosynovitis is a common enthesopathy of the tendon of the wrist. It is most important to rule out infection, for this is an emergent problem that requires prompt referral. Infectious tenosynovitis will usually demonstrate marked tenderness and more pain than noninfectious tenosynovitis. The patient with septic tenosynovitis will frequently have an elevated temperature, lymphangitis, erythematous swelling, and severe pain with attempted motion along with an elevated white blood count.
• Ganglions of the wrist are benign synovial cysts and usually do not require treatment. An initial aspiration with injection of corticosteroids is acceptable. There is a 50% recurrence rate. With an accurate diagnosis, no further treatment is necessary. Surgery, though commonly done, has a significant recurrence rate and is only indicated in unusually symptomatic wrists.
• Placing the wrist in a splint post injection for a short time is often helpful.
• Hand arm vibration syndrome (HAV) is a relatively common industrial injury in workers whose job involves work with frequent and sustained vibrations. Sensory impairment of the fingers and Raynaud's phenomenon are the common complaints. It must be differentiated from carpal tunnel syndrome, as the treatment is never surgical for HAV. The treatment is primarily reduction of vibration exposure and taking a slow release calcium channel blocker (e.g., nifedipine).
• Acute carpal tunnel syndrome (CTS) occasionally occurs with acute trauma to the wrist, most commonly with severe sprains. It can occur in fractures and with a direct blow to the volar aspect of the wrist. There is rapid and intense development of symptoms with paresthesias, pain, and numbness in the distribution of the median nerve. This is an urgent (four to eight hours) surgical problem. It can be differentiated from other problems by the measurement of the pressure in the carpal tunnel.
• Acute episodes of traumatic arthritis frequently follow minor wrist fractures and severe sprains. One of the common sites of traumatic arthritis of the wrist is the trapezio-metacarpal joint at the base of the first metacarpal. Persistent and increasing impairment of this joint from arthritis often requires surgical treatment.

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

• Work Loss Data Institute. Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss Data Institute; 2008. 128 p. [148 references]

Not applicable: The guideline was not adapted from another source.

2004 (revised 2008 May 29)

Work Loss Data Institute - Public For Profit Organization

Not stated

Not stated

There are no conflicts of interest among the guideline development members.

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute. Forearm, wrist, and hand (acute & chronic), not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss Data Institute; 2007 May 16. 113 p.

The Official Disability Guidelines product line, including ODG Treatment in Workers Comp, is updated annually, as it has been since the first release in 1996.

This NGC summary was completed by ECRI on April 4, 2005. This NGC summary was updated by ECRI on January 18, 2006, April 11, 2006, November 9, 2006, March 29, 2007, and August 17, 2007. This summary was updated by ECRI Institute on December 19, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.