Anatomy of the wrist

The wrist complex is formed by nine bones which articulate to form a series of small joints that move together creating the wide range of movements available in the wrist.

The radio-carpal joint is the largest joint at the wrist and is often referred to as the ‘wrist joint proper’. It is formed by the radius (long bone of the forearm) and a set of four small bones in the wrist, collectively known as the proximal carpal row. This joint is primarily responsible for wrist extension (revving a motorbike) and wrist flexion (downward curling of the wrist).

The small bones of the proximal carpal row are listed here and shown below in the left image:

  • Scaphoid
  • Lunate
  • Triquetrum
  • Pisiform

The proximal carpal row in turn articulates with the distal carpal row of the wrist, which forms the mid carpal joint of the wrist.

The distal carpal row is made up of a further 4 small bones, also shown in the left image below:

  • Trapezium
  • Trapezoid
  • Capitate
  • Hamate

The entire wrist complex is encapsulated within a thin but strong layer around the joint that is lined with a lubricating substance called synovial fluid which allows for frictionless movement of the joints within.

The radiocarpal joint and the mid carpal joint work together to provide the following movements, shown below in the right image:

  • Wrist extension e.g. revving a motorbike
  • Wrist flexion e.g. curling of the wrist
  • Radial deviation e.g. side flexing wrist towards the thumb
  • Ulnar deviation e.g. side flexing wrist towards the little finger

Due to the complexity of the wrist joint and the high functional demand placed upon it during activities of daily life, it can be a common source of pain and injury.

The radiocarpal joint is the most common joint to become arthritic. Risk factors associated with radiocarpal joint osteoarthritis include:

  • Scapholunate joint instability (a small joint created by the scaphoid and the lunate bones of the proximal carpal row). Disruption of the ligamentous structures within this joint can result in joint instability.  This instability has been reported to increase abnormal mechanics within the radiocarpal joint which in turn causing wrist osteoarthritis (Johnson et al. 2013).
  • Age – the rate of wrist osteoarthritis increases in line with age.
  • Previous fracture i.e. a broken bone, to the hand/wrist can alter the mechanics of the wrist resulting in increased susceptibility to osteoarthritis.
  • Ligamentous injuries of the wrist sustained during a fall,  increases the chance of osteoarthritis within the radiocarpal joint (Anderson et al. 2011 cited by Johnson et al. 2013).
  • There is a familial link i.e. if one of your family members has osteoarthritis, you have an increased risk.

The wrist joint surfaces are coated with a layer of articular cartilage. Articular cartilage provides a smooth, friction free surface for joint movement to occur. The articular cartilage of the joint can become thinner. Progressive disruption of the articular cartilage results in osteoarthritis.  Osteoarthritic joints are commonly associated with inflammation of the synovium. Inflammation of the synovium is commonly called synovitis. Synovitis has been associated with an increased rate of joint degeneration.

How do you know if you have osteoarthritis of the wrist?

Osteoarthritis is a progressive degenerative condition, often taking many months or even years before becoming symptomatic (painful). Here is a list of the most common symptoms:

Common symptoms of wrist osteoarthritis include:

  • Deep dull aching pain located within the wrist joint
  • Episodes of increased pain, often this is quite sharp on certain movements and can be associated with synovitis
  • Pain with weight bearing activities such as Yoga, press ups or leaning on a table
  • Stiffness particularly in the morning or after a period of inactivity – the stiffness is often associated with pain and usually dissipates as you start moving
  • Change in your joint shape – osteoarthritis can result in a thickened and swollen wrist

How is osteoarthritis of the wrist diagnosed?

Diagnosing wrist joint osteoarthritis requires a professional assessment, this can be completed by your physiotherapist. Obtaining a correct diagnosis is essential, enabling your clinician to prescribe the most appropriate treatment modality for you.

The formulation of a diagnosis starts with a formative interview. This includes taking a detailed medical history about how your pain started and what aggravates and eases your symptoms. A series of clinical tests are also completed involving wrist joint palpation (feeling) along with assessing your wrist range of movement and strength.

If your clinician believes you may have osteoarthritic changes in your wrist joint, you may be referred for x-ray (see above image). An x-ray is seen as the gold standard imaging tool for the assessment and diagnosis of bone and joint disorders, including osteoarthritis.

It is able to assess the presence of osteoarthritis within the joint as well as the severity of arthritic change. You may also be referred for a series of blood tests if your physiotherapist is suspicious there may be an underlying systemic inflammatory disorder such as rheumatoid arthritis (Lee et al, 2013).

Although x-ray is an excellent modality for diagnosing osteoarthritis, many patients suffer symptoms which do not directly correlate with the severity of osteoarthritis seen on x-ray. If synovitis is present, patients often experience higher levels of pain than expected. Synovitis is not seen on X-ray.

Diagnostic musculoskeletal ultrasound is a highly effective dynamic imaging technique, routinely used for assessing the presence of synovitis associated with osteoarthritis. Research has shown diagnostic musculoskeletal ultrasound as an effective tool for assessing arthritic joint changes associated with osteoarthritis, rheumatoid arthritis and synovitis (Wakefiled et al, 2000 & Kaeley et al, 2020).

Complete has a team of highly skilled clinicians holding dually qualified physiotherapists and musculoskeletal sonography. During your initial assessment your clinician will perform a comprehensive assessment of your wrist using both clinical testing and diagnostic imaging.

If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.

How do we treat osteoarthritis of the wrist?

The vast majority of patients suffering from osteoarthritis of the wrist responded very well to physiotherapy management and learn to self manage the condition. It is essential you preserve the flexibility and strength to help maintain the health of your joint.

Physiotherapy rehabilitation for osteoarthritis of the wrist commonly involves:

  • Wrist joint stretches to maintain and increase range of movement
  • Wrist and grip strengthening exercises
  • Joint manipulation and soft tissue release techniques are also used to increase your joint movement and ease pain
  • We may use some taping techniques and/or recommend the use of a wrist brace.

Here are a few top tips you may like to try yourself (we would always recommend you get your wrist fully assessed before embarking on too much self-management)

  • Rest from activities that aggravate your symptoms. If this is not possible try to modify how you complete these tasks. This may involve taking regular breaks.
  • Try some gentle wrist stretches (see image above)
  • Try using a wrist support when lifting and carrying heavy objects such as suitcases or shopping.
  • Keep you joint warm – wear gloves in the winter or use a hot water bottle to warm up your wrist.
  • Increase your grip strength by squeezing a stress ball or a tennis ball.
  • Over-the-counter pain medication such as paracetamol or a nonsteroidal anti-inflammatory gel such as Voltarol can be used to reduce pain. Ask your pharmacist before starting any medication.

What if conservative management does not work?

Injection therapy is an effective tool for reducing pain and inflammation associated with wrist joint osteoarthritis.  It is considered an appropriate treatment option when conservative management has failed to reduce symptoms, or when:

  • Pain has persisted for over 3 months
  • Pain is limiting you from embarking in a physiotherapy rehabilitation
  • Pain is limiting you from completing activities of daily living including work and sporting activities
  • Pain is affecting your sleep

At Complete all injection techniques are performed under ultrasound guidance. Dynamic, real-time ultrasound imaging is used to accurately and effectively guide a needle directly to the source of your pain. Research has proven ultrasound guided injections to be more accurate, have less side effects and more effective at reducing pain than land marked injections.

All clinicians at Complete are experienced in performing ultrasound-guided injections for wrist osteoarthritis. Complete run a same-day service on all ultrasound-guided injections. You do not need a referral from a doctor or bring a prescription. Your clinician is a qualified independent prescriber and will be able to prescribe the most effective medication for you.

There are two main injection options available for the treatment of osteoarthritis of the wrist:

Ultrasound-guided corticosteroid injection

A corticosteroid injection is a safe and effective injection option used to reduce the swelling associated with wrist joint arthritis (Lee et al., 2013). A combination of corticosteroid and a short acting local anaesthetic is injected into your wrist joint using ultrasound guidance.  A corticosteroid injection (also known as a steroid injection) is a potent, injectable, anti-inflammatory medication which has been used routinely within musculoskeletal medicine for many decades. It provides a pain free environment for you to effectively rehabilitate your wrist. Current evidence suggests an average of 10-12 weeks of excellent pain relief with a corticosteroid injection, however this pain reduction often lasts longer.

Ultrasound-guided hyaluronic acid injection

Hyaluronic acid is a man-made synthetic replica of the joint’s natural lubricant. It has an anti-inflammatory and is an effective technique for reducing pain and inflammation within arthritic joints. It is an effective alternative to a corticosteroid injection for the treatment of osteoarthritis (Gigante et al., 2010). Hyaluronic acid injections are also combined with a short acting local anaesthetic to provide a comfortable experience during the injection process.

To ensure you experience the best possible results it is highly recommended that a course of physiotherapy is started 10-14 days following the injection.

If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.

References:

GIGANTE, A., GIGANTE, A., CALLEGARI, L. and CALLEGARI, L., 2010. The role of intra-articular hyaluronan (Sinovial®) in the treatment of osteoarthritis. Rheumatology international, 31(4), pp. 427-444.

JOHNSON, J.E., LEE, P., MCIFF, T.E., TOBY, E.B. and FISCHER, K.J., 2013. Effectiveness of surgical reconstruction to restore radiocarpal joint mechanics after scapholunate ligament injury: An in vivo modeling study. Journal of Biomechanics, 46(9), pp. 1548-1553.

KAELEY, G.S., BAKEWELL, C. and DEODHAR, A., 2020. The importance of ultrasound in identifying and differentiating patients with early inflammatory arthritis: a narrative review. Arthritis research & therapy, 22(1), pp. 1-10.

LEE, J.H., LEE, J., JUNG, S.-., YOON, C.-., KWOK, S.-., PARK, S.-., KIM, H.-. and PARK, K.-., 2013. FRI0140 Midcarpal joint effusion is as common as radiocarpal joint effusion in swollen wrists of patients with rheumatoid arthritis. Annals of the Rheumatic Diseases, 72(Suppl 3), pp. A417.

WAKEFIELD, R.J., GIBBON, W.W., CONAGHAN, P.G., O’CONNOR, P., MCGONAGLE, D., PEASE, C., GREEN, M.J., VEALE, D.J., ISAACS, J.D. and EMERY, P., 2000. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: A comparison with conventional radiography. Arthritis & Rheumatism, 43(12), pp. 2762-2770.