Wrist Sprain
Upper LimbOverview
Wrist sprains involve acute ligamentous injury to the wrist complex, commonly affecting the scapholunate, lunotriquetral, or radiocarpal ligaments. These injuries typically result from forced hyperextension, hyperflexion, or radial/ulnar deviation mechanisms. Severity ranges from Grade I (mild ligamentous stretching) to Grade III (complete ligamentous rupture).
Pathophysiology
Ligamentous structures around the wrist are stretched or torn when the joint is forced beyond its normal range of motion. This causes disruption of collagen fiber alignment, inflammatory cascade activation, and microvascular bleeding within the ligamentous tissue. The injury compromises proprioceptive feedback and joint stability, leading to inflammation, swelling, and pain. Grade I involves microscopic tearing without functional instability; Grade II involves partial tearing with some functional compromise; Grade III represents complete rupture with significant instability and potential for chronic pain or instability if not properly managed.
Typical Presentation
Site
Dorsal or volar wrist, often localized to the radiocarpal joint, scapholunate joint, or lunotriquetral articulation; may involve multiple ligamentous structures
Quality
Sharp, aching, or throbbing pain; may be accompanied by clicking or clunking sensations indicating ligamentous laxity
Intensity
Grade I: mild to moderate (3-5/10); Grade II: moderate to severe (5-7/10); Grade III: severe with functional limitation (7-10/10)
Aggravating
Gripping activities, forced wrist extension or flexion, radial/ulnar deviation movements, weight-bearing through the hand, twisting motions, sports involving ball handling
Relieving
Rest and immobilization, ice application, elevation, non-steroidal anti-inflammatory medications, gentle passive motion within pain-free range
Associated
Swelling (may be diffuse or localized), bruising, reduced grip strength, warmth over injury site, reduced wrist range of motion, difficulty with fine motor tasks, apprehension with certain movements, possible feeling of instability or 'clunking'
Orthopaedic Tests
Scaphoid Shift Test (Watson's Test)
Procedure
Patient seated, forearm pronated. Grip the wrist from the radial side and press your thumb firmly on the scaphoid tubercle on the palmar side. Move the wrist from ulnar deviation with slight extension into radial deviation with slight flexion, keeping the thumb pressure on, then release the pressure. Test both wrists.
Positive Finding
A painful clunk as the scaphoid is pushed dorsally over the rim of the radius and then reduces when the pressure is released, or reproduction of the patient's dorsal wrist pain.
Sensitivity / Specificity
Reference: Schmauss D, Pöhlmann S, Weinzierl A, Schmauss V, Moog P, Germann G, et al. Relevance of the Scaphoid Shift Test for the Investigation of Scapholunate Ligament Injuries. J Clin Med. 2022;11(21).
Interpretation
Suggests scapholunate ligament injury or instability. Pain without a clunk is common and less telling. A painless clunk can occur in lax but uninjured wrists, which is why both sides are tested. Suspected scapholunate injury after trauma needs imaging and a hand surgery opinion. The reference previously shown for this test could not be matched to any published paper and has been withdrawn. From 447 patients checked against arthroscopy for scapholunate ligament injury: sensitivity 50% overall and 61% in patients referred with suspected scapholunate injury, where specificity was 62%. A negative test does not exclude injury.
Scaphoid Compression Test (Axial Loading)
Procedure
With the wrist in neutral, hold the patient's thumb and push it gently along its long axis towards the wrist.
Positive Finding
Pain at the radial side of the wrist, in the snuffbox region.
Interpretation
On a 'sprained' wrist, the purpose of this test is to screen for a missed scaphoid fracture. Radial-sided pain with axial loading after a fall means treat as a possible scaphoid fracture and arrange imaging. The reference previously shown for this test could not be matched to any published paper and has been withdrawn. The figure previously stored here was identical to the one on the scaphoid fracture page and had no source. This test screens for scaphoid fracture; no study reports its accuracy for wrist sprain, so no figure is shown.
Wrist Flexion-Extension Range of Motion Assessment
Procedure
With the forearm supported and the fingers relaxed, measure active and then passive wrist flexion and extension with a goniometer. Compare with the other wrist.
Positive Finding
Less range than the other side, or pain at end of range.
Interpretation
Records how much the injury limits movement and gives a baseline for rehabilitation. It does not identify which structure is injured. A painful, clearly limited wrist after a fall needs a fracture excluded first.
Radial and Ulnar Deviation Range of Motion
Procedure
With the forearm pronated and supported, measure active radial and ulnar deviation with a goniometer and compare with the other wrist.
Positive Finding
Less range than the other side, or pain on the movement.
Interpretation
Pain on ulnar deviation points towards ulnar-sided structures (TFCC, ulnocarpal region); pain on radial deviation points towards radial-sided structures (radial styloid, scaphoid). Use it to decide which specific tests to add.
Wrist Ligament Stress Test (Radial and Ulnar Collateral Ligament)
Procedure
Stabilise the forearm, hold the hand and gently apply radial and then ulnar deviation stress with the wrist in neutral. Compare with the other wrist.
Positive Finding
Pain on the stressed side of the wrist, or more give than on the other wrist.
Interpretation
Pain suggests a sprain of the wrist capsule, but isolated collateral ligament injuries of the wrist are uncommon. Localised pain or instability should prompt the specific tests (scaphoid, scapholunate, TFCC) and imaging if a fracture is possible.
Grip Strength Testing (Dynamometry)
Procedure
Patient seated, elbow at 90° by the side, forearm in neutral. Measure grip with a hand dynamometer, three trials per hand, and record the mean.
Positive Finding
Weaker grip on the injured side, or pain during gripping.
Interpretation
Pain-limited grip is common after any wrist injury. Useful as a baseline and for tracking rehabilitation; it does not identify the injured structure.
⚠ Red Flags
- •Severe swelling with signs of compartment syndrome (pain disproportionate to injury, pain with passive finger extension, paresthesias)
- •Signs of neurovascular compromise (absent distal pulses, severe pallor, cold hand, progressive paresthesias)
- •Open wound or penetrating injury suggesting possible foreign body
- •Severe deformity suggesting possible associated fracture (particularly scaphoid fracture)
- •Loss of conscious control or severe neurological symptoms
- •Signs of infection (spreading erythema, warmth, systemic fever)
- •Wrist instability with clinical evidence of midcarpal instability (positive scapholunate dissociation test)
⚡ Yellow Flags
- •Litigation or compensation claim related to injury
- •Significant fear-avoidance behavior disproportionate to clinical findings
- •High pain catastrophization scores
- •Previous chronic pain history or central sensitization features
- •Psychological distress or mood disorder affecting rehabilitation adherence
- •Poor social support for recovery
- •Occupational demands incompatible with recovery timeline
Osteopathic Techniques
Region
Wrist and radiocarpal joint
Technique
Rationale
Reduces muscular guarding and promotes local circulation to facilitate healing; addresses hypertonic flexor and extensor muscles that develop secondary to ligamentous injury and protective muscle splinting
Region
Wrist articulations (radiocarpal, midcarpal, intercarpal)
Technique
Rationale
Gentle oscillatory movements maintain joint mobility and proprioceptive feedback without stressing healing ligaments; prevents stiffness and promotes synovial fluid nutrition to articular cartilage
Region
Forearm, wrist flexors and extensors
Technique
Rationale
Muscle energy techniques normalize muscle tone and restore balanced force couples around the wrist; reduces protective muscle guarding and improves active range of motion as healing progresses
Region
Lymphatic drainage of wrist and hand
Technique
Rationale
Promotes drainage of inflammatory exudate and supports the healing cascade; reduces swelling and improves tissue perfusion to accelerate resolution of acute inflammation
Region
Cervical and thoracic spine, shoulder girdle
Technique
Rationale
Addresses secondary compensatory tension patterns that develop as upper limb pain forces patients to alter movement patterns; poor postural adaptation can perpetuate wrist dysfunction
Region
Wrist and hand
Technique
Rationale
Gentle, pain-free positioning facilitates proprioceptive recovery and tissue healing without aggressive loading; supports natural healing processes through functional integration
Rehabilitation Exercises
Wrist Flexion-Extension Pendulum Swings
Wrist Radial-Ulnar Deviation in Neutral Position
Wrist Extensor Stretch (Flexed Wrist with Finger Pressure)
Wrist Flexor Stretch (Extended Wrist with Dorsal Finger Pressure)
Isometric Wrist Flexion Resistance (No Movement)
Isometric Wrist Extension Resistance (No Movement)
Resistance Band Wrist Flexion with Progressive Resistance
Resistance Band Wrist Extension with Progressive Resistance
Proprioceptive Training: Wrist Stabilization on Balance Disc
Forearm and Wrist Posture Correction During Computer Use
Grip Strengthening with Therapy Ball (Progressive Squeezing)
Active Pronation-Supination in Neutral Wrist Position
Referral Criteria
- •Any sign of red flag symptoms (neurovascular compromise, compartment syndrome, infection, significant instability)
- •Persistent pain and dysfunction beyond 6-8 weeks despite conservative management
- •Clinical evidence of scapholunate dissociation or other midcarpal instability requiring specialized imaging and intervention
- •Suspected scaphoid fracture (pain in anatomical snuffbox, positive scaphoid compression test) requiring orthopedic evaluation
- •Grade III ligamentous tear with significant functional impairment potentially requiring surgical reconstruction
- •Development of chronic pain features or central sensitization requiring pain medicine or psychology referral
- •Failure to progress with conservative management or repeated re-injury suggesting need for specialist hand therapy
- •Occupational demands requiring functional restoration beyond scope of primary practitioner
- •Associated injury to multiple ligaments or suspected perilunate injury requiring specialist hand surgery assessment