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Case studies are posted regularly and the moderators response follows a few days after a case is posted. Please feel free to post your ideas we may find you have a better answer than the moderator!

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Wrist sprain or something more? - 3/14/2007

A friendly patient is referred to you from a general Dr. with the diagnosis of wrist sprain. His script says strengthing program for wrist sprain. You do a detailed wrist exam and you find the following: Tenderness in the scapho-lunate region, positive Watson's shiift test, ROM is about 50% of opposite side, strength is about 50% of opposite side and he has no numbness or tingling. Pain is significant when gripping or pushing up out of a chair. What is the best treatment plan for the patient at this time? A strengthening program per Dr.'s orders or something else? Let us know what you think….

Click here for moderators response.

Moderator	This patient reports the wrist pain began about 3 mths ago
3/15/2007 Mike Borst	The best option for this patient is a long thumb opponens splint and referral to a hand surgeon for definitive diagnosis.
3/15/2007 Anonymous	I would also check snuffbox tenderness and xrays as well as details on initial injury. I would place in a splint and refer to hand surgeon.
3/15/2007 Anonymous	Modalities for pain management,splinting - no strength for now.
3/15/2007 Karen R.	The client is a good candidate for a Xray (ie; A/P, lateral and carpal views.)You need to see if there is a displacement or angulation of the scaphoid or lunate. There a radius or unlar positive or negatvie shift. Is this an old injury or currect?? SLAC............
3/15/2007 Andrea	Hold the strengthening, see if pt. can get 2nd opinion from hand surgeon. Recommend an MRI to r/o ligament tear/partial tear. I would splint for resting as well.
3/16/2007 Anonymous	The script did not say "aggressive" strengthening only strengthening which may be graded to tolerance; monitoring patients response closely. This may be a hypermobile person (positive Watson's test) who would benefit from a graded isometric strengthening program. If symptoms increased then report back to the MD and problem solve together.
3/18/2007 MJH	SL dissociation probable. Radiology: Should have scaphoid series and clenched fist views to confirm dx. Discuss concerns w/ referral source. Splint, no PRE's (painfree) until 8-10 wks. if S-L dissociation is confirmed.
3/22/2007 t.g.tilak francis	triangular fibrocartilage damage
3/26/2007 Sally	I'd ask for an x-ray while gripping and see if there is any S-L dissociation or possibly a CMC boss. I've seen the same pattern of pain and weakness with a simple dorsal carpal ganglion and also with an S-L tear. The pain from a boss is so close to the S-L, it could be that too.
4/18/2007 Anonymous	I think a long opponens orthotic with icing, possiibly OTC tylenol and order radioghraphs to r/o scaphoid fx or S-L dissociation.
6/11/2007 Anonymous	Definitely not aggressive strengthening. Wrist sprain is not a Dx. To me it means the Dr. doesn't really know how to assess the wrist, so should refer to ortho/hand surgeon for further assessment.
6/11/2007 Anonymous	Could be on the way to SLAC wrist if pain began that long ago. Hand surgeon referral- X-ray on loaded wrist, MRI, check for degeneration of scaphoid
8/19/2007 Billie Kay Halsey OTR/CHT	Stabilization for scapholunate ligament tear, recommend x-rays looking for gap in SL.
11/13/2008 Anonymous	I WOULD SPLINT PATIENT IN A THUMB SPICA FOREARM BASED, SHOW JOINT PROTECTION AND ADVISE PATIENT OF dO'S AND DONT'S WHILE AWAITING FOR POSSIBLE FURTHER TESTINGS> i WOULD CALL THJE DOCTOR AND REPORT MY FINDINGS.
3/9/2009 Anonymous	plain films to r/o scaphoid fx