Common sporting Wrist injuries INTRODUCTION diagnosis

diagnosis wrist injuries
Common Sporting
Wrist Injuries
In order to properly diagnose the wrist injuries in
sport, the clinician should have a good awareness
of the basic anatomy of the wrist and investigate
appropriately. This article describes common wrist
injuries, investigations and treatment.
By Dr Mike Rossiter, MB BS MSc (SEM) FFSEM (UK) MRCGP
and MR David Warwick, MD FRCS FRCS (Orth)
INTRODUCTION
Movement
Wrist injuries in sport are common
but are often poorly diagnosed and
therefore not managed adequately. In
order to properly diagnose the wrist
injury, the clinician should have a good
awareness of the basic anatomy of
the wrist and investigate appropriately.
However, as the wrist is a complicated
joint, even with good clinical skills and
diagnostic tests an accurate diagnosis
is not always possible and therefore
a “wrist sprain” may be the most
appropriate diagnosis. This article
aims to briefly describe the common
injuries of the wrist, investigations and
treatment.
The radio-carpal and ulno-carpal
joints in combination allow the wrist
to flex, extend, abduct, adduct and
circumduct. Rotation (pronation and
supination) occurs at the distal radioulnar joint.
ANATOMY OF THE WRIST
Bones and joints
The wrist joint is one of the most
complex joints in the body. It is the
articulation between the distal radius
and ulnar head with the scaphoid,
lunate and triquetral bones (the
proximal row). It is a synovial ellipsoid
joint surrounded by a capsule, which
is attached to the lower ends of the
radius and ulna and the proximal row
of the carpal bones. The capsule is
strengthened by a complex system of
anterior and posterior ligaments, which
stabilise the wrist in all positions. The
triangular fibrocartilage complex (TFCC)
sits between the ulna head, lunate and
triquetrum, stabilising the distal radioulnar joint in rotation and providing a
cushion to the ulnar side of the wrist.
A synovial membrane lines the capsule
and attaches to the margins of the
articular surfaces.
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Tendons and muscles
The following muscles are responsible
for each movement:
n Flexion: flexor carpi radialis (FCR),
flexor carpi ulnaris (FCU), palmaris
longus (PL) (+flexor digitorum
superficialis (FDS), flexor digitorum
profundus (FDP) and flexor pollicis
longus (FPL))
n Extension: extensor carpi radialis
(ECR), extensor carpi radialis brevis
(ECRB) and extensor carpi ulnaris (ECU)
(+extensor digiti (ED), extensor indices
(EI), extensor digiti minimi (EDM) and
extensor pollicis longus (EPL))
n Radial abduction: FCR, extensor carpi
radialis longus (ECRL), abductor pollicis
longus (APL) and extensor pollicis
brevis (EPB)
n Ulnar adduction: FCU and ECU.
Intercarpal ligaments
The intercarpal joints lie vertically
between the individual bones of the
proximal row and distal row of the
carpus, and horizontally between the
proximal carpal row and distal carpal
row. The scaphoid and lunate are
linked by the scapho-lunate ligament,
and the lunate and triquetrum by the
luno-triquetral joint. These ligaments
are essential for stable function of the
wrist.
21
Wrist injuries in sport are often
poorly diagnosed and inadequately
managed. Even with good clinical skills
and diagnostic tests, an accurate
diagnosis is not always possible
Relationship to the wrist
Several tendons, nerves and blood
vessels cross the wrist, all of which can
be injured or cause pain.
The following structures pass anterior
to the flexor retinaculum (medial to
lateral):
n FCU tendon (which attaches to the
pisiform bone)
n Ulnar nerve
n Ulnar artery
n Palmaris longus tendon attaching
to the flexor retinaculum and palmar
aponeurosis
n Palmar cutaneous branch of the
median nerve
n FCR
Structures passing beneath the flexor
retinaculum (medial to lateral)
n FDS and FDP (they share a common
synovial sheath)
n Median nerve
n FPL.
The following structures pass posterior
to the extensor retinaculum (medial to
lateral):
n Posterior cutaneous branch of the
ulnar nerve
n Superficial branch of radial nerve.
Structures passing beneath the
extensor retinaculum include the
fibrous septae from six compartments
containing the extensor tendons. Each
numbered compartment has a synovial
sheath. From radial to ulnar, they are:
1. APL and EPB
2. ECRL and ECRB (posterior to the
distal radio-ulnar joint)
3. EPL
4. ED and EI
5. EDM
6. ECU.
The radial artery passes between
the first and second compartments.
INVESTIGATIONS
fractures, hook of hamate fracture,
displaced scaphoid fractures requiring
fixation, declaration or otherwise
of a healed scaphoid fracture). CT
arthrography enhances accuracy.
Ultrasound
This is an excellent investigation
to assess soft-tissue injuries,
tendinopathies and superficial ganglia.
It is cheap and can be used in an
outpatient setting and can also be
used dynamically. However, it is userdependent.
X-rays
Wrist arthroscopy
Plain X-rays can confirm a bone or
joint injury. However, a negative X-ray
does not exclude a bony injury.
A clenched-fist view may
demonstrate an acute scapho-lunate
ligament rupture, with the gap widening
as the joint is axially loaded.
Scaphoid views should be taken if
there is clinical suspicion of a scaphoid
injury, and repeated 2 weeks later if still
suspicious (by which time, fracture-line
resorption and shift in the fracture’s
position usually discloses the injury).
Use a carpal tunnel view, with
the wrist in dorsiflexion, if a hook of
hamate fracture is suspected.
This is a very valuable way of
investigating the wrist, as most
structures can be visualised and
passive movements assessed.
Magnetic resonance
imaging
Magnetic resonance imaging (MRI)
is the most sensitive method of
diagnosing an acute ligament or bone
injury and has superseded isotope
bone scanning for this purpose.
In the non-acute setting when a
TFCC or interosseous ligament
tear is suspected, the accuracy is
enhanced by intra-articular contrast
(arthrography).
Computed tomography
Computed tomography (CT) is the most
specific method of identifying bone
anatomy (which does not show so
well on MRI). CT is best used to define
cortical margins that are difficult to
define on plain X-ray (eg. comminuted
ACUTE WRIST INJURIES
These occur mainly from acute trauma,
such as being hit by an object or falling
on to an outstretched hand. There
is also a proportion of athletes who
injure their wrists in weight training,
where poor technique or the use of
weights that are too heavy leads to
hyperextension injuries. This may be
prevented or reduced by wearing
appropriate prophylactic strapping in
order to prevent hyperextension.
Common injuries
n Fracture distal radius
n Fracture scaphoid
n Wrist “sprain” (a common eventual
diagnosis – the exact cause can still be
difficult to diagnose even after thorough
investigation; it is therefore a diagnosis
of exclusion)
n Scapho-lunate sprain and other
intercarpal ligament sprains
n TFCC tear
n Scapho-lunate tear
n Bone bruising.
History
A clear history of the mechanism of
injury may give a clue to the diagnosis
(eg. a fall on an outstretched hand for
a fractured scaphoid or forced ulnar
deviation and rotation for a TFCC tear).
Inspection
Look for swelling, bruising and
deformity.
Palpation
Feel systematically to assess each
bone, joint and tendon for tenderness.
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sportEX medicine 2009;41(Jul):21-26
diagnosis wrist injuries
Movement
Measure the active and passive range
of movement in all directions. Do
specific stress tests for scapho-lunate
instability, luno-triquetral instability and
distal radio-ulnar joint instability.
Fracture of the distal radius
The distal radius is vulnerable in a
Figure 1: Radius
and ulnar plate
Figure 2: Scaphoid
non-union
fall on the outstretched hand. The
type of fracture depends on age. In
adolescents, before closure of the
growth plates, a physeal injury of the
distal radius is more likely to occur
than a scaphoid fracture. In young and
middle-aged adults, the distal radius
fractures across the metaphysis.
With increasing energy, the fracture
becomes comminuted. Snowboarders
and motocross riders are particularly
prone to this. In the older, osteopenic
patient, the fracture impacts and tilts
dorsally (Colles’ fracture).
Diagnosis is secured by X-ray.
Occasionally CT is needed to define the
extent of comminution and plan surgical
reconstruction.
Simple undisplaced fractures
are managed in a cast for 5 weeks.
Displaced fractures need manipulation
and then stabilisation with metalwork –
wires or plates (Fig. 1).
Fracture of the scaphoid
Figure 3: Scaphoid fixed with a screw and bone graft from the
distal radius
Figure 4: Terry Thomas
sign
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This is a common fracture to miss, and
there should be a high clinical suspicion
after a fall on to an outstretched
hand. Symptoms and signs include a
swollen and tender anatomical snuffbox
(although the unaffected side may also
be tender). There may also be pain
applying pressure over the scaphoid
tuberosity and scapho-lunate interval.
Investigations include scaphoid
X-rays. If these are negative and
clinical suspicion is still high, further
investigation with an MRI scan is
indicated. This test is very sensitive for
the presence of a fracture because of
the dramatic signal changes. However,
MRI does not define cortical margins
well; if surgery is contemplated, then a
CT scan provides much better definition
of the fracture line. The main risk of
missing this fracture is non-union (Fig.
2) due to its poor blood supply leading
to chronic wrist pain and loss of grip
strength.
Ninety per cent of undisplaced
waist fractures heal in a promptly
applied cast within 8–12 weeks. The
union rate for proximal pole fractures
and displaced fractures is much less
reliable. These latter two configurations
warrant early surgery. There is an
increasing trend to fix undisplaced
waist fractures immediately with a
percutaneous cannulated compression
screw in order to speed recovery and
return to training (Fig. 3).
Scapho-lunate ligament tear
The scapho-lunate ligament maintains
the proximal pole of the scaphoid
adjacent to the lunate (scapho-lunate
gap) and stabilises the palmar rotation
force of the scaphoid against the
dorsal rotation force of the lunate.
This structure is injured when the
wrist hyperextension mechanism that
might result in a scaphoid fracture
instead disrupts the adjacent scapholunate ligament. This may occur as a
partial tear with pain but no instability,
best treated by rest and sometimes
arthroscopic debridement. More
complete injuries may result in dynamic
scapho-lunate instability, with normal
plain X-rays but pain with use and an
increased radiological scapho-lunate
gap with the fist clenched. Complete
disruption of the scapho-lunate
ligament results in an instability pattern
visible on plain X-rays, with widening
of the scapho-lunate gap (the “Terry
Thomas sign”) (Fig. 4) and the lunate
tilted backwards with the scaphoid
flexed on the lateral view (dorsal
intercalated segment instability, DISI).
On examination, there is
tenderness over the scapho-lunate
ligament (just beyond the bony
prominence on the back of the distal
radius known as Lister’s tubercle). It
may be possible to elicit a positive
Watson’s test (not specific for the
injury). The test involves applying
pressure to the palmar portion of the
scaphoid while moving the wrist into
ulnar deviation. When the wrist is
then moved into radial deviation, the
scaphoid cannot flex as it is blocked by
the examiner’s thumb. If the scapholunate ligament is torn, the scaphoid will
move dorsally against the examiner’s
finger, causing pain. When the scaphoid
pressure is removed, the scaphoid then
moves back into position with a clunk.
MRI arthrography is helpful in
diagnosing this injury, with characteristic
soft-tissue signal changes and
contrast flowing through the space.
Wrist arthroscopy is the definitive
investigation. The tear can be
identified and the severity of instability
established. In later stages, associated
arthritis can be assessed. Minor tears
can be debrided.
Complete unstable scapho-lunate
injuries should be repaired as soon
as they are diagnosed. In the first
few weeks, a direct repair is possible;
thereafter, the tissue degrades and an
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indirect repair (capsulodesis) is needed.
Results of repair are unpredictable and
often disappointing if delayed months
after the initial injury. If left for too
long, then irreversible deformity and
osteoarthritis can develop. Over time,
the abnormal position of the scaphoid
and lunate results in degenerative
changes at the radio-scaphoid, midcarpal and then radio-lunate joints
and are referred to as scapho-lunate
advanced collapse (“SLAC wrist”).
Salvage procedures include, among
others, proximal row carpectomy,
scaphoid excision with mid-carpal
fusion, and full wrist fusion.
Fracture of hook of hamate
The hook of the hamate lies distally
and radial to the pisiform and forms the
lateral border of the canal of Guyon,
through which the ulnar artery and
nerve run.
Fracture of the hook is classically
from either a direct blow or blocked
swing of a club or racquet. Most
patients have pain and tenderness on
the ulnar side of the palm, with pain
increased by gripping and reduced
grip strength. There may also be ulnar
nerve paraesthesia and mild carpal
tunnel syndrome signs and symptoms.
In delayed cases, the FDP tendon to
the little finger, which runs alongside the
hook, may rupture.
The fracture cannot be diagnosed
on simple anteroposterior and lateral
X-rays. It can sometimes be seen on
a carpal tunnel view. If there is still
diagnostic doubt, a CT scan is the
definitive test (Fig. 5).
If diagnosed in the first 2–3
weeks (unusual), then treatment is by
immobilisation in a cast. If the patient
presents later, then surgical excision of
the hook produces very good results.
CHRONIC WRIST PAIN
Excluding missed acute injuries, causes
include:
n Tendinopathies
n Ganglion and dorsal impingement
n TFCC injuries
n Neuropathy
n Arthritis
n Kienbock’s disease
n Piso-triquetral pain
n Snapping ECU.
General assessment
History
The affected part of the wrist may
24
indicate the problem (eg. dorsal may
be intersection syndrome). Stiffness
at rest may indicate a tendinopathy or
arthritis, whereas pain on loading (eg.
in gymnastics) may be due to a bony
or joint problem. Neural symptoms may
be due to a local entrapment, but if the
symptoms extend above the wrist, then
it is important to exclude pathology in
the elbow or neck.
Figure 5: CT scan
of fractured hook
of hamate
Examination
The wrist should be examined
systematically: look, feel, move.
Investigation
Depending on the likely diagnosis, there
is a role for X-rays, MRI, ultrasound,
nerve conduction studies and
arthroscopy.
Tendinopathy
De Quervain’s tenosynovitis
This is an inflammation of the APL and
EPL tendon in the synovial sheath and
is more common in gripping sports
such as rowing and canoeing. There is
tenderness and swelling over the radial
styloid and a positive Finklestein’s test
(closing the fingers over the thumb
and then ulnar deviation of the wrist
produces pain over the radial styloid).
The tenosynovitis can be detected on
ultrasound scan. The most effective
primary treatment is an injection of
cortisone into the tendon sheath (Fig.
6). Splinting or strapping to immobilise
the wrist and physiotherapy (ultrasound,
massage, stretches) are adjuncts.
Surgical decompression of the tendon
is usually curative but rarely necessary.
Intersection syndrome
This is actually a frictional bursitis
where the APL and EPL tendons cross
over the ECR. There is tenderness
and crepitus just proximal and
radial to Lister’s tubercle. This is a
relatively common condition in rowers,
canoeists and racquet sportspeople.
The diagnosis, usually made clinically,
can be confirmed on either ultrasound
or MRI. Treatment consists of
physiotherapy, non-steroidal antiinflammatory drugs (NSAIDs), relative
rest and correction of any technique
errors. If this fails, a cortisone injection
into the area is often effective.
Other tendinitides
These are common in endurance
sports with repetitive wrist movement,
Figure 6: Injection
for de Quervain’s
Figure 7: Volar
ganglion
Figure 8: Ulnocarpal impaction
such as rowing and canoeing.
Increased risks in these sports include
blade design, poor grip and poor
technique, possibly from fatigue.
Relative rest, physiotherapy and
strapping, as well as correcting any
causative factors, are usually successful.
An accurate cortisone injection is very
helpful in more significant cases. Surgery
is rarely required.
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diagnosis wrist injuries
Ganglion and dorsal impingement
Ganglion cysts
Ganglion cysts are idiopathic but
probably reflect a variation in normal
joint or tendon sheath function. Cysts
near joints are connected to the joint.
The leading theory is that a type of
check valve forms that allows fluid out
of the joint but not back in. The cyst
contains clear fluid similar to, but thicker
than, normal synovial fluid. They are
most often found around the scapholunate joint but can occur anywhere
around the wrist joint (Fig. 7).
Diagnosis may be made clinically, or
small ganglion cysts can be identified
on ultrasound or MRI. However, the
cysts are often incidental and therefore
it is important to ensure that this is the
cause of the painful wrist rather than
masking another cause.
Ganglion cysts often come and go
spontaneously, and so most of the time
they can be left alone. Symptomatic
ganglions can be treated by direct
pressure (traditionally hitting it with
the family Bible!), aspirated or excised,
but all of these methods have a risk
of recurrence (70–80% with pressure,
40% with aspiration, 10% with excision).
Impingement
Dorsal synovial impingement is
common in sports that involve
repetitive hyperextension. It is caused
by the capsule and synovium snagging
between the distal edge of the radius
and the back of the lunate-capitate
on extension. The athlete complains
of pain on hyperextension under
load, pointing to the back of the wrist
joint. On examination, there is focal
tenderness and the pain is reproduced
by forced passive hyperextension.
Occasionally, ultrasound or MRI shows
a lesion (and excludes the differential
diagnosis of a small or occult
dorsal wrist ganglion). If suspected
clinically, then a cortisone injection
is both diagnostic and therapeutic.
Immobilisation in a splint is helpful.
For refractory cases, or to secure
the diagnosis, wrist arthroscopy is
recommended.
TFCC injuries
The TFCC is the stabiliser of the wrist
joint and consists of triangular cartilage,
ulnar meniscus, ulnar collateral and
carpal ligaments, and ECU tendon. It
can be injured in two ways.
A central perforation occurs with
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a fall on the outstretched hand but
more frequently occurs as a natural
degenerative process in patients
with a relatively long ulna (ulnocarpal impaction; Fig. 8). The patient
has pain in the ulnar corner, which
is worse on sporting manoeuvres
needing ulnar tilt. On examination,
there is tenderness over the ulnar
head, with pain provoked by forced
ulnar tilt. Diagnosis is confirmed by MRI
arthrography. A cortisone injection helps
mild cases; more severe cases need
arthroscopic surgery to trim the tear
and decompress the ulnar head.
A peripheral detachment occurs
with a violent wrench or fall in rotation
on the hand. The distal radio-ulnar joint
becomes unstable. This is a rare but
disabling injury for the athlete. Diagnosis
is confirmed by anteroposterior
instability on balloting (compressing) the
ulnar head. Treatment requires surgery
(arthroscopic or open) and prolonged
rehabilitation.
Neuropathy
Carpal tunnel syndrome
This condition is caused by
compression of the median nerve
(Fig. 9) within the carpal tunnel of
the wrist, leading to tingling and pain
or paraesthesia in the median nerve
territory of the hand (thumb, index,
middle and radial side of the ring
fingers). Symptoms may radiate to the
elbow and are often worse at night. It
is important to exclude the neck as the
source of the pain.
The condition is seen in sports
that involve repetitive wrist flexion
(eg. rowing) and in sports with direct
pressure on the nerve (eg. cycling,
handball).
Diagnosis is usually clinical with a
positive Phalen’s test (passive wrist
flexion reproducing symptoms) or
Tinel’s test (tingling in the median
nerve territory of the hand by
tapping over the median nerve in the
wrist). Thenar muscle wasting and
established sensory loss indicate
severe compression and justify urgent
assessment for surgical release. If
there is diagnostic doubt, then nerve
conduction tests confirm the cause.
In mild cases, treatment consists
of relative rest, NSAIDs and night
splints, although these are often poorly
tolerated. A cortisone injection into the
carpal tunnel is effective in around 70%
of cases. Surgical decompression is
usually curative.
Ulnar nerve compression
The ulnar nerve can be compressed
as it passes through Guyon’s canal. It
is often seen in cyclists who use drophandlebars due to direct pressure over
the nerve as the wrist is forced into
ulnar deviation. Compression causes
pain and paraesthesia in the little
finger, ulnar side of the ring finger and
hypothenar eminence. In severe cases
there is reduced grip, with wasting
of the hypothenar and interosseous
muscles.
Diagnosis is often made clinically
but, again, nerve conduction tests may
be necessary.
Mild cases usually resolve with
relative rest, NSAIDs and a change of
Acute wrist injuries mainly occur from
acute trauma, such as being hit by an
object or falling onto an outstretched
hand. There are also some athletes who
injure their wrists in weight training, where
poor technique or too heavy weight
leads to hyperextension injuries.
25
changes, a gadolinium-enhanced MRI
scan is diagnostic.
Treatment consists of
immobilisation in early cases. The
natural history is often benign. Some
cases need surgery to decompress or
revascularise the lunate.
Piso-triquetral pain
Figure 10: Keinbock’s disease
grip. Severe and persistent cases may
need surgical decompression. However,
scar tenderness can be an issue.
Osteoarthritis
Snapping ECU
This may follow an acute injury, usually
a poorly executed tennis shot, or
it may be exposed as a chronically
developing condition. In normal rotation,
the ECU passes across the back of
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Have you had any experience with
“problem” wrist injuries?
Which investigations helped to
provide a diagnosis?
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The wrist can develop arthritis
spontaneously as part of an individual’s
genetic programme. The demands of
sport may expose symptoms (although
there is no evidence that sport causes
arthritis, unless there is a predisposing
sporting injury). Previous sporting injury
can cause arthritis in specific patterns
(eg. scaphoid fracture, scapho-lunate
injury, pisiform fracture, intra-articular
radius fracture). Initial treatment is
conservative – modifying the technique
and tempering sporting ambitions.
Splinting and an occasional cortisone
injection can help. There is no role for
physiotherapy. Some patients require
surgery for intrusive symptoms; if
possible, total wrist fusion is avoided.
Some part of the complex articulation
can be preserved in order to maintain
some movement (partial wrist fusion).
However, loss of wrist movement
and coordination from surgery is
likely to reduce sporting performance
considerably. Modern wrist
replacements, although increasingly
trusted for low-demand individuals, are
unlikely to withstand the demands of
an athlete.
Piso-triquetral arthritis is unusual, but
it can follow a fracture or can develop
spontaneously. Pain is located on
the palmar-ulnar corner of the wrist,
aggravated by flexion in ulnar deviation
(eg. tennis, golf). A special supinated
lateral X-ray is needed to show this
joint. Treatment is by cortisone injection
or excision.
Piso-triquetral instability can occur
in patients with lax joints or with a
previous injury that has damaged the
ligaments that support this joint. Again,
there is pain in the ulnar-palmar corner,
aggravated by grip in flexion and ulnar
deviation. On examination, the joint
can be balloted laterally. Treatment
is by amending sporting posture
or, occasionally for troublesome
symptoms, pisiform excision.
the ulnar head, restrained in a groove.
If the restraints tear or gradually fail,
then the ECU snaps across the back
of the ulna head in rotation. An acute
tear (very rarely diagnosed) is treated
in an above-elbow cast. A chronic injury
needs surgical reconstruction of the
ECU sheath.
Clinical Sports Medicine (revised
2nd edn) by Peter Bruckner and Karim
Khan was used as a template for this
article.
online
Launch the extra
by clicking on
the image
A series of
animations
overviewing
the anatomy
of the wrist
The Authors
David Warwick, MD BM FRCS FRCS(Orth) European Diploma of Hand Surgery is a
consultant hand surgeon at Southampton University Hospitals NHS Trust. He is
also Reader in Orthopaedic Surgery at the University of Southampton. His elective
and trauma practice is confined to conditions of the hands, wrists, elbows and nerves. He
provides a tertiary referral service for the States of Jersey, the Isle of Wight and the British
army (training and recruitment). He looks after many sportspeople, including four gold medal
Olympians and two silver medal Olympians. He has looked after national-level rugby, diving,
hockey, cricket and soccer players. He is club surgeon to Southampton Football Club and
Hampshire County Cricket Club. He has admitting rights at Wessex Nuffield Hospital, BUPA
Southampton Hospital and Jersey General Hospital. He has written many articles and book
chapters; most recently, he edited and authored the Oxford Handbook of Hand Surgery.
Keinbock’s disease
This is an avascular necrosis of the
lunate (Fig. 10). The aetiology is unclear
but is possibly from repeated trauma.
There is chronic mid-dorsal and volar
wrist pain. It is more common in
athletes in their twenties. Diagnosis is
made by X-ray, which shows sclerosis
of the lunate and, in later cases,
crumbling of the lunate, with altered
alignment of the other carpal bone and
arthritis. If suspected before plain X-ray
26
Mike Rossiter, MB BS MSc (SEM) FFSEM (UK) MRCGP is a sports physician at
the English Institute of Sport, Bisham Abbey and an associate specialist in
orthopaedics and sports and exercise medicine at the North Hampshire Hospital
Basingstoke. He also has sports clinics in Basingstoke and Parkside Hospital. He is
an honorary senior lecturer and examiner in sports and exercise medicine at the University
of Bath. He is club doctor at London Irish Rugby Club and chief medical officer for England
and Great Britain Hockey and also for the Great Britain Synchronised Swimming Team. He
was team doctor for both the men’s and women’s hockey teams at the Commonwealth Games
in 2006 and the Beijing Olympics in 2008. He was one of the club doctors at Southampton
Football Club until 2008.
sportEX medicine 2009;41(Jul):21-26