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Dorsal wrist syndrome

What is the dorsal wrist syndrome?

Dorsal wrist syndrome (DWS) is a condition that causes chronic pain in the wrist usually worse after activity. It slowly subsides after work and limits but often doesn’t prevent physical activity.  It is most common in young patients who are otherwise well with previously normal wrists.

What causes the dorsal wrist syndrome?

The Dorsal Wrist Syndrome is usually preceded by injury to the wrist joint. The injury may not be immediately obvious because it is in the form of repetitive strain or over use. A better term might be an overload injury. Typical examples are gymnastics, CrossFit, weightlifting and yoga where there is repetitive loading of the extended wrist. A fall onto an outstretched hand may also precipitate the dorsal wrist syndrome.

The most common cause is due to a partial tear to some of the capsule and or ligaments between the bones in the wrist.  Most commonly this involves the ligament between the scaphoid and the lunate and the capsule around the joint. The extent of the tear is dependent on the severity of the fall  and in the case of overuse the nature and duration of the load eg power weightlifting.

The wear and tear of the ligaments causes synovitis within the wrist joint. This results in pain. The repetitive tearing of some fibers of the scapholunate ligament may result in the formation of a dorsal wrist ganglion. This ganglion is usually small (occult) and not large enough to cause a visible lump on the back of the wrist. It does however cause pain because it becomes pinched between the bones of the wrist when the wrist is extended.

Other contributors to the dorsal wrist syndrome may be scaphoid impaction. This occurs during loaded wrist extension when the scaphoid bone knocks against the dorsal edge of the distal radius repeatedly, causing inflammation, synovitis and pain. Over time a bony spur may form on the back of the scaphoid.

How do you diagnose the dorsal wrist syndrome?

The diagnosis of dorsal wrist syndrome is suspected with a typical history as above. Clinical examination reveals pain across the back of the wrist. This pain is worse when the wrist is pushed backwards. Pain may also be experienced on the palm side of the wrist during this maneuver. There occasionally mild swelling present.

It is important to exclude other potential causes of wrist pain before the diagnosis is confirmed. An xray of the wrist with stress views is essential. An MRI may be requested but this is an expensive investigation and is not required in every presentation. An ultrasound examination performed by an experienced musculoskeletal ultrasonographer is a reliable means to identify the occult ganglion and is much cheaper than an MRI scan.

How is the dorsal wrist syndrome treated?

The essential components of treatment include activity modification specifically avoiding loaded wrist extension. A brace may be useful to assist with pain control early on and to limit end range extension when returning to activity to prevent recurrence. Anti inflammatory medication may also help.  Because synovitis is a major cause of the pain, A local steroid injection to the wrist joint can significantly improve the pain.

It is important to recognize that the dorsal wrist syndrome may take several months to settle and attempts to rapidly return to full  prior activity may result in recurrence of symptoms.

If an occult ganglion has been identified then surgery can be considered earlier to remove the ganglion as these patients respond well to removing the ganglion. This can be done either open or arthroscopically.

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