Background & Etiology
The wrist joint contains the ends of the radius and ulna (forearm bones) and eight carpal bones (which form the floor of the carpal tunnel.) It allows the hand to move with a wide range of motion and flexibility. The wrist joint is surrounded by two burse. A burse is a fluid filled sack that serves to reduce friction between tendons, and between tendons and bone. The two major bursee of the wrist are the radial burse and the ulnar burse.
- Radial burse: reduces friction on the tendons that run from the forearm through the wrist and into the hand, serving the thumb. This burse extends to the wrist crease.
- Ulnar burse: reduces friction on the tendons that run from the forearm through the wrist and into the hand, serving the index, middle, and ring fingers.
- A direct blow to the burse can produce inflammation and irritation.
- A fall onto the wrist or burse.
- Pressure on the burse from use of the wrist.
- Repeated stress injury to the burse and tendon from using the hand, which can also cause tendinitis and bursitis.
- Complications from rheumatoid arthritis, osteoarthritis or gout.
- Infection of the burse or wrist
- Burse can become swollen as a response to other wrist conditions.
- Pain and tenderness over the location of the burse
- Swelling
- Loss of motion of the wrist
- Pain with activities that stress the burse like typing and writing, or activities that cause stress on the tendons that are lubricated by the burse.
- Initial treatment of bursitis includes avoiding activities that produce pain or stress of the burse and associated tendons.
- Splinting of the involved area
- The use of ice to reduce inflammation and pain.
- NSAIDS (nonsteroidal anti-inflammatory drugs)
- Hand Therapy
- Drainage of the fluid in the burse for severe cases. Fluid can be checked for possible infection.
- Antibiotic in the case of infections of the burse
- Surgery may be indicated in extreme cases if the problem becomes chronic.
Hand therapists are occupational or physical therapists, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Hand therapy for a wrist bursitis must remain conservative at the onset to not aggravate the condition. Emphasis will be in rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has reduced a program of stretching and light strengthening will be initiated to restore full motion and improve strength to reduce stress on the tendons and wrist joint.
Common Hand Therapy interventions in the treatment of Wrist Bursitis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the wrist. Use of mobilization techniques also help to modulate pain.
- Splinting as appropriate to limit use of involved area.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the forearm to support, stabilize, and decrease the stresses place on the burse and tendons of the wrist joint.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the upper extremity and improve movement techniques and mechanics of the involved upper extremity to reduce stress on burse and tendons in daily activities.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation of the involved burse.
- Home program including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Avoiding the activities that produce the pain or stress the involved burse is the first line of treatment.
- RICE: (Rest, Ice, Compression, Elevation) should be used to reduce the stress on the burse.
- Splinting of involved area as appropriate.
- NSAIDS (non steroidal anti-inflammatory drugs) to reduce pain and inflammation.
- Needle drainage to remove excessive fluid from the burse
- Injection of steroids to reduce inflammation in burse
- In the case of infection antibiotics may be prescribed,
- In severe recurrent conditions surgery to remove the burse may be indicated.
Prognosis
In general, patients respond well to conservative treatment of wrist bursitis. It is important that once the pain and inflammation is reduced and motion and strength are restored that the patient gradually returns back to full activities. Instruction in daily activities or sport performance is helpful to reduce the chance of a reoccurrence of the bursitis. In most cases full return to activity will take from 2-6 weeks depending on the severity of the condition. As a preventive measure individuals should:
- Make modifications in work or daily activities such and typing and writing or wearing protective equipment to avoid prolonged pressure or unexpected blows on the burse.
- Maintain strength and flexibility to reduce stress on the burse and tendons of the wrist
- Avoid highly repetitive activities whenever possible.