The guidelines established by the New York State Workers Compensation Board outline fundamental principles for addressing wrist sprains. These instructions aim to assist healthcare professionals in determining appropriate therapeutic approaches within the framework of a comprehensive assessment.
Healthcare professionals specializing in managing wrist sprains can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.
It is important to underscore that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of wrist sprains should involve collaboration between the patient and their healthcare provider.
Wrist Sprains
Wrist sprains (which are partially or totally disrupted ligaments) typically occur with acute traumatic events and commonly result from slips, trips, and falls. Wrist sprain is often a diagnosis of exclusion among patients with pain in the setting of trauma in the absence of a fracture. Sprains may also occur in conjunction with a fracture.
Diagnostic Studies
X-Rays
Recommended – to determine whether a fracture is present, particularly for patients with scaphoid pain or scaphoid tubercle tenderness.
CT Scan
Recommended – to determine whether a fracture is present, particularly for patients with scaphoid pain or scaphoid tubercle tenderness with negative x-rays.
MR Arthrography
Recommended – for patients without improvement in wrist sprains after approximately 6 weeks of treatment. Rationale for Recommendations – MR arthrograms are especially helpful to identify ligamentous issues such as scapholunate, lunotriquetral, and TFCC tears that may be diagnosed as simple sprains. Thus, MR arthrography is recommended after approximately 6 weeks of clinical management without patient improvement.
Medications
For most patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Acetaminophen (or the analog paracetamol) may be a reasonable alternative to NSAIDs for patients who are not candidates for NSAIDs, although most evidence suggests acetaminophen is modestly less effective. There is evidence that NSAIDs are as effective for relief of pain as opioids (including tramadol) and less impairing.
NSAIDs for Treatment of Acute, Subacute, or Chronic Wrist Sprain
Recommended – for treatment of acute, subacute, or chronic wrist sprain. Over-the-counter (OTC) agents may suffice and should be tried first.
Frequency/Duration: As needed use may be reasonable for many patients.
Indications for Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects that necessitate discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended – for concomitant use of cytoprotective classes of drugs for patients at high risk of gastrointestinal bleeding.
Indications: For patients with a high-risk factor profile who also have indications for NSAIDs, cytoprotective medications should be considered, particularly if longer-term treatment is contemplated.
Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended. Dose and frequency per manufacturer. There is not generally believed to be substantial differences in efficacy for prevention of gastrointestinal bleeding.
Indications for Discontinuation: Intolerance, development of adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should have the risks and benefits of NSAID therapy for pain discussed.
Recommended – Acetaminophen or aspirin as the first-line therapy appear to be the safest regarding cardiovascular adverse effects.
Recommended – If needed, NSAIDs that are non-selective are preferred over COX-2 specific drugs. In patients receiving low-dose aspirin for primary or secondary cardiovascular disease prevention, to minimize the potential for the NSAID to counteract the beneficial effects of aspirin, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen for Treatment of Wrist Sprain Pain
Recommended – for treatment of wrist sprain pain, particularly in patients with contraindications for NSAIDs.
Indications: All patients with wrist sprain pain, including acute, subacute, chronic, and post-operative.
Dose/Frequency: Per manufacturer’s recommendations; may be utilized on an as-needed basis. There is evidence of hepatic toxicity when exceeding four gm/day.
Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Opioids
Recommended – for the treatment of select patients with pain from severe wrist sprains.
Indications: Select patients with severe pain from severe wrist sprains with insufficient control from other means, including acetaminophen and NSAIDs or with contraindications for NSAIDs. Considerable cautions are recommended concerning opioids, and minimum numbers of doses should be prescribed as the duration of treatment for wrist sprains is usually limited.
Frequency/Dose: As needed dosing. Among the few patients requiring opioids, most require at most a few days to not more than seven days of treatment and then generally have insufficient pain for further treatment with opioids.
Indications for Discontinuation: Resolution of pain sufficiently to not require opioids, consumption that does not follow prescription instructions, adverse effects.
Rationale for Recommendation – Most patients do not require opioids. Some patients, particularly with more severe sprains may require opioids. They are recommended for limited duration (not more than seven days) use in select patients with wrist sprains.
Rehabilitation
Rehabilitation following a work-related injury should be dedicated to restoring functional abilities essential for daily and work activities, aiming to return the injured worker to their pre-injury status to the extent possible. Active therapy necessitates internal effort from the patient to complete specific exercises or tasks.
Passive therapy comprises interventions that do not require the patient’s exertion but rely on modalities delivered by a therapist. Passive interventions are generally considered a means to facilitate progress in an active therapy program, leading to the achievement of objective functional gains. Emphasis should be on active interventions over passive ones.
Patients are advised to continue both active and passive therapies at home to extend the treatment process and maintain improvement levels. Assistive devices may be incorporated into the rehabilitation plan as an adjunctive measure to facilitate functional gains.
Therapy – Active
Therapeutic Exercise – for the treatment of moderate or severe acute or subacute wrist sprains. Recommended for such cases, with the frequency, dose, and duration varying based on the severity of functional deficits. Total visits may range from two to three for mild deficits to 12 to 15 for more severe deficits, with ongoing documentation of objective functional improvement.
If ongoing deficits persist, more than 12 to 15 visits may be warranted with documentation of improvement toward specific goals. A home exercise program should be developed and performed in conjunction with therapy as part of the rehabilitation plan.
Therapy – Passive
Relative Rest – Recommended for the treatment of acute wrist sprains. Ice – Self-application – Recommended for treating acute wrist sprains. Heat – Self-application – Recommended for the treatment of acute wrist sprains. Mobilization / Immobilization – Recommended splinting for the treatment of moderate or severe acute or subacute wrist sprains. Evidence supports the use of splinting in initial care.
Surgery
Not recommended for the treatment of acute or subacute wrist sprains in the absence of a remediable defect. There is insufficient evidence supporting the use of surgery in such cases.
