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Spaghetti Wrist

Spaghetti Wrist is a severe and complex injury of the wrist characterized by multiple lacerations that involve the flexor tendons, median and ulnar nerves, and sometimes the radial or ulnar arteries. The term “spaghetti wrist” was coined because, during surgery, the numerous cut tendons resemble strands of spaghetti spilling from the wound. This type of injury is most often the result of deep, sharp trauma and is considered one of the most devastating injuries to the upper extremity.

Causes of Spaghetti Wrist

Spaghetti wrist injuries typically occur due to sharp penetrating trauma. Common causes include:

  • Glass or knife lacerations – often accidental, such as cutting glass or during falls through windows.
  • Workplace accidents – involving power tools, machinery, or industrial equipment.
  • Suicidal or self-inflicted injuries – deliberate wrist-cutting can result in severe tendon and nerve damage.
  • Violence-related trauma – stab wounds or assaults with sharp objects.

Because the volar (palm-side) wrist contains tightly packed tendons, nerves, and blood vessels, even a single deep cut can cause extensive multi-structure damage.

Tendon Problems

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Anatomy Involved

The wrist is a compact anatomical region where many critical structures pass from the forearm to the hand. In spaghetti wrist injuries, damage often involves:

Flexor tendons:

  • Flexor digitorum superficialis (FDS)
  • Flexor digitorum profundus (FDP)
  • Flexor pollicis longus (FPL)

Nerves:

  • Median nerve (controls thumb, index, middle finger motor function and sensation)
  • Ulnar nerve (controls intrinsic hand muscles, ring, and little finger sensation)

Arteries:

  • Ulnar artery
  • Radial artery (sometimes)

Clinical Features

  • Visible wound: Deep laceration across the volar wrist.
  • Loss of finger flexion: Inability to bend fingers or thumb due to tendon disruption.
  • Loss of sensation: Numbness or tingling in the palm or fingers, depending on nerve involvement
  • Weakness or paralysis: Loss of fine motor skills, grip strength, and hand coordination.
  • Bleeding: May be severe if major arteries are cut, potentially life-threatening.
  • Deformity: Fingers may rest in an extended or abnormal position.

Diagnosis

  • Mechanism of injury and depth of wound.
  • Assessment of tendon function (flexion), sensation, and circulation.
  • Performed in the operating room under anesthesia for accurate assessment.
  • X-rays to rule out fractures or foreign bodies.
  • Doppler ultrasound or angiography if vascular injury is suspected.

Treatment and Management

1. Initial Emergency Care:

  • Control bleeding with direct pressure and tourniquet if necessary.
  • Wound cleaning and sterile dressing.
  • Intravenous fluids and stabilization if there is significant blood loss.
  • Tetanus prophylaxis and antibiotics to reduce infection risk.

2. Definitive Surgical Repair:

  • Timing: Ideally performed within 24 hours for best outcomes.
  • Tendon repair: Using multi-strand core sutures to restore finger flexion.
  • Nerve repair: Microsurgical repair of median and ulnar nerves, sometimes requiring nerve grafts.
  • Artery repair: Microvascular anastomosis of the ulnar or radial artery to restore blood supply.
  • Layered closure: Careful repair of tendons, nerves, and vessels in anatomical order.

3. Postoperative Care and Rehabilitation:

  • Immobilization in a splint with wrist and fingers in a flexed position.
  • Early controlled mobilization protocols (under guidance of a hand therapist).
  • Gradual strengthening exercises to improve function.
  • Sensory re-education for nerve recovery.

Complications

  • Tendon adhesions: Scar tissue restricting tendon gliding, limiting finger movement.
  • Joint stiffness: Due to prolonged immobilization or inadequate rehabilitation.
  • Nerve deficits: Permanent numbness, weakness, or muscle wasting if repair is incomplete.
  • Poor circulation: Vascular injury may result in ischemia or tissue loss.
  • Infection: Especially in contaminated or delayed cases.
  • Functional disability: Difficulty regaining fine motor control, grip strength, or full range of motion.

Prognosis

  • Extent of injury: The more structures involved, the more difficult recovery becomes.
  • Timeliness of surgery: Early repair improves chances of tendon and nerve healing.
  • Rehabilitation compliance: Strict hand therapy is crucial for restoring motion.
  • Associated injuries: Severe crush injuries or contamination worsen prognosis.

Psychosocial Impact

Spaghetti wrist injuries can be life-altering. The prolonged recovery period, visible scars, and incomplete return of hand function may cause emotional distress, anxiety, or depression. Occupational challenges may arise if hand function is critical for employment. Psychological support and vocational rehabilitation may be necessary components of care.

Conclusion

Spaghetti wrist is one of the most devastating wrist injuries, involving multiple tendons, nerves, and arteries. The complexity of the anatomy makes surgical repair extremely challenging, requiring microsurgical expertise and prolonged rehabilitation. Early intervention, meticulous repair, and committed physiotherapy are the keys to maximizing recovery. While complete restoration of normal hand function may not always be possible, advances in surgical techniques and therapy protocols allow many patients to regain meaningful use of their hand, improving independence and quality of life.

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