Soft Tissue Injury of the Wrist
by Nicole Larson
As I was flying over the handlebars I thought, “oh no, this is going to be bad”. I continued toward the ground head first, landing on both my right hand/wrist and face while my bike carried speed down the hill before coming to a quick stop against a tree. I sat on the trail for a couple minutes assessing for any potential injuries. My lip was cut and my wrist was sore but otherwise, nothing serious. Eventually, I carried my bike back up to the trail and walked it down to where my friends were waiting. From there I managed to ride the remaining 2/3 of the trail with gradually increasing pain and discomfort in my right wrist. It wasn’t until I arrived at the truck and took my glove off that I realized I may really be injured.
The swelling was increasing quickly along the radial (thumb) side of my wrist around the base of the 1st metacarpal and anatomical snuffbox. If you’re not familiar with the snuffbox follow your thumb bone (1st metacarpal) down toward the lateral side of the wrist until you feel a groove before sliding up onto the distal end of the radius. If you spread out your thumb away from your palm and fingers this will contract the tendons that make up the walls of the snuffbox and accentuate the area. It was in here that I felt the highest degree of point tender pain when palpated. In addition to the swelling, the pain was increasing while range of motion at the wrist was decreasing.
There was also a patch of swelling on the dorsal (back of the hand) surface over the trapezium and scaphoid bones. These are two carpals along the radial side of the wrist (see image). The scaphoid makes up the floor of the snuffbox and can be felt with your other thumb in this location when moving your wrist from side to side. It is the most commonly fractured carpal.
Worried that I may have fractured my scaphoid, I went for an x-ray the following morning. “It looks somewhat deformed” the nurse said to a student nurse she was training, “but that could just be the swelling”. After the x-ray was done, the doctor informed me that everything looked normal. However, a typical scaphoid fracture can take 7-10 days post injury to appear on an x-ray due to poor blood flow to sections of the bone. Thankfully, the x-ray the following week also showed no signs of a fracture.
After 7-10 days post injury as the swelling diminished, bruising began to appear on the anterior (palm side) portion of the thenar eminence (the wad of muscle between the thumb and first finger) along the 1st metacarpal and in the anterior wrist. Given the complex nature of the wrist and the degree of swelling, it was difficult initially to narrow down what I may have done. Possibilities included a scaphoid fracture as well as a ligament sprain and/or muscle strain.
Based on my own assessment, location of pain and probable mechanism of injury (position of my wrist when it hit the ground) I feel it is likely that I injured, but not completely ruptured, my radial collateral ligament. (see image).
The RCL prevents excessive ulnar deviation (wrist bending too far to the side away from the thumb). Due to the location of bruising along my thumb and anterior wrist, it is also likely that I strained, but not completely ruptured, a muscle or tendon of the thumb.
The wrist, or radiocarpal joint, is one of the most complex joints in the body. It is comprised of multiple bones, ligaments, tendons and other structures. This makes diagnosis of a soft tissue injury difficult. The eight carpal bones of the wrist articulate proximally with the radius and ulna of the forearm and distally with the metacarpals (longer bones within the palm that articulate with the bones, or phalanges, of the fingers). Each carpal also articulates with the bone next to it creating many smaller joints, each connected by multiple ligaments. Depending on severity, symptoms of all potential injuries to the wrist can be similar, especially in the acute phase.
Symptoms of a scaphoid fracture:
Pain and swelling in the snuffbox and thumb side of the wrist
Pain when trying to pinch or grasp something
Decreased range of motion of the wrist and thumb
Symptoms of a sprain:
Ligaments are tough bands of flexible, non-contractile connective tissue that attach bone to bone and provide stability to a joint. Depending on severity, symptoms of a ligament sprain may include:
Instability at the joint
Popping or snapping noise
Decreased range of motion
Pain is moderate-intense while at rest or with movement
Difficulty or inability to continue the activity
Local heat, edema and bruising may be present
Symptoms of a strain:
Tendons are tough bands of fibrous tissue that connect muscle to bone. A strain is an overstretch injury to a musculotendinous unit which consists of the muscle, it’s tendons, their osseous attachments and the junction between the muscle belly and tendon (musculotendinous junction). Depending on severity, symptoms of a strain may include:
Snapping noise at time of injury
Local heat, edema, hematoma and bruising may be present
A palpable gap in the tissue
Loss of strength and range of motion
Difficulty or inability to continue activity
Recovery and rehabilitation
Considering the degree of pain, swelling and lack of mobility during the first week, the healing process seemed to go much quicker than I anticipated.
The first 3 or 4 days after an injury occurs is the acute stage. The best rehabilitation during this time is to rest, ice and elevate. For the first 2 days, there was very little movement of my wrist or thumb as they were immobilized in a splint. I made the mistake of not taking the splint off over that time due to the uncertainty of how bad the injury might be.
For the rest of the first week, I kept the splint and sling on most of the day and night. It was taken off 2-3 times everyday to ice and move within a pain free range in order to maintain circulation and available range of motion.
During the second week, I began using small amounts of a topical Arnica cream. Arnica is indicated for pain and swelling associated with bruises, aches and sprains. It is useful for it’s analgesic, anti-inflammatory and anti-coagulation effects which assist in the healing process. Ice remained an important part of my daily routine. Application of cold decreases the temperature of the skin, muscles and joints it is applied to. It creates a vasoconstriction and increases blood viscosity which prevents excess blood from reaching the injured tissue and reduces the swelling, inflammation and bleeding. Cold therapy will also decrease pain and muscle spasms. For optimal results, it is best to ice the area until it feels numb.
Typical stages are:
A sensation of cold
Tingling or itching
Aching or burning
Numbness or analgesia
Glucosamine is a supplement that occurs naturally in our bodies. It produces chemicals involved in building tendons, ligaments, cartilage and the synovial fluid found in joints. It my also help prevent the breakdown of joint cartilage, the rubbery tissue that cushions the articulating surfaces of bones. I began taking glucosamine 1-2 times each day.
All of this, including frequent mobilization within my pain free range caused the swelling to decrease significantly over weeks 2 and 3. As the swelling decreased, my ability to grasp objects and touch my thumb to little finger became easier.
During week 3, I switched to using only the tensor bandage without the splint or sling. I was significantly weaker in my right hand and arm and the atrophy of all muscles was obvious. In addition to continued use of arnica, ice and glucosamine, focus of my rehabilitation became increasing strength with little or no movement at the joint. This means I would stabilize my hand and wrist with my other hand while contracting the muscles involved in each range of motion of the wrist:
Wrist Range of Motion
Flexion and extension
Abduction and adduction
Supination and pronation
I also worked on strengthening the muscles of the thumb in all ranges – flexion, extension, abduction, adduction and opposition.
By week 4, I was feeling a marked increase in stability and strength. I continued with much of the same treatments but with progression from ice to a contrast hydrotherapy and incorporating some movement of the joints. The contrast hydro involves the application of heat for 2-3 min followed by cold for another 30 sec-1 min or until numb. This causes alternating vasodilation and vasoconstriction which creates an increase in local circulation. This helps move metabolites, decreases edema and increases tissue healing. I also incorporated some movement of the wrist and hand with a theraband and putty. The theraband is a long, thin elastic band used to create resistance while moving the wrist in all ranges explained above. The putty is squeezed in the palm to increase grip strength. After every exercise, I used ice to prevent any inflammation from occurring due to the increase in activity.
By week 5, the pain and swelling had almost completely disappeared despite some obvious scar tissue remaining in the area. I incorporated a weight to further increase the load on the muscles of my forearm and hand.
This entire experience was both humbling and educational. As a massage therapist, an injury to my wrist or arm is something I’ve always been afraid of. However, it helped reinforce everything I’ve learned about assessment and treatment of soft tissue injuries. The rehabilitation process requires a considerable amount of self discipline with the use of ice, regularly performing the relevant exercises and maintaining adequate health overall to assist the body in the healing process. I am now healed and more motivated than ever to help my clients feel the best they can!