Pathology
Trauma is the term for injury to the body from an external source. Severity of trauma is classified by the amount of force used to cause the injury. Trauma can be caused by a single major force or minor repetitive, smaller forces over time (Cumulative Trauma Disorder (CTD)).
Other injury classifying features:
- If the skin was breached (open injury)
- If skin layer remained intact (closed injury)
Minor injuries, where soft tissue is bruised or stretched, but not torn are called a “contusion.” A contusion means the injury was closed and requires only symptomatic treatment of the soft tissues (alone of in combination) such as:
- The skin
- Subcutaneous tissue
- Muscles
- Tendons
- Ligaments
- Arteries
- Nerves
The same force of trauma sustained by different patients will result in different injury severity because of changes occurring in our body’s internal structure with aging.
Below is a graph divided into 20- year increments depicting an identical force sustained by individuals at different ages. It compares the time it takes for each group to heal and become symptom-free. The white section is when the patient is symptom-free and the yellow section is when the patient has symptoms including pain, stiffness, weakness, and poor function. Note, the curve does not come back to baseline and shifts to the right with aging.
Treatment
There are three common approaches to symptomatic treatment for all types of soft tissue injuries:
- R.I.C.E. treatment (Rest, Ice, Compression, Elevation)
- Anti-inflammatory treatment
- Controlled early motion
- Therapy
The stages of R.I.C.E. are used to treat injuries such as a strain (muscle injury) and a spring (a ligament stretch injury).
The Rest stage is usually done for 24-48 hours and can include the use of slings, splints or other types of immobilizers unless otherwise advised by a physician.
The Ice stage is used for no more than 20-30 minutes, three to four times per day. Icing treatment functions by causing the arteries to narrow the size of their lumen, which in turn decreases swelling and the pain from the subsequent increased pressure. Ice treatment is best applied by using an ice slush. Ice slush is made by mixing crushed ice with water in a bag. The ice bag should not be placed in direct contact with the skin but instead use a buffer layer between the skin and ice bag like a towel to prevent skin freezing.
The Compression stage is the wrapping of a body part to further assist in minimizing swelling and is used in conjunction with elevation. The best compressive wrapping has multiple layers providing a cushion effect. The compression wrapping should not cause constriction of the blood supply. Constriction is recognized by increasing pain to the body part wrapped. Other signs of a tight compressive dressing are:
- A cold sensation in the wrapped limb
- Blue discoloration of the body part
- Any change in color from the natural skin color of the body part
The Elevation stage of treatment is best done by elevating the limb to the level of the heart. If elevation is lower than this, the effects of gravity on the veins will increase vein pressure and cause the blood to have difficulty traveling back to the heart. This can result in limb swelling.
The use of anti-inflammatory medication helps treat the pain, swelling, and inflammation occurring after injury.
Examples of anti-inflammatories include:
- Aspirin products
- Naprosyn
- Mobic
- Indocin
- Arthrotec
- Celebrex
- Ibuprofen
- Motrin
- Advil
All of these medications have side effects and should be taken with this knowledge in mind. Prescriptions should be discussed with your pharmacist and physician.
Controlled early motion and therapy to the involved limb decreases the effects of prolonged immobilization. Prolonged immobilization results in stiffness, muscle atrophy, weakness and also shortens the time to return to the pre-injury state.
The type of therapy recommended will depend on the type of tissue injured and the severity of the injury. Consult your surgeon for the best advice.
When treating a wrist contusion, a sling can provide comfort but is not ideal for wrist injuries as it frequently places the hand below the level of the heart when in the seating or standing position. This can worsen swelling, inflammation and the resultant throbbing pain. Therefore, it is preferable not to use a sling but instead to actively elevate the hand above heart level, like when doing the pledge of allegiance, with modifications of this position depending on body position. Carrying a pillow with you may assist in positioning of the hand.
Mobilization of shoulder and elbow should be included in the recovery program to prevent stiffness of the joints.
The home exercise program given to the wrist is referred to as the Six Pack Hand program and is provided below.
The program is progressed from exercise one through six. The wrist should be mobilized early with the assistance of the contralateral uninjured hand. Placing the wrist in the praying position and in the opposite direction is helpful in preventing stiffness. Exercises like throwing a dart facilitate a gentle –ergonomic exercise for the wrist.
