INJURIES: WRIST

The wrist is an area of interest within snowboarding, particularly due to the high prevalence of injuries caused by falls with an outstretched arm in beginner snowboarders.

The forearm bones (radius and ulnar) connect distally to form the radioulnar joint, enabling movements like forearm supination/pronation. The radius also meets distally with the first row of the carpal bones (scaphoid, lunate, and triquetrum) to form the primary wrist joint - the radiocarpal joint. This joint is responsible for the major wrist movements like flexion, extension, and radial/ulnar deviation.

Note. From Hand and Wrist Anatomy, by Murdoch Orthopaedic Clinic, 2024, Murdoch Orthopaedic (https://murdochorthopaedic.com.au/our-surgeons/paul-jarrett/patient-information-guides/hand-wrist-anatomy/). Copyright 2024 by Murdoch Orthopaedic Clinic.

Figure 2. Bony anatomy of the hand

Surrounding the wrist are ligaments that provide stability for the joint like the palmar and dorsal radiocarpal ligaments. The triangular fibrocartilage complex (TFCC) provides stability for the ulnar aspect of the wrist as well as acting as a load bearing structure. Important tendons include the wrist flexors (flexor carpi radialis and ulnaris) and extensors (extensor carpi radialis and ulnaris), which help stabilise the wrist. Nerves such as the median, ulnar, and radial nerves innervate the hand and wrist, affecting grip strength and sensation.

Figure 3. Ligamentous anatomy of the hand

Note. From Hand Injuries in Sports: Diagnosis and Treatment Strategies, by The Sports Medicine Review, 2024, Sports Med Review (https://www.sportsmedreview.com/by-joint/hand/). Copyright 2024 by The Sports Medicine Review.

One of the most common injuries to the wrist are fractures to the distal radius, typically resulting from falling backwards onto an outstretched hand position (Idzikowski et al., 2000). Furthermore, the scaphoid’s anatomical position being adjacent to the radius also makes it a vulnerable site for fracture in a FOOSH mechanism of injury (Rhemrev et al., 2011). However, isolated ligamentous injuries of the wrist, scaphoid, and perilunate complex are rarer than distal radius fractures and typically occur in more advanced riders from high-energy collisions (Idzikowski et al., 2000).

While there is some variability in protocols between institutions, rehabilitation for wrist injuries generally follows a more standardised progression compared to other joint injuries. With the exception of the healing time frames being the main differing factors, rehabilitation for all of these wrist injuries tend to follow a similar process. It typically involves a period of immobilisation of the joint, followed by a period of gentle ROM exercises and introduction of light strengthening exercises, and is then progressed to heavier resistance exercises and stronger grades of mobilisations until the patient is able to return to sport. It should be emphasised that athletes participating in sports where wrist use is minimal (i.e., snowboarding), may be able to return to sport in a cast prior to complete healing (Beleckas & Calfee, 2017). However, this decision requires careful consideration of the athlete’s age, level of competition, and weighing the risks and benefits to participation.

The following exercises provided in this resource will be categorised based on the addressed impairments rather than following a healing timeframe. This approach acknowledges that rehabilitation rarely follows a linear path, and each patient's recovery journey is unique. For example, a patient several weeks into rehabilitation might still benefit from basic range of motion exercises despite being "past" the early healing stage. By organising exercises according to the impairments, treating physiotherapists can select the most appropriate interventions based on their clinical reasoning and the patient’s needs, regardless of where they are in their healing timeline.

Distal Radius Fractures: Recommendations

The primary goal of distal fracture rehabilitation is to manage pain whilst also restoring ROM, strength, and hand function (Ikpeze et al., 2016). During the immobilisation period, it is critical that the patient commences passive and active ROM exercises of the unsplinted joints immediately (i.e., finger, shoulder, elbow) to prevent stiffness (Ikpeze et al., 2016; Beleckas & Calfee, 2017). Once there is radiographic evidence of union, the cast is removed and the patient is transitioned over to a removable brace for comfort (Beleckas & Calfee, 2017). During this period, wrist ROM and strengthening is commenced with pain and swelling management being a secondary consideration (Ikpeze et al., 2016; Beleckas & Calfee, 2017). As previously mentioned, patients can be considered for return to sport at this time given the upper extremity is not required for snowboarding, with the understanding that a new fall can cause further injury (Beleckas & Calfee, 2017).

Similarly, clinical guidelines by Mehta et al. (2024) suggests that early physiotherapy AROM exercises of the hand, wrist, and shoulder along with light daily activities should be initiated within the first 3-weeks after a surgically repaired distal radius fracture (A-level consensus). At 2 weeks, submaximal progressive strengthening such as light load gripping involving towel or putty squeezing should be commenced for both surgically and conservatively managed distal radius fractures (B-level consensus). Throughout this, clinicians can use manual therapy (MWM, accessory mobilisations, sustained stretching) guided by the patient’s tolerance and fracture stability to address pain, ROM and function for both surgically and conservatively managed distal radius fractures. Additionally, techniques such as manual lymph drainage, exercises, elevation, compression gloves, and low-stretch bandaging can be implemented conjunctively to address swelling, pain, ROM, and function in both populations.

Henn and Wolfe (2014) recommended radiographic healing and at least 80% return to motion and strength prior to return to sport.

Scaphoid Fractures: Recommendations

The primary goals of physiotherapy are to restore AROM, reduce swelling, increase grip and wrist strength, and return to functional tasks (Physiopedia, 2022). During the immobilisation period, the hand should be kept elevated to minimise swelling whilst completing AROM exercises for the finger, elbow, and shoulder to minimise stiffness (Hayat & Varacallo, 2023). Once the period of immobilisation is completed, the main goal is to increase wrist ROM through AROM and supination and pronation exercises (Hayat & Varacallo, 2023). Gentle wrist and thumb AROM is typically commenced at 6 weeks for operatively managed fractures and 10-12 weeks for conservatively managed fractures (Halim & Weiss, 2016; Winston & Weiland, 2017). Grip strengthening exercises should begin at 10-12 weeks and aim to advance to progressive resistance exercises as tolerated (Halim & Weiss, 2016; Winston & Weiland, 2017).

Similar to distal radius fractures, Henn and Wolfe (2014) recommended radiographic healing and at least 80% return to motion and strength prior to return to sport. However, given wrist use is minimal in snowboarding, the athlete can be considered for return to sport prior to full healing (Beleckas & Calfee, 2017).

Wrist Ligament Injuries: Recommendations

For mild cases of wrist sprains, the use of rest, ice, elevation and mobilisation will be sufficient (May Jr & Varacallo, 2023). However, for more severe sprains requiring extensive rehabilitation, the patient will be required to complete active and passive ROM exercises for the unsplinted joint to minimise stiffness. Once the period of immobilisation is complete, the patient will then begin strengthening and proprioception exercises of the wrist, gradually increasing loads and intensity (Helmig et al., 2018).

ADDRESSING AROM

Wrist AROM

Rest your affected forearm on a stable surface (e.g., edge of a table or bed) with your wrist hanging off the edge and free to move.
Slowly move your wrist through each motion of flexion, extension, radial/ulnar deviation
Moving through each direction as far as comfortable, leaning into stiffness but not pain
Repeat each motion as comfortable

Wrist PROM (Flexion/Extension)

Rest your affected forearm on a stable surface (e.g., table, bed, or even your lap)
Use your unaffected hand to gently hold your affected wrist near the joint, focusing on isolating the wrist movement.
Using the unaffected hand, move the affected wrist through each motion of flexion and extension
Push through each direction as far as comfortable, leaning into stiffness but not pain
Can progress intensity of PROM (either through grades of resistance or oscillation durations) as tolerated
Repeat each movement as comfortable

Forearm Pronation/Supination

Sit or stand with both elbows tucked close to your sides, bent at a 90° angle
Slowly rotate your forearm to turn your palm up and down, alternating between these two movements.
Repeat as comfortable

Wrist Circles

Rest your affected forearm on a stable surface (e.g., edge of a table or bed) with your wrist hanging off the edge and free to move.
Gently move the wrist in a clockwise direction, drawing small circles (the larger the circle, the more ROM required)
Complete as much as comfortable, then changing to a anti-clockwise direction as repeat

Digits Touching

Rest your affected forearm on a stable surface (e.g., table, bed, or even your lap) with palms facing up
Without moving your wrist, gently press your thumb (first digit) against your index finger (second digit), middle finger (third digit), ring finger (fourth digit), and pinky (fifth digit)
Repeat as comfortable

Weight-Bearing Wrist Flexion/Extension Stretch

Adapted from: Snowboard Addiction. (2021). Rehab Series: Mobilizing Injured Wrists and How To Minimize Injury Falling [Video]. Youtube. https://www.youtube.com/watch?v=I2hWFcMSpck&ab_channel=SnowboardAddiction

Weight-bearing wrist extension:

Start in a 4-point kneel position with both hands placed flat on the floor and fingers pointed forward
Gently lean your body forward over your wrists as far as comfortable, feeling a stretch along the front of the wrists and forearms.
Hold this position briefly before easing back and releasing the stretch
Repeat each movement as comfortable

Weight-bearing wrist flexion:

Start in a 4-point kneel position with the dorsal aspect of both hands on the floor and fingers pointed towards you
Most people will already feel a stretch in this position, however, you can also move backwards to progress the stretch
Moving back as far as comfortable, leaning into stiffness but not pain
Holding this position briefly before easing forward and releasing the stretch

ADDRESSING STRENGTH

Towel/Ball Squeeze

Ideally, have your forearms rested on a stable surface (e.g., table, bed, or even your lap)
Using a scrunched up towel or soft ball (e.g., stress ball), gently squeeze the towel/ball as hard as tolerated before releasing the squeeze
Decrease the intensity of squeeze if pain is felt
Repeat as comfortable

Dumbbell Wrist Flexion/Extension

Rest your affected forearm on a stable surface (e.g., edge of a table or bed) with your wrist hanging off the edge and free to move.
To target wrist extension, hold a dumbbell/weight with palms facing down and slowly lift the weight up toward the ceiling before controlling the weight back down to a neutral position
To target wrist flexion, hold a dumbbell/weight with palms facing up and slowly lift the weight up toward the ceiling before controlling the weight back down to a neutral position
Repeat as comfortable

Push-ups

Start in a plank position with your hands placed slightly wider than shoulder-width apart, arms extended
Whilst maintaining a neutral spine, slowly lower chest to the floor
Push through the palms to extend arms, returning to the starting position

Note: Wall push-ups or knee push-ups can be a regression to this exercise

Plate of Marbles

Stand with elbows tucked close to your sides, bent at a 90° angle and holding a plate with marbles
Whilst holding this position, aim to keep the marbles in the centre of the plate

Note: Adding more marbles to the plate will make the exercise harder, and adding less marbles will make it easier

ADDRESSING PROPRIOCEPTION

Slosh Pipe

Adapted from: Peninsula Hand Therapy. (2023). Slosh Pipe for proprioception retraining [Video]. Youtube. https://www.youtube.com/watch?v=DVy8mlWCHfw&ab_channel=PeninsulaHandTherapy

Using 1m PVC pipe with half a cup of water inside
Stand upright and hold the pipe out in front of you at shoulder height with your palms facing down
Hold this position and aim to keep the pipe level and focus on maintaining an even water level inside

Fractures

Distal radius fractures:

For conservatively managed distal radius fractures, patients are typically placed in a cast for 4-6 weeks (Beleckas & Calfee, 2017). After around 6 weeks, once the fracture site is no longer tender and imaging shows evidence of union, the patient can gradually resume weight-bearing activities and progress rehabilitation (Beleckas & Calfee, 2017). Return to sport or full activity typically occurs 6-9 weeks post-injury and is guided by the patient’s pain levels, functional ROM, and ability to use the hand without guarding (Beleckas & Calfee, 2017).

For surgically managed distal radius fractures, specifically rigid internal fixation, the patient is immediately placed in an irremovable plaster for 10-14 days, and will transition to a removable brace (Beleckas & Calfee, 2017). Union is often achieved at 6 weeks post-surgery, whereby the brace is then removed entirely and the patient can further progress their rehabilitation (Beleckas & Calfee, 2017). Significant functional recovery and ROM is commonly seen within the first 3 months, however, improvements can continue for up to a year (Abramo et al., 2008; Dillingham et al., 2011)

Scaphoid fractures:

The time until union for scaphoid fractures depends on the location of the fracture. Fractures of the distal third will reach union around 6-8 weeks, middle third is around 8-12 weeks, and proximal third is around 12-24 weeks (Hayat & Varcallo, 2023). The longer healing times for proximal third fractures are attributed to the limited blood supply and retrograde arterial flow in that region.

For both conservatively and surgically managed scaphoid fractures, the patient is initially placed into a splint or a cast for 7-14 days (Hayat & Varcallo, 2023) and can typically return to full activity and sports at 3 months provided the patient is pain-free and imaging confirms adequate healing (Halim & Weiss, 2016).

Generally, Perkin’s formula can be applied to bony fractures as a rough guide on healing timelines:

Figure 4. X-ray showing left distal radius fracture

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Note. From "Finger Fractures as an Early Manifestation of Primary Hyperparathyroidism Among Young Patients: A Case Report of a 30-Year-Old Male With Recurrent Osteoporotic Fractures," by A. Ozaki and T. Tanimoto, 2016, Medicine, 95(20), Figure 3 (https://doi.org/10.1097/MD.0000000000003683). Copyright 2016 by Wolters Kluwer Health.

Figure 5. X-ray showing right scaphoid fracture

Table 1. Perkin's formula for upper and lower limb fractures

Wrist Ligament injuries

Healing timelines for ligamentous wrist injuries vary widely based on the individual presentation. Minor sprains typically improve after 24-48 hours (May Jr & Varacallo, 2023), and athletes with these minor injuries can even return to sport almost immediately in a cast or splint (Morrell et al., 2017). However, with more severe ligamentous injuries, the patient would require a period of immobilisation and will typically be in a cast for 4-6 weeks (Morrell et al., 2017). For these more significant ligamentous injuries, return to sport may not occur for 4-6 months and is based on the restoration of full, painless ROM and an absence of tenderness to palpation (Morrell et al., 2017; Helmig et al., 2018)

Figure 6. MRI showing radial collateral ligament tear

INJURIES: WRIST

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