Photo Quiz

Unusual Wrist Bruise



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2001 Nov 1;64(9):1601-1602.

A 43-year-old man presented to the emergency department after a fall backward onto his wrist, with complaints of pain in his right wrist. Radiographs showed no fracture of the wrist, metacarpals or other bones. There were no dislocations or subluxations noted. The entire wrist and thumb were markedly swollen and diffusely tender, with no localization to the pain. A diagnosis of soft tissue injury was made. The patient's wrist was placed in a customized fiberglass thumb spica/wrist splint, and follow-up was scheduled.

One week later, when the splint was removed, there was still noticeable swelling to the thenar eminence (Figure 1), with significant yellowing to the bruise (which usually occurs after the bruise is more than one to five days old),1,2 but the wrist was relatively non-tender. There was tenderness on abduction and extension of the thumb, and there was pain on flexing the thumb and on pinch grip. Photographs were taken one week after the injury, which revealed an unusual pattern of bruising in the wrist flexor creases (Figure 2).

FIGURE 1.*

View Large


FIGURE 1.*


FIGURE 1.*

FIGURE 2.*

*— These images were taken with an electronic digital camera at 1.4 megapixel resolution.

View Large


FIGURE 2.*

*— These images were taken with an electronic digital camera at 1.4 megapixel resolution.


FIGURE 2.*

*— These images were taken with an electronic digital camera at 1.4 megapixel resolution.

Question

Which one of the following conditions does this type of bruising signify?

A. Occult fracture of the scaphoid bone.

B. Migration of deep hematoma fluid along fascial planes from a thumb sprain.

C. Subluxation of the lunate bone.

D. Tear of superficial palmar branch of the radial artery.

E. Rupture of flexor carpi radialis tendon.

Discussion

The correct answer is B: Migration of deep hematoma fluid from a thumb sprain. In a soft tissue injury, there is bleeding from the torn muscles and ligaments, but this blood is usually confined by the fascia and does not appear as surface bruising. As the hematoma resolves, the swelling and edema of the injured soft tissues go down. As fibrolysis of the clot occurs, liquefied blood and clot can track along the fascial planes. The migrating hematoma can emerge where the fascial planes are reflected superficially, because they form attachments to the skin. In this case, blood from the thenar eminence has migrated proximally and appears superficially at the proximal and distal palmar creases, where the fascia comes through the carpal tunnel.3

The tears are most likely to the thenar muscles (i.e., opponens pollicis, abductor pollicis brevis and possibly the adductor pollicis). The yellow color of the bruise is caused by hemoglobin breakdown products within the hematoma, whereas the deep purple bands in the flexor creases are from old fibrinolysed blood.1,2

Rupture of the superficial palmar branch artery would lead to much larger hematoma formation, and because this artery is superficial to the flexor retinaculum, it would not be confined in the carpal tunnel; the hematoma would not appear in the palmar creases. A ruptured flexor tendon would also not produce a large hematoma, and it would be confined within the flexor tendon sheath. An occult scaphoid fracture would likewise not be expected to produce bruising that migrates out to the creases, for it would be intra-articular hematoma within the carpal joint capsule. Although scaphoid fractures may easily be missed on initial radiographs, they would not typically cause the thenar swelling and unusual bruising seen here. Subluxation of the lunate would be seen on the radiographs.

REFERENCES

1. Stephenson T, Bialas Y. Estimation of the age of bruising. Arch Dis Child. 1996;74:53–5.

2. Langlois NE, Gresham GA. The ageing of bruises: a review and study of the colour changes with time. Forensic Sci Int. 1991;50:227–38.

3. Clemente CD. Anatomy: a regional atlas of the human body. 4th ed. Baltimore: Williams & Wilkins, 1997.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.


Copyright © 2001 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article