Presentation on theme: "Common Hand and Wrist Injuries"— Presentation transcript:
1 Common Hand and Wrist Injuries Andrew Getzin, MDCayuga Medical CenterSports Medicine and Athletic PerformanceIthaca CollegeThank Dr. Alexandria Hall for and the New York State College Association for inviting me to speakBackground:Board Certified Family Physician but do primarily sports medicineI no longer do much family medicine.I cover the summer at IC, when Gyn comes in for I ask- isn’t there a real doctor that can see her.I have worked as the team physician at Ithaca College for 12 years. I see most of the orthopedic problems. It has given me a nice sense of what are common hand injuries in this population.I have a little advantage with this talk. 2 weeks ago I gave this talk to my hand surgeon. We reviewed the slides and gave them a chance to correct me if she disagreed.
2 How I Will Approach Each Problem What is it?Does it need any special imaging?How do I treat it?What are the indications to refer?I will give a case for many of themReferral different for each person- non-dominant pinky vs. dominant, concert pianist
3 Finger Injury PearlsTreatment should restrict motion of the injured structures while allowing uninjured joints to remain mobilePatients should be counseled that it is not unusual for an injured digit to remain swollen for some time and that permanent deformity is possible even after treatment
5 Finger AnatomyFigure 1.Anatomy of the finger. (A) Joints and ligaments. (B) Tendons.
6 Finger Case 1During infield practice a high school baseball player injured his dominant right pinky while covering his glove to field a grounder. The ball longitudinally hit his right 5th finger. He developed pain but kept playing. After practice, he noticed that he was unable to fully extend his distal phalange. He buddy taped it over the next few weeks but ultimately developed an extension lag that limits his ability to type but with no other functional limitations from the injury.
7 Mallet Finger (Baseball Finger) Injury to the extensor tendon at the DIP jointMost common closed tendon injury of the fingerMechanism: object striking finger, creating forced flexionTendon may be stretched, partially torn, or completely separated by a distal phalanx avulsion fracture
8 Mallet Finger Presentation Pain at dorsal DIP jointInability to actively extend the jointCharacteristic flexion deformityOn exam, very important to isolate the DIP joint to ensure extension from DIP and not the central slipIf can’t passively extend consider bony entrapmentAll of these need x-raysFigure 2.Injury to the joint extensor tendon at the distal interphalangeal joint (mallet finger)
9 Mallet Finger Treatment Splint DIP in neutral or slight hyperextension for 6 weeksCochrane review- all splints same resultsSurgical wiring does not improve outcomeOffice visit every 2 weeksIf not extension lag at 6 weeks, splint at night and for activity for 6 weeks.Conservative treatment effective up to 3 months delayed presentationPatient should not flex fingerIf they flex, the 6 weeks clock starts againIf they take splint off, the finger must be held in extension.Best results if treated earlyPotential for skin necrosisLook at their skinKim hates the splint to the rightIf bony mallet- get post reduction x-ray (in the splint)Handoll. Interventions for treating mallet finger injuries. Cochrane Database 2004
10 Mallet Finger Referral Bony avulsion >30% of joint spaceInability to achieve passive extensionDespite proper treatment permanent flexion of the fingertip is possibleNo fracture reduction in the splintCould fuse the finger which would prevent deformity
11 Finger Case 219 year old Ithaca College football player, defensive back was holding onto the running back by his jersey trying to tackle him but the back broke the tackle. The defensive player developed sudden distal 4th finger pain and was unable to fully flex the DIP joint.
13 Flexor Digitorum Profundus Tendon Injury (jersey finger) Athlete’s finger catches another player’s clothingForced extension of the DIP joint during active flexion75% occur in the ring fingerForce can be concentrated at the middle or distal phalanx-Flexor digitorum profundus tendon inserts into the base of the distal phalanx- volar base-Relatively uncommon, but devastating is missedThe true definition is a bony injuryIf not fixed by 2 weeks the blood supply is so limited that it needs to necrosis of the finger
14 Jersey Finger Presentation Pain and swelling at the volar aspect of DIP jointCan often feel fullness proximally if tendon retractedNeed to isolate the DIP to properly testFigure 4. Flexor digitorum profundus tendon injury(jersey finger). Note that the injured finger is held in forcedextension.
15 Jersey Finger Physical Exam Figure 5. Evaluating flexor digitorum tendon injury. (A) The profundus test is performed by holding the affected finger’sMCP and PIP joints in extension and asking the patient to flex the DIP joint. The other fingers should be flexed at the MCPand PIP joints. (B) The superficialis test is performed by holding the unaffected fingers in extension and asking the patientto flex the injured finger. (MCP = metacarpophalangeal; PIP = proximal interphalangeal; DIP = distal interphalangeal.)
16 Jersey Finger Treatment/ Referral All need to be referred for surgery immediatelyTendon retractsAvulsion fragment may limit retractionBlood supply compromisedPermanent loss of flexion
17 Central Slip Extensor Tendon Injury- Boutonnière deformity PIP joint is forcibly flexed while actively extendedVolar dislocation of the PIP jointExamine with PIP joint in degrees of flexion, can’t active extend but can passively extendTenderness over dorsal aspect of the middle phalanxCommonly occurs in basketballFigure 6.Boutonniére deformity caused by a central slip extensor tendon injury. (A) Normal alignment. (B) Boutonniére deformity.
18 Central Slip Extensor Tendon Injury Treatment A delay in proper treatment will cause boutonniere deformityDeformity can develop over several weeks or occasionally acutelySplint PIP in extension for 6 weeksCan still play sportsBoutonnier- flexion of PIP coupled with extension of MCP and DIPTakes several weeks- lateral bands slip inferiorly
19 Central Slip Extensor Tendon Injury Referral Avulsion fracture involving more than 30 percent of the jointInability to achieve full passive extension
20 Collateral Ligament Injuries Forced ulnar or radial deviationCan cause partial or complete tearPIP is usually involvedPresent with pain at the affected ligamentEvaluate with involved joint at 30 degrees of flexion and MCP at 90 degrees of flexion
21 Collateral Ligament Injuries- Treatment If joint stable and no large fracture- can buddy tapeNever leave the pinky alone?Physical Therapy- if joint stiffFigure 7.Buddy taping for the treatment of finger injuries. (A) Self-adhesive wrap. (B) Velcro wrap.
22 Collateral Ligament Injuries- Referrals Unstable jointLarge associated fractureInjury in a childcan involve the growth plate in a childThese can hurt for up to 6 monthsThey stay swollen- capsular thickeningRefer to hand PT if getting stiff
23 Volar Plate Injury Hyperextension, such as dorsal dislocation PIP is usually affectedCollateral damage is often presentThe loss of joint stability can cause hyperextension deformity
24 Volar Plate Injury- Diagnosis Maximal tenderness at volar aspect of affected jointBruising, swellingFull extension and flexion possible if joint stableCollaterals should be testedRadiographs may show an avulsion fracture at the base of involved phalanx
25 Volar Plate Injury- Treatment Progressive splinting starting at 30 degrees flexionFollowed by buddy tapingIf less severe, can buddy tape immediatelyCan play sports if splinted
26 Volar Plate Injuries- Referral Unstable jointLarge avulsion fragmentThese are associated with PIP fracture dislocation
28 Finger Case #3Ultimate frisbee player tried dove to block an opponents disc and he jammed his thumb on the ground. He was able to keep playing but it swelled and became ecchymotic.
29 Ulnar Collateral Ligament Injury of the Thumb (Skier’s Thumb)(GameKeeper’s Thumb) Caused by forced abduction of the 1st MCP jointLeft untreated the joint will be unstable with weak grip strength
30 Skier’s Thumb- Diagnosis Difficulty opposing pinky to thumbSwelling and black and blue over thenar eminenceCan’t hold an OK signConsider digital block and to facilitate ligament testingKim does not digital block, nor has she ever seen anybody do it
31 Stener LesionFigure 8. Stener lesion. Note that the proximal end of the UCL displaces outside of the adductoraponeurosis. (UCL = ulnar collateral ligament.)Adductor Aponeurosis: fibers of the adductor pollicis tendon (intrinsic hand muscle) with fibers of the extensor aponeurosisOne of the big debate is when to get the MRI.Pt. wants to avoid the OR. Fine after a cast for 6 weeks because stiff but will loosen up. MRI can help show the patient.
32 Skier’s Thumb Grading/Treatment Grade 1Pain without instability with stressSplinting 1-2 weeksGrade 2Pain with mild instability: gapping <20 degreesCasting 3-6 weeksGrade 3Stenner’s LesionInstability: gapping > 20 degrees or > 35 degrees compared to unaffect thumbEarly surgical intervention within 2-3 weeks
34 Skier’s Thumb Referral FractureUnstable jointStener lesion
35 Distal Tuft Fractures Common due to crush injuries Painful Splint in extension for 3 weeks
36 Fraction Alignment Figure 4. Detecting rotation in middle phalanx fractures. If no rotation is present, all fingertips will be on the same plane and pointing toward the scaphoid bone. (A) No rotation. (B) Rotation.Reducing fractures?Hematoma block?Check the other hand, it can be the baselineCan passively extend the wrist and will cause the fingers to flex
37 Proximal and Middle Phalange Fractures Most common in athletesFall or direct blunt traumaMore difficult than metacarpal fracturesClose relationship between fractured bone and pulley system
38 Phalanage Fracture Treatment Early motion (3-5 days)Splint and take outCan buddy tape
40 Finger Case 416 year old baseball player had a frustrating discussion with his coach about playing time so punched a locker. He immediately developed pain over the outside aspect of his right hand and lost the normal morphology of the 5th knuckle.
41 Metacarpal Fractures Most common hand fracture 30-35%Usually involves the neckFight or fall common mechanism4TH and 5th most common fractures
42 Metacarpal Fractures Diagnosis Present with edema over the dorsum of the handPoint tenderEcchymosisThe distal fragment usually displaces volarly due to the interosseous musclesRadiographs: AP, lateral, oblique
43 Metacarpal Fracture Treatment Angulation up to 40+ degrees can be toleratedAttempt reduction?Different cast typesStatius, et al, Immediate immobilization gives good results in boxer’s fractures with volar angulation up to 70 degrees: a prospective randomized trial comparing immediate mobilization with cast immobolization. Arch Orthop Trauma Surg 2003;123:534-7Kim rarely operates on theseStatius, Arch Orthop Trauma Surg 2003;123:534-7
44 Metacarpal Fracture-Complications MalrotationCommon with spiral or oblique fracturesGreater than 10% malrotation leads to scissoring effect of the fingersMetacarpal headLoss of knuckleCan you feel the metacarpal head in the palm- if hockey or stick handling can be a problemCan have an extensor lag that gets better over time
46 Proximal PIP dorsal dislocation 20 year old Ithaca College football defensive lineman ran to the sideline with right 4th finger pain and deformity. He clearly had a dorsal PIP dislocation. Gentle longitudinal traction resulted in joint relocation. No visible deformity was apparent after relocation and he had passive FROM at DIP and PIP. The finger was buddy taped and the athlete returned to play. X-ray following the game revealed soft tissue swelling. He was buddy taped and finished his season.
47 Proximal PIP dorsal dislocation (Coach’s Finger) Most common dislocated joint in the bodyCan injure the volar plate or cause an avulsion fracture of the middle phalanxThe severity of this injury often is underestimated and improper treatment can cause long-term morbidityFigure 2.Reduction technique for proximal interphalangeal joint dislocations. Apply distal tension on the injured finger while applying volarly directed pressure to the middle phalanx. Hold the proximal phalanx in place while applying counterpressure.
48 Proximal PIP dorsal dislocation- relocation Reduce via gentle longitudinal tractionIf initially unsuccessful should hyperextend the distal portion to unlockIf not done <1 hour consider a digital blockI had to use sticky spray during football game one timePut the wrist into flexion because it relaxes the flexor tendonThere is often a rotator component- a Chinese finger trap- gently
49 Post Reduction CareRadiographs should be obtained to ensure joint congruityExamine collateralsPIP should be splinted in less than 30 degreesX-ray in the splintLocal for the dorsal V sign on the lateral
53 Wrist Case 124-year-old male FOOSH (fell on outstretched hand) while skiing over the weekendSeen at the mountain clinic and told “wrist sprain”
54 Scaphoid Fracture Most common fractured bone in the wrist Peanut shaped bone that spans both row of carpal bonesDoes not require excessive force and often not extremely painful so can be delayed presentationI have missed one of these- football player, initial x-ray was normal and pain was on his distal radiusIf missed can develop long term arthritis
55 Scaphoid Fracture Presentation Pain over the anatomic snuff boxPain is not usually severeOften present late
56 Scaphoid Fracture Pathoanatomy Blood supplied from distal poleIn children, 87% involve distal poleIn adults, 80% involve waistTreatment depends on location of fracture
57 Imaging AP, lateral, oblique and scaphoid view Radiographs can be delayed for up to 4 weeks?MRI, bone scan, or treat and repeat film
58 Scaphoid Fracture Treatment Cast 6-12 weeksShort arm vs. long armFollow patient every 2 weeks with x-rayCT and clinical evaluation to determine healingConsider screwing earlyInclude the thumb, below the elbow
59 Non Operative Treatment- Disadvantages Nonunion rate 5-55%Delayed unionMalunion“cast disease”- joint stiffnessProlonged immobilization- sometimes >12 weeksLoss of time from employment and avocations
60 Scaphoid Fracture - Referral Angulated or displaced (1mm)Non-union or AVNProximal fracturesLate presentationEarly return to play desired
61 Union Rates 100%High Union Rates- approaches 100%61
62 Wrist Case 2Soccer player has pain in ulnar side of wrist after a fall
63 Triangular Fibrocartilage Complex (TFCC) Tear Fall on dorsiflexed and ulnar deviated wristAxial load with forearm in hyperpronationPositive ulnar variance predisposes to injuryBecause they bear more weight at the wrist,Normally 80/20 but longer ulna is 60/40- Measurement: - requires zero rotation view: (measured on PA radiograph w/ wrist in neutral supination/pronation); - draw transverse line at the level of the lunate fossa, and a second transverse line at the level of the ulnar head; - the difference indicates ulnar variance;
64 TFCC Tear Diagnosis Exam Imaging Ulnar sided wrist pain Often experience a clickImagingRadiographsMR arthrogram
65 TFCC Tear Treatment Splinting Time Injection Surgical treatment DebridementRepairOpen vs. arthroscopicUlnar shortening osteotomy
66 TFCC Tear Referral Pain They take a long time to get better- 3-6 months of splinting
67 Wrist Case 325-year-old tennis player twists wrist as he falls backwards reaching for a lob
68 Scapholunate Dissociation Most common ligamentous instability of the wristPatients may have high degree of pain despite apparently normal radiographsPhysicians should suspect this injury if patient has wrist effusion and pain seemingly out of proportion to the injuryIf improperly diagnosed can lead to chronic painLocated proximal axial line from 3rd metacarpalAlso can lead to arthritis in years
69 Scapholunate Dissociation- Diagnosis ExamWatson’s testScaphoid shuck testPain/swelling over dorsal wrist, proximal rowImagingPlain films: >3mm difference on clenched fist viewScaphoid ring signGrab the distal pole scaphoid and then when radial deviate you should feel it push your finger awayAlways get comparison viewsThe scaphoid falls into flexion and looks like a ring
70 Scapholunate Dissociation Treatment If discovered within 4 weeks, surgeryAfter 4 weeks, conservative treatment reasonableBracingNSAIDSConsider evaluation by hand surgery to confirm no surgery needed
71 Scapholunate Ligament Dissocation Referral All will go onto to cause some problemAllow the specialist to make the ultimate decision
72 Wrist Case 4The Ithaca College starting softball shortstop presented with pain at the base of her left thumb. It was aggravated by hitting when she rolled her left hand over the top.
73 DeQuervain’s Tenosynovitis Pain due to inflammation of the short extensor and abductor tendons of the thumbRepetitive or unaccustomed griping and grasping causes friction over the distal radial styloid
74 DeQuervain’s Tenosynovitis: Diagnosis Swelling and pain over 1st dorsal compartment+Finkelstein’s test
75 DeQuervain’s Tenosynovitis: Treatment SplintInjection- 1st lineup to 90% are pain free if injected within 6 monthsSplinting performs poorly in comparison to steroid injectionPost injection flare!Splint for a couple weeks after the injectionColdham F.. British Journal of Hand Therapy.2006
77 Wrist Case #5An Ithaca College crew athlete presented following spring break training trip in Georgia. She reported pain distal dorsal medial forearm, accompanied by swelling, and palpable/audible crepitus. Her pain was exacerbated by feathering her oar.
78 Intersection syndrome Friction point where muscle bellies of 1st compartment- Abductor Pollicis Longus and Extensor Pollicis Brevis cross 2nd and 3rd dorsal compartmentsInflammatory peritendinitisCommon with rowers due to clenched fist and thumb abductionFriction and crepitus felt 4-5cm proximal to radial styloid with rest flexion and extension and radial deviationCompartment1: (APL) abductor pollicus longus (mid ulna-base of 1st metacarpal), (EPB) Extensor pollicis brevis (distal ulna-base of proximal phalange)Compartment 2: Extensor carpi radialis longus (humerus-base of 2nd metacarpal), Extensor carpi radialis brevis (common extensor bundle to base of 3rd metacarpal)Compartment 3: Extensor pollicis Longus (distal to APL and proximal to EPB on the ulna-base of distal thumb phalange)About a 60 degree angle between.Also seen in skiers due to poling
79 Intersection Syndrome Diagnosis Pain and swelling about 2-3 finger breadths proximal to dorsal wrist jointPalpable crepitus (“squeaker’s wrist”Fig. 2A. —28-year-old male tennis player who presented with tender mass on distal forearm. Axial T2-weighted fat-suppressed fast spin-echo image (TR/TEeff, 2,300/88) shows peritendinous and subcutaneous edema (arrow) in region of intersection of first extensor compartment and second extensor compartment tendons. Individual tendons are not well discerned.
81 Intersection Syndrome Referral Failure of conservative measuresTenosynovectomy and fasciotomy of abductor pollicis longus can be performed
82 Ganglion CystAccount for 60% of soft tissue, tumor-like swelling affected the hand and wristDevelop spontaneously in year oldsFemale to male, 3:1Cyst filled with soft, gelatinous, sticky, and mucoid fluidLocation65% dorsal scapholunate joint20-25% volar distal aspect of the radius10-15% flexor tendon sheathMass generated from chronic irritation of the wrist that cause fluid productionExcess fluid leaks into subcutaneous space where a cyst is formed
83 Ganglion Cyst Diagnosis Usually obvious on exam- may be helpful to flex and extend wristRadiographs, ultrasound, or MR not usually indicatedIf they have had trauma look for scapholunate dissocationThey come from the SC joint
84 Ganglion Cyst- Treatment Watchful waiting- most resolve spontaneously over timeBible treatment- not recommendedAspiration/InjectionNo recurrence in 27-67% of patientsGive patients reassurance when they see gelitanous fluid that it is not a cystCan transiluminate
85 Ganglion Cyst Referral Patient preferencePainCosmetic?20% recurrence ratesBump vs. a scarThe smaller ones tend to be more painful-proximal interosseous nerve- motor branch of the radial nerve
86 Carpal Tunnel Syndrome Most common nerve entrapment disorderPain and parasthesias from high pressures in the carpal tunnel causing compression and inflammation of the median nerveCarpal bones dorsally and transverse carpal ligament (flexor retinaculum) ventrallyMedian nerve compression: osteoarthritis, rheumatoid arthritis, diabetes, hypothyroidism, repetitive use, trauma, pregnancy
88 Hand Diagrams Sn = 0.64; Sp = 0.73 NPV = 0.91 Tinel + hand diagram – PPV = 0.71Ann Intern Med 1990 Mar 1;112(5):321-7.
89 Carpal Tunnel Syndrome Always compare with the unaffected sideDocument when phalen’s becomes +Durken’s compressive test- higher sensitivity
90 Sensitivity and Specificity For both Phalen’s and Tinel’s is LOWPhalen’s – Sn= 0.75 ; Sp = 0.47Tinel’s – Sn= 0.60; Sp= 0.67Combine with hand diagram and historyAnn Intern Med 1990 Mar 1;112(5):321-7
91 Nerve Conduction Study Can be painful and costlyReserve for patients whohave failed conservative therapydiagnosis is uncertainlate presentation with thenar wasting and motor dysfunctionFalse negative rates as high as 10%AAOS guidelineHowever, does not help surgery decisionCan help with mild carpal tunnel-night time symptomsOperateAlways have symptomsDennervation of thenar musclesJ Hand Surg [Am] 1995 Sep;20(5):848-54
92 Carpal Tunnel Syndrome Diagnosis Pain involves thumb, first two fingers and radial half of the fourth fingerPalpation: thenar eminence wastingROM: thumb weakness and difficulty pincher graspingDiagnostic Tests or special maneuversNerve conduction studiesTinel’sPhalen’sNight time symptoms most common
94 Carpal Tunnel Injection Short term efficacy: RCT, 70% vs 34% at 2 weeks (steroid vs sham)NNT = 2.8Long-term benefits are more variable43% of patients above required referral to surgeryInjection technique: 23-25g needle; 1-2 cc of lidocaine plus 20-40mg Methylprednisolone. Injected radial side of palmaris longus tendonShould not inject into the nerve-the median nerve can go out- should not inject severe carpal tunnel- wrist to surgeryGood for pregnant peopleKim does not inject-PregnancyOld peopletraumaMuscle Nerve 2004 Jan;29(1):82-8
95 Carpal Tunnel Syndrome Referral Constant numbness and tinglingThenar eminence wastingIf get EMG, moderate to severe carpal tunnel or dennervation
96 Kienbock Disease Avascular necrosis/vascular insufficiency ?repetitive microfractures of lunateYoung adults years oldRisk factors: negative ulnar varianceNobody knows for sure-occlusive blood suplly-loads across the wrist
97 Kienbock Disease: Diagnosis EXAMWrist pain that radiates up the forearmstiffness, tenderness, swelling over lunatepassive dorsiflexion of middle finger produces characteristic painRadiographs, MRIAll have decreased motion
98 Kienbock Disease Stage I – IV Stage I: MRI only Stage II: Sclerosis Stage III: Some collapseStage IV: Total collapse
99 Kienbock Disease: Treatment Primarily surgicalEARLY: Radial shortening, ulnar lengtheningLATE: proximal row carpectomy, arthrodesisReduce ulnar loadLasts years and motion 50% of unaffected side