Common Hand and Wrist Injuries

Common Hand and Wrist Injuries
Andrew Getzin, MD Cayuga Medical Center Sports Medicine and Athletic Performance Ithaca College Thank Dr. Alexandria Hall for and the New York State College Association for inviting me to speak Background: Board Certified Family Physician but do primarily sports medicine I 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.

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 them Referral different for each person- non-dominant pinky vs. dominant, concert pianist

Finger Injury Pearls Treatment should restrict motion of the injured structures while allowing uninjured joints to remain mobile Patients 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

Finger Pathology Fractures, Dislocations Ligament/tendon injuries
Mallet Finger Jersey Finger Central slip extensor tendon injury (Boutonniere Deformity) Collateral ligament injury Volar plate injury Skier’s thumb Fractures, Dislocations Distal Tuft Fractures/Crush injury Phalange fractures Metacarpal fractures Boxer’s fracture Dorsal PIP dislocations

Finger Anatomy Figure 1. Anatomy of the finger. (A) Joints and ligaments. (B) Tendons.

Finger Case 1 During 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.

Mallet Finger (Baseball Finger)
Injury to the extensor tendon at the DIP joint Most common closed tendon injury of the finger Mechanism: object striking finger, creating forced flexion Tendon may be stretched, partially torn, or completely separated by a distal phalanx avulsion fracture

Mallet Finger Presentation
Pain at dorsal DIP joint Inability to actively extend the joint Characteristic flexion deformity On exam, very important to isolate the DIP joint to ensure extension from DIP and not the central slip If can’t passively extend consider bony entrapment All of these need x-rays Figure 2. Injury to the joint extensor tendon at the distal interphalangeal joint (mallet finger)

Mallet Finger Treatment
Splint DIP in neutral or slight hyperextension for 6 weeks Cochrane review- all splints same results Surgical wiring does not improve outcome Office visit every 2 weeks If not extension lag at 6 weeks, splint at night and for activity for 6 weeks. Conservative treatment effective up to 3 months delayed presentation Patient should not flex finger If they flex, the 6 weeks clock starts again If they take splint off, the finger must be held in extension. Best results if treated early Potential for skin necrosis Look at their skin Kim hates the splint to the right If bony mallet- get post reduction x-ray (in the splint) Handoll. Interventions for treating mallet finger injuries. Cochrane Database 2004

Mallet Finger Referral
Bony avulsion >30% of joint space Inability to achieve passive extension Despite proper treatment permanent flexion of the fingertip is possible No fracture reduction in the splint Could fuse the finger which would prevent deformity

Finger Case 2 19 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.

Jersey Finger

Flexor Digitorum Profundus Tendon Injury (jersey finger)
Athlete’s finger catches another player’s clothing Forced extension of the DIP joint during active flexion 75% occur in the ring finger Force 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 missed The true definition is a bony injury If not fixed by 2 weeks the blood supply is so limited that it needs to necrosis of the finger

Jersey Finger Presentation
Pain and swelling at the volar aspect of DIP joint Can often feel fullness proximally if tendon retracted Need to isolate the DIP to properly test Figure 4. Flexor digitorum profundus tendon injury (jersey finger). Note that the injured finger is held in forced extension.

Jersey Finger Physical Exam
Figure 5. Evaluating flexor digitorum tendon injury. (A) The profundus test is performed by holding the affected finger’s MCP and PIP joints in extension and asking the patient to flex the DIP joint. The other fingers should be flexed at the MCP and PIP joints. (B) The superficialis test is performed by holding the unaffected fingers in extension and asking the patient to flex the injured finger. (MCP = metacarpophalangeal; PIP = proximal interphalangeal; DIP = distal interphalangeal.)

Jersey Finger Treatment/ Referral
All need to be referred for surgery immediately Tendon retracts Avulsion fragment may limit retraction Blood supply compromised Permanent loss of flexion

Central Slip Extensor Tendon Injury- Boutonnière deformity
PIP joint is forcibly flexed while actively extended Volar dislocation of the PIP joint Examine with PIP joint in degrees of flexion, can’t active extend but can passively extend Tenderness over dorsal aspect of the middle phalanx Commonly occurs in basketball Figure 6. Boutonniére deformity caused by a central slip extensor tendon injury. (A) Normal alignment. (B) Boutonniére deformity.

Central Slip Extensor Tendon Injury Treatment
A delay in proper treatment will cause boutonniere deformity Deformity can develop over several weeks or occasionally acutely Splint PIP in extension for 6 weeks Can still play sports Boutonnier- flexion of PIP coupled with extension of MCP and DIP Takes several weeks- lateral bands slip inferiorly

Central Slip Extensor Tendon Injury Referral
Avulsion fracture involving more than 30 percent of the joint Inability to achieve full passive extension

Collateral Ligament Injuries
Forced ulnar or radial deviation Can cause partial or complete tear PIP is usually involved Present with pain at the affected ligament Evaluate with involved joint at 30 degrees of flexion and MCP at 90 degrees of flexion

Collateral Ligament Injuries- Treatment
If joint stable and no large fracture- can buddy tape Never leave the pinky alone ?Physical Therapy- if joint stiff Figure 7. Buddy taping for the treatment of finger injuries. (A) Self-adhesive wrap. (B) Velcro wrap.

Collateral Ligament Injuries- Referrals
Unstable joint Large associated fracture Injury in a child can involve the growth plate in a child These can hurt for up to 6 months They stay swollen- capsular thickening Refer to hand PT if getting stiff

Volar Plate Injury Hyperextension, such as dorsal dislocation
PIP is usually affected Collateral damage is often present The loss of joint stability can cause hyperextension deformity

Volar Plate Injury- Diagnosis
Maximal tenderness at volar aspect of affected joint Bruising, swelling Full extension and flexion possible if joint stable Collaterals should be tested Radiographs may show an avulsion fracture at the base of involved phalanx

Volar Plate Injury- Treatment
Progressive splinting starting at 30 degrees flexion Followed by buddy taping If less severe, can buddy tape immediately Can play sports if splinted

Volar Plate Injuries- Referral
Unstable joint Large avulsion fragment These are associated with PIP fracture dislocation

Finger Case #3 Ultimate 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.

Ulnar Collateral Ligament Injury of the Thumb (Skier’s Thumb)(GameKeeper’s Thumb)
Caused by forced abduction of the 1st MCP joint Left untreated the joint will be unstable with weak grip strength

Skier’s Thumb- Diagnosis
Difficulty opposing pinky to thumb Swelling and black and blue over thenar eminence Can’t hold an OK sign Consider digital block and to facilitate ligament testing Kim does not digital block, nor has she ever seen anybody do it

Stener Lesion Figure 8. Stener lesion. Note that the proximal end of the UCL displaces outside of the adductor aponeurosis. (UCL = ulnar collateral ligament.) Adductor Aponeurosis: fibers of the adductor pollicis tendon (intrinsic hand muscle) with fibers of the extensor aponeurosis One 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.

Skier’s Thumb Grading/Treatment
Grade 1 Pain without instability with stress Splinting 1-2 weeks Grade 2 Pain with mild instability: gapping <20 degrees Casting 3-6 weeks Grade 3 Stenner’s Lesion Instability: gapping > 20 degrees or > 35 degrees compared to unaffect thumb Early surgical intervention within 2-3 weeks

Skier’s Thumb Treatment

Skier’s Thumb Referral
Fracture Unstable joint Stener lesion

Distal Tuft Fractures Common due to crush injuries Painful
Splint in extension for 3 weeks

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 baseline Can passively extend the wrist and will cause the fingers to flex

Proximal and Middle Phalange Fractures
Most common in athletes Fall or direct blunt trauma More difficult than metacarpal fractures Close relationship between fractured bone and pulley system

Phalanage Fracture Treatment
Early motion (3-5 days) Splint and take out Can buddy tape

Proximal Phalange Fractures- Referral
Inability to maintain proper alignment Rotation Irreducible Injury Any intra-articular fracture

Finger Case 4 16 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.

Metacarpal Fractures Most common hand fracture
30-35% Usually involves the neck Fight or fall common mechanism 4TH and 5th most common fractures

Metacarpal Fractures Diagnosis
Present with edema over the dorsum of the hand Point tender Ecchymosis The distal fragment usually displaces volarly due to the interosseous muscles Radiographs: AP, lateral, oblique

Metacarpal Fracture Treatment
Angulation up to 40+ degrees can be tolerated Attempt reduction? Different cast types Statius, 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;123:534-7 Kim rarely operates on these Statius, Arch Orthop Trauma Surg 2003;123:534-7

Metacarpal Fracture-Complications
Malrotation Common with spiral or oblique fractures Greater than 10% malrotation leads to scissoring effect of the fingers Metacarpal head Loss of knuckle Can you feel the metacarpal head in the palm- if hockey or stick handling can be a problem Can have an extensor lag that gets better over time

Metacarpal Fracture Referral
Rotation Angulation > 70 degrees Preference

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.

Proximal PIP dorsal dislocation (Coach’s Finger)
Most common dislocated joint in the body Can injure the volar plate or cause an avulsion fracture of the middle phalanx The severity of this injury often is underestimated and improper treatment can cause long-term morbidity Figure 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.

Proximal PIP dorsal dislocation- relocation
Reduce via gentle longitudinal traction If initially unsuccessful should hyperextend the distal portion to unlock If not done <1 hour consider a digital block I had to use sticky spray during football game one time Put the wrist into flexion because it relaxes the flexor tendon There is often a rotator component- a Chinese finger trap- gently

Post Reduction Care Radiographs should be obtained to ensure joint congruity Examine collaterals PIP should be splinted in less than 30 degrees X-ray in the splint Local for the dorsal V sign on the lateral

Proximal PIP Dorsal Dislocation- Referral
Avulsion fracture > 1/3 of joint space Irreducible fracture Instability post-reduction Any question refer- low threshold

Wrist Pathology Fracture Nerve Injury Ligament-Tendon Injuries Other
Scaphoid Ligament-Tendon Injuries TFCC tear Scapholunate dissociation DeQuervain’s Intersection Syndrome Ganglion Cyst Nerve Injury Carpal tunnel Other Kienbocks

Wrist Case 1 24-year-old male FOOSH (fell on outstretched hand) while skiing over the weekend Seen at the mountain clinic and told “wrist sprain”

Scaphoid Fracture Most common fractured bone in the wrist
Peanut shaped bone that spans both row of carpal bones Does not require excessive force and often not extremely painful so can be delayed presentation I have missed one of these- football player, initial x-ray was normal and pain was on his distal radius If missed can develop long term arthritis

Scaphoid Fracture Presentation
Pain over the anatomic snuff box Pain is not usually severe Often present late

Scaphoid Fracture Pathoanatomy
Blood supplied from distal pole In children, 87% involve distal pole In adults, 80% involve waist Treatment depends on location of fracture

Imaging AP, lateral, oblique and scaphoid view
Radiographs can be delayed for up to 4 weeks ?MRI, bone scan, or treat and repeat film

Scaphoid Fracture Treatment
Cast 6-12 weeks Short arm vs. long arm Follow patient every 2 weeks with x-ray CT and clinical evaluation to determine healing Consider screwing early Include the thumb, below the elbow

Non Operative Treatment- Disadvantages
Nonunion rate 5-55% Delayed union Malunion “cast disease”- joint stiffness Prolonged immobilization- sometimes >12 weeks Loss of time from employment and avocations

Scaphoid Fracture - Referral
Angulated or displaced (1mm) Non-union or AVN Proximal fractures Late presentation Early return to play desired

Union Rates 100% High Union Rates- approaches 100% 61

Wrist Case 2 Soccer player has pain in ulnar side of wrist after a fall

Triangular Fibrocartilage Complex (TFCC) Tear
Fall on dorsiflexed and ulnar deviated wrist Axial load with forearm in hyperpronation Positive ulnar variance predisposes to injury Because 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;

TFCC Tear Diagnosis Exam Imaging Ulnar sided wrist pain
Often experience a click Imaging Radiographs MR arthrogram

TFCC Tear Treatment Splinting Time Injection Surgical treatment
Debridement Repair Open vs. arthroscopic Ulnar shortening osteotomy

TFCC Tear Referral Pain
They take a long time to get better- 3-6 months of splinting

Wrist Case 3 25-year-old tennis player twists wrist as he falls backwards reaching for a lob

Scapholunate Dissociation
Most common ligamentous instability of the wrist Patients may have high degree of pain despite apparently normal radiographs Physicians should suspect this injury if patient has wrist effusion and pain seemingly out of proportion to the injury If improperly diagnosed can lead to chronic pain Located proximal axial line from 3rd metacarpal Also can lead to arthritis in years

Scapholunate Dissociation- Diagnosis
Exam Watson’s test Scaphoid shuck test Pain/swelling over dorsal wrist, proximal row Imaging Plain films: >3mm difference on clenched fist view Scaphoid ring sign Grab the distal pole scaphoid and then when radial deviate you should feel it push your finger away Always get comparison views The scaphoid falls into flexion and looks like a ring

Scapholunate Dissociation Treatment
If discovered within 4 weeks, surgery After 4 weeks, conservative treatment reasonable Bracing NSAIDS Consider evaluation by hand surgery to confirm no surgery needed

Scapholunate Ligament Dissocation Referral
All will go onto to cause some problem Allow the specialist to make the ultimate decision

Wrist Case 4 The 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.

DeQuervain’s Tenosynovitis
Pain due to inflammation of the short extensor and abductor tendons of the thumb Repetitive or unaccustomed griping and grasping causes friction over the distal radial styloid

DeQuervain’s Tenosynovitis: Diagnosis
Swelling and pain over 1st dorsal compartment +Finkelstein’s test

DeQuervain’s Tenosynovitis: Treatment
Splint Injection- 1st line up to 90% are pain free if injected within 6 months Splinting performs poorly in comparison to steroid injection Post injection flare! Splint for a couple weeks after the injection Coldham F.. British Journal of Hand Therapy.2006

DeQuervain’s Tenosynovitis: Referral
Recurrence despite repeated injections If don’t respond cut the sheet volarly

Wrist Case #5 An 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.

Intersection syndrome
Friction point where muscle bellies of 1st compartment- Abductor Pollicis Longus and Extensor Pollicis Brevis cross 2nd and 3rd dorsal compartments Inflammatory peritendinitis Common with rowers due to clenched fist and thumb abduction Friction and crepitus felt 4-5cm proximal to radial styloid with rest flexion and extension and radial deviation Compartment1: (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

Intersection Syndrome Diagnosis
Pain and swelling about 2-3 finger breadths proximal to dorsal wrist joint Palpable 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.

Intersection Syndrome Treatment
Splinting Activity modification Icing Nsaids Corticosteroid injection Inject perpendicular

Intersection Syndrome Referral
Failure of conservative measures Tenosynovectomy and fasciotomy of abductor pollicis longus can be performed

Ganglion Cyst Account for 60% of soft tissue, tumor-like swelling affected the hand and wrist Develop spontaneously in year olds Female to male, 3:1 Cyst filled with soft, gelatinous, sticky, and mucoid fluid Location 65% dorsal scapholunate joint 20-25% volar distal aspect of the radius 10-15% flexor tendon sheath Mass generated from chronic irritation of the wrist that cause fluid production Excess fluid leaks into subcutaneous space where a cyst is formed

Ganglion Cyst Diagnosis
Usually obvious on exam- may be helpful to flex and extend wrist Radiographs, ultrasound, or MR not usually indicated If they have had trauma look for scapholunate dissocation They come from the SC joint

Ganglion Cyst- Treatment
Watchful waiting- most resolve spontaneously over time Bible treatment- not recommended Aspiration/Injection No recurrence in 27-67% of patients Give patients reassurance when they see gelitanous fluid that it is not a cyst Can transiluminate

Ganglion Cyst Referral
Patient preference Pain Cosmetic? 20% recurrence rates Bump vs. a scar The smaller ones tend to be more painful -proximal interosseous nerve- motor branch of the radial nerve

Carpal Tunnel Syndrome
Most common nerve entrapment disorder Pain and parasthesias from high pressures in the carpal tunnel causing compression and inflammation of the median nerve Carpal bones dorsally and transverse carpal ligament (flexor retinaculum) ventrally Median nerve compression: osteoarthritis, rheumatoid arthritis, diabetes, hypothyroidism, repetitive use, trauma, pregnancy

Carpal tunnel syndrome

Hand Diagrams Sn = 0.64; Sp = 0.73 NPV = 0.91 Tinel + hand diagram –
PPV = 0.71 Ann Intern Med 1990 Mar 1;112(5):321-7.

Carpal Tunnel Syndrome
Always compare with the unaffected side Document when phalen’s becomes + Durken’s compressive test- higher sensitivity

Sensitivity and Specificity
For both Phalen’s and Tinel’s is LOW Phalen’s – Sn= 0.75 ; Sp = 0.47 Tinel’s – Sn= 0.60; Sp= 0.67 Combine with hand diagram and history Ann Intern Med 1990 Mar 1;112(5):321-7

Nerve Conduction Study
Can be painful and costly Reserve for patients who have failed conservative therapy diagnosis is uncertain late presentation with thenar wasting and motor dysfunction False negative rates as high as 10% AAOS guideline However, does not help surgery decision Can help with mild carpal tunnel -night time symptoms Operate Always have symptoms Dennervation of thenar muscles J Hand Surg [Am] 1995 Sep;20(5):848-54

Carpal Tunnel Syndrome Diagnosis
Pain involves thumb, first two fingers and radial half of the fourth finger Palpation: thenar eminence wasting ROM: thumb weakness and difficulty pincher grasping Diagnostic Tests or special maneuvers Nerve conduction studies Tinel’s Phalen’s Night time symptoms most common

Carpal Tunnel Syndrome Treatment
Ice Activity modification Workspace modification Splinting Injection Surgery

Carpal Tunnel Injection
Short term efficacy: RCT, 70% vs 34% at 2 weeks (steroid vs sham) NNT = 2.8 Long-term benefits are more variable 43% of patients above required referral to surgery Injection technique: 23-25g needle; 1-2 cc of lidocaine plus 20-40mg Methylprednisolone. Injected radial side of palmaris longus tendon Should not inject into the nerve -the median nerve can go out- should not inject severe carpal tunnel- wrist to surgery Good for pregnant people Kim does not inject- Pregnancy Old people trauma Muscle Nerve 2004 Jan;29(1):82-8

Carpal Tunnel Syndrome Referral
Constant numbness and tingling Thenar eminence wasting If get EMG, moderate to severe carpal tunnel or dennervation

Kienbock Disease Avascular necrosis/vascular insufficiency
?repetitive microfractures of lunate Young adults years old Risk factors: negative ulnar variance Nobody knows for sure -occlusive blood suplly -loads across the wrist

Kienbock Disease: Diagnosis
EXAM Wrist pain that radiates up the forearm stiffness, tenderness, swelling over lunate passive dorsiflexion of middle finger produces characteristic pain Radiographs, MRI All have decreased motion

Kienbock Disease Stage I – IV Stage I: MRI only Stage II: Sclerosis
Stage III: Some collapse Stage IV: Total collapse

Kienbock Disease: Treatment
Primarily surgical EARLY: Radial shortening, ulnar lengthening LATE: proximal row carpectomy, arthrodesis Reduce ulnar load Lasts years and motion 50% of unaffected side

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Common Hand and Wrist Injuries

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