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Common Hand and Wrist Injuries Andrew Getzin, MD Cayuga Medical Center Sports Medicine and Athletic Performance

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Presentation on theme: "Common Hand and Wrist Injuries Andrew Getzin, MD Cayuga Medical Center Sports Medicine and Athletic Performance"— Presentation transcript:

1 Common Hand and Wrist Injuries Andrew Getzin, MD Cayuga Medical Center Sports Medicine and Athletic Performance Ithaca College

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?

3 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

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

5 Finger Anatomy

6 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.

7 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

8 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

9 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 Handoll. Interventions for treating mallet finger injuries. Cochrane Database 2004

10 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

11 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 4 th finger pain and was unable to fully flex the DIP joint.

12 Jersey Finger

13 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

14 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

15 Jersey Finger Physical Exam

16 Jersey Finger Treatment/ Referral All need to be referred for surgery immediately

17 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

18 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

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

20 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

21 Collateral Ligament Injuries- Treatment If joint stable and no large fracture- can buddy tape Never leave the pinky alone ?Physical Therapy- if joint stiff

22 Collateral Ligament Injuries- Referrals Unstable joint Large associated fracture Injury in a child

23 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

24 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

25 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

26 Volar Plate Injuries- Referral Unstable joint Large avulsion fragment

27

28 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.

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

30 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

31 Stener Lesion

32 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

33 Skier’s Thumb Treatment

34 Skier’s Thumb Referral Fracture Unstable joint Stener lesion

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

36 Fraction Alignment

37 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

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

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

40 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 5 th knuckle.

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

42 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

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

44 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

45 Metacarpal Fracture Referral Rotation Angulation > 70 degrees Preference

46 Proximal PIP dorsal dislocation 20 year old Ithaca College football defensive lineman ran to the sideline with right 4 th 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 body Can injure the volar plate or cause an avulsion fracture of the middle phalanx

48 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

49 Post Reduction Care Radiographs should be obtained to ensure joint congruity Examine collaterals PIP should be splinted in less than 30 degrees

50 Proximal PIP Dorsal Dislocation- Referral Avulsion fracture > 1/3 of joint space Irreducible fracture Instability post-reduction

51 WRIST

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

53 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”

54 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

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

56 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

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 weeks Short arm vs. long arm Follow patient every 2 weeks with x-ray CT and clinical evaluation to determine healing Consider screwing early

59 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

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

61 Union Rates 100%

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

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

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

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

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

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

68 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 3 rd metacarpal

69 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

70 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

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

72 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.

73 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

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

75 DeQuervain’s Tenosynovitis: Treatment Splint Injection- 1 st line –up to 90% are pain free if injected within 6 months Splinting performs poorly in comparison to steroid injection Coldham F.. British Journal of Hand Therapy.2006

76 DeQuervain’s Tenosynovitis: Referral Recurrence despite repeated injections

77 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.

78 Intersection syndrome Friction point where muscle bellies of 1 st compartment- Abductor Pollicis Longus and Extensor Pollicis Brevis cross 2 nd and 3 rd 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

79 Intersection Syndrome Diagnosis Pain and swelling about 2-3 finger breadths proximal to dorsal wrist joint Palpable crepitus (“squeaker’s wrist”

80 Intersection Syndrome Treatment Splinting Activity modification Icing Nsaids Corticosteroid injection

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

82 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

83 Ganglion Cyst Diagnosis Usually obvious on exam- may be helpful to flex and extend wrist Radiographs, ultrasound, or MR not usually indicated

84 Ganglion Cyst- Treatment Watchful waiting- most resolve spontaneously over time Bible treatment- not recommended Aspiration/Injection –No recurrence in 27-67% of patients

85 Ganglion Cyst Referral Patient preference Pain Cosmetic?

86 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

87 Carpal tunnel syndrome

88 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.

89 Carpal Tunnel Syndrome

90 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

91 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% J 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 finger –Palpation: thenar eminence wasting –ROM: thumb weakness and difficulty pincher grasping –Diagnostic Tests or special maneuvers Nerve conduction studies Tinel’s Phalen’s

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

94 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 Muscle Nerve 2004 Jan;29(1):82-8 Injection technique: 23-25g needle; 1-2 cc of lidocaine plus 20-40mg Methylprednisolone. Injected radial side of palmaris longus tendon

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

96 Kienbock Disease Avascular necrosis/vascular insufficiency –?repetitive microfractures of lunate Young adults years old Risk factors: negative ulnar variance

97 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

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

99 Kienbock Disease: Treatment Primarily surgical –EARLY: Radial shortening, ulnar lengthening –LATE: proximal row carpectomy, arthrodesis

100 Thank You!


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