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Sport Injuries Hand and Wrist HAND AND WRIST HAND WRIST.

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Presentation on theme: "Sport Injuries Hand and Wrist HAND AND WRIST HAND WRIST."— Presentation transcript:

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2 Sport Injuries Hand and Wrist

3 HAND AND WRIST HAND WRIST

4 HAND FUNCTIONS 45% GRASP 45% PINCH – Side pinch (key pinch) – Tip pinch (writing) – Chuck pinch (thumb to index/ring) 5% HOOK – Carry bag 5% PAPERWEIGHT

5 HAND & FINGER ANATOMY 9 Finger Flexors Median nerve Transverse carpal ligament 5 deep flexors pass through superficialis tendons and insert on distal phalanx of each finger and thumb 4 superficial flexors insert on middle phalanx of digits 2-5 Annular ligaments = pulleys (A1-A5) – PREVENT BOWSTRINGING

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7 HAND ANATOMY VOLAR PLATE – Thickened portion of joint capsule – Static stabilizer (hyperextension) COLLATERAL LIGAMENTS – Medial and lateral stability – Maximally tight at ____ degrees MCP flexion ____ degrees PIP flexion ____ degrees DIP flexion

8 HAND ANATOMY digits FLEXOR – FDP – FDS – Volar plate Extensor – Central bands – Lateral bands

9 Finger Anatomy

10 NERVES OF THE HAND RADIAL MEDIAN ULNAR WRIST AND FINGER EXTENSION THENAR COMPARTMENT, OPPOSITION, PINCER GRIP INTRINSIC MUSCLES POWER GRIP

11 How I Will Approach Each Problem What is it? Does it need any special imaging? How do I treat it? What are the indications for surgery?

12 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

13 MALLET FINGER

14 ANATOMY – Dorsal avulsion – Extensor digitorum tendon tear MECHANISM: – Forced flexion of extended digit TREATMENT: – No fracture: DIP extended for 6-8 weeks – FRACTURE: if <30% joint surface, splint x 4 weeks – If >30%  Might need ORIF – Less than full passive extension????? COMPLICATIONS: – Pressure necrosis from splint – Permanent extensor lag

15 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

16 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

17 JERSEY FINGER ANATOMY: – Tendon retracts – Avulsion fragment may limit retraction – Blood supply compromised MECHANISM: – Forced extension of flexed finger TREATMENT: – Refer immediately COMPLICATIONS: – Permanent loss of flexion

18 JERSEY FINGER EXAM FINDINGS: – Unable to flex isolated DIP – Localized tenderness along flexor tendon – FDP: hold PIP straight and flex DIP – FDS: hold MCP straight and flex PIP or hold all fingers in extension except affected and flex

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

20 CENTRAL SLIP AVULSION ANATOMY – Extensor digitorum communis tendon disruption – Lateral bands migrate in volar direction MECHANISM: – Volar-directed force on middle phalanx against semi-flexed finger attempting to extend

21 CENTRAL SLIP AVULSION EXAM: – Pain, swelling over dorsal PIP – PIP in degrees flexion – May have limited extension (better at 0 degrees than 30 degrees) TREATMENT – Surgery if >30% joint surface involved with avulsion fx – PIP splint in full extension 4-5 weeks – Protect 6-8 weeks for sports – *allow DIP to flex- relocates lateral bands COMPLICATIONS: – Boutonierre deformity

22 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

23 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

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

25 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

26 VOLAR PLATE RUPTURE EXAM FINDINGS: – Tender volar PIP – Bruising, swelling MECHANISM: – Hyperextension injury – Ruptures distally from attachment at middle phalanx

27 VOLAR PLATE RUPTURE TREATMENT: – Early mobilization – Extension block splint – Buddy tape – Surgery if >30% joint involved COMPLICATIONS: – Swan neck deformity: extensor tendons pull PIP into hyperextension, DIP flexion Swan Neck Deformity

28 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

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30 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

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

32 Finger Case 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.

33 GAMEKEEPER’S THUMB MECHANISM – Hyperabduction of thumb – EXAM: – Weak, painful pinch – Pain over ulnar thumb – XRAYS BEFORE STRESS

34 GAMEKEEPER’S THUMB SIGNS – Pain over ulnar thumb – Stress testing positive Testing in Extension and 40 degrees of FLEXION of MCP

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

36 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

37 Stener Lesion

38 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

39 Skier’s Thumb Treatment

40 Finger Fractures

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

42 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

43 Rotational Alignment

44 Middle and Proximal Phalangeal Fractures Might need Surgery: Inability to maintain proper alignment Rotation Irreducible Injury Intra-articular fracture

45 Finger Case 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.

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

47 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

48 Metacarpal Shaft 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

49 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

50 THUMB CMC FRACTURE DISLOCATION (BENNETT’S FRACTURE) Anatomy: – Anterior oblique carpometacarpal ligament holds palmar fragment in normal anatomic position – Abductor pollicis longus (APL) pulls metacarpal shaft fragment radial & dorsal Treatment – Reduction Traction, abduction, extension, pronation – Often unstable, requires surgery

51 ROLANDO’S FRACTURE ANATOMY – 3 part fracture at metacarpal base – Comminuted with “Y” or “T” fragment TREATMENT – May be non-surgical if highly comminuted – Surgery if fragments are large and amenable

52 DIP JOINT DISLOCATION MECHANISM – Hyperextension, varus/valgus forces ANATOMY – Usually dorsal – Rare – Strong collateral ligaments usually prevent TREATMENT – Reduction: digital block first – Splint in degrees flexion for days

53 PIP JOINT DORSAL DISLOCATION (COACH’S FINGER) MECHANISM – Hyperextension with disruption of volar plate ANATOMY – Loss of volar stabilizing force causes phalanx to ride dorsally TREATMENT – Reduction: avoid longitudinal traction – Post-reduction: dorsal extension block splint with PIP blocked at degrees flexion BEWARE OF THE VOLAR DISLOCATION PROXIMAL PHALANX CONDYLE BUTTONHOLES THROUGH THE TORN EXTENSOR MECHANISM OFTEN CAN’T BE CLOSED REDUCED

54 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

55 Proximal PIP dorsal dislocation- Reduction Reduce via minimal longitudinal traction If initially unsuccessful should hyperextend the distal portion to unlock

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

57 WRIST

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

59 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

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

61 Ganglion Cyst- Treatment Watchful waiting- most resolve spontaneously over time Aspiration/Injection – No recurrence in 27-67% of patients

62 Ganglion Cyst Surgery Patient preference Pain Cosmetic?

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

64 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

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

66 Scaphoid Fracture Pathoanatomy Blood supplied from distal pole In Adolescents, mostly involve distal pole In adults, mostly involve waist Treatment depends on location of fracture

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

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69 Scaphoid Fracture Imaging Initial plain films often normal Bone scan 100% sensitive and 92% specific at 4 days MRI, CT scan

70 SCAPHOID FRACTURE TREATMENT – Initial radiographs positive distal third heal in approx 6-8 weeks middle third frx heal in 8-12 weeks proximal third heal in weeks – Initial radiographs negative MRI Immobilize thumb spica cast x 7-14 days Take out of cast, re-evaluate for tenderness If +tenderness but neg radiographs….

71 Scaphoid Fracture Surgery: – Angulated or displaced (1mm) – Non-union or AVN – Scapholunate dissociation – Proximal fractures – Late presentation – Early return to play

72 Non Operative Treatment- Disadvantages Nonunion rate could be HIGH Mal-union “cast disease”- joint stiffness Prolonged immobilization- sometimes >12 weeks Loss of time from employment

73 Union Rates 100%

74 Wrist Case 34-year-old female hairdresser with thumb pain for 2-3 months Gradual onset Now thumb hurts with any movement

75 Wrist Case 4 The College player 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.

76 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

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

78 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

79 DeQuervain’s Tenosynovitis, Surgery Recurrence despite repeated injections

80 Wrist Case An College crew athlete presented following spring break training trip in Georgia. She reported pain distal dorsal forearm, accompanied by swelling, and palpable/audible crepitus.

81 Intersection syndrome Friction point where muscle bellies of 1 st compartment- APL, EPB 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

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

83 Intersection Syndrome Treatment Splinting Activity modification Icing NSAIDS Corticosteroid injection

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

85 Wrist Case 25-year-old tennis player twists wrist as he falls backwards.

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87 SCAPHOLUNATE DISSOCIATION

88 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

89 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

90 Scapholunate Dissociation Treatment If discovered within 4 weeks, surgery After 4 weeks, conservative treatment reasonable – Bracing – NSAIDS – Delayed Surgery

91 Triangular Fibrocartilage Complex (TFCC) Tear Fall on dorsiflexed and ulnar deviated wrist Axial load with forearm in hyperpronation

92 TFCC Anatomy

93 TFCC Tear Pathoanatomy Tear in structures of TFCC Positive ulnar variance predisposes to injury

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

95 TFCC Tear History Ulnar-sided wrist pain aggravated by pronation/ supination

96 TFCC Tear Physical Exam Press test TFCC grind test Check for DRUJ injury

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

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

99 Ulnar shortening osteotomy TFCC Tear Treatment

100 GOLFER’S FRACTURE Hook of hamate fracture – Swing of golf club – 2% of all carpal fractures – 1/3 of all hamate fractures = golf related Distal lateral border of Guyon’s Canal High rate of non-union – May consider early operative treatment

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102 GOLFER’S FRACTURE CARPAL TUNNEL VIEW

103 GUYON’S CANAL SYNDROME ANATOMY – Ulnar nerve rides between pisiform and hamate – Feeds interosseous muscles, hypothenar muscles, lumbricals (intrinsic muscles) TREATMENT – Pad area – NSAIDS – r/o hamate fracture

104 Finger injuries in rock climbing

105  Rock climbing is an increasingly popular recreational activity despite the obvious inherent risks

106 Rock Climbing

107 Traditional Leading

108 Sport Climbing

109 Competitive Disciplines

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111 Climbing Injuries Climbers are susceptible to overuse injuries of the upper limb: Studies consistently report a high prevalence of finger related injuries (Jones et al, 2008; Shoffl et al, 2003)  Disruption of the annular pulley system (particularly A2)  Rotator cuff and shoulder impingement syndromes which are associated with prolonged and repeated reaching overhead (Peters, 2001)  Tendonopathies

112 Why are the fingers susceptible ?  During the crimp grip wrist extension increases the mechanical advantage of the finger flexors and reduces active insufficiency ( Lockwood, 1998)  Paradoxically this hand position may increase the pre-disposition of the climber to injury (Joel et al, 2000)

113 Why the 3 rd & 4 th fingers ?  Flexion of the remaining fingers when holding a one finger pocket may increase the maximum holding force up to 48% (Shweizer, 2001)  Lumbrical tears to the third or fourth lumbrical may occur if the finger is dynamically loaded ( Shweizer 2003 )

114 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

115 Carpal tunnel syndrome

116 Hand Diagrams Tinel + hand diagram – PPV = 0.71 Ann Intern Med 1990 Mar 1;112(5):321-7.

117 Carpal Tunnel Syndrome

118 Sensitivity and Specificity For both Phalen’s and Tinel’s is LOW High Combined with hand diagram and history Ann Intern Med 1990 Mar 1;112(5):321-7

119 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

120 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

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

122 Carpal Tunnel Injection Short term efficacy: RCT, 70% vs 34% at 2 weeks – 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: 20-40mg Methylprednisolone.

123 Carpal Tunnel Syndrome Surgery Constant numbness and tingling Thenar eminence wasting If get EMG: Severe carpal tunnel or dennervation

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125 Kienbock Disease Lunatomalacia Avascular necrosis/vascular insufficiency – ?repetitive microfractures of lunate Young adults yo Risk factors: negative ulnar variance

126 Kienbock Disease EXAM:: Wrist pain that radiates up the forearm – stiffness, tenderness, swelling over lunate passive dorsiflexion of middle finger produces characteristic pain

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

128 Kienbock Disease TREATMENT: – Surgical EARLY: Radial shortening, ulnar lengthening LATE: proximal row carpectomy, arthrodesis

129 References Hand Surgery Textbooks Allyson S. Howe, MD Andrew Getzin, MD Gareh Jones

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