Hand Injuries in the Athlete Tim Brown, MD The Hand Center Department of Orthopaedics Greenville Health System

Hand Injuries in the Athlete Due to use patterns and relative lack of protection, the hand is the most frequently injured body part in sports Majority of injuries are minor sprains and strains and do not seek medical attention Most resolve in a short period of time and do not lead to long term pain or functional loss

Hand Injuries in the Athlete Will focus on those injuries requiring treatment Flexor or extensor tendon injuries Joint dislocations Fractures of the hand or the carpus Ligament Injuries Triangular Fibrocartilaginous Complex (TFCC) injuries

Hand Injuries in the Athlete Initial Presentation on the field or court Initial evaluation and management Diagnostic Work Up Definitive Treatment Recovery Return to Sport

Hand Injuries in the Athlete Differences in Management based on Athlete’s age and career prospects Children High School College Professional Individualize treatment based on need for immediate return to sport versus long term risks

Tendon Injuries in the Athlete Tendon Anatomy

Mallet Finger Rupture of extensor attachment to distal phalanx Fingertip forced to flex while trying to extend Presents with a droop and cannot extend Easy to passively extend Typically pain-free and does not present until later

Mallet Finger Treatment Xray to rule out fracture Small bone fragment usually treated same as no bone involvement Splint distal joint in hyperextension for 6-10 weeks until can extend against resistance Allow PIP motion Can play sports in splint while healing Treatment delays lead to prolonged healing times

Mallet Finger Splint

Central Slip Rupture Boutoniere deformity Volar dislocation of PIP joint or forced flexion of PIP joint while trying to extend Immediate pain Loss of ability to extend PIP joint

Central Slip Rupture Xray to evaluate for fracture or dislocation Splint 8-10 weeks in full PIP extension Allow other joints to move Can typically play sport in splint

Central Slip Rupture Delay in diagnosis or inadequate treatment can lead to permanent problems Boutoniere Deformity Pain Contractures Stiffness

Flexor Tendon Ruptures “Jersey Finger” Finger in heavy grip flexion and DIP forced to extend Feel “POP” Trouble bending entire finger Cannot bend DIP joint

Flexor Tendon Rupture Xray to rule out fracture or dislocation Treatment – Surgical reattachment of tendon to bone Six weeks in a splint encompassing entire hand and forearm Full activity at 3 - 6 months Grip restored with some residual stiffness What happens if choose not to treat it?

Joint Dislocations Distal Interphalangeal Joint – RARE Proximal Interphalangeal Joint (PIP) VOLAR is BAD Dorsal not as bad unless fracture dislocation Metacarpal Phalangeal Joint (MCP) Volar is rare Dorsal is more common and often needs surgery to reduce

Joint Dislocations CarpoMetacarpal Joints (CMC) Thumb CMC dislocation Unstable and often needs surgical treatment Ring and Small CMC dislocations Wrist Dislocation, uncommon, unstable, and very obvious

Ligament Injury at PIP Jammed Finger “Stoved Finger” if you are from Pittsburgh Tear volar ligaments without dislocation Pain, Limited Motion Splint or Buddy Tape for comfort Takes months for the swelling and pain to resolve Volar Plate Tear

Thumb Ligament Injury Ulnar collateral ligament at thumb MCP joint “Gamekeeper’s” or “Skier’s Thumb” Forced Palmer abduction of the thumb Fall on ski pole or lacrosse stick, caught in helmet Immediate pain Cannot pinch or hold cup Unstable on exam

Thumb Ligament Injury Treatment Xray to rule out fracture Stress Xray to compare to other side MRI if unable to evaluate “STABLE” – Thumb spica cast for 6 weeks “UNSTABLE” – Surgical repair then thumb spica cast or slint for 6 weeks

Hand Fractures Immediate pain, swelling, and deformity Painful to touch on exam Unable to use broken part If suspected, get Xrays

Finger Fractures Treatment concepts are simple A crooked finger is a bad finger A stiff finger is a bad finger Don’t want to end up with a crooked or a stiff finger

Finger fractures Treatment Options: Immobilize Buddy tape Cast Splint Surgery

Finger Fractures Goals of Treatment: Early Stability and Early Mobility A Pretty Xray and a stiff hand is still a bad hand

Scaphoid Fractures Fall on outstretched hand Athlete often feels like it is a sprain Not much pain Often delay in seeking treatment “It should have felt better by now”

Scaphoid Fractures Snuff Box tender Radial Wrist extension tender Splint Immediately High index of suspicion Xray with special views First set of Xrays often does not show fracture Further evaluation with repeat xrays, MRI, CAT scan

Scaphoid Fracture Treatment Early diagnosis Nondisplaced /Acute – Cast 6-12 weeks until healed Displaced/ Acute - Surgery Subacute or chronic – Surgery with likely bone graft The longer the delay in treatment, the more involved the treatment and the less likely to heal Evidence suggests that untreated scaphoid fracture will lead to wrist arthritis in 10 – 15 years

Hook of Hamate Fracture Baseball batters and golfers Often Stress fracture that progresses to complete fracture Acute event leading to sudden pain, but often history of hand soreness with batting Tender at base of hypothenar eminence Pain with impact, painfree at rest Usually is the “top” hand

Hook of hamate fracture Xrays – difficult to see on plain xrays Special Views – may be of some help MRI – diagnostic in acute setting CT – helpful in chronic setting

Hook of Hamate Fracture Limited role for casting in the athlete Surgical fixation often leads to disappointing results Excision of the broken part (hook of hamate) leads to significant pain reduction, high satisfaction scores, and return to prior level of function Can return to sport as soon as scar tenderness allows

TFCC Injuries Triangular Fibrocartilage Complex Holds the ulnar side of the wrist together Pain over ulnar styloid and just radial to ulnar styloid Can be overuse or single traumatic episode Golfers, baseball players, tennis players, Rowers “Grounded a club” or “Hit a root” Tennis players – usually nondominant hand with two-handed backhand Hurts to supinate, extend, circumduct wrist

TFCC Injuries Initial treatment – rest, splint 4-6 weeks, therapy MRI – often false negatives, need dedicated views, high quality magnet

TFCC Injuries Surgical Treatment Arthroscopic debridement for Central and flap tears Arthroscopic repair for peripheral tears Recovery Debridement – immediate motion, return to sport in 6-12 weeks Repair – 6-8 weeks immobilization, Return to sport in 4-6 months Return to equal or higher level of sport common

Hand Injuries in the Athlete Case Presentations Hand Injuries in the Athlete

Hand Injuries in the Athlete 21 yo defensive end lands on left thumb while making a tackle Presents in locker room after practice, cannot pinch, hurt to lift shoulder pads off Exam- pain over ulnar collateral ligament of thumb, cannot pinch, unstable to stress testing History of left thumb injury treated during 9th grade season, casted but did not miss a game

Hand Injuries in the Athlete Xrays – bone fragment at base of proximal phalanx, something old at CMC joint Treatment?

Ulnar collateral ligament at thumb Placed spica cast, played in cast for final 3 weeks of the season Surgical repair of UCL after season, Immobilized 6 weeks Stability returned Ready for Spring practice

Thumb UCL Injury Discussion Skill players are frequently unable to perform and more likely to have early surgery Injury may end season Non –skill players can frequently perform with hand in a cast and delay surgery until after the season and get equivalent long term results

Hand Injuries in the Athlete 26 yo collegiate football wide receiver presenting for summer school, reports he injured his right long finger in spring practice 6-8 weeks ago “Jammed it” “it should have been better by now” Exam – swelling at right long PIP joint, ROM 0-90 degrees flexion at PIP joint

PIP Injury Xray healed fracture at base of middle phalanx with persistent subluxation Treatment?

PIP injury Treatment Subacute injury, healed with persistent subluxation Surgical treatment to restore anatomy discussed, but rejected by the athlete because of good ROM, and desire to participate in summer practice and senior season

Hand Injuries in the Athlete 19 yo quarterback got index finger of throwing hand caught in a defenders shoulder pads while “stiff-arming” Felt some pain in the hand Tried to pass on the next play and could not throw and took himself out of the game Exam – Pain with any palpation of index metacarpal, could take through full ROM, could not pinch

Metacarpal Fracture Xray – minimally displaced long oblique index metacarpal fracture Treatment?

Metacarpal Fracture Splint Cast Buddy tape Surgery Position considerations Needs normal length, ROM, and Strength to be able to “post” the ball and ability to pronate finger during throwing to get spin on the ball. Athlete and team wanted ASAP return to play

Metacarpal Fracture Treatment Splinted immediately Surgery 2 days later

Treatment Metacarpal Fracture Removable Splint Postop Started ROM and rubber band strengthening at POD1 Full ROM at POD6 Bone Stimulator Missed 3 games, xray showed some healing, regained Full ROM and pinch and grip strength Returned for 4th game post injury

Treatment Metacarpal Fracture

Hand Injuries in the Athlete 20 yo Middle linebacker fell making tackle in spring practice 16 days ago C/O pain with ROM of left wrist and when lifting weights Immobilized when presented Exam – minimal tenderness at wrist, no pain at snuffbox, no pain with stress testing Xrays – multiple views normal

Hand Injuries in the Athlete MRI – signal uptake in scaphoid waist

Hand Injuries in the Athlete Casted 6 weeks Repeat Xrays Normal, no sign of fracture No Pain after cast removal Released to play in summer practice, reported no pain

Hand Injuries in the Athlete More to the Story Represents 9 months later after playing the entire season complaining that left wrist “sore” while playing and not progressing in bench press because of sore wrist Unaware of any new injury (But he is a linebacker)

Scaphoid Fracture Xrays show scaphoid nonunion

Scaphoid Nonunion Treatment Surgery to place bonegraft and screw Immobilized 8 weeks “soreness” resolved Xrays prior to summer practice showed healed scaphoid Last seen 2 years later just before leaving school to prepare for the draft Reported no problems with left wrist

Schphoid Nonunion

Hand Injuries in the Athlete 20 yo LHD college baseball outfielder with sudden pain in ulnar side of right palm while hitting a ball Normally hits 1000 balls a day Cannot swing a bat without pain No pain at rest or with any other activity Exam – Pain over base of hypothenar eminence to palpation Xrays – including supinated and carpal tunnel view normal

Hand Injuries in the Athlete MRI –multiple ligaments show signal change throughout wrist Dark line at base of hook of hamate Treatment?

Hook of Hamate Fracture Had been splinted 1 month after xrays before MRI with no relief Surgical Excision of Hook Of Hamate, Hook was unstable and not attached to the rest of the bone Rested 3-4 weeks, no splint Batting practice @ 5-6 weeks with padded glove Played in games at 8 weeks

Hand Injuries in the Athlete 18 yo RHD college freshman tennis player presents after season with 6 months of worsening left ulnar wrist pain Hurts to “load” wrist just before impact and to “release” wrist after impact in backhand Had one injection of corticosteroid and been taped and splinted with no relief Exam – tender dorsal and ulnar wrist, pain with supinated extension. “click” on circumduction

Hand Injuries in the Athlete MRI – read as “normal possible ulnar impaction syndrome” Treatment

TFCC Tear Treatment Chose Arthroscopy because even though MRI normal, “I know something in there is wrong” Peripheral TFCC tear seen and repaired

TFCC Tear Long arm cast 1 month Short arm cast for 1 month Placed in dynamic extension limiting splint 1 month No pain at 3 month visit Wore dynamic brace for fall season Spring season, playing with no brace and reported pain free

Hand Injuries in the Athlete 22 yo defensive lineman felt “POP” in left ring finger in last practice before first game of senior season No active flexion of DIP joint of left ring finger Xrays – normal “Jersey Finger” Treatment?

Jersey Finger Recommended Treatment is surgical reattachment of the tendon to the bone. Post Op Six weeks with entire hand in splint Unrestricted activities at 3 months What did he say?

Jersey finger “Doc, if I miss this season I will not get drafted” “What happens if I don’t do it?” “You mean all that will happen is I won’t bend the tip of that finger?” “I’m just going to tape it and play, see you later” Who was right?

Jersey finger He played his senior season He was drafted in the first round He signed a $ 40 Million contract He still can’t bend the tip of his ring finger

What do I need to remember? Treatment is situation specific for the athlete, the stage of their career, and their need to return to sport. The “jammed” finger needs medical attention quickly. Send for xrays if any question. Always be worried about the possibility of scaphoid fracture with any wrist sprain. This is one condition that NEEDS to be OVERTREATED.