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

2. 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

3. 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

4. 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

5. 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

6. Tendon Injuries in the Athlete
Tendon Anatomy

7. 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

8. 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

9. Mallet Finger Splint

10. 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

11. 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

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

13. 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

14. 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 months
Grip restored with some residual stiffness
What happens if choose not to treat it?

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. Finger fractures Treatment Options: Immobilize Buddy tape Cast Splint
Surgery

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

24. 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”

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

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

32. 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

33. Hand Injuries in the Athlete
Case Presentations
Hand Injuries in the Athlete

34. 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

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

36. 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

37. 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

38. 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

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

40. 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

41. 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

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

43. 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

44. Metacarpal Fracture Treatment
Splinted immediately
Surgery 2 days later

45. 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

46. Treatment Metacarpal Fracture

47. 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

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

49. 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

50. 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)

51. Scaphoid Fracture
Xrays show scaphoid nonunion

52. 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

53. Schphoid Nonunion

54. 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

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

56. 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 5-6 weeks with padded glove
Played in games at 8 weeks

57. 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

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

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

60. 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

61. 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?

62. 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?

63. 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?

64. 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

65. 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.