ML Hand&Wrist Injuries - Mississippi Athletic Trainers ... Hand_Wrist Injuries.pdf · – Pain/swelling(atulnar(aspectof(thumb(MCP(joint – Laxity(with(stability(tes&ng ... ML Hand&Wrist

Athle&c Injuries of the Hand & Wrist

Ma8 Lewis, MD Fellow

MS Sports Medicine and Orthopaedic Center

Extensor Tendons

Extensor Tendon Injuries

•  Injury can be caused by lacera&on, trauma, or overuse

•  Most commonly injured digit is the long finger

Most commonly seen injuries in athle&cs: •  Zone I

“Mallet Finger” •  Zone III

Central slip avulsion •  Zone V

Sagi8al band rupture

Zone I: Mallet Finger

Injury to terminal extensor tendon distal to the DIP joint of the finger

•  Mechanism: trauma&c blow to &p of finger •  Presenta&on: inability to extend at DIP joint •  XR may show bony avulsion or pure soS &ssue injury

Zone I: Mallet Finger “Bony Mallet”

So8 Tissue Mallet

Treatment

Nonopera&ve •  Indica&ons:

•  Acute (<12wks) soS &ssue injury •  Nondisplaced bony injury

•  Technique: •  Extension splin&ng of DIP joint •  Must wear 6-‐8 wks •  Maintain PIP joint mo&on

Opera&ve •  Indica&ons:

•  Volar subluxa&on of distal phalanx •  >50% ar&cular surface involved •  >2mm ar&cular gap

•  Technique: •  CRPP vs ORIF

Zone III: Central Slip (“Boutonniere Deformity”)

Disrup&on over the PIP joint of digit •  Mechanism: lacera&on or trauma&c avulsion

•  Presenta&on: PIP flexion, DIP extension – Elson Test

•  XR oSen normal; may have bony avulsion

Zone III: Central Slip

Elson Test •  Bend PIP joint 90° over the

edge of a table

•  Ask pa&ent to extend middle phalanx against resistance

•  In presence of central slip injury: •  Weak PIP extension •  DIP will go rigid

•  In absence of central slip injury: •  DIP joint will remain

floppy because the lateral bands are not ac&vated

Treatment Nonopera&ve •  Indica&ons:

•  Acute closed injuries (<4wks) •  Technique:

•  Splint PIP in full ext for 6 wks •  Then part-‐&me splint x4-‐6wks •  Allow ac&ve DIP mo&on


•  Acute displaced avulsion fx •  Open injury that needs I&D

•  Technique •  Primary central band repair •  Can be done with suture anchor

Zone V: Sagi8al Band Rupture “Boxer’s Knuckle”

Disrup&on over MCP joint of digit •  Mechanism: Forced extension of a flexed digit or lacera&on

•  Presenta&on: Extensor lag and flexion loss

•  XR oSen normal

Zone V: Sagi8al Band Rupture


•  Acute injuries (within 1 week)

•  Technique: •  Extension splint x4-‐6 wks


•  Chronic injuries (more than 1 wk)

•  Professional athlete

•  Technique: •  Direct suture repair

Flexor Tendons

Flexor Tendon Injuries

Injury caused by lacera&on or avulsion

Most commonly seen injury in athle&cs: •  Zone I

FDP avulsion “Jersey finger” Most commonly the ring finger

Zone I: Jersey Finger Avulsion injury of FDP from inser&on at base of distal phalanx •  Mechanism: maximal contrac&on of FDP during forceful DIP extension

•  Presenta&on: – pain/tenderness over volar distal finger – finger lies in slight extension rela&ve to other fingers – no ac&ve flexion of DIP

•  XR may show avulsion fragment

Zone I: Jersey Finger

Treatment

Nonopera&ve •  Not recommended


•  All zone I FDP injuries

•  Technique: •  Direct tendon repair or direct reinser&on with a bu8on if no bony avulsion

•  ORIF with wire or screw for bony avulsion fragment

Thumb Collateral Ligament Injury Most commonly Ulnar Collateral Ligament “Skier’s” or “Gamekeeper’s” thumb •  Mechanism: hyper abduc&on or extension at the MCP joint

•  Presenta&on: – Pain/swelling at ulnar aspect of thumb MCP joint – Laxity with stability tes&ng

•  XR may show bony avulsion; stress XR may show gapping on the ulnar side

Thumb Collateral Ligament Injury


•  par&al tears with < 20° of side to side valgus instability

•  Technique: •  Immobiliza&on x4-‐6 wks


•  > 20° side to side valgus instability •  >35° of opening •  Stener lesion-‐ avulsed ligament displaced

above adductor aponeurosis

•  Technique: •  May use suture, suture anchors, or small

screw to repair ligament

PIP Joint Disloca&ons Dorsal disloca&on most common May be purely ligamentous injury or may be a fracture-‐disloca&on Involves injury to volar plate and at least one collateral ligament Presenta&on: pain and deformity at PIP joint XR will show fracture in fracture-‐disloca&ons

Dorsal PIP Disloca&on


•  Reducible disloca&ons •  <40% joint involved if fx

•  Technique •  Reduce and buddy tape x3-‐6 wks •  Dorsal ext block splint if fx


•  Failed reduc&on •  >40% joint involved if fx

•  Technique: •  Open reduc&on and volar plate

extrac&on if no fx and can’t reduce •  ORIF vs CRPP for fx’s

Common Fractures in Athletes

Hand

•  Phalanx •  Metacarpal

Wrist

•  Scaphoid •  Hook of Hamate •  Distal Radius

Phalangeal Fractures Distal, Middle, and Proximal phalanges Sports is the most common cause of phalangeal fractures in the 10-‐29 age group Proximal phalanx: deformity usually apex volar Middle phalanx: deformity will be apex dorsal if proximal to FDS OR apex volar if distal to FDS

Phalangeal Fracture

Distal Phalanx Fx Treatment


•  Most cases

•  Technique: •  Reduce and splint


•  Associated nail bed injury

•  Technique: •  Remove nail, repair nail bed,

and replace nail

Middle & Proximal Phalanx Fx Treatment


•  extraar&cular with < 10° ang or < 2mm shortening and no rota&onal deformity

•  Technique: •  Buddy taping with 3 wks immobiliza&on, then

mo&on


•  Irreducible or unstable fx •  > 10° ang or 2mm shortening or rota&onally

deformed

•  Technique: •  CRPP vs ORIF with wires or screws

Metacarpal Fractures May be fractures of the head, neck, or shaS Acceptable angula&on depends on fx loca&on Mechanism: direct blow to hand or rota&on with axial load Presenta&on: Pain, swelling, deformity XR to show fracture 30° pronated view for 4th & 5th MTC fx 30° supinated view for 2nd & 3rd MTC fx

Metacarpal Fractures

Metacarpal Fractures •  Criteria for nonopera&ve management: – Acceptable angula&on and shortening – No rota&onal deformity •  May assess by lining up the fingernails in flexion

Acceptable Sha8 AngulaDon

Acceptable Neck AngulaDon

Acceptable Shortening

Index & Long 20 15 2-‐5mm

Ring 30 35 2-‐5mm

Small 40 55 2-‐5mm


•  Stable pa8ern •  No rota&onal deformity •  Acceptable ang & shortening

•  Technique: •  Splint/Cast immobiliza&on with

MCP’s flexed 70-‐90°


•  Ar&cular fractures •  Unacceptable alignment •  Mul&ple shaS fractures

•  Technique: •  CRPP vs ORIF

Scaphoid Fractures Most commonly fractured carpal bone Waist-‐ 65% Proximal 1/3-‐ 25% Distal 1/3-‐ 10% (most common in kids)

Mechanism: axial load across hyperextended, radially deviated wrist Presenta&on: anatomic snurox tenderness

dorsally scaphoid tubercle tenderness

volarly

Scaphoid Anatomy •  75% covered by ar&cular car&lage •  Major blood supply enters dorsally and supplies proximal 80% •  Minor blood supply enters distal tubercle and supplies distal 20% •  AVN rate increases with more proximal fractures

Scaphoid Fractures

XR may show the fracture if displaced XR may also appear nega&ve acutely if nondisplaced If clinically suspicious, treat as a fracture and re-‐XR in 2-‐3 weeks MRI most sensi&ve to diagnose occult fracture acutely


•  Stable, nondisplaced fracture

•  Technique: •  Thumb Spica Cast •  Longer immobiliza&on for more proximal fx’s •  Return to play only when imaging shows a

healed fx


•  Displacement > 1mm •  Proximal pole fx’s •  ORIF may allow faster &me to union and

return to play

•  Technique: •  ORIF vs perc Screw

Hook of Hamate Fractures OSen seen in golf, baseball, hockey Mechanism: typically caused by a direct blow

grounding a golf club checking a swing

Presenta&on:

hypothenar pain pain with &ght grip

XR: Need carpal tunnel view to see it

Hook of Hamate Fractures

Treatment


•  Most acute fractures

•  Technique: •  Short arm cast x 6 wks


•  Chronic painful non-‐unions

•  Technique: •  Excision of fx fragment vs

ORIF

Distal Radius Fractures

One of the most common orthopaedic injuries In athle&cs, most commonly will be seen in skeletally immature athletes Commonly apex volar angula&on (Colle’s fx) or physeal injury


Mechanism: fall onto outstretched hand Presenta&on: pain, swelling, deformity about the wrist XR to demonstrate the fracture


Adult Treatment Nonopera&ve •  Indica&ons:

•  Extra-‐ar&cular •  < 5mm radial shortening •  < 5° dorsal angula&on

•  Technique: •  CR and SAC


•  Intra-‐ar&cular fx •  > 5mm radial shortening •  > 5° dorsal angula&on •  Loss of reduc&on

•  Technique: •  CRPP •  ORIF •  Ex-‐Fix

Pediatric Treatment


•  Extra-‐physeal •  < 9yo; < 30° dorsal angula&on •  > 9yo; < 20° dorsal angula&on

(These numbers are controversial and decision is based on age, fx loca&on, and type of deformity)

•  Technique: •  Cast, +/-‐ CR


•  Any fracture that cannot be reduced and held with cas&ng within acceptable limits

•  Technique: •  CR and cas&ng vs CRPP


Thank you

ML Hand&Wrist Injuries - Mississippi Athletic Trainers ... Hand_Wrist Injuries.pdf · – Pain/swelling(atulnar(aspectof(thumb(MCP(joint – Laxity(with(stability(tes&ng ... ML Hand&Wrist

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