TIM BROWN, MD THE HAND CENTER DEPARTMENT OF ORTHOPAEDICS GREENVILLE HEALTH SYSTEM Hand Injuries in...

Tim Brown, MDThe Hand Center

Department of OrthopaedicsGreenville 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


Will focus on those injuries requiring treatment

Flexor or extensor tendon injuriesJoint dislocationsFractures of the hand or the carpusLigament InjuriesTriangular Fibrocartilaginous Complex

(TFCC) injuries


Initial Presentation on the field or courtInitial evaluation and managementDiagnostic Work UpDefinitive TreatmentRecoveryReturn to Sport


Differences in Management based on Athlete’s age and career prospects

ChildrenHigh SchoolCollegeProfessional

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 extendPresents with a droop and cannot extendEasy to passively extendTypically pain-free and does not present until

later

Mallet Finger Treatment

Xray to rule out fractureSmall bone fragment usually treated same as

no bone involvementSplint distal joint in hyperextension for 6-10

weeks until can extend against resistanceAllow PIP motionCan play sports in splint while healingTreatment delays lead to prolonged healing

times

Mallet Finger Splint

Central Slip Rupture

Boutoniere deformityVolar dislocation of PIP joint or forced flexion

of PIP joint while trying to extendImmediate painLoss of ability to extend PIP joint


Xray to evaluate for fracture or dislocationSplint 8-10 weeks in full PIP extensionAllow other joints to moveCan typically play sport in splint


Delay in diagnosis or inadequate treatment can lead to permanent problems

Boutoniere DeformityPainContracturesStiffness

Flexor Tendon Ruptures

“Jersey Finger”Finger in heavy grip flexion and DIP forced to

extendFeel “POP”Trouble bending entire fingerCannot bend DIP joint

Flexor Tendon Rupture

Xray to rule out fracture or dislocationTreatment – Surgical reattachment of tendon

to boneSix weeks in a splint encompassing entire

hand and forearmFull activity at 3 - 6 monthsGrip 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 BADDorsal not as bad unless fracture dislocation

Metacarpal Phalangeal Joint (MCP)Volar is rareDorsal is more common and often needs

surgery to reduce

Joint Dislocations

CarpoMetacarpal Joints (CMC)

Thumb CMC dislocationUnstable and often needs surgical treatment

Ring and Small CMC dislocationsUnstable and often needs surgical treatment

Wrist Dislocation, uncommon, unstable, and very obvious

Ligament Injury at PIP

Jammed Finger“Stoved Finger” if you

are from PittsburghTear volar ligaments

without dislocationPain, Limited MotionSplint or Buddy Tape

for comfortTakes 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 thumbFall on ski pole or lacrosse stick, caught in helmetImmediate painCannot pinch or hold cupUnstable on exam

Thumb Ligament Injury Treatment

Xray to rule out fractureStress Xray to compare to other sideMRI 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:

ImmobilizeBuddy tapeCastSplintSurgery

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 handAthlete often feels like it is a sprainNot much painOften delay in seeking treatment

“It should have felt better by now”

Scaphoid Fractures

Snuff Box tenderRadial Wrist extension tenderSplint ImmediatelyHigh index of suspicionXray with special viewsFirst set of Xrays often does not show

fractureFurther evaluation with repeat xrays, MRI,

CAT scan

Scaphoid Fracture Treatment

Early diagnosis

Nondisplaced /Acute – Cast 6-12 weeks until healedDisplaced/ 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 golfersOften Stress fracture that progresses to

complete fractureAcute event leading to sudden pain, but often

history of hand soreness with batting

Tender at base of hypothenar eminencePain with impact, painfree at restUsually 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


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 ComplexHolds the ulnar side of the wrist togetherPain over ulnar styloid and just radial to ulnar

styloidCan be overuse or single traumatic episodeGolfers, baseball players, tennis players,

Rowers“Grounded a club” or “Hit a root”Tennis players – usually nondominant hand

with two-handed backhandHurts 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 TreatmentArthroscopic debridement for Central and flap

tearsArthroscopic repair for peripheral tears

RecoveryDebridement – immediate motion, return to

sport in 6-12 weeksRepair – 6-8 weeks immobilization, Return to

sport in 4-6 monthsReturn to equal or higher level of sport common


Case Presentations


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


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


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


19 yo quarterback got index finger of throwing hand caught in a defenders shoulder pads while “stiff-arming”

Felt some pain in the handTried 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

SplintCastBuddy tapeSurgery

Position considerationsNeeds 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 immediatelySurgery 2 days later

Treatment Metacarpal Fracture

Removable Splint PostopStarted ROM and rubber band strengthening

at POD1Full ROM at POD6Bone StimulatorMissed 3 games, xray showed some healing,

regained Full ROM and pinch and grip strength

Returned for 4th game post injury

Treatment Metacarpal Fracture


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


MRI – signal uptake in scaphoid waist


Casted 6 weeks

Repeat Xrays Normal, no sign of fracture

No Pain after cast removal

Released to play in summer practice, reported no pain


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

TreatmentSurgery to place bonegraft and screwImmobilized 8 weeks“soreness” resolvedXrays prior to summer practice showed

healed scaphoidLast seen 2 years later just before leaving

school to prepare for the draftReported no problems with left wrist

Schphoid Nonunion


20 yo LHD college baseball outfielder with sudden pain in ulnar side of right palm while hitting a ball

Normally hits 1000 balls a dayCannot swing a bat without painNo 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


MRI –multiple ligaments show signal change throughout wrist

Dark line at base of hook of hamate

Treatment?


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 splintBatting practice @ 5-6 weeks with padded glovePlayed in games at 8 weeks


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


MRI – read as “normal possible ulnar impaction syndrome”

Treatment

TFCC Tear

TreatmentChose 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 monthShort arm cast for 1 monthPlaced in dynamic extension limiting splint 1

monthNo pain at 3 month visitWore dynamic brace for fall seasonSpring season, playing with no brace and

reported pain free


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 OpSix weeks with entire hand in splintUnrestricted 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.

TIM BROWN, MD THE HAND CENTER DEPARTMENT OF ORTHOPAEDICS GREENVILLE HEALTH SYSTEM Hand Injuries in...

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