Common Hand and Wrist Injuries

1. Common Hand and Wrist Injuries Andrew Getzin, MD Cayuga Medical Center Sports Medicine and Athletic Performance agetzin@cayugmed.org www.cayugamed.org/sportsmedicine Ithaca College

2. How I Will Approach Each Problem What is it? Does it need any special imaging? How do I treat it? What are the indications to refer?

3. 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

4. Finger Pathology Fractures, Dislocations Distal Tuft Fractures/Crush injury Phalange fractures Metacarpal fractures Boxer’s fracture Dorsal PIP dislocations Ligament/tendon injuries Mallet Finger Jersey Finger Central slip extensor tendon injury (Boutonniere Deformity) Collateral ligament injury Volar plate injury Skier’s thumb

5. Finger Anatomy

6. Finger Case 1 During infield practice a high school baseball player injured his dominant right pinky while covering his glove to field a grounder. The ball longitudinally hit his right 5th finger. He developed pain but kept playing. After practice, he noticed that he was unable to fully extend his distal phalange. He buddy taped it over the next few weeks but ultimately developed an extension lag that limits his ability to type but with no other functional limitations from the injury.

7. Mallet Finger (Baseball Finger) Injury to the extensor tendon at the DIP joint Most common closed tendon injury of the finger Mechanism: object striking finger, creating forced flexion Tendon may be stretched, partially torn, or completely separated by a distal phalanx avulsion fracture

8. 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

9. Mallet Finger Treatment Splint DIP in neutral or slight hyperextension for 6 weeks Cochrane review- all splints same results Surgical wiring does not improve outcome Office visit every 2 weeks If not extension lag at 6 weeks, splint at night and for activity for 6 weeks. Conservative treatment effective up to 3 months delayed presentation Handoll. Interventions for treating mallet finger injuries. Cochrane Database 2004

10. Mallet Finger Referral Bony avulsion >30% of joint space Inability to achieve passive extension Despite proper treatment permanent flexion of the fingertip is possible No fracture reduction in the splint

11. Finger Case 2 19 year old Ithaca College football player, defensive back was holding onto the running back by his jersey trying to tackle him but the back broke the tackle. The defensive player developed sudden distal 4th finger pain and was unable to fully flex the DIP joint.

12. Jersey Finger

13. 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

14. Jersey Finger Presentation Pain and swelling at the volar aspect of DIP joint Can often feel fullness proximally if tendon retracted Need to isolate the DIP to properly test

15. Jersey Finger Physical Exam

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

17. 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 15-30 degrees of flexion, can’t active extend but can passively extend Tenderness over dorsal aspect of the middle phalanx

18. 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

19. Central Slip Extensor Tendon Injury Referral Avulsion fracture involving more than 30 percent of the joint Inability to achieve full passive extension

20. 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

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

22. Collateral Ligament Injuries- Referrals Unstable joint Large associated fracture Injury in a child

23. 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

24. Volar Plate Injury- Diagnosis Maximal tenderness at volar aspect of affected joint Bruising, swelling Full extension and flexion possible if joint stable Collaterals should be tested Radiographs may show an avulsion fracture at the base of involved phalanx

25. 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

26. Volar Plate Injuries- Referral Unstable joint Large avulsion fragment

28. Finger Case #3 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.

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

30. 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

31. Stener Lesion

32. 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

33. Skier’s Thumb Treatment

34. Skier’s Thumb Referral Fracture Unstable joint Stener lesion

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

36. Fraction Alignment

37. 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

38. Phalanage Fracture Treatment Early motion (3-5 days) Splint and take out Can buddy tape

39. Proximal Phalange Fractures- Referral Inability to maintain proper alignment Rotation Irreducible Injury Any intra-articular fracture

40. Finger Case 4 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 5th knuckle.

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

42. Metacarpal 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

43. 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

44. 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

45. Metacarpal Fracture Referral Rotation Angulation > 70 degrees Preference

46. Proximal PIP dorsal dislocation 20 year old Ithaca College football defensive lineman ran to the sideline with right 4th finger pain and deformity. He clearly had a dorsal PIP dislocation. Gentle longitudinal traction resulted in joint relocation. No visible deformity was apparent after relocation and he had passive FROM at DIP and PIP. The finger was buddy taped and the athlete returned to play. X-ray following the game revealed soft tissue swelling. He was buddy taped and finished his season.

47. 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

48. Proximal PIP dorsal dislocation- relocation Reduce via gentle longitudinal traction If initially unsuccessful should hyperextend the distal portion to unlock If not done <1 hour consider a digital block

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

50. Proximal PIP Dorsal Dislocation- Referral Avulsion fracture > 1/3 of joint space Irreducible fracture Instability post-reduction