Wrist, Hand and Finger InjuriesBY-DR. SUMANTA GHOSH

• Wrist injuries– Scaphoid fractures– Wrist ligament sprains– Fracture hook Hamate– Triangular fibrocartilage complex tear– Scapholunate disassociation

• Hand and Finger injuries– Metacarpal fractures– Phalanx fractures– Ulnar collateral ligament sprains 1st MCP– Mallet finger– Boutonniere deformity– Avulsion of flexor digitorum profundus tendon

Fracture Scaphoid•Mechanism- fall on the outstretched hand

•Patient usually does not present to a clinician until sometime after injury

•Key examination findings–Swelling and loss of grip strength–Snuffbox tenderness (to be compared with the non affected side)–Swelling in the snuffbox

–Limitation in end range flexion and extension–Pain on axial compression of the thumb towards the radius or direct pressure on scaphoid tuberosity

•Investigations–Plain radiographs with special scaphoid views usually demonstrate the fracture

–If a scaphoid fracture is suspected clinically, but the radiograph is normal, then also its not ruled out

•MRI is an ideal investigation in acute injuries•Bone scan •In absence of MRI or Bone scan, get a repeat X-ray after about two weeks (wrist immobilized till that time)

•Treatment –Stable fracture

•Immobilized for eight weeks in a scaphoid cast extending from proximal forearm to, but not including, the interphalangeal joint of the thumb

•Upon cast removal, re assess the fracture clinically and radiologically

•Radiological union of scaphoid should occur before finally discharging the patient

–Unstable of significantly displaced fractures require immediate percutaneous fixation or open reduction and internal fixation

•Complications of scaphoid fractures

–Delayed union–Non union–Avascular necrosis

• Post immobilization rehabilitation– Stiffness and weakness are chief problems– Mobilization and strengthening of the wrist– Make sure there has been no ligament involvement– If the wrist is intact, the athlete may be able to return to

certain activities using a protective device– Compression tubing worn under the protective splint

reduces edema and improves comfort

Scapholunate disassociation•Fortunately, most wrist traumatic events do not lead to significant capsuloligamentous or bony structural failure

•A pre dynamic injury can progress to a dynamic or static carpal instability, & leads to a chronic regional wrist joint tendinosis

•Scapholunate disassociation is due to scapholunate ligament tear and loss of secondary restraints

•Rotatory subluxation of the scaphoid occur as a result of disruption of its ligamentous attachments due to acute trauma

•Examination reveals tenderness about 2 cm distal to the Lister’s tubercle on radial side of lunate

•May be little or no swelling

•Watson test positive for pain and scaphoid moves dorsally

•Stress radiographs may reveal a gap of greater than 3mm between scaphoid and lunate

•A lateral radiograph may show an increased volar flexion of the distal pole of the scaphoid and DF of lunate

•If these tests are negative, MRI is indicated

•Treatment–Open reduction and repair of the ligament and internal fixation–There is some degree of permanent reduction in wrist motion

Fracture hook Hamate•Occurs most often while swinging a golf club, tennis racquet or baseball bat

•Fracture usually occurs when the club strikes the ground instead of the ball, forcing the top of the handle of the club against the hook of the hamateof the top hand

•This mechanism may compress the superficial and deep terminal branches of the ulnar nerve, producing both motor and sensory changes

•Symptoms include reduced grip strength and ulnar wrist pain

•Examination reveals volar wrist tenderness over the hook of Hamate

•Routine radiographs and special views also may miss it, so CT and MRI are the investigations of choice

• Most cases seen in sports medicine clinics are actually stress fractures that present late, in some cases fracture is likely to be a completed stress fracture not due to acute trauma

• If diagnosis is delayed, or the fracture fails to heal clinically within four weeks of immobilization, then excision of the fractured hook of Hamate is performed followed by three weeks of wrist immobilization

de Quervain’s Tenosynovitis•Inflammation of the synovium of the abductor pollicis longus and extensor pollicis brevis tendons as they pass in their synovial sheath in a fibro osseous tunner at the level of the radial styloid

•This is the most common radial sided tendinopathy in athletes and occurs particularly with racquet sports, ten pill bowlers, rowers and canoeists

•There is local tenderness and swelling which may extend proximally and distally along the course of the tendons

•Finkelstein’s test is diagnostic

• Treatment– Splinting– Local electrotherapy modalities– Stretching and strengthening exercises– Corticosteroid and anesthetic injection into the tendon

sheath is usually helpful– In rare cases surgical release is necessary

Ganglions

• Ganglions occur in athletes of any age

• These are the synovial cysts communicating with the joint space

• Most often present as a relatively painless swelling

• Occur in several common sites on both aspects of the wrist, most commonly the scapholunate space

• Ultrasonography is a useful investigation however MRI highlights ganglion cysts

• Teatment is only indicated for a symptomatic ganglions

• Aspiration and/or steroid injection are at least temporarily effective

• Some persistent symptomatic ganglions require surgery

Triangular Fibrocartilage Complex tear• TFCC lies between the ulna and the carpus, and is a major

stabilizer of the distal radioulnar joint

• TFCC consists of • Triangular fibrocartilage• Ulnar meniscus homolog• Ulnar collateral ligament • Extensor carpi ulnaris sheath and• Numerous carpal ligaments

• Common site of ulnar wrist pain

• Compressive loads on the wrist, especially if accompanied by ulnar deviation (gymnastics, diving, golf and racquet sports), may tear the central portion of the cartilage

• It can also be damaged after distal radial- ulnar fracture or potential with disruption to the distal radio ulnar joint

•Examination–Tenderness and swelling over dorsal ulnar aspect of the wrist–Pain on resisted wrist DF and ulnar deviation–Clicking sensation at the wrist and reduced grip strength

•Investigation–MRI is the investigation of choice–Ultrasonography shows promise for matching MRI in TFCC lesion

• Treatment – Protective bracing– Strengthening when able to– Heat and electrotherapy– Arthroscopy permits accurate diagnosis and excision of

any torn cartilage

Kienbock’s Disease•Avascular necrosis of the Lunate, possibly because of repeated trauma

•May present as chronic, dorsal or volar wrist pain in an athlete with repeated impact on wrist

•Most common in athletes in twenties

•Localized tenderness over the lunate and loss of grip strength

• Radiographs show a smaller lunate with increase radio opacity

• MRI and bone scan

• In acute stage- immobilization may be therapeutic

• In chronic stage- surgery is required

Carpal Tunnel Syndrome• Median nerve compression in the carpal tunnel along with the flexor

digitorum profundus, flexor digitorum superficialis and flexor pollicis longus tendons

• Characterized by burning volar wrist pain with numbness or paresthesia in the distribution of the median nerve

• Nocturnal paresthesia are characteristic

• Pain may radiate to the forearm, elbow and shoulder.

• Tinel’s sign may be positive

• NCV helps in diagnosis

• Mild cases treated with NSAIDs and splinting, non responding cases injected with steroid

• Persistent cases may require surgery

Hand and Finger InjuriesSprain of the UCL of the First MCP joint

• Injury to the UCL of the thumb is one of the most common injuries seen in athletes, also known as skier’s thumb

• Usually results from forced abduction and hyper extension of the MCP joint

• Patient may complain of weakness of thumb index pinch grip

• Examination reveals swelling and tenderness over the ulnar aspect of the first MCP

• Before testing stability, radiography performed to exclude avulsion fracture

• Stress tests positive with pain for partial and complete tears

• Deviation within 10- 20degrees considered as partial

• Partial tears treated conservatively with a splint immobilization with MCP is slight flexion for 6 weeks

• Further protective splint is required during return to sport and may be required up to 12 months

• A complete tear requires surgical repair, a displaced avulsion fracture also requires open reduction and internal fixation with K wires

• After surgery, thumb is placed in thumb spica for about 4- 6 weeks

Mallet Finger• Flexion deformity occurring from avulsion of the extensor

mechanism from the DIP joint

• Mechanism- commonly ball striking the extended finger tip, forcing the DIP joint into flexion while extensor mechanism is actively contracting

• Seen commonly in baseball catchers, football receivers, cricketers and basketball players

• O/E-– Inability to extend the DIP– Tenderness over dorsal aspect of DIP– If left untreated develops into chronic mallet finger like

deformity

• Investigations– Radiography to exclude avulsion fracture of the distal

phalanx or dislocation of DIP– Avulsion fracture considered significant if greater than

one third of the joint surface is involved: requires ORIF– Any subluxation requires ORIF– # dislocation of epiphyseal plate may occur in children:

requires open or closed reduction

• Treatment– Uncomplicated Mallet finger: splinting of the DIP in

hyperextension for 8 weeks with regular monitoring– Splint is then worn for another 6- 8 weeks while engaging

in sporting activity– Patient should emphasized to keep DIP in hyperextension

all the time

Boutonniere Deformity• Disrutption of central slip of extensor digitorum communis

tendon at its insertion at the base of the middle phalanx, allowing migration of the lateral bands in a volar and proximal direction

• Allows the middle phalanx to be pulled into flexion by the flexor digitorum superficialis

• May arise from blunt trauma over the dorsal aspect of the PIP joint or acute flexion of the joint against active resistance, such as in ball sports

• The deformity is often absent at initial presentation but develops some time later in the untreated cases

• Classic deformity consists of hyperextension of the DIP joints with a flexion deformity of the PIP joint

• O/E- – May include flexion deformity of the PIP with tenderness

over the dorsal slip of the middle phalanx– Patient lacks full extension of PIP– Radiography occasionally shows avulsion fracture,

always follows volar PIP dislocation

• Treatment – Any PIP injury showing lag of active extension should be

treated as an acute extensor tendon rupture– Treatment of choice, even if the lag is less than 30

degrees, is to splint the finger with the PIP in full extension while allowing active flexion of the DIP, for six weeks

– On return to sports, protective splinting is used for another 6-8 weeks

– Associated avulsion # middle phalanx involving > one third of the joint surface require ORIF

Avulsion Flexor Digitorum Profundus• Commonly seen in ring finger

• Caused by sportsman grabbing an opponent’s clothing, resulting in distal phalanx being forcibly extended while athlete is actively flexing

• Patient often feels a snap, the condition is often referred to as ‘Jersey finger’

• On examination, finger assuming position of extension relative to the other fingers

• Inability to actively flex the DIP

• Radiography performed to exclude any avulsion fractures of the distal phalanx

• Treatment is urgent surgical repair with reattachment profundus tendon to the distal phalanx (within 10 days)