BrJ Sports Med 1997;31:191-196

Sports injuries of the hand and wrist

Nicholas Barton

One in four of all fractures involves the hand orwrist. This is true of sports injuries too. Even iffractures of the distal radius are excluded, inju-ries to the carpus, metacarpals, and phalangesare common in sport. Soft tissue injuries tojoints are almost as common.The use of the hand and wrist in different

sports affects the way they may be injured.Soccer players (except the goalkeeper) are notallowed to handle the ball, but in rugby footballand its American and Australian derivativesplayers grasp not only the ball but their oppo-nents, so hand injuries are more common. Inbasketball, netball, volleyball, handball, andfives the moving ball is struck directly by thehand, which is therefore at considerable risk ofinjury.' However, even propelling a ball at amoment of your choice in ten-pin bowling cancause problems; other throwing sports aremore likely to damage the elbow or shoulder. Ingolf a stationary ball is struck by a club,whereas in racket games the ball is moving; inhockey and ice-hockey there are also directclashes between players. In cricket, baseball,and rounders, while only one player uses a bat,the others may or may not wear protectivegloves. Gloves are also used in boxing, but notin other fighting sports such as judo or karate.

Falling on to the outstretched hand is themain risk in athletic sports, particularly jump-ing, gymnastics, climbing, skating, and ski-ing.Sportsmen should therefore be taught to fall inthe safest way, rolling as they hit the ground.2In some sports, the hands are used to providepropulsion, as in rowing, but more often theyguide the machine, whether it be a bicycle, car,or boat (sailing or motor).Many sports injuries to the hand are minor

ones, but some are more serious than theyseem and need correct diagnosis and treat-ment. A "dislocation" may really be a fracture-dislocation so radiographs must be taken.Wrist injuries are often serious, even withapparently normal radiographs.

Nottingham UniversityHospital and HarlowWood OrthopaedicHospital, UnitedKingdomN J Barton

Correspondence to:Mr N J Barton, 34 RegentSt, Nottingham NG1 5BT,United Kingdom.

Accepted for publication13 March 1997

Method ofstudyThe literature has been reviewed by searchingthe indices of the most specific journals ofsports medicine and hand surgery. Otherpapers were already known to me. Theinformation thus gained has been augmentedby 26 years of experience.

SoccerThe most popular organised game in the worldis association football or soccer. Injuries to thehand occur in roughly equal proportions fromfalling on to the hand, contact with anotherplayer, and the ball striking the hand. The lastoccurs mostly in goalkeepers who, although

only one of 11 players, sustain one third of thehand injuries because the other players are notallowed to handle the ball. Goalkeepers are alsosubject to the uncommon but serious injurywhich was described in 1994 under theintriguing title "The goalkeeper's fear of thenets".' Three amateur footballers before thestart of their games were jumping up tosuspend the netting on the hooks attached tothe goalposts but instead sustained ringavulsion injuries when their rings caught on thehooks. One case was revascularised but theother two patients preferred to accept amputa-tion.The right hand is injured three times more

often than the left. The injuries are predomi-nantly fractures rather than joint injuries; inplayers under the age of 15 these are greenstickfractures. Fractures of the phalanges are themost common, followed by fractures of themetacarpals,4 but a significant number of play-ers sustain a fracture of the scaphoid, which ismore serious. Ligamentous injuries may occurin the carpus, leading to carpal instability later.

FRACTURES OF THE SCAPHOIDScaphoid fractures sometimes fail to unitedespite treatment, but if they are not treatedthey will almost certainly not unite.

Unfortunately, the diagnosis is not easy.Clinical signs are unreliable,5 but one shouldnot omit clinical examination because preciselocalisation of tenderness allows one to orderthe appropriate x ray views. Radiographs mayshow an obvious fracture but even experiencedorthopaedic surgeons and radiologists mayoverlook a fracture or, almost as bad, diagnosea fracture when there isn't one.6 Routine wristx ray pictures are not enough, and the diagno-sis requires special views to show the scaphoidwell: a posteroanterior view in ulnar deviation,a semipronated oblique in ulnar deviation, asemisupinated oblique view, and a lateral. TheZiter view combines several of these elements.7Other carpal bones may also be fractured.

If there is doubt, the wrist should be kept inplaster for two weeks and then reassessed. Abone scan is the most useful investigation.8 Ifthat is normal, a fracture can probably beexcluded. If it shows localised uptake, the mat-ter must be pursued further: in some cases acomputed tomography scan may show ascaphoid fracture when repeated ordinaryscaphoid x-ray views have failed to do so.Delay in treatment greatly increases the like-

lihood ofnon-union, but there is little unanim-ity as to the best method of treatment.9 Inmuch of Europe and in North America, it isusual to immobilise the whole arm, includingthe thumb, in an above-elbow plaster for six

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weeks, followed by a below-elbow plaster foranother six weeks. The case for an above-elbowplaster is not convincing, and our own studieshave shown that a below-elbow plaster leavingthe thumb free (as for a Colles' fracture) is justas effective as immobilising the thumb.'0 Thewrist must be effectively immobilised for atleast eight weeks and often twelve. Sportsmenneed a lot of persuading to accept this but, ifthere is a definite fracture of the scaphoid, it iswell worth sacrificing that period at the begin-ning to avoid the much longer period ofdisability when it fails to unite. The patientmust be seen every week or two to make surethe cast is still really immobilising the wrist.

CricketThe second most popular organised gamethroughout the world is cricket, played by mil-lions of people throughout the British Com-monwealth, especially in the Indian subconti-nent. A ball, about the size of a tennis ball butvery hard, is delivered at a speed of up to 140km per hour. A batsman attempts to strike itwith a wooden bat and the fielders try to stop itand, in particular, to catch it before it hits theground. Only one of the fielders is allowed towear protective gloves.

In amateur cricketers, most injuries to thehand are sustained while trying to catch theball, which often strikes the end of the fingercausing serious damage to joints, especiallydorsal fracture-dislocation of the proximalinterphalangeal joint. This injury also occurs inbaseball (although a baseball is slightly softerand lighter than a cricket ball) and in Austral-ian rules football.Most other hand injuries sustained at cricket

have a good result, but prevent the cricketerfrom playing for three to twelve weeks. Profes-sional cricketers, being more expert, are lesslikely to injure themselves while catching theball but face faster bowling and are thereforemore prone to finger injury while batting."Protective batting gloves need to be improved.

FRACTURE-DISLOCATION OF THE PROXIMALINTERPHALANGEAL JOINTDorsal dislocation of the interphalangeal jointsmay result from a forcible extension injury. Anend-on blow causes the more serious fracture-dislocation, which clinically looks much thesame. It is reasonable to reduce any disloca-tion, but essential to have the joint x-rayedimmediately afterwards so as not to overlook anassociated fracture.

In fracture-dislocations the anterior part ofthe base of the middle phalanx is broken offand stays in its previous position, while the restof the middle phalanx dislocates dorsally. Theyare relatively easy to reduce and remain stableas long as the joint is flexed, but they dislocateagain if the joint is extended. Many methods oftreatment of varying complexity have beenrecommended.'2 McElfresh et al" advocated anextension-block splint which allows flexion butprevents extension; a less cumbersome versionwas described by Strong.'4 If this method isused, a check radiograph must be taken withthe finger in the splint with the joint extended

as far as the splint allows, to make sure thatconcentric reduction is maintained.

Splinting alone may be inadequate. It may benecessary to transfix the reduced joint with aKirschner wire. Twyman and David" simplyput the pin in the head ofthe proximal phalanx;they call this "the doorstop procedure". Afterthree weeks, the wire is removed and anextension-block splint applied for anotherthree weeks, during which the range ofextension allowed is gradually increased. If thefinger is left free after only three weeks, it maydisplace again. In some cases, especially if thebony fragment is large, open reduction andinternal fixation may be indicated, but shouldbe performed by a skilled and experiencedhand surgeon.

Rugby football and its derivativesIn rugby union football and its relatives rugbyleague, Australian rules and American football,injuries are common, especially to the kneeand, very seriously, to the cervical spine. Inthese versions of football, the players catch andcarry the ball and are tackled by other players,also using their hands, so hand injuries arerelatively common although fortunately sel-dom serious. In one season at Cambridge, aUniversity town with many colleges, 72 pa-tients were treated at the local hospital for handinjuries sustained while playing rugbyfootball,"6 many of which were caused deliber-ately. Forty six sustained fractures, mostly ofthe phalanges, some of these occurring whenthe tackling player caught his finger in thepocket of his opponent's shorts. A similarmechanism is the most common cause of therare avulsion of the insertion of flexor digito-rum profundus tendon.'7 Rugby players in thesouthern hemisphere sensibly have no pocketsin their shorts, although the tackler's fingersmay still get caught in the waistband. Americanfootballers are also prone to this injury.'8

Interphalangeal dislocations are often com-pound. Players sustaining these injuries mustbe sent to hospital, both for proper treatment ofthe wound to prevent infection of the joint andfor x-ray to detect any associated fracture. Dis-locations and fracture-dislocations at the proxi-mal interphalangeal joint also occur fairlyfrequently.

AVULSION OF THE PROFUNDUS TENDONThis rare injury is almost confined to rugbyfootball. It almost always affects the ring finger.The tendon is pulled off its insertion on to thedistal phalanx; there is seldom a fracture, soradiographs are normal. Experimental studiesoddly enough usually do produce a fracture.'9The patient can still flex the metacarpo-

phalangeal joint (using the intrinsics) and theproximal interphalangeal joint (using flexordigitorum superficialis) but not the distalinterphalangeal, or end joint, of the finger.

If diagnosed at the time, the tendon shouldbe reattached surgically, but the result may bedisappointing because the force of the injurytears the vincula, and the tendon sheath is filledwith blood which forms adhesions. Thediagnosis is usually not made until later, by

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Hand and wrist injuries

which time a tendon graft to the profundus isrequired. Although good results can sometimesbe achieved,'7 there is a risk that the function ofthe intact and normal superficialis tendon maybe compromised. Alternatives are arthrodesisor tenodesis of the distal interphalangeal joint,but many patients find the disability so slightthat they choose to have nothing done.

GolfIf a golfer misses the ball and the club hits theground, the impact is transmitted up the shaftof the club to the handle causing a fracture ofthe hook of the hamate.20 It is always the upperhand that is injured. The same injury can becaused by a tennis or badminton racquet or acricket or baseball bat if a particularly violentimpact takes place. Beckenbaugh, the co-author ofone ofthe best papers on this injury,2"sustained it himselfbut it was not diagnosed byhis colleagues for a long time.Two cases have been reported of golfers who

wanted to change the rubber grip on the handleof a golf club and tried to separate it by inject-ing white spirits from a syringe into the spacebetween the grip and handle.22 Each acciden-tally injected his other hand, causing severepain and vascular problems needing treatmentin hospital, after which both digits survived.

FRACTURE OF THE HOOK OF THE HAMATEAs with the scaphoid, ordinary radiographs ofthe wrist will not show this injury. It requiresspecial views: an oblique one and a viewthrough the carpal tunnel with the wristextended, but correct and precise positioning isessential. If pain prevents full extension, lateraltomograms or a computed tomography scanwill show the fracture. Because it is not shownin ordinary x-ray views, it is seldom diagnosedacutely and may present later with painfulnon-union. The key to diagnosis is localisationof tenderness; the hook of the hamate is about1.5 cm distal and lateral to the easily palpablepisiform. There may be ulnar nerve symptoms,which is not surprising in view of the proximityof both the superficial sensory and deep motorbranches of that nerve to the hook. Mild carpaltunnel syndrome has also been described.Some of the flexor tendons are also close to thehook, so sometimes there is pain on moving thering and/or little fingers.

If the fracture is diagnosed immediately,immobilisation in a plaster cast can produceunion. In the more common late cases, the besttreatment is excision of the fragment23; it isdeeper and larger than would be expected andhas flexor tendons laterally (they may be frayedor even ruptured) and the motor branch of theulnar nerve curling round it medially anddistally, so the operation needs great care.Some patients, particularly those who havesuffered violent injuries such as road trafficaccidents or falls, complain ofweakness of gripor tenderness of the scar after excision, butmost sportsmen are satisfied with the resultand resume their sport. Professional cricketersare able to play again after a few weeks whenthe tenderness has settled.

Watson and Rogers were disappointed withtheir results after excision and claim that reten-tion ofthe hook prevents ulnar migration oftheflexor tendons, which weakens the grip. Theytherefore devised a method ofbone grafting thehook and used it with success in four patients.24Afterwards the wrist was immobilised for sixweeks. The fracture can simultaneously be sta-bilised with a Kirschner wire; a mini-Herbertscrew should give better fixation. However,most hand surgeons have found the results ofexcision to be good.

Ski-imgThe most common hand injury in ski-ing is atear of the ulnar collateral ligament of themetacarpophalangeal joint of the thumb. Thisis caused by the handle of the ski-stick or theloop around it, or by the ground. One wouldexpect this injury to be more common on arti-ficial ski slopes because the skier is out of prac-tice and the surface is full of holes into whichthe thumb may slip, but a study in Belgiumfound that artificial slopes were more likely tobreak the thumb than to tear its ligaments.25The thumb is pulled sideways and usually

the ligament tears off at its distal end where itis attached to the base of the proximal phalanx:sometimes the ligament remains intact butpulls off the bit ofbone to which it is attached.

DETACHMENT OF THE ULNAR COLLATERALLIGAMENT OF THE METACARPOPHALANGEALJOINT OF THE THUMBThis is often, although wrongly, called "game-keeper's thumb", but gamekeepers sustain agradual stretching of the ligament by breakingthe necks of rabbits over many years.26 Theacute injury would be better called "skier'sthumb" as ski-ing is its most common cause.

If the ligament is completely torn, there isobvious laxity allowing the thumb to bedisplaced sideways away from the index finger.There is usually bruising on the ulnar (finger)side of the metacarpophalangeal joint of thethumb. If there is no fracture, the radiographswill be normal, but early operation is indicatedbecause, as pointed out by Stener,27 the adduc-tor aponeurosis always comes to lie betweenthe ligament and where it should be attached,so normal healing cannot occur. The ligamentis therefore replaced and reattached surgically,after which the thumb should be protected inplaster for three weeks.

In recent years there has been some enthusi-asm for conservative treatment.28 This may beappropriate ifthe torn ligament is not displacedoutside the aponeurosis. The difficulty is howto determine this. Abrahamsson et al9 considerthat the displaced ligament is palpable on clini-cal examination and recommend immobilisa-tion in plaster if it cannot be felt. Othersurgeons find this difficult, so ultrasonographyand magnetic resonance imaging have beenemployed, the latter being more reliable.'0

Ifthere is a fracture, the radiograph will showwhether it is displaced or not. Stener andStener" showed that there can be a fractureand a torn ligament together and in about halfthe cases the bony fragment is attached to the

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ligament and in half it is not.32 Stability shouldtherefore be tested even if the fracture is undis-placed. If it is stable, 1-2 mm of displacementis acceptable and can be treated in a plaster ofParis thumb spica for three weeks. If the joint isunstable, if the displacement is greater, or if thefragment is rotated, it should be exposed andreattached surgically. If there are two frag-ments, one displaced and one not, operation isindicated because the ligament is probablyattached to the displaced one.

BoxingThe term "boxer's fracture" is sometimesapplied to the common fracture of the neck ofthe fifth metacarpal as this usually is caused bypunching, although often a less inebriatedopponent avoids the blow and the fist hits awall instead. For some reason it has becomecommon in the last 20 years to express anger bydeliberately punching a wall, which is now acommon cause of this fracture.

In proper boxing matches, the fighters aremore skilled and their hands are protected byboxing gloves, so these fractures are lesscommon. A study of 11 173 professionalboxers in New York State over a seven yearperiod, which rightly was concerned mainlywith head injuries, found 38 fractures ofwhich14 were of the metacarpals and three of thephalanges.3' Professional boxers may, however,be much troubled by compression-impactioninjuries to the carpometacarpal joints of theindex and middle fingers.'4 "Repetitive stress tothe stable longitudinal arch eventually resultsin cartilage damage, osteochondral fracture,and a chronically painful arthrosis"." If simplerest and protection do not resolve the symp-toms, arthrodesis may be required; fortunatelythese joints normally have hardly any move-ment so there is no functional loss.

In addition to the 38 fractures in the NewYork State study, there were 18 cases of acuteor chronic synovitis causing swelling of the sec-ond or third metacarpophalangeal joints("boxer's knuckle"); most responded to con-servative treatment, although surgery has beenadvocated in severe cases." Rupture of thedorsal capsule of the metacarpophalangealjoint of a finger is another injury caused bypunches, often in proper boxing.'6 It iscommonly overlooked but may benefit fromsurgery, even in late cases. This may be the truecause of what was earlier described as "synovi-tis".

FRACTURE OF THE NECK OF THE FMIFHMETACARPALIt is a mistake to overtreat these. Ford et al7proved that excellent results are obtained byminimal treatment, even in cases with markedangulation. Neither reduction nor immobilisa-tion is necessary. A bandage should be appliedto remind the patient and other people that thehand has been broken, and movement of thehand should be encouraged at an early stage.There is often an extension lag for a while, butfull movements are nearly always regained, andthe minor cosmetic blemish seldom troublespatients with this injury.

Rock climbingThe most common hand injury in rock climb-ing is to the soft tissues of the fingertips, result-ing from severe and prolonged pressurecombined with abrasion. Avulsion of digitsthrough the distal or proximal interphalangealjoints in crack climbing has been reported.'8

DAMAGE TO THE FIBROUS FLEXOR TENDONSHEATHNormally the flexor tendons are held in placeby the fibrous flexor sheath and especially bythe stronger parts of it, which form pulleys.Loss of these pulleys allows the tendon to bow-string forwards during flexion.

In May 1989 Steve Bollen, a rock climberhimself, examined the hands of 67 climberstaking part in the first British Open ClimbingChampionship at Leeds.'9 He found that 25%of them had bowstringing, which is almostunknown among non-climbers. The obviousway to prevent bowstringing would be to weara ring, but that would invite serious ring avul-sion injuries if the climber fell and the ringcaught on something. Non-stretch tape maylimit the problem, but could also be a risk. Bol-len found, by biomechanical analysis, that aman falling and taking his weight on one fingercould apply a force of 450 N at right angles tothe flexor tendon. If this is enough to damage anormal tendon sheath, it is hard to believe thatany surgical reconstruction or replacementcould withstand it.More recently Bollen and Wright studied

radiographs of the hands of 36 rock climbersaged 20-50 (mean 31) years and comparedthem with matched controls from the accidentand emergency department. Of the climbers,17 had osteochondral cysts, 14 had osteo-phytes, and two had osteoarthritis; two of thecontrols had cysts but none had osteophytes orosteoarthritis.40 In addition, the climberstended to have greater cortical thickness andscalloping of the neck of the proximal phalanx,which was attributed to thickening of theattachment of the distal end of the A2 pulley ofthe fibrous flexor sheath. It is planned to repeatthis study in five years to see if "the young starsofthe rock-climbing world oftoday become thegnarly-handed, middle-aged adults of tomor-row".

Ten-pin bowlingA paper from the Mayo clinic in 1972 reported25 patients with pain and hypersensitivity overthe ulnar digital nerve of the thumb, with pal-pable thickening of that nerve.4' Of these, 17were keen ten-pin bowlers and played fivetimes a week or more. In this type of bowling,the thumb is put into a hole in the bowl, and itwas thought that this had caused the fibrosisaround the nerve which was found in mostpatients who were explored, although one alsohad a chronic proliferative synovitis whichseems to arise from the sheath of the flexorpollicis longus tendon.The simplest treatment is rest from bowling.

A change in grip may be effective. Somepatients were relieved by wearing a plastic

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Hand and wrist injuries 195

thumb guard for from six weeks to six months.Surgical neurolysis helped in some cases.

Stress fracture of the ring finger has alsobeen reported.42

RowingBlisters are the really common problems of thehands, but the repetitive flexion and extensionof the wrist can cause peritendonitis crepitans,a condition causing pain, swelling, and crepituswhere two of the thumb tendons cross over theradial wrist extensors, about three inches abovethe wrist, toward the radial side of the extensorsurface. For this reason, it is known in Americaas the intersection syndrome.The condition settles quickly with rest, but if

that is not accepted, may be cured by surgicalrelease.43

BicyclingRacing cyclists may bear up to one third oftheir body weight on the handlebars. The ulnarnerve, where it enters the hand at thehypothenar eminence, has little protective softtissue covering and may suffer compressionagainst the handle ofthe bicycle." The elementof vibration adds to the problem. The result isimpaired or altered sensation in the little andring fingers; if the deep motor branch of thenerve is also affected, then there is weakness ofthe small muscles ofthe hand. Acute symptomsfollow a very long ride, especially over roughterrain, and they may persist for monthsdespite stopping cycling; other cases present ina more chronic form. Special padded gloves areavailable for cycling, and most serious cyclistsuse these. Periodic changes in grip is the bestsolution; drop handlebars allow this to beachieved more easily than upright ones.

GymnasticsGymnasts subject their wrists to a combinationof axial compression and extreme ranges ofmovement, so it is not surprising that they getproblems45; indeed, they think that pain in thewrist is a "normal and direct result of thesport" so they may ignore treatable disorders.The most common is a tear of the triangularfibrocartilage between the distal end of the ulnaand the triquetrum46; this is particularly at riskif the gymnast has a slightly longer ulna thanusual (called positive ulnar variance). However,a similar situation can arise as a consequence ofgymnastics; in adolescent girls the epiphysealplate at the distal end of the radius may fuseprematurely so that it stops growing prema-turely while the ulna continues to grow andabuts on the carpus.4" Arthroscopy of the wristallows the triangular fibrocartilage to beinspected, but it may be necessary to shortenthe ulna.

Other sportsIn basketball, neallll, and handball, the ball ispropelled directly by the hands which aretherefore at risk especially the thumbs. Liga-mentous injuries occur but are not as commonas one might expect. The use of the handrequired in the game "does not tolerate mostprotective gear such as splints or tape".48

Skaters may fall and have their hands runover by other skaters. On ice, this producesnasty lacerations which may be associated withcompound fractures.49Low temperature injuries can occur in

winter sports and mountaineering.

ConclusionThe problem in treating sportsmen is that theirdesire to continue sport may lead them toneglect serious injuries, for which they pay aheavy price later. Most serious sportsmen andwomen are young and understandably notinclined to think of the problems that they maybe storing up for middle and old age-forexample, those adolescent gymnasts who aredeforming their wrists.Merle and Dautel50 in France "recently

examined a motorcycle champion who hadsuffered more than 29 articular, juxta-articular,and diaphysial fractures in the course of hiscareer. None of the digital chains was intact;they all had sequelae of fractures: malunionswith bone angulation or rotation and post-traumatic arthritis.... However, his hand wasquite functional, each digital chain having auseful sector and range of motion. As for hispain, this retired champion would only say 'Ican live with it: it's all in the head anyway"'.However, there are injuries where proper

treatment is needed, which will require aconsiderable absence from sport. This is notonly to avoid problems 20 years later but toallow a full recovery and resumption of sportthe following season. This is in the player'sinterest, but he or she often lacks the maturityto recognise this and certainly cannot beexpected to have the knowledge to recognisethe small proportion of injuries requiring seri-ous treatment. That is the job of the sportsdoctor: to make a full, early, and accurate diag-nosis and sort the "wheat", needing curativetreatment, from the "chaff", which only needspalliation.

I am grateful to Dr M E Batt and Mr R G Hackney for theirhelp.

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