sports injuries wrist iaoc

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Sports Injuries of the Wrist

Adam C WattsConsultant Elbow and Upper Limb Surgeon, Wrightington Hospital

Visiting Professor Manchester University

2www.wrightington.com

Sports injuries of the wristWrist and hand injuries approx. 9% sports

injuries

Traumatic

Overuse / stress

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Scaphoid FracturesMost common wrist fracture in athlete

Falls

Contact with other players

Stress fracture may occur

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Aim of treatment of scaphoid fractures

PrimaryAchieve sound

union

Secondaryshortest time with

lowest risk and disruption to patient

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Cast immobilisation

InconvenientMuscle

atrophyJoint

stiffness

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Low riskLow cost


Screw fixation

Early return to function

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Higher direct costsGreater risks

Sportsmen

Lost income3rd party

pressure

Earlier return to playGreater risks


Predicting Union

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Decision Making

Scaphoid tubercle fracture

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Decision Making

Trans-scaphoid perilunate dislocation

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Decision Making

Proximal pole fracture

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13www.wrightington.com 13


Assessment of displacement

Translation

Gap

Angulation

Rotation

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}>1mm


Displaced scaphoid fractures

Relative risk of non-union displaced fractures in cast 4.4 (c.i. 2.2-8.7)

For displaced fractures odds ratio of non-union of 16.9 for cast treatment versus surgical fixation

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Assessment of displacement

MRI gold standard : X-ray sensitivity 33-47% positive predictive value 27-86% (Bhat 2004)

Arthroscopy gold standard: Xray sensitivity 75% positive predictive value 10% (Lozano-Calderon 2006)

Reliability intraobserver interobserverX-rays 0.54 0.27CT 0.65 0.43CT and X-rays 0.63 0.48

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Does vascularity matter?

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Avascular

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Fracture displacement measured on CT or MRI appears to be key to assessing risk of non-union


Displaced fractures>2mm displacement

on CT = Non-union 50% in cast

≤2mm displacement on CT = 100% union in cast

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Undisplaced fracture

Union in 4 week cast = 96%

Can surgery beat this?

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5 Questions Yes to any consider surgery

1. Is there an associated ipsilateral wrist injury?2. Is there a proximal pole fracture?3. Is there a waist fracture that is displaced on

scaphoid series radiographs?4. Is there a waist fracture that is shown to have

more than 2mm displacement on CT/MRI?5. Is there a waist fracture that is shown to have

up to 2mm displacement in an individual who requires early wrist motion?

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Hook of Hamate Fracture

Scapholunate Ligament

Scapholunate

> 3mm

Scapholunate

Investigation

• XR• Stress Radiograph• CT• Arthrogram• MRI• MR Arthrogram• Arthroscopy

Arthroscopic Classification

Garcia-Elias 5 Qs1. Is the dorsal SL ligament intact?2. If the dorsal SL ligament is disrupted can it be

repaired with good healing potential?3. Is the scaphoid aligned normally with a

radioscaphoid angle of 45° or less, indicating a normal STT capsule and ligaments?

4. Is the carpal malalignment easily reducible?

Cable Augmented Modified Brunelli

ECU Instability / tendinopathy

• Hypersupination of forearm• Voluntary Contraction of ECU• Ulnar deviation of wrist• Flexion

Anatomy

Allende and Le Viet

Presentation

• Symptoms– Young athletes– Racket or stick sports– Painful snapping– Clicking over dorso-ulnar

wrist during rotation– Acute– Chronic

• Signs:– Ice cream scoop test– ECU synergy test

Hayton Ice cream scoop test

ECU synergy test

Investigations

• Ultrasound

MacLennan et al JHSa 2008

MRI scan

• Allende & Le Viet 2005

Management

• Conservative– Rest– NSAIDs– Physiotherapy– Local steroid– Splint Immobilisation– Plaster (Patterson 2011) long-arm cast elbow

flexed 90°, wrist 30° extension, radial deviation, and pronation

Operative

• Symptomatic subluxation or dislocation• Direct repair (Inoue) in acute cases (Radial)• But sheath retraction and tendon thickening• Osteo-fibrous sheath Reconstruction:– Retinaculum flap– FCU tendon– Free graft– Deepening of the groove

Linea Jugata


Ulnar Sided Wrist Pain -TFCC

Palmer Classification

www.wrightington.com

Physeal arrest in gymnast


Summary

• Same pathology

• Athlete at centre of decision making

• Work with team to accelerate recovery


sports injuries wrist iaoc

Healthcare

fracture displacement

com27scaphoid fracture

playersstress fracture

cast treatment

lowest risk

hand injuries

scaphoid series radiographs

positive predictive