Hands and Wrist Problems In Sports Medicine

Gary Podolsky MD

Objectives

•  To review surface anatomy and function of the hand and wrist

•  Discuss common injuries of the hand and wrist and their mechanism of injury

•  Review clinical skills in the detection and treatment of hand and wrist injuries relevant to an office based practice in Sports Medicine

Introduction

Sports Medicine Clinicians must have a good knowledge of the surface and functional anatomy of the wrist and hand in order to correctly assess injuries. Such information will guide the physical examination and help arrive at an accurate diagnosis so that the most appropriate treatment may be begun immediately.

Familiarity with surface anatomy makes the clinician aware of the normal appearance of uninjured extremities as well as common normal variations, which should not be mistaken for pathological conditions.

Examination of the Wrist and Hand

A general examination of the hand and wrist begins with inspection of the limb.

Colour is noted to reflect adequate circulation.

Observation of the position and lie of the hand and wrist is noted. The normal hand at rest is in a semi-flexed position.

The palmar surface should have normal development of the thenar and hypothenar eminences. Atrophy of these muscle groups is a clue to longstanding disability. The hand may also be observed for contractures.

Figure 1 Dorsum and Palmar Wrist

With a closed fist the fingers will naturally point towards the scaphoid bone in a symmetrical way unless disrupted by an injury.

Figure 2 Normal Attiude of hand

Figure 3 Demonstration of Normal Metacarpal position

Viewing the fist end on can also assess Rotarary deformity of the fingers. In both these instance the normal anatomy is preserved in normal hands but in injuries to the metacarpals such as with a Boxer's Fracture the rotary deformity from the fracture will be more easily stand out from these viewpoints. When in doubt the opposite hand may be used in comparison.

Fractures may be obvious or hairline and suspicion aroused by gentle palpation

Normal Landmarks of the Hand

Distal Interphalangeal Crease

Proximal Interphalangeal Crease

Palmar Digital Crease

Distal palmar Crease

Proximal Palmar crease

Ulnar Nerve

Medial Nerve

Thenar eminence

Hypothenar eminence

Common Sports Injuries of the Hand and Wrist

There are many common terms for sports injuries that reflect their frequency and association with certain sports. As clinicians it is best to use exact specific terms particularly when confusion may arise but vernaculum terms are more widely used by athletes, coaches, and athletic trainers. It is helpful to know these vernacular names even if they are sometimes a little misleading in order to communicate with patients. Our discussions will include the antomical description as well as this best conveys the mechanism of injury.

Mallet Finger

This represents a disruption of the extensor mechanism of the finger at the terminal phalanx. At rest a normal finger should be in a neutral slightly flexed position. In fact people cannot voluntary bend their distal phalanx in isolation. A mallet finger looks like a mallet since the extensor mechanism is torn, the intact flexor tendon bends the joint foreward. An athlete may have pain and swelling but may continue to play and present later despite obvious deformity. They will still have normal flexural strength but none in extension. By relaxing their flexural tone they may present the illusion of having some extension but when formally tested for extension they will have none.

Treatment is simple and involves splinting the DIP joint in extension while allowing the PIP normal movement for 6-8weeks. A commercially available Stack splint is available for this. The patient must wear this constantly for 6 weeks. If prematurely fleed the fibrous union will break and immobilization must be restarted. After 6 weeks the splint may be still used for sleeping, occupation or sport while the tendon continues to strengthen.

Splinting the entire finger is not advised as this leads to much stiffness and atrophy.

Figure 4 Simulation of Acute and Late presentation of Mallet finger

Pseudomallet Finger

This injury involves a small avulsion fracture at the phalangeal insertion of the extensor tendon into the terminal phalanx. These present similarly to mallot finger except here the injury involves a boney diruption and not a tendinous one. This diagnosis is confirmed on x-ray and treatment consists of stack splinting for 6 weeks as well.

If unrecognised or neglected a mallet finger may become chronic once the window of opportunity for splinting for effective healing has passed. After several months splinting may not be effective, as the tendon ends have healed without reapposing themselves. For these patients with significant deformity, plastic surgery may later help.

Jersey Finger or Footballer's Finger

Jersey Finger injury involves a disruption to the flexural tendon of the finger and often occurs as a players finger is caught in another's jersey during a tackle. This injury is demonstrated by demonstrating an isolated injury to the flexoral tendon.

Profundus test

The flexor digitorum profundus flexes the distal interphalangeal joint . The examiner hold the other joints of the finger (metacarpeal phalangeal joint and proximal interphalangeal joints) straight while the patient attempts to flex the finger. If the tendon is torn the finger will not bend.

The Superficialis test is used to test the flexoral digitorum superficial tendon, which flexes the Proximal interphalangeal joint the examiner holds the patient's adjacent fingers in full extension while the patient attempts to flex the entire finger. A normal test will have the PIP joint flex while the DIP joint is in extension.

These tendon injuries must be referred to plastic surgeons and cannot be splinted effectively.

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Figure 5 Profundus and Superficialis tests of Flexors

Boutonierre Deformity

This involves a tear in the central slip of the extensor digitorum communis over the proximal interphalangeal joint with migration of the lateral bands volar to the axis of the joint. The patient cannot flex the distal joint.

Acute injuries may have finger swelling so this injury may be overlooked on initial examination. If neglected it may lead to finger deformity. Treatment involves splinting the proximal joint in extension with distal joint left free. This prevents lateral band adherence and retinacular ligament contracture.

Locally our hand physiotherapist is involved early on in care and also has the patient wrap a small segment of Coban compression to decrease the edema. We prefer to follow these patients closely and ensure that they are compliant with their 24 hour splinting.

Figure 6 Boutonniere deformity simulated

Scaphoid Fractures

Fractures to the scaphoid bone are very common in sports medicine but are also frequently misdiagnosed as strains and become causes of litigation. Despite it being very frequent, scaphoid fractures may be difficult to definitively diagnose even with good x-ray films including the scaphoid view. Diagnosticians must always consider the possibility of a scaphoid fracture if the mechanism of injury supports that possibility of one, and be prepared to treat that injured hand as a scaphoid fracture. The blood flow to the scaphoid flows distal to proximal and if this is disrupted even by an invisible hairline fracture osteonecrosis to the scaphoid may occur leading to long-term disability.

The most common source of injury is of a Fall Onto an Outstretched Hand (or FOOSH). The patient will have pain to their midhand especially at the " anatomical Snuffbox" named such for the British custom pof placing their snuff on their wrist there.

Figure 7 Identification of Anatomical Snuff box

Clinicians should gently palpate this area to determine if there is scaphoid tenderness. Next palpate the adjacent lunate between the thumb and forefinger while the wrist is moved laterally and medially ( Watson test for mechanical instability of the lunate indicating disruption of the scapholunate ligament).

Xray views should include good Anterior-Posterior (AP) and Lateral views as well as the scaphoid view. Xrays should always be views that you are satisfied with and having a view repeated because of an overlapping structure or poor quality is always recommended. Despite normal x-rays a scaphoid view may still be present and this injury should be treated as such.

Casting (thumb spica cast) or splinting (thumb spica splint) should be done. The latter if there is significant edema will protect the joint in any case so even if the patient has only a scapholunate strain they will still benefit from an immediate splinting. Incorporating the thumb into the cast is an important as this will minimize scaphoid movement facilitating healing.

The patient may be rexamined in a week and rex-rayed. At this point there may still be some fractures that will still not show up yet. Casting is still recommended. If there is an urgent need to establish a diagnosis for return to play a bone scan may be ordered. The bone scan must be specially ordered and involves review of radiolabeled uptake by healing bones to confirm fractures.

Scaphoid fracture management may be tedious or frustrating to physicians and athletes alike but extreme diligence must be kept to not let one missed diagnosis occur as this could end an athlete's career.

Dequervain's Tenosynovitis

This is a common yet frequently confusing clinical entity for general practitioners. It is due to inflammation of the first compartment of the hand involving the tendons of the extensor pollicis brevis and adductor pollicis longus causing painful movement of the thumb. It is usually from an overuse injury or may be from an acute injury. Pain may be generalized and confusing to the athlete. Examination confirms point tenderness to the regions of the involved tendons distinguishing this from other injuries such as a scaphoid fracture.

Figure 8 Finkelstein's test

Finklestein's test confirms the diagnosisi. The patient makes a fist with the thumb inside and slowly ulnar deviates the wrist to produce pain as the APL and EPV are stretched.

Treatment involves rest especially avoiding the activity or sport that may have precipitated the event. Early physiotherapy and non-steroidal antinflammatory medications may help. Corticosteroid injections may be used for refractory cases.

Trigger finger

This involves a painful locking of a finger during flexion as a nodule catches on the proximal pully of the finger. These may be very carefully injected with corticosteroids. Our facility refers these to hand surgeons for evaluation as surgical resection is sometimes required.

Skier's thumb

Skier's thumb is caused by a sudden valgus strain to the medial collateral ligament of the thumb such as when a skier has their thumb hooked in the loop of their ski pole.

Patients will have tenderness over their MCL. A x-ray helps rule out fractures. Our approach is to place the joint under mild valgus stress after x-ray has ruled out other fractures.

Figure 9 Isolating the 1st Metacarapal and applying gentle valgus strain

Boxer's Fracture (Streetfighter's Fracture)

Boxer's rarely get this fracture of the lateral metacarpals since they are trained to impact their blows in line with the second and third metacarpals. More commonly streetfighters will lash out at a wall or opponent and impact their 4 th and 5 th metacapals with a strong axial load, fracturing them.

The patient presents with swelling and pain, which may hide the deformity. X-rays confir the fracture and the degree of angulation. Gross rotatary deformity may require reduction but this is not commonly needed.

Casting involves an Ulnar gutter splint where the wrist is controlled and the metacarpal phalangeal joints of the 4 th and 5 th fingers are flexed. This maintains the fracture while leaving unaffected fingers alone to prevent unnecessary stiffness.

Fractures of the hamate may occur from a direct blow onto an outstretched hand. Point tenderness to the hamate will make one suspicious for this injury, which is best, demonstrated on the carpel tunnel view x-ray. Treatment involves a simple wrist cast for relief and union.

Conclusion

Hand and wrist injuries can present intimidating challenges to beginning practitioners. A consistent and systematic evaluation will diagnose the majority of conditions. Specific x-rays or bone scans will be necessary for some conditions.

Pain out of proportion to a physical finding should always be considered a possible fracture and appropriate measure- analgesia, splinting and rest should be implemented as if the injury were fractured. Close follow up of uncertain cases will ensure injuries are responding correctly as well as reinforce patient compliance with their rehabilitation program.

References:

Hoppenfield S Physical Examination of the Spine and Extremities, Norwalk, Appleton-Century-Crofts, 1976

Photographs Skylark Medical Studio 264 Tache Winnipeg MB ã .2005

Functional Anatomy of the Hand and Wrist Mark R Hutchinson ASM Team Physician Course 2002

Physical Exam of the Hand and Wrist William W Dexter Mary Lloyd Ireland ASM Team Physician Course Feb 4,2001

Sports Medicine Secrets Morris B Mellion Philadelphia Mosey 1994