Common Hand and Wrist Injuries Andrew Getzin, MD Cayuga Medical Center Sports Medicine and Athletic...
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Transcript of Common Hand and Wrist Injuries Andrew Getzin, MD Cayuga Medical Center Sports Medicine and Athletic...
Common Hand and Wrist Injuries
Andrew Getzin, MDCayuga Medical Center
Sports Medicine and Athletic [email protected]
www.cayugamed.org/sportsmedicineIthaca College
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?
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
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
Finger Anatomy
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.
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
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
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
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
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.
Jersey Finger
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
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
Jersey Finger Physical Exam
Jersey Finger Treatment/ Referral
All need to be referred for surgery immediately
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
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
Central Slip Extensor Tendon Injury Referral
• Avulsion fracture involving more than 30 percent of the joint
• Inability to achieve full passive extension
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
Collateral Ligament Injuries- Treatment
• If joint stable and no large fracture- can buddy tape
• Never leave the pinky alone
• ?Physical Therapy- if joint stiff
Collateral Ligament Injuries- Referrals
• Unstable joint
• Large associated fracture
• Injury in a child
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
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
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
Volar Plate Injuries- Referral
• Unstable joint• Large avulsion
fragment
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.
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
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
Stener Lesion
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
Skier’s Thumb Treatment
Skier’s Thumb Referral
• Fracture
• Unstable joint
• Stener lesion
Distal Tuft Fractures
• Common due to crush injuries
• Painful• Splint in extension for 3
weeks
Fraction Alignment
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
Phalanage Fracture Treatment
• Early motion (3-5 days)• Splint and take out• Can buddy tape
Proximal Phalange Fractures- Referral
• Inability to maintain proper alignment
• Rotation• Irreducible Injury• Any intra-articular
fracture
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.
Metacarpal Fractures• Most common hand
fracture– 30-35%
• Usually involves the neck
• Fight or fall common mechanism
• 4TH and 5th most common fractures
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
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
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
Metacarpal Fracture Referral
• Rotation
• Angulation > 70 degrees
• Preference
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.
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
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
Post Reduction Care
• Radiographs should be obtained to ensure joint congruity
• Examine collaterals
• PIP should be splinted in less than 30 degrees
Proximal PIP Dorsal Dislocation- Referral
• Avulsion fracture > 1/3 of joint space
• Irreducible fracture
• Instability post-reduction
WRIST
Wrist Pathology• Fracture
– Scaphoid
• Ligament-Tendon Injuries– TFCC tear– Scapholunate
dissociation– DeQuervain’s– Intersection Syndrome– Ganglion Cyst
• Nerve Injury– Carpal tunnel
• Other– Kienbocks
Wrist Case 1
• 24-year-old male FOOSH (fell on outstretched hand) while skiing over the weekend
• Seen at the mountain clinic and told “wrist sprain”
Scaphoid Fracture• Most common
fractured bone in the wrist
• Peanut shaped bone that spans both row of carpal bones
• Does not require excessive force and often not extremely painful so can be delayed presentation
Scaphoid Fracture Presentation
• Pain over the anatomic snuff box
• Pain is not usually severe
• Often present late
Scaphoid Fracture Pathoanatomy
• Blood supplied from distal pole
• In children, 87% involve distal pole
• In adults, 80% involve waist
• Treatment depends on location of fracture
Imaging
• AP, lateral, oblique and scaphoid view
• Radiographs can be delayed for up to 4 weeks
• ?MRI, bone scan, or treat and repeat film
Scaphoid Fracture Treatment• Cast 6-12 weeks• Short arm vs. long
arm• Follow patient every 2
weeks with x-ray• CT and clinical
evaluation to determine healing
• Consider screwing early
Non Operative Treatment- Disadvantages
• Nonunion rate 5-55%• Delayed union• Malunion• “cast disease”- joint stiffness• Prolonged immobilization- sometimes >12
weeks• Loss of time from employment and avocations
Scaphoid Fracture - Referral
• Angulated or displaced (1mm)
• Non-union or AVN• Proximal fractures• Late presentation• Early return to play
desired
Union Rates 100%
Wrist Case 2
Soccer player has pain in ulnar side of wrist after a fall
Triangular Fibrocartilage Complex (TFCC) Tear
• Fall on dorsiflexed and ulnar deviated wrist
• Axial load with forearm in hyperpronation
• Positive ulnar variance predisposes to injury
TFCC Tear Diagnosis
• Exam– Ulnar sided wrist pain– Often experience a
click
• Imaging– Radiographs– MR arthrogram
TFCC Tear Treatment• Splinting• Time• Injection• Surgical treatment
– Debridement– Repair– Open vs. arthroscopic– Ulnar shortening
osteotomy
TFCC Tear Referral
• Pain
• They take a long time to get better- 3-6 months of splinting
Wrist Case 3
25-year-old tennis player twists wrist as he falls backwards reaching for a lob
Scapholunate Dissociation
• Most common ligamentous instability of the wrist
• Patients may have high degree of pain despite apparently normal radiographs
• Physicians should suspect this injury if patient has wrist effusion and pain seemingly out of proportion to the injury
• If improperly diagnosed can lead to chronic pain
• Located proximal axial line from 3rd metacarpal
Scapholunate Dissociation- Diagnosis
• Exam– Watson’s test– Scaphoid shuck test– Pain/swelling over
dorsal wrist, proximal row
• Imaging– Plain films: >3mm
difference on clenched fist view
– Scaphoid ring sign
Scapholunate Dissociation Treatment
• If discovered within 4 weeks, surgery
• After 4 weeks, conservative treatment reasonable– Bracing– NSAIDS– Consider evaluation by
hand surgery to confirm no surgery needed
Scapholunate Ligament Dissocation Referral
• All will go onto to cause some problem
• Allow the specialist to make the ultimate decision
Wrist Case 4
The Ithaca College starting softball shortstop presented with pain at the base of her left thumb. It was aggravated by hitting when she rolled her left hand over the top.
DeQuervain’s Tenosynovitis• Pain due to
inflammation of the short extensor and abductor tendons of the thumb
• Repetitive or unaccustomed griping and grasping causes friction over the distal radial styloid
DeQuervain’s Tenosynovitis: Diagnosis
• Swelling and pain over 1st dorsal compartment
• +Finkelstein’s test
DeQuervain’s Tenosynovitis: Treatment
• Splint• Injection- 1st line
– up to 90% are pain free if injected within 6 months
• Splinting performs poorly in comparison to steroid injection
Coldham F.. British Journal of Hand Therapy.2006
DeQuervain’s Tenosynovitis: Referral
• Recurrence despite repeated injections
Wrist Case #5 An Ithaca College crew
athlete presented following spring break training trip in Georgia. She reported pain distal dorsal medial forearm, accompanied by swelling, and palpable/audible crepitus. Her pain was exacerbated by feathering her oar.
Intersection syndrome• Friction point where muscle
bellies of 1st compartment- Abductor Pollicis Longus and Extensor Pollicis Brevis cross 2nd and 3rd dorsal compartments
• Inflammatory peritendinitis• Common with rowers due to
clenched fist and thumb abduction
• Friction and crepitus felt 4-5cm proximal to radial styloid with rest flexion and extension and radial deviation
Intersection Syndrome Diagnosis
• Pain and swelling about 2-3 finger breadths proximal to dorsal wrist joint
• Palpable crepitus (“squeaker’s wrist”
Intersection Syndrome Treatment
• Splinting
• Activity modification
• Icing
• Nsaids
• Corticosteroid injection
Intersection Syndrome Referral
• Failure of conservative measures
• Tenosynovectomy and fasciotomy of abductor pollicis longus can be performed
Ganglion Cyst
• Account for 60% of soft tissue, tumor-like swelling affected the hand and wrist
• Develop spontaneously in 20-50 year olds
• Female to male, 3:1• Cyst filled with soft, gelatinous,
sticky, and mucoid fluid• Location
– 65% dorsal scapholunate joint– 20-25% volar distal aspect of
the radius– 10-15% flexor tendon sheath
Ganglion Cyst Diagnosis
• Usually obvious on exam- may be helpful to flex and extend wrist
• Radiographs, ultrasound, or MR not usually indicated
Ganglion Cyst- Treatment
• Watchful waiting- most resolve spontaneously over time
• Bible treatment- not recommended
• Aspiration/Injection– No recurrence in 27-67% of patients
Ganglion Cyst Referral
• Patient preference• Pain• Cosmetic?
Carpal Tunnel Syndrome• Most common nerve
entrapment disorder• Pain and parasthesias
from high pressures in the carpal tunnel causing compression and inflammation of the median nerve
• Carpal bones dorsally and transverse carpal ligament (flexor retinaculum) ventrally
Carpal tunnel syndrome
Hand Diagrams
Sn = 0.64; Sp = 0.73
NPV = 0.91
Tinel + hand diagram – PPV = 0.71
Ann Intern Med 1990 Mar 1;112(5):321-7.
Carpal Tunnel Syndrome
Sensitivity and Specificity
• For both Phalen’s and Tinel’s is LOW– Phalen’s – Sn= 0.75 ; Sp = 0.47– Tinel’s – Sn= 0.60; Sp= 0.67
• Combine with hand diagram and history
Ann Intern Med 1990 Mar 1;112(5):321-7
Nerve Conduction Study
• Can be painful and costly• Reserve for patients who
– have failed conservative therapy– diagnosis is uncertain– late presentation with thenar wasting and motor
dysfunction
• False negative rates as high as 10%
J Hand Surg [Am] 1995 Sep;20(5):848-54
Carpal Tunnel Syndrome Diagnosis– Pain involves thumb, first two fingers and
radial half of the fourth finger– Palpation: thenar eminence wasting– ROM: thumb weakness and difficulty pincher
grasping– Diagnostic Tests or special maneuvers
• Nerve conduction studies• Tinel’s• Phalen’s
Carpal Tunnel Syndrome Treatment
• Ice
• Activity modification
• Workspace modification
• Splinting
• Injection
• Surgery
Carpal Tunnel Injection• Short term efficacy:
RCT, 70% vs 34% at 2 weeks (steroid vs sham)– NNT = 2.8– Long-term benefits are
more variable• 43% of patients above
required referral to surgery
Muscle Nerve 2004 Jan;29(1):82-8
Injection technique: 23-25g needle; 1-2 cc of lidocaine plus 20-40mg Methylprednisolone. Injected radial side of palmaris longus tendon
Carpal Tunnel Syndrome Referral
• Constant numbness and tingling
• Thenar eminence wasting
• If get EMG, moderate to severe carpal tunnel or dennervation
Kienbock Disease
• Avascular necrosis/vascular insufficiency– ?repetitive microfractures of lunate
• Young adults 15-40 years old
• Risk factors: negative ulnar variance
Kienbock Disease: Diagnosis
• EXAM– Wrist pain that radiates
up the forearm – stiffness, tenderness,
swelling over lunate• passive dorsiflexion of
middle finger produces characteristic pain
• Radiographs, MRI
Kienbock Disease
• Stage I – IV– Stage I: MRI only– Stage II: Sclerosis– Stage III: Some
collapse– Stage IV: Total collapse
Kienbock Disease: Treatment• Primarily surgical
– EARLY: Radial shortening, ulnar lengthening– LATE: proximal row carpectomy, arthrodesis
Thank You!