Overview of Pathologies
Athletic participation frequently places the hand and wrist at risk of injury. It has been reported that as few as 3% to as many as 25% of all athletic injuries involve the hand and wrist. Certain sports place exceedingly high demands on the hand and wrist. For instance, gymnasts are reported to have a 49% to 87% incidence of wrist injury over the course of their gymnastic career.
All sports increase the risk of falls and collisions in athletes, which may lead to sprains, fractures, and dislocations. Additionally, overuse of the hand and wrist in competition and training may lead to tendinopathy and tendon rupture. Injuries often occur in sport- and position-specific patterns as a result of unique biomechanics. For instance, the palms of baseball players are subject to repeated blunt trauma from catching and batting, predisposing these athletes to fractures of the hook of the hamate, an injury otherwise uncommon in the general population and even in athletes from other sports. Cyclists may experience compression of the ulnar nerve at the wrist that is related to their grip, whereas bowlers may experience irritation of the ulnar digital nerve of the thumb.
Consultants must be familiar with the spectrum of pathology affecting the athlete’s hand and wrist and then use a thorough and methodical history and physical examination to narrow the differential diagnosis. Further imaging studies are then used to confirm diagnoses and determine treatment options.
Because numerous pathologic conditions may affect the wrist, division of the wrist into four quadrants facilitates consideration of and the ability to remember the various differential diagnoses. For the purposes of this chapter, the radial quadrant will include the area from the flexor carpi radialis (FCR) to the extensor carpi radialis longus (ECRL), the dorsal quadrant will extend from the ECRL to the extensor carpi ulnaris (ECU), the ulnar quadrant will extend from the ECU to the flexor carpi ulnaris (FCU), and the volar quadrant will extend from the FCU to the FCR.
Common sporting-related injuries that affect the radial quadrant include FCR tendinopathy; scaphoid or trapezial ridge fracture; De Quervain tenosynovitis and intersection syndrome; thumb carpometacarpal (CMC) synovitis, fracture, or dislocation; volar wrist ganglion; superficial radial nerve entrapment; and scaphotrapezotrapezoidal (STT) or thumb CMC arthritis. Figure 71-1 illustrates the relevant surface anatomy of the radial quadrant.
Tendon disorders are prominent within the radial quadrant. These disorders include FCR tendinopathy, De Quervain tenosynovitis, and intersection syndrome. These injuries are frequently due to overuse such as in racquet sports and rowing and tend to present with an insidious onset. The FCR tendon is easily palpable along the entire length of the radial-volar side of the forearm just ulnar to the radial artery. Pain distally at or just proximal to the wrist flexion crease over the FCR tendon suggests FCR tendonitis. De Quervain tenosynovitis refers to inflammation of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) as they course through a fibro-osseous tunnel at the radial styloid. De Quervain tenosynovitis is the most common wrist tendonitis, particularly in athletes who participate in racquet sports and rowing. Intersection syndrome (also called crossover tendonitis ) is a tendinopathy located at the anatomic crossing of the first (APL/EPB) over the second (ECRL/extensor carpi radialis brevis) compartments in the distal third of the forearm. Intersection syndrome presents similar to De Quervain tenosynovitis, but the pain is 4 to 5 cm more proximal and is frequently accompanied by audible and palpable crepitance. Intersection syndrome is frequently seen in rowers, weightlifters, football lineman, and powder skiers because of the repetitive wrist extension and radial deviation required by these activities.
Fractures are common after a collision or fall onto an outstretched hand. Such fractures present with immediate pain, swelling, and tenderness. Radial quadrant fractures include the radial styloid, scaphoid, trapezial ridge, and thumb metacarpal base. The scaphoid is the most commonly fractured carpal bone, representing roughly two thirds of all carpal fractures, and thus a high index of suspicion should always be maintained regarding injury to this bone. The typical mechanism of injury is a fall onto an outstretched hand; such injuries are very common in contact sports, basketball, skiing, snowboarding, and skateboarding. In fact, Rettig has recommended that all athletes with radial-sided wrist pain be diagnosed with a scaphoid fracture until proven otherwise. Less common and at times easily missed are fractures of the trapezial ridge. The mechanism of injury is often the same as for a scaphoid fracture, but the pain is located in the thenar eminence. In a professional baseball player, a malunited trapezial ridge fracture that was missed was reported to lead to FCR tendonitis.
Degenerative processes such as STT and CMC arthritis are common in aging athletes and usually present insidiously; however, an acute event often will exacerbate preexisting pain that was only mild.
The radial quadrant is the second most common location for a ganglion cyst (usually dorsal and adjacent to the scapholunate [SL] ligament). Volar wrist ganglions are typically intimately associated with the radial artery adjacent to the FCR tendon and are the most commonly encountered mass in the radial quadrant. They typically arise from either the FCR tendon sheath or radioscaphoid joint.
Nerve entrapment may also present in the radial quadrant. The dorsal sensory branch of the radial nerve becomes superficial as it exits from beneath the brachioradialis muscle roughly 5 cm proximal to the radial styloid. It runs adjacent to the cephalic vein, which is easily visible along the radial border of the wrist, and is susceptible to blunt trauma and entrapment in this area, producing pain known as Wartenberg syndrome.
The next quadrant is the dorsal quadrant (ECRL to ECU). Athletes may present with pain in this region from carpal instability (SL ligament tears, midcarpal instability, and perilunate injuries); extensor tendinopathy and carpal boss; distal radius, capitate, and lunate fractures; Kienböck disease; scaphoid impaction; and dorsal ganglion cysts. Each of these conditions manifests focal pain as shown in Figure 71-2 , which illustrates the relevant surface anatomy of the dorsal quadrant.
As in the radial quadrant, pain from tendinopathy most often occurs as a result of overuse and repetitive actions. At times, extensor tendonitis can present with rather impressive swelling and pain over the wrist or digital extensor tendons. A bony prominence known as a carpal boss can sometimes occur at the insertion of the radial wrist extensors. Although it is often clinically silent, a carpal boss can become symptomatic with overuse of the wrist or after a direct blow is sustained in this area.
Pain directly dorsal over the SL interval (at the location of a 3-4 wrist arthroscopy portal) can be due to scaphoid impaction, an SL ligament tear (or a larger spectrum of a carpal instability injury pattern), a dorsal carpal ganglion, fracture (scaphoid or lunate), or Kienböck disease. Scaphoid impaction, which is often seen in gymnasts and weightlifters, occurs with repetitive wrist hyperextension that results in impingement of the scaphoid on the dorsal edge of the radius and presents with pain upon wrist extension with the potential for osteophyte formation. Carpal instability encompasses a broad spectrum of ligamentous deficiency including acute and chronic conditions from traumatic and atraumatic causes. In athletes, the most common of these conditions, particularly after an acute traumatic event, is injury of the scapholunate ligament. These injuries are very common in contact sports, and the examiner should always have a high index of suspicion because missed injuries can lead to chronic debilitating wrist arthritis known as scapholunate advanced collapse.
Historically the ulnar quadrant has been the least well understood of the four quadrants and has been termed “the black box” by Kleinman and others. Recent advancements in our understanding of ulnar-sided wrist pain have led to much improved diagnostic and therapeutic care for these injuries. It is useful to distinguish between pathology arising from the radioulnar, ulnocarpal, and intercarpal articulations and pathology that is extraarticular. Figure 71-3 shows the ulnar quadrant surface anatomy.
One of the most common extraarticular sources of ulnar-sided wrist pain is the ECU tendon. Tendinopathy of the ECU is extremely common in athletes, second only to the incidence of De Quervain tendonitis. Tendinopathy of the ECU has a predilection for baseball, hockey, golf, and racquet sports, typically with pain generated by a backhand volley. When the forearm is pronated and the wrist is in neutral, the tendon has a direct course through its sheath toward its insertion on the base of the fifth metacarpal. However, this angle increases when the wrist is positioned in supination, ulnar deviation, and wrist extension. Excessive extension, as well as rapid flexion, ulnar deviation, and supination, can cause tendinopathy or lead to attritional or traumatic ruptures of the ECU subsheath, resulting in painful subluxation or dislocation of the tendon, often associated with a snapping sensation.
When assessing ulnar-sided wrist pain, injury to the triangular fibrocartilage complex (TFCC) should always be kept in mind. This structure provides support to the distal radioulnar joint (DRUJ) and transmits axial load across the ulnocarpal joint. Athletic endeavors that involve high-energy or repetitive axial or torsional forces may lead to ulnar impaction syndrome, tear of the TFCC, and DRUJ instability. Persons with ulnar positive variance are known to be at higher risk for the development of ulnar impaction. Although the incidence of ulnar-positive wrists in athletes is not known, it has been noted that football lineman and gymnasts may be at higher risk for the development of ulnar-positive variance because of chronic distal radial physeal loading and premature arrest.
Moving distally on the dorsal-ulnar wrist, the intercarpal (lunotriquetral [LT] ligament) and carpometacarpal articulations are encountered. Injury to the LT ligament may occur with a fall, particularly with hyperextension and twisting, although the exact mechanism is controversial. CMC fractures at the base of the fifth metacarpal are common after blunt force injury or after striking with the ulnar side of the hand. Dorsal triquetral fractures are also common after a fall during sports and should be kept in mind when focal pain is present over the dorsal aspect of the triquetrum. A pronated oblique radiograph is necessary at times to find this small avulsion fracture. Anatomically, this injury represents more of an extrinsic ligament avulsion than a true carpal fracture.
Lastly, the volar quadrant should be considered. The surface anatomy of this quadrant can be seen in Figure 71-4 . From an osseous standpoint, the pisiform and hook of the hamate are important to consider given their higher predilection for injury during sport. The pisiform is a mobile sesamoid within the FCU tendon, which may then continue to insert on portions of the hamate and the base of the fifth metacarpal. The hamate hook protrudes from the hamate body and is a site of muscular and ligamentous attachment. Injuries to these ulnar-sided carpal bones are relatively rare but should be considered in athletes who use bats, racquets, clubs, or sticks, because errant impact is transmitted directly to the hypothenar region of the nondominant palm. A history of a “check swing” in baseball or a “fat” shot in golf should raise suspicion further. A fall onto the outstretched hand may also be responsible for fractures of these structures. Increased participation in sports has led to a recent increase in the prevalence of acute ulnar carpal fractures and chronic stress fractures. Additionally, arthritis may develop between the pisiform and the triquetrum with which it articulates.
The FCU, which inserts onto the pisiform, can be a source of volar-ulnar wrist pain. Tendinosis may develop with repetitive microtrauma, such as that which occurs in racquet sports. Occasionally, acute calcific tendinitis may develop, which may be mistaken for infection or gout because of the sometimes dramatic erythema and intense pain associated with this condition.
The volar quadrant houses the most critical neurovascular structures of the hand and wrist. The ulnar artery and nerve course deep and radial to the FCU tendon and enter the wrist at Guyon’s canal. In this location the ulnar artery is relatively superficial and may be compressed against the underlying hamate. Repetitive blunt trauma may therefore cause local arterial occlusion or aneurysmal dilation, which may further lead to distal embolization or compression of the nearby ulnar nerve. These clinical findings are referred to as the hypothenar hammer syndrome, which is well described in baseball catchers, as well as some tennis players and golfers. It usually presents as dysthesias or intolerance of the ring and small fingers to cold temperatures.
The ulnar nerve is more commonly compressed at the elbow, particularly in athletes who throw. However, compression or irritation at the wrist may also occur at Guyon’s canal as a result of an extrinsic mass effect such as a ganglion, lipoma, or aneurysmal dilation of the ulnar artery, as well as focal prolonged external compression. This last entity is well described in cyclists.
The median nerve, along with the digital flexor tendons, crosses the wrist in a fibro-osseous sheath known as the carpal tunnel. Compression of the median nerve within this sheath is the most common peripheral compression neuropathy, but it is not considered particularly common in the athletic population. Nevertheless, it has been described in sports that require forceful or prolonged gripping, such as cycling and rock climbing, or that require repeated direct volar pressure on the extended wrist, as in wheelchair rim propulsion. Additionally, exposure to vibration has been associated with a risk of carpal tunnel syndrome, with implications for motor sport athletes.
We will now consider injuries to the hand and fingers. The hand and digits are especially vulnerable to injury during athletic participation, and in fact are the most commonly fractured body site, making up 32% of all high school sports-related fractures. Both phalangeal and metacarpal fractures are extremely common in sports, with phalangeal fractures representing more than half of all sports-related hand fractures. Additionally, injuries to certain ligaments and tendons occur with such frequency that they carry the name of the offending sport, such as “skier’s thumb” or “boxer’s knuckle.”
Starting distally, we will consider injuries to the distal interphalangeal (DIP) joint. Fingertip crush injuries are extremely common in athletes and may result in distal phalangeal fractures and nail bed injuries. Distal phalangeal fractures are the most common of all hand fractures. In the skeletally immature athlete, a unique dorsally displaced transphyseal distal phalanx fracture known as a Seymour fracture can present with associated nail bed incarceration in the fracture site. Axial loads to the end of the finger can rupture the terminal tendon, resulting in the inability to extend the DIP joint, which is termed “mallet finger” or “baseball finger.” This injury is particularly common in athletes who play baseball, football, and basketball and is the most common closed tendon injury in athletes. On the opposite side of the digit, an avulsion of the flexor digitorum profundus (FDP) from its insertion may occur with swift pulling away of a forcefully flexed finger. This injury frequently occurs while grabbing the jersey of an opponent in football or rugby and therefore is commonly called “jersey finger.” The ring finger is involved in more than 75% of cases.
Moving proximal, the PIP joint is next considered. According to Rettig, the proximal interphalangeal (PIP) joint is the most commonly injured structure of the hand in athletes. Disruption of the extensor mechanism, collateral ligaments, and/or volar plate may occur in this highly constrained hinge joint. These injuries are usually partial and often are referred to as a “jammed finger,” but they can range from minor sprains to open fracture/dislocation. A 10-year review of the National Football League database found that dorsal PIP dislocations are the most common hand injury. Dislocations present with gross malalignment and are often reduced by the player or trainer “on the field” with manual traction. After closed reduction, the joint should be assessed clinically by applying gentle angular force and ensuring that a stable, concentric range of motion is present. The joint also should be assessed radiographically to rule out an associated fracture and confirm that congruent reduction has occurred. Radiographic stress views may be helpful in detecting subtle instability.
At the level of the PIP joint, the insertion of the extensor mechanism dorsally is known as the central slip. Disruption of the central slip can lead to a deformity known as a boutonnière deformity; prompt recognition of this injury is paramount.
At the metacarpophalangeal (MCP) joint, dorsal pain is common after athletic injuries. Causes of this pain may include collateral ligament injuries, sagittal band ruptures, dorsal capsule ruptures, and fracture. Often associated with striking, injuries in this area carry eponyms such as “boxer’s fracture” (i.e., a fifth metacarpal neck fracture) and “boxer’s knuckle.” Boxer’s knuckle classically refers to disruption of the dorsal MCP capsule, but some authors have applied it to closed sagittal band ruptures as well. On the volar side of this joint, pain may result from a volar plate injury, a sesamoid fracture, or the common trigger finger.
Although all digits are subject to collateral ligament injuries from sports-related trauma, the thumb collateral ligaments warrant additional discussion because of their critical role in stable pinching and gripping in athletes. Although the acute injury derives its name from downhill skiing (“skier’s thumb”), ulnar collateral ligament (UCL) injuries are very common in many athletic pursuits, including racquet, ball, and stick sports.
One last uncommon but important athletic hand injury to mention is flexor pulley ruptures. The digital flexor tendons are stabilized by a system of annular and cruciate pulleys, with the A2 and A4 pulleys overlying the proximal and middle phalanges, respectively. These two pulleys are the most critical to prevent bowstringing of the flexor tendons. Sustained resistive flexion forces on the fingers may result in acute pulley ruptures, which are most commonly seen in rock climbers engaging in a crimp position hold. Isolated A4 ruptures have been reported in professional baseball pitchers.
History and Physical Examination
General information that should be initially gathered for all patients includes the patient’s age, sport, position, hand dominance, any preexisting pain or injury to the involved hand/wrist, factors that worsen or relieve pain, and associated medical conditions. For athletes, it is important to know the player’s position and the specific stresses placed on the hand and wrist. This information is important not only for diagnosis of the injury but also to guide appropriate return to play. An injury in the throwing hand of a quarterback will likely be managed very differently compared with the identical injury in a defensive lineman. When obtaining a history, patients should be asked about chronicity, mechanism of injury, initial management, subjective weakness, and any associated loss of consciousness.
When examining the wrist and forearm of a patient, the examiner should begin seated across from the patient, with the patient’s elbow resting on the examination table and the hand toward the ceiling with the forearm in neutral rotation (as if starting an arm wrestling match) ( Fig. 71-5 ). General inspection should include any focal areas of swelling, ecchymosis, or effusion, any open wound or laceration, and any finger or joint malalignment. The patient should be asked to point to the area of maximal tenderness, and this area should be evaluated last.
Next, active and passive range of motion should be evaluated with use of a goniometer. Active and passive range of motion should be determined for all relevant joints of the digits, thumb, and wrist. Specifically, active and passive motion of the wrist includes flexion and extension, radial and ulnar deviation, and pronosupination. During active motion, any pain or mechanical symptoms of locking or popping should be documented. It is quite common for patients with true carpal pathology to have some loss of wrist flexion. Normal wrist active range of motion is roughly 80 degrees of flexion, 70 degrees of extension, 30 degrees of ulnar deviation, 20 degrees of radial deviation, and 90 degrees of both pronation and supination. Range of motion is always compared with the opposite side.
Next, grip strength should be determined with the use of a dynamometer and compared with the contralateral unaffected side. Weakness of grip strength is a very sensitive global assessment tool for wrist and hand pain and can be used to track improvement in subsequent visits, as well as aid in return-to-play decisions (many physicians use 85% grip strength as a relative guideline in the return-to-play algorithm).
The most useful tool for ascertaining the correct diagnosis for hand and wrist pathologies is knowledge of the surface anatomy. Most hand and wrist structures are directly palpable once the examiner learns their exact locations. Ascertaining the point of maximal tenderness is the most critical physical examination maneuver for determining the correct diagnosis in the hand and wrist (see Figs. 71-1 to 71-4 ). Later in this chapter we will look at each quadrant of the wrist and the fingers to specifically address these points of maximal tenderness.
Lastly, no physical examination is complete without a detailed neurovascular examination. Radial and ulnar pulses, as well as capillary refill to all fingertips, should be documented for all patients. If any concern exists about vascular compromise, an Allen test should be performed, which is described in detail in the physical examination portion of this chapter. Median, ulnar, and radial sensory examination should be carried out, preferably with a two-point discriminator, with normal discrimination being less than 5 mm. Intrinsic and extrinsic muscle strength should be documented, along with any associated muscle atrophy. Sport-specific neurovascular pathologies exist, such as ulnar nerve entrapment in Guyon’s canal in cyclists and hypothenar hammer syndrome in baseball catchers.
The interosseous membrane and elbow (discussed in a different chapter) should always be evaluated as well, because concomitant injuries can occur and may be overlooked in the face of a hand or wrist injury.
The physical examination of the wrist should proceed in a systematic fashion. We prefer to begin the examination in areas that are nonpainful and conclude the examination at the area of maximal tenderness. In this chapter, we will begin with the radial quadrant and work around the wrist.
Radial Quadrant
The radial quadrant may be thought of as extending from the FCR to the ECRL (see Fig. 71-1 ). Again, common pathologies affecting the radial quadrant include FCR tendinopathy; scaphoid or trapezial ridge fracture; De Quervain tenosynovitis and intersection syndrome; thumb CMC synovitis, fracture, or dislocation; volar wrist ganglion; superficial radial nerve entrapment; and STT or thumb CMC arthritis. The FCR tendon is subcutaneous and can be palpated in its entirety from the musculotendinous junction until it enters the fibro-osseous FCR tunnel at the STT joint on its way to insert on the second metacarpal base. The FCR can be more easily visualized by placing the wrist in flexion and slight radial deviation and having the patient resist wrist flexion. Tenderness along the FCR tendon distally is seen in persons with FCR tendinopathy or FCR tunnel syndrome and may be exacerbated with resisted wrist flexion. Just distal to the wrist flexion crease and in line with the course of the FCR lies the bony protuberance of the distal pole of the scaphoid (volar tubercle or scaphoid tuberosity). Being able to reliably palpate this structure is critical. It will become more prominent with wrist radial deviation and flexion and less palpable with ulnar deviation and extension. This anatomic landmark is critical for wrist examination and for performing a Watson scaphoid shift test, which will be described later in this chapter. Distal pole scaphoid fractures and even scaphoid waist fractures and SL ligament tears will have pain reproduced with a dorsally applied pressure to the volar tubercle.
A trapezial ridge fracture will present with pain in the thenar region after a fall. The trapezial ridge serves as the radial attachment of the transverse carpal ligament and can be avulsed with a sizable bony fragment. A carpal tunnel radiographic view or computed tomography scan aids in the diagnosis of this easily overlooked fracture.
Moving slightly radial, the radial artery is easily palpable, and pulses and results of an Allen test should be documented. The superficial branch of the radial artery can be palpated as it courses obliquely across the volar-radial aspect of the wrist just proximal to the scaphoid tuberosity. The deep branch of the radial artery dives beneath the first dorsal compartment into the proximal aspect of the anatomic snuffbox.
Moving in a dorsal and radial direction, the next palpable structure is the radial styloid and first dorsal compartment (APL and EPB). The very tip of the radial styloid is easily palpable and represents the distal edge of the first dorsal compartment tendon sheath. Tenderness at this location may represent a radial styloid fracture or a radiocarpal ligament sprain in the acute injury setting, or more often De Quervain tenosynovitis in a subacute or insidious presentation. A Finkelstein test has been shown to be reliable and very sensitive (although not always specific) for De Quervain tenosynovitis. In its original description, this test is performed by passively flexing the thumb of the patient and assessing for pain ; however, the test has been modified by many examiners, who ask the patient to place the thumb within a closed fist and deviate the wrist in an ulnar direction ( Fig. 71-6 ). Pain also may be elicited with resisted thumb abduction and extension. Similar pain located about 4 to 5 cm proximal to the radial styloid and slightly more ulnar is typically due to intersection syndrome. Often, intersection syndrome is accompanied by audible or palpable crepitation at this precise location, and a positive Finkelstein test may also be manifested.
