General Principles
Overview
- •
Fortunately, most sports-related hand and wrist injuries, when addressed in a timely manner, do not represent a significant threat to limb viability, long-term function, or eventual return to sports.
- •
Perhaps the greatest morbidity from these injuries results from delayed presentations or missed injuries.
- •
Hand function is closely linked to full flexion of the ulnar three digits, prehension grip in the radial three digits, and a stable, mobile wrist.
Physical Examination
- •
Dictated by the context of the injury. No single, comprehensive evaluation applies to all maladies.
- •
Attention is directed toward the individual part and system (bone, joint, tendon, nerve, etc.) in question.
Observation/Inspection
- •
Focal swelling, digital perfusion, digital malrotation, digital cascade, and any penetrating injury must be noted.
- •
Any difference in posture of one digit relative to the others should not be dismissed or minimized because this often signifies a displaced fracture, tendon avulsion, or joint subluxation.
- •
In the absence of a penetrating injury, isolated pallor of a digit usually represents spasm of the digital vessels. Although this often resolves with digital warming or reduction of associated displaced fractures or dislocations, digital viability remains in question until perfusion is actually observed.
- •
Even in closed fractures, the digital vessels can tear or thrombose, representing a surgical emergency.
- •
Dorsal swelling of the hand is a nonspecific finding and may not represent a significant injury.
Palpation
- •
Careful palpation of specific bones or ligaments in question is fundamental to assessment. There are not many “referred-pain” injuries in the hand or wrist—tenderness to palpation does not lie.
- •
Focused palpation will usually localize the injured structure within an area of generalized edema demonstrating diffuse swelling; for example, a swollen wrist following distal radius fracture or perilunate injury
- •
Tenderness over a scapholunate ligament, even in the setting of normal radiographs, will suggest an underlying ligament tear that would have poor prognosis if not recognized and treated.
Specific Injuries and Conditions
Nail Bed Injury
Description: Any tear or disruption of the sterile or germinal matrix of the nail bed; may or may not be associated with an underlying distal phalanx fracture or actual disruption of the nail plate ( Fig. 51.1 )
Figure 51.1
Nail bed injury.
Mechanism of injury: Usually caused by dorsal crush of the fingertip (such as when the fingertip is crushed by another player’s cleated shoe); however, may also occur with axial load to the fingertip that results in flexion fracture of the distal phalangeal shaft and tear of the overlying nail bed
Presentation: If the nail bed is disrupted, subungual hematoma results. The tear may extend peripherally beyond the borders of the nail fold into the surrounding skin (see Fig. 51.1 ).
Physical examination: Gross instability of the fingertip with nail bed injury is suggestive of a concomitant distal phalangeal shaft fracture.
Differential diagnosis: If the base of the nail plate is flipped out dorsally over the nail fold, consider an open fracture of the proximal portion of the phalanx. In skeletally immature patients, the presence of the physis at this location may result in failure to recognize what is, in fact, an open Salter–Harris I phalangeal fracture.
Diagnostics: Physical examination is usually sufficient. Anteroposterior (AP) and lateral radiographs reveal an underlying distal phalanx fracture.
Treatment: For small subungual hematoma encompassing a portion of the nail plate, no intervention is necessary. Decompression of the hematoma through needle fenestration of the nail plate can offer pain relief; however, this may increase the likelihood of wound sepsis if performed on a playing field (see Fig. 51.1 ). For larger hematomas (50% of the nail plate) with tearing beyond the nail fold borders, formal repair is recommended. Under a digital block anesthetic, the nail plate should be removed, the wound irrigated, and the nail matrix repaired with either a topical skin adhesive or a 7-0 resorbable suture. The adjacent skin rip is repaired with a 5-0 nylon suture. An underlying phalangeal tuft fracture is nonsurgically managed. However, the associated unstable distal phalangeal shaft requires washout and perhaps pin stabilization.
Prognosis and return to play: If no nail bed repair is required, immediate return to play is alright. Following nail bed repair, the fingertip (including distal interphalangeal joint [DIP]) should be dressed and splinted to protect from impact. If there is an associated unstable phalangeal shaft fracture requiring pin fixation, return to play should be delayed until pin removal. Prognosis for nail plate growth is directly related to anatomical restoration of the nail bed. If there is a wide scar in the matrix, a ridge or split in the nail plate will occur. Open fractures through the nailbed require urgent surgical debridement in the operating room. Displaced distal phalangeal shaft fractures are often unstable and require pinning.
Mallet Finger
Description: Loss of terminal extensor mechanism attachment to the distal phalanx with resultant flexion deformity of the DIP joint
Mechanism of injury: Sudden forced flexion of the DIP joint during active extension through the terminal tendon, often as a result of a ball jamming the fingertip ( Fig. 51.2 )
Figure 51.2
Mallet finger.
Presentation: The DIP joint is maintained in flexion with an inability to actively bring the joint into full extension. Varying degrees of pain, often with minimal or no pain; swelling or ecchymosis may be noted over the dorsal aspect of the joint.
Differential diagnosis: Distal phalanx fracture or DIP dislocation
Diagnostics: Posteroanterior (PA) and lateral radiographs of a digit to assess if injury is limited to the soft tissue (tendon only) or has associated bony avulsion (see Fig. 51.2 ). Lateral radiographs determine stability based on the size of the bony component and whether palmar subluxation is present.
Treatment: Acute mallet injuries with no subluxation on the lateral radiographs require full-time splinting of the DIP joint in extension for 6–8 weeks (see Fig. 51.2 ). Displaced bony components with joint involvement of >30% and/or palmar subluxation often require surgery to restore joint congruity. The DIP joint will usually require transarticular pinning in full extension with surgery. Primary surgical repair of acute, closed, soft-tissue mallet injuries has not proven to be superior and may have more significant complications.
Prognosis and return to play: Noncompliance with splint wear will negatively impact the outcome and usually results in mild-to-moderate degrees of extension lag. The functional effect of this is variable. Most athletes nonsurgically treated will return to play within a week (while splinted). With surgical treatment, return to play will depend on the athlete’s ability to protect a transarticular pin. Any activity requiring grasp is likely to result in bending or breakage of the pin.
Jersey Finger
Description: Traumatic avulsion of flexor digitorum profundus (FDP) from distal phalanx ( Fig. 51.3 ); tendon may detach alone or avulse a palmar fragment of the distal phalanx; ring finger most commonly affected
Figure 51.3
Jersey finger.
Mechanism of injury: Forced passive extension of DIP joint during active flexion of DIP joint
Presentation: Typically seen in football and rugby players attempting to grab a jersey; variable degree of pain, although the player may complain of pain proximally in the finger or palm at the level of the retracted tendon. Usual concern is inability to flex the involved DIP joint. Unfortunately, many of these cases are delayed presentations.
Physical examination: Ecchymosis may be present at DIP joint, depending on timing of presentation. The flexor tendon stump may be tender or palpable in the palm or along the digit, depending on the level of proximal retraction. Bony avulsions tend to become incarcerated along the flexor sheath (often at the A4 pulley over the middle phalanx). Loss of active DIP joint flexion is the most specific finding.
Differential diagnosis: Distal phalanx fracture and DIP joint dislocation
Diagnostics: PA and lateral radiographs of injured digit to check for bone avulsion fragment; ultrasound may identify a retracted tendon rupture.
Treatment: Surgical reattachment of the flexor tendon within 7–10 days if the tendon has retracted into the palm; if tendon has retracted only to the proximal interphalangeal (PIP) level, reattachment may be successful with a delay of up to a few weeks. For flexor tendon avulsions with bony component, internal fixation is necessary to restore continuity of the flexor tendon.
Prognosis and return to play: Soft tissue FDP avulsions require 12 weeks of protected activity before return to full gripping and grasping activities. Bony avulsions amenable to open reduction and internal fixation (ORIF) require 4–6 weeks of protected activity. Both types of FDP avulsions also require extensive hand therapy after surgery.
Proximal Interphalangeal (PIP) Joint Dislocation and Fracture-Dislocation
Description: Usually, the middle phalanx displaces dorsal to the proximal phalanx. However, rotatory (with the proximal phalanx condyle protruding between the lateral band and central slip), volar, and lateral dislocations, though less frequent, do occur. With dorsal dislocation, fracture often occurs at middle phalangeal base ( Fig. 51.4 ). Direct axial load, however, may result in a comminuted pilon fracture of the entire articular surface and metaphysis.
Figure 51.4
Proximal interphalangeal (PIP) joint dislocation.
Mechanism of injury: Usually, hyperextension of PIP joint with varying degrees of axial loading; often occurs from a ball, another participant, or ground jamming into the finger.
Presentation: Usually with pain and swelling around PIP joint with or without angular deformity; patient will be apprehensive to active or passive motion
Physical examination: Pain localized to PIP joint with swelling; collateral ligaments will be tender because they are disrupted; occasionally will have skin laceration or a palmar skin tear.
Differential diagnosis: Volar plate injury without dislocation; phalangeal, articular, or periarticular fracture
Diagnostics: PA and lateral radiographs of the injured digit must be performed to verify congruent reduction and rule out fracture or subluxation but can be delayed for a few days if “on the field” reduction is clinically stable. If the initial reduction attempts seem unsuccessful, radiographs should be obtained before repeated efforts. Reduction may be impeded from a fracture component or different orientation of dislocation (see Fig. 51.4 ).
Treatment: Digital blocks with 1% lidocaine without epinephrine may be helpful. Closed reduction employing longitudinal traction, slight extension, and dorsal pressure over middle phalanx for dorsal dislocations. After reduction, range of motion (ROM) and joint stability must be evaluated. Radiographic or fluoroscopic confirmation of reduction is required within a few days. Without a significant periarticular fracture, instability requiring surgery is unlikely. For rotatory dislocation, manipulation with the metacarpophalangeal (MCP) and PIP in flexed position facilitates reduction. Volar dislocation is reduced with slight PIP flexion and dorsal translation of the middle phalangeal base. Following reduction of volar dislocation, it is crucial to protect the central extensor slip insertion (which generally is always disrupted in volar dislocation) with immobilization of PIP in full extension in order to avoid inevitable progression to boutonniere deformity. For fracture-dislocations , closed reduction with longitudinal traction and subsequent dorsal blocking splint to hold the flexed PIP joint may be adequate, depending on size of fractured palmar joint margin. In general, if fracture involves <40% of the articular surface, this technique is useful. The joint is gradually moved into greater degrees of extension with weekly radiographic verification of maintained reduction over the ensuing 4–6 weeks. Fractures with persistent dorsal subluxation after closed reduction require surgical stabilization.
Prognosis and return to play: Return to play is usually minutes after closed reduction of dorsal dislocations. Buddy taping to adjacent digits or aluminum extension block splinting should suffice; early follow-up radiographs are mandatory . Athletes with stable reduction of dorsal dislocation without associated fracture can continue playing most sports, avoiding forced passive hyperextension for initial 3 weeks. Volar dislocations need to be splinted in full extension for approximately 6 weeks to protect the central slip. During this time, active DIP motion is employed to promote gliding of lateral bands. Swelling and stiffness may persist for several months. Open surgical treatment of fracture-dislocations requires no forceful grip or impact for 4–6 weeks and usually results in some loss of PIP motion.
Metacarpal Fracture
Description: Fracture of metacarpal neck, shaft, or base
Mechanism of injury: Axial load or clenched fist impact are common mechanisms for distal or proximal metaphyseal fractures. Direct dorsal impact (such as baseball striking batter’s hand or another participant stepping on hand) often results in shaft fractures ( Fig. 51.5 ).
Figure 51.5
Metacarpal fracture.
Presentation: Localized swelling, with or without angular deformity of digits
Physical examination: Point tender over metacarpal fracture with swelling; angular and sometimes rotational deformity (scissoring) of digits (see Fig. 51.5 ). Scissoring is more easily detected if patient is able to offer a certain degree of digital flexion.
Differential diagnosis: Contusion or MCP joint dislocation
Diagnostics: PA, lateral, and oblique radiographs of the hand
Treatment: Surgical treatment for fractures with angulation of >50 degrees of ring and small fingers and angulation of >20 degrees of index and middle fingers. Shortening of >5 mm and shaft fractures of the border digits (small and index) may also need ORIF. Significant rotational deformity/scissoring also is an indication for ORIF. Most cases are nonsurgically treated with splint spanning wrist and hand for 3–4 weeks. Reduction of metacarpal neck fractures is practically difficult to maintain using a splint or cast. Pinning is usually required, often leading to joint stiffness; hence, most metacarpal neck fractures are allowed to heal with some flexion deformity as long as there is no rotational component or associated loss of PIP flexion.
Prognosis and return to play: Stable fractures not requiring surgery usually require 3–4 weeks of splinting while swelling and soreness subsides. Transition to hand-based splints may allow skilled position players to return within 1–2 weeks depending on level of discomfort. Surgically treated fractures require 2–4 weeks before ROM and pain allow return to sports.
Injuries to the PIP Joint Central Extensor Slip Insertion/Boutonniere Deformity
Description: Central slip of the extensor tendon inserts on the dorsal base of the middle phalanx. Disruption of this insertion results in loss of full active PIP joint extension. Over time, adjacent lateral band tendons migrate and become fixed palmar to the axis of rotation of the PIP joint, resulting in a boutonniere deformity characterized by PIP flexion and DIP hyperextension ( Fig. 51.6 ).
Figure 51.6
Injuries to the PIP joint central extensor slip insertion/boutonniere deformity.
(From Green D, Hotchkiss R, Pederson W, eds. Green’s Operative Hand Surgery , 5 th ed. Philadelphia: Churchill Livingstone, Elsevier; 2005.)
Mechanism of injury: May occur with forced passive PIP flexion against active extension through the central slip tendon, resulting in avulsion; volar PIP dislocations often result in avulsion of the central slip insertion; dorsal PIP laceration through the central slip (hockey skate) will result in boutonniere deformity if left untreated.
Presentation: Often has a subtle presentation and a high index of suspicion is required. Nonspecific presence of swelling is usually present about the PIP joint, and the joint may be maintained in slight flexion (see Fig. 51.6 ). However, in the immediate phase, the patient may be able to maintain PIP extension through the lateral bands, which have not yet palmarly migrated.
Physical examination: Palpate for tenderness directly over the central slip insertion on the dorsal middle phalangeal base. Collateral ligament tenderness may also be present, but tenderness at the central slip insertion should raise concern. A sensitive method to assess disruption of the central slip is the Elson test (see Fig. 51.6 ). A digit is placed on a table with the PIP joint flexed over the edge. While the proximal phalanx is held firmly flat on the table by the examiner, the patient attempts active extension of the PIP joint. Any pressure felt by the examiner on the dorsum of the middle phalanx suggests some continuity of the central slip insertion. If the central slip has torn and retracted proximally, there will be loss of active PIP extension as well as reduced passive DIP flexion (normally floppy and supple) during the attempt.
Differential diagnosis: Nonspecific swelling around PIP joint could represent anything from mild collateral ligament injuries to periarticular fractures.
Diagnostics: PA and lateral plain radiographs are needed to rule out periarticular fractures or avulsion of dorsal margin of middle phalangeal base.
Treatment: For closed injuries noted early (within 2–3 weeks), the lateral bands may not have yet become fixed in a position palmar to the axis of rotation. Closed treatment with full-time PIP splinting in full extension and active DIP flexion/extension exercises often results in healing of the central slip to its insertion bed while preserving lateral band mobility; should be continued for 6–8 weeks. Open lacerations require primary surgical repair of the tendon followed by protection of the repair with full PIP extension splinting and active DIP motion as discussed earlier. Delayed presentations with fixed boutonniere postures are exceedingly difficult to treat. Salvage procedures in the form of terminal extensor tendon releases and even PIP fusion may be required depending on the degree and rigidity of the contracture.
Prognosis and return to play: Primary prognostic factors are prompt diagnosis and initiation of closed treatment. The digit must be protected from PIP flexion for at least 6 weeks. Fixed boutonniere deformities have a poor prognosis in terms of regaining full active motion.
Flexor Tendon Laceration
Description: Transection of flexor tendon at wrist, hand, or finger
Mechanism of injury: Laceration to palmar aspect of wrist, hand, or digit, often from cleat, spikes, or blade of skate
Presentation: Skin laceration with inability to flex digit(s) distally ( Fig. 51.7 ); resting cascade of digit in question will demonstrate less resting flexion of the DIP or PIP joint than surrounding digits
