12  Hand Injuries in the Athlete

12.1 Metacarpal and Phalangeal Fractures

Metacarpal and phalangeal fractures are the most common injuries in the upper extremity both in athletes and the general population alike.1 Although fracture patterns may not differ from those seen in the general population, time to recovery and functional expectations are much greater for the athlete. Stable anatomical fixation is key to initiating early active range of motion (ROM). Recent advancements in instrumentation allow for percutaneous techniques that are rigidly stable and minimally invasive.

12.1.1 Intra-articular Phalangeal Fractures

Unicondylar fractures are common among athletes. Unfortunately, these injuries are frequently misdiagnosed as a sprain and, consequently, often present in a subacute fashion.2 Weiss et al³ reported on their series on 30 consecutive patients with unicondylar fractures of the proximal phalanx. Their findings indicated that 19 of their 38 fractures occurred at sporting events and identified four predominant fracture patterns. Class 1 was a volar oblique, class 2 a long sagittal, class 3 dorsal coronal, and class 4 volar coronal. Types 1 and 2 failed under tension applied across the collateral ligaments, whereas types 3 and 4 failed in compressions due to hyperflexion or hyperextension, respectively. Class 1 volar oblique type fractures were the most common (n = 22). The mechanism of injury is thought to occur due to a force, which produces lateral angulation and rotation on a slightly flexed digit. Additionally, the volar oblique fracture pattern affected the inner condyle of the outermost digits. Lastly, fractures treated with a single K-wire were most likely to undergo late displace and have the worst outcomes.³

Authors’ Favored Surgical Technique

Percutaneous techniques are attempted when patients present within 7 to 10 days of injury. If a closed or percutaneous reduction cannot be obtained, a mini-open midlateral approach is used to expose the fracture site. The skin is divided sharply, the lateral bands are identified and retracted dorsally. A pointed reduction clamp is used for provisional fixation, and reduction is confirmed with fluoroscopy. A guidewire for a cannulated headless compression screw is then advanced parallel to the articular surface as perpendicular to a fracture plane as possible. A second K-wire is placed into the fracture fragment to prevent rotation on screw insertion. Screw size is estimated using the cannulated depth gauge. The near cortex is then reamed and an appropriately sized screw is advanced over the guidewire and across fracture. A typical screw measures 8 to 10 mm. If there is a large metaphyseal extension, the derotational guidewire can be used to insert an additional screw. If the insertion of two screws is anticipated, the second guidewire should be inserted from the phalanx into the condylar fragment from the opposite side of the digit. The trajectory of the second K-wire typically takes a dorsal proximal to volar distal orientation to traverse the fracture plane in a perpendicular fashion. The skin is nicked with a 11 blade and blunt dissection is carried down to the bone with hemostats. The length of the screw is estimated with a depth gauge and the appropriate-sized screws are then inserted as previously described.

Post-op Care and Outcomes

Active ROM exercises are initiated immediately post-op and strengthening exercises are started 4 to 6 weeks following surgery. Athletes can return to competitive athletics a week after surgery with the injured finger buddy taped to an adjacent digit.

Geissler et al⁴ reported on 25 patients with intra-articular fractures of the phalanges stabilized percutaneously with cannulated headless compression screws. Eighteen patients had unicondylar fractures of the proximal phalanx, three had intra-articular fractures of the base of the proximal phalanx, and four had intra-articular fractures of the base of the distal phalanx of the thumb. All fractures healed without displacement or malunion. No patient required hardware removal. Average ROM for unicondylar phalangeal fractures was 5 degrees of flexion to 85 degrees of flexion. Average ROM for fractures of the thumb distal phalanx base was 15 degrees of extension to 60 degrees of flexion. Geissler4 concluded that percutaneous cannulated headless compression screw fixation was superior to K-wires as it affords stable fixation without the risk of pin tract infection or hardware irritation. We apply this fixation principles to other coronally unstable intra-articular phalangeal fractures ( Fig. 12.1, Fig. 12.2, Fig. 12.3, Fig. 12.4, Fig. 12.5, Fig. 12.6).

12.1.2 Phalangeal Shaft Fractures

Phalangeal shaft fractures occur in various morphologies, including transverse, oblique, spiral, and comminuted patterns, all of which are amendable to various fixation techniques. However, the athlete has the added burden of early return to play. Low-profile locked plating provides the most ridged fixation at our disposal. The increased dissection required for application plate have been associated with increased stiffness and prolonged time to union. The increased risk of stiffness occurs because of the intimate relationship between the extensor and flexor mechanisms of the digit to the phalanges. Consequently, there is no optimal surface available for plate placement that would avoid insult to the tendon apparatus of the digits. The risk of scaring and stiffness may be somewhat mitigated in the collegiate athlete due to the abundant physical therapy resources at their disposal. Kodama and colleagues5 retrospectively reviewed 105 metacarpal and phalangeal fractures. They identified 20 athletes who required early return to sport within 1 month from injury. This subgroup was treated with ORIF. Mean follow-up was 27 months and average total active ROM was 263 degrees. Conclusions are somewhat limited due to sample size of 20 and heterogeneity in fracture morphology treated.

Fig. 12.1 Middle phalanx proximal base intra-articular fracture with ulnar angulation.

Fig. 12.2 Middle phalanx fracture with clinically evident ulnar angulation.

Fig. 12.3 PA P2 base fracture with intra-articular extension. Single cannulated screw provides rotational stability by applying compression across the fracture.

Fig. 12.4 Lateral P2 base fracture with intra-articular extension. Single cannulated screw provides rotational stability by applying compression across the fracture.

Fig. 12.5 Eight weeks’ status postpercutaneous cannulated screw fixation.

Fig. 12.6 Eight weeks’ status postpercutaneous cannulated screw fixation.

Fig. 12.7 Midlateral approach on the ulnar aspect of the digit.

Fig. 12.8 2-mm locking plate. Medartis. (Basel, Switzerland)

Fig. 12.9 2-mm locking plate. Medartis. (Basel, Switzerland)

A midaxial approach is centered over the fracture as previously described ( Fig. 12.7, Fig. 12.8). If access to the base of the phalanx is required, a portion of the lateral band can be divided to improve exposure. When practical, we prefer to approach the fracture on the ulnar aspect of the digit to avoid injury to the insertions of the lumbricals on the lateral bands. The fracture is identified and fracture hematoma is cleared and the fracture is provisionally fixed with K-wire and clamps as necessary. Rotational alignment is checked clinically and fracture reduction is confirmed under fluoroscopy. A 1.5-mm plate is precontoured and placed along the side of the phalanx. Nonlocking screws are used to secure the plate to the bone followed by locking screws to create a fixed angle construct. We typically attempt to place three screws on the other side of the fracture ( Fig. 12.9).

If early return to sports is not necessary, less invasive percutaneous techniques may be implemented as previously described. Long oblique fractures, where the length of greater than twice the diameter of the diaphysis and spiral fractures are well suited for cannulated headless compression screw fixation. When using headless screws in the shaft, it is important to predrill both the near and far cortex to avoid cortical blowout on screw insertion.

Post-op Care and Outcomes

Dabezies⁶ reported on 22 patients who attained average total active ROM 247 degrees open reduction and internal fixation (ORIF) of proximal phalangeal fractures. Skilled athletes return to sport as soon as wound heals with injured digit buddy tapped to the adjacent digit. Contact players may return to play with club cast to avoid forceful gripping of an opponent’s jersey ( Fig. 12.10).

Fig. 12.10 Ole Miss linebacker 1 week’s status post-ORIF of proximal phalanx.

12.1.3 Metacarpal Fractures

Metacarpal (MC) fractures occur commonly among contact sport players. The most frequently affected metacarpals are those of the small and ring finger. Of note, MC neck fractures (aka boxer’s fracture), is rarely seen in actual boxers and is more characteristic in amateur brawlers. The major deforming force acting on the MC are the intrinsic musculature. The volar axis of pull produces the typical apex dorsal angulation seen with these fractures. The border metacarpals are more susceptible to shortening than the central metacarpals which are tethered by the deep transverse intermetacarpal ligaments. Malalignment of the metacarpals is known to produce to unique complications in the hand. Every 2 mm of fracture shortening produces 7 degrees of extensor lag. There is measureable loss of grip strength with greater than 30 degrees of volar angulation.7 Any amount of malrotation produces digit scissoring and clinically noticeable overlap.⁸

Conceptually, MC shaft malalignment tolerances increase as you move distally and ulnarly in the hand. The increased motion at the carpometacarpal (CMC) joints of the ulnar metacarpals allows them to compensate for greater angulation than their radial counterparts. Fractures that occur more distally produce less shortening and less volar displacement of the MC joint for a given amount of flexion angulation than a more proximal fracture with the same amount of angulation. As a result, a distal small finger MC neck fractures may tolerate as much as 70 degrees of flexion, where as an index finger midshaft fracture should not be allowed to heal with greater than 5 to 10 degrees of malalignment. Fractures within alignment tolerances after reduction typically heal with excellent outcomes after cast immobilization for 8 to 12 weeks. As with phalangeal fractures, if immediate return to play is necessary, ORIF of even well-aligned fractures should be discussed with the player and their family.

Authors’ Favored Surgical Technique

We usually prefer 2-mm plates with 1.5- or 2-mm screws for MC fracture fixation. We aim to place a minimum of four bicortical locking screws on either side of the fracture. Locking cage plates with staggered screw holes allow for placement of screws over a broader surface area. Oblique fractures are provisionally reduced with clamps and fixed with lag screws. Fixation is then protected with a 2.0 mm plate in the standard neutralization fashion. Maximizing the construct’s working length and contact foot print minimizes stress risers and the potential for refracture in the athlete ( Fig. 12.11, Fig. 12.12).

Post-op Care and Outcomes

Active ROM in initiated immediately post-op. Athlete returns to play 1 to 2 weeks postoperatively after wound has healed. Geissler⁹ reported on retrospective cohort of 10 patients with MC shaft fractures treated with ORIF. Eight patients were treated with plates and screws, two with simple lag screws. All patients returned to play within 2 weeks from surgery. All fractures healed within 8 weeks postoperatively.

Fig. 12.11 Unstable ring finger spiral metacarpal shaft fracture (a) in a collegiate football player stabilized with 2-mm Medartis (Basel, Switzerland) locking cage plate (b).

Fig. 12.12 Unstable small finger spiral metacarpal shaft fracture (a) in a collegiate football player stabilized with 2-mm Medartis (Basel, Switzerland) locking cage plate (b).

12.2 Carpal Fractures

Hand and wrist injuries constitute 3 to 9% of all sports injuries.10 Carpal fractures typically result from a direct axial load or a direct blow from a solid object such as a ball or a bat. Eliciting the sport and position of the athlete plays a critical part of the medical history as certain injuries are characteristics of specific sports. Scaphoid fractures, for example, can occur in an instance of 1 in a 100 of college football players.¹⁰ Hook of the hamate and trapezial ridge fractures often occur in stick handling sports such as golf, baseball, and tennis.

12.2.1 Scaphoid Fractures

Scaphoid fractures are the most common carpal fractures accounting for 6 to 7% of all carpal fractures.11 Scaphoid fractures are not unique to the athlete and are commonly seen after a fall of outstretched hand and forcible hyperextension when catching a ball. Scaphoid fractures, in general, have gained notoriety for their propensity to progress to nonunion. The irregular anatomy of the bone makes it difficult to identify fractures on plain films. As a result, these fractures classically present in a delayed fashion. Tenuous blood supply and strong deforming forces further contribute difficulties achieving union. The primary blood supply of the scaphoid enters along its dorsal ridge and perfuses the proximal 80% of the bone in a retrograde fashion.¹² Consequently, the more proximal of the fracture line, the longer time to union and the higher the incident of avascular necrosis (AVN). The prevalence of AVN of the proximal pole has been reported to be as high as 30% after scaphoid waist fracture and nearly 100% with proximal fifth fractures.¹³ Time to union can be as fast as 6 weeks in scaphoid tubercle fractures and greater than 4 months for proximal pole fractures. Scaphoid waist fractures can be expected to heal by 3 months when treated conservatively with cast immobilization. Prolonged healing time frames can have serious implications on an athlete’s career and should be discussed in depth at initial presentation.

Evaluation

The athlete will present in an acute or subacute fashion with radial-sided wrist pain after falling onto outstretched hand. Symptoms may be relatively mild and the injury may have been misdiagnosed as a wrist sprain. On physical examination, the patient will demonstrate snuff box tenderness or tenderness directly over the scaphoid tubercle. A scaphoid view should be obtained in addition to the three standard projections of the wrist. This view is obtained by placing the palm flat on the cassette, the shoulder and elbow at 90 degrees, and the wrist in ulnar deviation. If radiographs are negative but there is high clinical suspicion of a fracture, the patient can be placed in short arm cast and repeat images are obtained in 2 weeks out of plaster. If immediate identification of the fracture is required, an MRI can be performed within the first 48 hours or a scintigraphy maybe performed after 72 hours to identify an occult fracture.^14–16 Computed tomography (CT) scan has been used to characterize fracture pattern and malalignment, but has been less effective in identifying an occult fracture compared to magnetic resonance imaging (MRI) and scintigraphy.¹⁷ When return to play is not necessary, nondisplaced fractures of the scaphoid waist can be managed with casting immobilization with union rates of 90 to 95%. Fractures of the middle and proximal third have been shown to have shorter time to union when immobilized with long arm thumb spicas. Fractures of the scaphoid tubercle or the distal third healed quickly regardless of type of cast.¹⁸

Absolute indications for acute fixation are displacement and fractures associated with carpal instability. Scaphoid displacement is characterized by 1-mm translation, 1-mm gap, or 15 degrees of angulation.^19,20 Angulation of the scaphoid can be estimated on a lateral projection by measuring the scapholunate or radiolunate angles. Values greater than 60 for scapholunate or 15 degrees for radiolunate are considered abnormal and are correlated with nonunion rates as high as 50%.^13,21,22 Proximal third scaphoid fractures, unstable fracture patterns, and delayed presentation are considered relative indications for fixation. Delayed presentation beyond 4 to 6 weeks increases incidence of nonunion in conservative management. Vertical oblique fracture patterns are inherently unstable, are unlikely to remain nondisplaced throughout their period of mobilization. Although fractures of the proximal third have been treated conservatively with cast mobilization, they typically require 4 to 5 months of casting. Consequently, some authors recommend early internal fixation for these troublesome fractures to minimize the complications associated with prolonged immobilization. Established scaphoid nonunions are known to progress to scaphoid nonunion advance collapse (SNAC).23 Accordingly, it is generally recommended that nonunions be addressed surgically even if asymptomatic. However, in the athlete, once an asymptomatic nonunion has been established, it should be addressed after the end of the season.

Surgical Treatment

Several surgical techniques have been described in the literature for the treatment of scaphoid fractures. Examples include dorsal and volar percutaneous techniques, arthroscopic-assisted techniques, and dorsal and volar open techniques. The palmar open exposure provides access to middle and distal third of the scaphoid, allows correction of the humpback deformity, and provides an opportunity for vascularized bone grafting. Additionally, it leaves the main dorsal blood supply undisturbed. The dorsal approach provides access to the proximal pole of the scaphoid. However, exposure and reduction maneuvers are limited by the dorsal blood supply.²⁴ The palmar approach extends from the scaphoid tubercle proximally along the radial aspect of the flexor carpi radialis (FCR). The superficial branch of the radial artery is identified and retracted. Alternatively, it may be ligated if more exposure is necessary. The FCR tendon sheath is then incised and the FCR is retracted ulnarly to expose the volar wrist capsule. The capsule is divided and in line with the incision. The scaphotrapeziotrapezoidal (STT) joint is identified and the volar tubercle of the trapezium is excised to gain access for the starting point of the guidewire of the Acutrak screw.²⁵ K-wires are inserted into the proximal and distal fragments and used as joysticks to reduce the fracture. A third K-wire can be advanced across the fracture site to hold the provisional reduction and protect against rotational displacement during screw insertion. Next, the guidewire for the cannulated screw may be driven in a retrograde fashion across the fracture along the axis of the scaphoid. Confirm with fluoroscopy that the far end of the guidewire has not been driven past the dense subchondral bone of the proximal pole. At this point, if there is a residual bony deficit at the fracture site, it may be filled with cancellous autograft harvested from the distal radius. Choose a screw that is 4-mm shorter than the estimated screw size predicted by the depth gauge. Appropriately countersinking the screw avoids prominent hardware proximally and distally. Confirm hardware position and fracture reduction on orthogonal fluoroscopic views. Remove the derotational K-wire and close the capsule. Hemostasis confirmed prior to skin closure.

The proximal pole of the scaphoid is exposed via a dorsal approach. A longitudinal incision is centered over the proximal pole of the scaphoid and made in line with the radial aspect of the long finger. Subcutaneous tissue is bluntly dissected to avoid injury to the dorsal cutaneous branches of the superficial radial sensory nerve. Identify and develop the interval between the third and fourth dorsal compartments and incise the capsule in line with the incision. Take care to avoid injury to the scapholunate ligament during the capsulotomy. Once the proximal pole of the scaphoid is identified, avoid excessive dissection over the dorsal scaphoid to prevent injury to its blood supply. Flex the wrist to gain access to the volar most aspect of the proximal scaphoid. The starting point for the guidewire will be immediately radial to the insertion of the scapholunate ligament on the proximal pole. Aim the trajectory of the guidewire down to the axis of the scaphoid and bury wire into the far subchondral bone. Confirm position of the wire with fluoroscopy taking care not to bend the guidewire during manipulation of the wrist. A second K-wire may be passed across the fracture site to protect against rotational displacement during screw insertion. Screw length is measured and inserted as previously described. Confirm hardware placement and fracture reduction on orthogonal fluoroscopic views ( Fig. 12.13).

Arthroscopic techniques are best suited for nondisplaced scaphoid fractures. Given that nondisplaced fractures are typically treated nonoperatively, clear indications for implementation of these surgical techniques remain somewhat controversial. Benefits include percutaneous insertion of hardware, direct visualization of fracture reduction, and limited postoperative immobilization.

Authors’ Favored Surgical Technique

A standard diagnostic wrist arthroscopy is performed with the scope inserted through the 3–4 portal. After ruling out associated injuries, the scope is transferred to the 6R portal and a 14-gauge needle is advanced through the 3–4 portal into the radiocarpal joint. The arthroscopy tower can be laid horizontally to allow real-time fluoroscopy during arthroscopy ( Fig. 12.14). The 14-gauge needle is then embedded into the cartilage just radial to the scapholunate ligament at the volar aspect of the proximal pole. The guidewire for the cannulated screw is then aimed at the base of the thumb and advanced through the needle and into the scaphoid along its axis. A second derotational pin may be placed across the fracture but outside the trajectory of the central screw. Reduction of the fracture is confirmed by transferring the arthroscope to the radial and ulnar midcarpal portals. Position of the guidewire and fracture alignment is confirmed on fluoroscopy. The near cortex is predrilled and an appropriately sized screw is advanced as previously described.²⁶

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