Soft Tissue Injuries of the Wrist and Hand



Soft Tissue Injuries of the Wrist and Hand


D. Nicole Deal

A. Bobby Chhabra



INTRODUCTION



  • Injuries to the wrist and hand are common in sports. In the past, these injuries were frequently designated as sprains. More recently, however, the “waste basket” terms wrist sprain and jammed finger have given way to a specific diagnosis and a defined treatment plan. An understanding of wrist and hand anatomy, biomechanics, and function allows the physician to pinpoint specific pathology and treatment, thus allowing quicker return to sport for the athlete with a wrist or hand injury. Missed or misdiagnosed injuries can result in permanent deformity and loss of function. Radiographs are indicated in nearly all cases to evaluate for fracture or dislocation and to evaluate for joint incongruity or avulsion fracture in cases of joint or tendon injury.


EPIDEMIOLOGY



  • The incidence of injuries to the wrist varies according to sport. Hand and wrist injuries occur more frequently in younger athletes than adults. A study performed at the Cleveland clinic found that 9% of all athletic participants under the age of 16 sustained injuries involving the wrist (4). In another study, 35% of all injuries in adolescent football players involved the wrist (42). Ligamentous laxity is often seen in athletes. This joint hypermobility can lead to partial or complete ligament tears following a loading of the wrist or may predispose to cumulative injury after repetitive stress (48). Overuse syndromes of the wrist are also common in athletes as a result of tension failure or shear stresses (35).


DORSAL WRIST SYNDROMES



  • Chronic wrist pain on the dorsal aspect of the wrist can be a result of occult dorsal ganglion or dorsal impaction/dorsal impingement syndromes. Ganglions account for the most frequent soft tissue tumors of the wrist. Of these, 60%-70% originate from the dorsal scapholunate ligament and are extraarticular manifestations of a connection to the scapholunate joint. A history of wrist trauma is found in 15% of patients with a dorsal ganglion (2). An occult dorsal ganglion is difficult to detect on clinical examination and may only be palpable with extreme flexion (2). Symptoms are generally inversely related to the size of the ganglion, as smaller, tense ganglions produce more pain than larger, soft cysts. Patients often complain of localized tenderness, limitation of motion, and/or weakness of grip. Ultrasound or magnetic resonance imaging (MRI) can be more useful than plain radiographs. Often, the diagnosis is made by exclusion. Initial treatment should include aspiration followed by steroid injection of the dorsal capsule followed by immobilization (44). When conservative treatment has failed to relieve the symptoms, excision of the capsule and ganglion from the scapholunate ligament is performed. Results are generally favorable, with ultimate full return to competition in the majority of cases.


  • Dorsal impaction syndromes occur as a result of repetitive loading of the wrist in maximum extension and happen most frequently to gymnasts. The shear forces created by this action may lead to localized synovitis or even osteocartilaginous fractures (26). The athlete will often complain of pain and point tenderness on the middorsal aspect of the wrist, at the projection of the lunocapitate joint (14). Progression of the problem may lead to radiographic changes including a hypertrophic ridge of the dorsal rim of the scaphoid or the dorsal border of the lunate as a result of impingement with the capitate during hyperextension. Successful treatment usually results from restriction of wrist hyperextension, strengthening of the wrist flexors, and local steroid injection. Failure of relief of symptoms should be followed by immobilization and cessation from sport for 4-6 weeks. If symptoms should continue to persist, either abandonment of the activity or surgical treatment consists of limited synovectomy and cheilectomy of hypertrophic margins that impinge during hyperextension. Return to sport may not be possible in all cases, but relief of pain generally occurs following treatment.



CARPAL INSTABILITY



  • Carpal instability can be seen in any athlete in a contact sport following a collision injury but may also be a result of chronic repetitive loading in noncontact sports. Carpal instability can be seen as a spectrum of injuries ranging in symptoms and functional deficit. Initial injury may present as something as innocuous as an occult dorsal or intracapsular ganglion (mentioned earlier) and progress to dynamic instability, then static instability, and ultimately to scapholunate advanced collapse (SLAC) (24). The dynamic instability is not apparent on routine radiographs but is reproduced by manipulation and seen on stress radiographs in pronated clenched fist views (8). Static instability can be seen on routine radiograph as abnormal carpal alignment (47). Carpal collapse is seen following complete disruption initially of ligaments between the scaphoid and lunate, progressing to disruption between the lunate and triquetrum and finally to the midcarpal joints. Carpal ligamentous injuries are common in athletes and require physicians, trainers, and therapists who treat and diagnose these injuries to have an understanding of the carpal anatomy and potential for progression to instability (45).


Scapholunate Dissociation



  • Scapholunate instability occurs as the ligamentous support of the proximal pole of the scaphoid is disrupted and the scaphoid rotates into palmar flexion. The carpal instability associated with this injury is a dorsal intercalated segmental instability (DISI) deformity. This can be reproduced clinically during physical examination by performing the Watson maneuver (49). Radiographically, this is shown by widening of the scapholunate interval (compared to the uninjured wrist), an increase in the scapholunate angle (> 70 degrees; normal, 30-60 degrees), and a cortical ring sign in which the distal pole of the perpendicular scaphoid is seen end-on on the anteroposterior view of the wrist.


  • Successful treatment may consist of closed reduction and percutaneous pinning if initiated within the first 3-4 weeks after injury. This may also be performed under arthroscopic guidance. In most cases, open reduction, ligamentous repair, and internal fixation with Kirschner wires is the most reliable treatment in the management of scapholunate ligament injuries in athletes. For chronic scapholunate dissociation without advanced arthritic changes, a dorsal capsulodesis and ligament reconstruction as described by Blatt (5), a Brunelli procedure using flexor carpi radialis (FCR) tunneled through the distal pole of the scaphoid (7), or when ligament reconstruction is not possible, a scaphotrapezial-trapezoidal fusion as described by Watson and Hempton (50) may be performed. Postoperatively, the wrist is immobilized in slight palmar flexion and pronation. Return to contact sports is limited after treatment for carpal instability.


Lunotriquetral Instability



  • Injuries to the lunotriquetral ligaments may range from sprain to partial tear to complete tear with or without carpal malalignment. The carpal instability associated with this injury is a volar intercalated segmental instability (VISI) deformity. This complete injury occurs rarely in athletes. Symptoms consist of pain on the dorso-ulnar side of the carpus with a positive lunotriquetral ballottement test as described by Reagan et al. (37). Injection of local anesthetic to the lunotriquetral joint usually relieves symptoms and restores grip strength. Routine radiographic evaluation is able to detect static instability as evident by volar flexion of the lunate in neutral deviation. Midcarpal arthrography and MRI may demonstrate incomplete or complete tears of the lunotriquetral ligaments, or radiocarpal arthrography may detect a simultaneous injury to the triangular fibrocartilage, particularly in an ulna-positive patient. Ulnar variance has been shown to be associated with the location of injury. An ulnar minus variance is related to radial axis injury, whereas an ulnar neutral or plus variance has been linked to ulnar axis injury.


  • Treatment of acute or untreated chronic injuries with no evidence of a tear consists of injection of a corticosteroid preparation followed by immobilization. Surgical treatment is considered when disabling pain continues and cessation from sport is not an alternative and consists of lunotriquetral ligament repair when possible. Arthroscopy may be valuable in staging and determining treatment and may be used to assist in reduction and pinning in both acute and chronic ligament tears without advanced collapse (52). In patients with an ulna plus variance, ulna shortening is the treatment of choice. Lunotriquetral arthrodesis has been performed but without uniform success (48) and is rarely performed in athletes (52).


ULNAR TRANSLOCATION



  • Ulnar translocation is an extremely rare injury in athletes that is usually a result of a severe violent impact, such as in motor sports. In order for complete translocation to occur, complete disruption of both the volar and dorsal radiocarpal ligaments must take place. As a result, the carpus is allowed to slide along the incline of the radius in the ulnar direction. Physical examination includes severe swelling, loss of motion, and deformity. Radiographic evaluation will demonstrate translation of the carpus, rotation of the proximal carpal row into palmar flexion, and scapholunate diastasis due to ulnar displacement of the lunate.


  • There is no role for nonoperative treatment in this injury. Surgical exploration reveals extensive capsular tears, frequently including the scapholunate ligament. Taleisnik (47) believes that capsular reattachment commonly results in recurrence, and if stability is achieved, it is usually at the expense of loss
    of motion. As a result, he recommends radiolunate arthrodesis to maintain reduction that results in a stable, pain-free wrist with satisfactory preservation of motion. This may allow an athlete to return to strenuous activity when full range of motion is not mandatory.


TRIANGULAR FIBROCARTILAGE COMPLEX INJURY



  • The triangular fibrocartilage complex (TFCC) is made up of the triangular fibrocartilage (TFC), a cartilaginous disc that lies on the ulnar head and several supporting ligaments and acts as a stabilizer of the distal radioulnar joint (DRUJ). Injury to this structure may result in 2 forms, perforation of the disc (traumatic or degenerative) or avulsion (traumatic) of the disc with or without avulsion of the supporting ligaments. Avulsion of the TFCC occurs following acute dislocation or subluxation of the distal ulna relative to the radius. Degenerative tears usually occur after the third decade (29). Ulnar variance may play a role in degenerative changes of the TFC. Palmer et al. (32) found the center of the TFC to be thinner in ulna plus wrists. Lunotriquetral tears may occur following degenerative perforation of the TFC leading to carpal instability. Young athletes with ulna plus variants, who participate in repetitive loading of the wrist, may be susceptible to degenerative changes of the TFC similar to older patients (14).


  • Patients with injury to the TFC frequently complain of ulnar-sided wrist pain exacerbated by forearm rotation. It is important to discern injury to TFC from injury to the DRUJ. Injury to the TFC is suspected when tenderness and crepitus are palpated between the ulna and triquetrum. Relief of pain during manual stabilization of the DRUJ during forearm rotation may be an indicator of DRUJ instability. Diagnostic evaluation may include plain radiographs, MRI, arthrography, and/or arthroscopy. Demonstration of ulna plus variance on plain radiographs adds to suspicion of TFC injury, and ulnolunate impaction “kissing” lesions are common. Arthrography may exhibit a communication between the radiocarpal and distal radioulnar joints. MRI and arthroscopy have been helpful in determining the size and location of lesion of the TFC.


  • Treatment of acute injury of the TFC includes immobilization of the wrist in neutral rotation for up to 4-6 weeks. Gradual progression of activities may then begin with the use of supportive splinting. An injection into the ulnocarpal space with steroid may also be helpful and diagnostic prior to immobilization. If the athlete is unable to return to sport and symptoms persist, then surgical debridement of the perforation and/or repair of the TFCC should be performed (28). Decompression can be obtained through ulnar shortening (25), DRUJ excisional hemiarthroplasty (6), or the Kapandji procedure (12). If a peripheral tear is found in the outer 15%-20% of the TFC, a repair may be considered in conjunction with ulnar recession as needed (48). For patients with ulna plus variance and a degenerative tear of the TFC, ulnar shortening is the treatment of choice, whereas excision of the TFC and the Darrach procedure should be avoided. For patients with ulna minus variant, debridement of the TFC defect may relieve pain and will not increase load transmission providing only the central third is removed. For acute avulsions causing DRUJ instability, above elbow immobilization with the DRUJ reduced usually is successful. If instability persists, reattachment of the TFC is performed, usually at the fovea of the ulnar styloid using suture and drill holes (16).


FINGERTIP INJURIES


Subungual Hematoma



  • Many crush injuries to the fingertips will damage the nail and underlying matrix, causing blood beneath the nail and throbbing pain. These injuries may also be associated with tuft fractures of the distal phalanx, which are typically open fractures because they communicate through the nail matrix disruption (18).


  • Hematoma involving less than 50% of the nail matrix may be drained using a heated paperclip, an 18-gauge needle, or a battery-operated cautery to create one or multiple holes in the nail. An anesthetic digital block may be necessary prior to drainage. Soaking the finger in sterile water with peroxide will facilitate drainage. A sterile dressing should then be applied, with a Stack splint in cases involving fracture (9,18).


  • Hematoma involving more than 50% of the underlying nail bed is presumed to be associated with an open fracture. Radiographs, surgical removal of the nail, thorough irrigation and debridement of the wound, repair of the nail matrix, and replacement of the nail with splinting are recommended (9).


Nail Avulsion



  • If nail avulsion occurs without damage to the underlying sterile matrix, the wound should be thoroughly cleansed and dressed with a nonadherent dressing. If the proximal portion of the nail has also been avulsed from the nail fold and germinal matrix, the patient’s cleansed nail or a piece of sterile gauze or foil should be slid under the eponychial fold to prevent adherence (9).


  • If any part of the sterile or germinal matrix has been torn or lacerated, removal of any remaining nail fragments and repair of the nail bed injury are mandatory. Again, the eponychial fold should be splinted open (9).


Fingerpad Injuries



  • Simple lacerations may be cleansed and sutured using nonabsorbable monofilament in adults or absorbable suture in children. Grossly contaminated wounds may be cleansed and left open.



  • Partial amputations with soft tissue loss measuring less than 1 cm (2) will heal by secondary intention and may be treated with cleansing and serial dressing changes. Even larger defects will heal well in children. Larger wounds involving exposed bone or tendon, nail bed injury, or more proximal amputation should be emergently treated by a hand surgeon (9,18).


JOINT INJURIES OF THE FINGERS



  • Dislocations are usually clinically apparent; are characterized by pain, limited movement, and digit deformity and should be radiographed prior to reduction to assess for associated fracture if there is any crepitus, bony point tenderness, or open injury.


  • Other dislocations can be reduced and splinted, and a postreduction radiograph obtained. Any irreducible dislocation or dislocation associated with an open wound requires emergent referral (34).


  • Local or regional anesthesia may be necessary to obtain adequate pain relief and relaxation for reduction. Digital blocks are placed by injecting the ulnar and radial webspaces of a digit, anesthetizing the dorsal and volar digital nerves. The local anesthetic should not contain epinephrine, which could cause digital ischemia.


Distal Interphalangeal Joint



  • Distal interphalangeal (DIP) joint dislocations are uncommon, almost always dorsal, and often open. These injuries are frequently associated with tendon disruption (see sections on mallet and jersey finger).


  • If there is no open wound or tendon rupture and closed reduction is possible, extension splinting for 2-3 weeks is recommended.


Proximal Interphalangeal Joint



  • Proximal interphalangeal (PIP) joint injuries are the most common joint injuries in sports, primarily occurring in athletes who participate in contact sports and ball handling (30,40).


DORSAL DISLOCATIONS

May 22, 2016 | Posted by in SPORT MEDICINE | Comments Off on Soft Tissue Injuries of the Wrist and Hand
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