CHAPTER 8
Wrist and Hand Injuries
Steven Beldner, MD, Marcel A. Bas, MD, and Daniel B. Polatsch, MD
The wrist joint is composed of the distal aspect of the two long forearm bones, the radius and ulna. The joint between these bones is called the radioulnar joint. The radioulnar joint allows the forearm to twist, or rotate back and forth (pronation and supination). Distal to the radius and ulna are the eight carpal bones, which are divided into two separate rows. This results in a proximal row and a distal row of carpal bones. The joint between the radius and first row of carpal bones is called the radiocarpal joint, and the joint between the two rows is called the midcarpal joint (see figure 8.1). These joints are responsible for flexion and extension of the wrist and radial and ulnar deviation of the wrist.
FIGURE 8.1 Radiocarpal and midcarpal joints of the wrist.
WRIST AND HAND INJURIES
Injury | Page |
Wrist Fractures | |
Triangular Fibrocartilage Complex Injuries | |
Scapholunate Ligament Tear or Dislocation | |
Wrist Tendinitis | |
Carpal Tunnel Syndrome | |
Ulnar Nerve Entrapment | |
CMC Fractures and Fracture Dislocations | |
CMC Boss | |
MP Joint Ligament Tears and Dislocations | |
Finger Fractures | |
Seymour Fractures | |
PIP and DIP Finger Collateral Ligament Injury | |
PIP and DIP Joint Dislocations | |
Jersey Finger | |
Mallet Finger | |
Swan Neck Deformity, or Volar Plate Rupture | |
Boutonniere Deformity, or Central Slip Rupture |
WRIST FRACTURES
Wrist fractures can occur whenever excessive force is applied to the wrist. Any bone can fracture if enough load (stress) is applied. Swelling, tenderness, and in severe cases deformity can occur at the fracture site after injury. One can frequently identify the fractured bone by looking for swelling, bruising, and deformity. Knowledge of the location of the bones and their correlation to visible and palpable landmarks allows the examiner to determine the structure injured.
DISTAL RADIUS FRACTURE
Common Causes
Distal radius fractures are the most common fractures of the upper extremity (Olsen 2015). In athletes, this generally results from falling on the wrist while running or jumping. In older athletes, this type of fracture can occur from a fall from a standing position due to the weakening of bone as people age.
Identification
Clinically there will be swelling and bruising over the wrist, and if the fracture is displaced, a deformity will be noted. Tenderness will localize directly over the radius. Motion of the wrist will cause pain in the area of the distal radius. In an unstable fracture, crepitus (crunching) can be palpated over the fracture site. In a small number of cases, numbness may be present in the fingers. This occurs due to trauma to the median nerve directly or from pressure caused by swelling which can pinch the median nerve in the carpal canal (carpal tunnel syndrome). The numbness can be experienced in the median nerve distribution which encompasses the thumb, index, middle and the radial side of the ring finger (thumb side).
Treatment
On the playing field, the wrist should be splinted to prevent motion. Ice should be applied if available. Raising the extremity to an elevation above the heart is also helpful in order to reduce internal bleeding and swelling. With any injury of the upper extremity, all bracelets and rings should be removed as soon as possible since swelling may prevent later removal and restrict blood flow to the part distal to the jewelry. Vascular compromise from restricted blood flow can be recognized if the affected part appears white (no circulation) or blue (circulation in but limited circulation out). The affected part appears blue since the remaining blood in that part gives up its oxygen to the ischemic tissue. Blood has a red color when it is fully oxygenated but changes to a blue color when that oxygen is lost.
Return to Action
Return to action is usually dictated by the severity of the fracture, which is determined by the treating physician. Most distal radius fractures heal in four to six weeks, but more time after bone healing is necessary to restore range of motion and strength. Refracture is a concern in the early healing process; protective splints may be required to reduce the risk of refracture during sports for the first few months.
Gymnast’s Wrist
Common Causes
Skeletally immature athletes who perform repetitive loading of the wrist may experience a stress fracture of the distal radius through an open growth plate. This is commonly referred to as gymnast’s wrist.
Identification
The athlete may present with swelling and tenderness over the distal radius growth plate, but no fracture is seen on X-rays. The fracture is not seen on X-ray because the growth plate is made up of cartilage. Cartilage fractures do not appear on X-ray since cartilage appears radiolucent (a clear area) and can only be visualized on MRI.
Treatment
Immediate treatment should involve the intermittent application of ice to reduce swelling and splinting the injured part. The wrist should be splinted until pain and swelling resolve. This generally takes two or three weeks if the athlete avoids loads on the wrist and splints the injured area.
Return to Action
Patients can return to activities once pain and swelling have resolved. Recurrent injury should be avoided in these patients since it may result in early growth plate closure that could require surgical correction.
SCAPHOID FRACTURE
Common Causes
Scaphoid fractures occur with a fall on an outstretched extremity; this is similar to what happens with distal radius fractures, but the wrist is usually in a more extended and radially deviated position (bent toward the thumb side).
Identification
The swelling and bruising are usually less dramatic than in distal radius fractures due to poor blood supply to the scaphoid bone. Tenderness is usually localized to the anatomic snuff box, which is distal to the radius on the thumb side of the wrist. The fracture may not be seen on plain X-rays, so magnetic resonance imaging (MRI) may be required for detection.
Treatment
Emergent treatment on the field is similar to that for distal radius fractures. Nondisplaced fractures can sometimes be managed in a splint or cast for six to eight weeks. Fracture healing is prolonged due to the poor blood circulation in this bone. Some cases may develop avascular necrosis (death of bone) and nonunion (delayed healing) due to the poor blood supply. Displaced fractures generally need surgical reduction and stabilization. Some patients with nondisplaced fractures may choose surgery to allow earlier range of motion and faster return to normal activity.
Return to Action
Some physicians allow their patients to return to play while the bone is healing if they wear a cast during sports. Most physicians recommend avoiding sports until the bone is healed and range of motion is restored, which is generally in 8 to 12 weeks.
HAMATE HOOK FRACTURE
Common Causes
These fractures are typically associated with athletes who hold a stick or club. The club applies compression to the hamate hook, which projects from the hamate bone in the palm of the hand. In tennis and polo players, this injury occurs in the dominant hand, while in baseball, golf, and hockey it occurs in the nondominant hand since these are the areas where the end of the club lies.
Identification
There generally is very little swelling and bruising with this injury since the hamate hook has a very poor blood supply. Tenderness can be elicited by applying pressure to the hamate hook. This injury is sometimes associated with numbness in the fourth and fifth fingers due to the bone’s proximity to the ulnar nerve in the wrist.
Treatment
Some physicians may consider immobilization in a splint or cast, but this is less than ideal since the bone ends may not heal together and refracture is likely due to the poor blood circulation in this healing bone. It is for this reason that most physicians recommend surgical excision of the hamate hook, since satisfaction rates are high for surgery in uncomplicated cases.
Return to Action
When treated in a splint or cast, the patient should have documented solid union on imaging before returning to sports. This generally takes three months, and refracture rates are extremely high. If surgical excision is elected, return to sports can occur four weeks post-op.
TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES
Common Causes
The triangular fibrocartilage complex (TFCC) is located on the ulnar (fifth digit) side of the wrist near the ulnar styloid (bump) of the wrist. The TFCC is a complex of ligaments that stabilize the radioulnar joint and extensor carpi ulnaris (ECU) tendon. Tears of the TFCC generally occur in athletes who are involved in strenuous forearm rotation (pronation and supination) such as in golf, tennis, baseball, hockey, lacrosse, and polo. When the forearm is forcefully pronated or supinated, the ligaments can be overloaded and can tear. If completely torn, the radioulnar joint or ECU tendon may dislocate.
Identification
There is minimal swelling and bruising associated with a TFCC tear. Pain is increased with forced pronation or supination. In large tears, instability may be present when compared to the opposite extremity. Tenderness can be elicited by palpating the soft spot distal to the ulna.
Treatment
Partial tears respond well to splinting or supportive wraps to protect from further injury during healing. Casts give better protection, especially if they extend above the elbow to control forearm rotation, but are poorly tolerated by many athletes. Cortisone injections may reduce swelling in the ligament to reduce the risk of further injury during the healing process. Although the majority of these injuries will heal with rehabilitation, some injuries may require surgical intervention.
Return to Action
Healing times of these injuries are variable based on the degree of injury and blood circulation at the injury site. Like other structures in the body that have poor blood supply, they are slow to heal. Athletes can return to sports once instability and pain have resolved. This can range from several days to several months.
SCAPHOLUNATE LIGAMENT TEAR OR DISLOCATION
Common Causes
Scapholunate ligament tears or dislocations occur from overloading the ligament by applying force on an extended wrist or falling on an outstretched arm with impact on the palm. The extent of these injuries can range from partial tears without instability to wrist dislocations, referred to as perilunate dislocation. In order for the wrist to dislocate, other ligaments or bones such as the lunotriquetral ligament need to fail. The higher the energy of initial injury, the more the disruption signified by swelling. Mild overloads can be seen in gymnasts or yoga enthusiasts due to loading the wrist in extension. These can also be associated with fluid leaking from the ligament, referred to as a ganglion cyst. Massive swelling and wrist deformity can be seen with higher-energy injuries such as perilunate wrist dislocations.
Identification
Swelling and bruising can be seen at the scapholunate junction. This can be identified in the middle of the wrist next to the anatomic snuff box. The pain is accentuated by forced wrist extension greater than flexion. With higher-grade injuries, instability of the wrist may be detected with wrist motion. X-rays may be normal when instability is not present, but scapholunate stress views may help visualize subtle instability. Magnetic resonance imaging can also be used to identify the extent of these injuries.
Treatment
Mild injuries without instability can be treated with soft wraps or splints and avoidance of the activity until the pain resolves. More serious injuries with instability may require casting or surgery.
Return to Action
Athletes can return to activity once pain has resolved, which can range from several days to months. More serious injuries associated with instability require surgical intervention. Surgery involves immobilization for 6 to 12 weeks, followed by extensive therapy.
WRIST TENDINITIS
Common Causes
Tendons are the “ropes” that connect muscles to the bone. When the muscle contracts, the tendons need to slide back and forth to allow the bone to move through a range of motion at the more proximal joint. The tendons are contained in fibro-osseous canals with synovial lining. The synovium produces a lubricant that facilitates the sliding of the tendon within the canals. If the tendon enlarges or the synovial lining thickens, the tendon can become pinched in the canal. Once the tendon is pinched, more swelling results, inciting further pinching. This creates a vicious cycle that needs to be broken in order to alleviate symptoms.
Any medical condition that causes increased size of the tendons predisposes the athlete to develop tendinitis. These conditions include diabetes mellitus, hypothyroidism, cessation of menstruation in women who have commenced menstruation but stopped for medical reasons (e.g., pregnancy, postmenopause, eating disorders), inflammatory arthropathy, and renal failure. Medicines such as fluoroquinolones (Levaquin and ciprofloxacin) also increase the risk of tendinitis through an unknown mechanism.
Identification
There are hundreds of different tendons throughout the body and when they are overused, the mechanical stress can lead to overload and failure. There are four commonly seen types of wrist tendinitis associated with popular sports.
Flexor Carpi Radialis (FCR) Tendinitis
This occurs in sports with repetitive wrist flexion such as golf and tennis. The tendon most commonly becomes entrapped as it enters a fibro-osseous canal at the level of the trapezial ridge (medial wrist, palm side). It can be associated with recent trapezial fractures since the bone healing can make the canal smaller and irritate the tendon. Tenderness can be elicited by forced flexion of the wrist and palpation just proximal to the trapezial ridge.
DeQuervain’s Tendinitis
This is a commonly seen overuse injury in cyclists and racket sports enthusiasts. It is a swelling of the tendons (abductor pollicis longus and extensor pollicis brevis) of the first dorsal compartment, which is on the back side of the base of the thumb where it meets the wrist. These tendons are irritated by excessive radial and ulnar deviation of the wrist as they rub against the radial styloid (thumb side of the wrist). Tenderness is elicited by palpating the radial styloid while the thumb is held in the palm and the wrist is deviated in an ulnar direction. This is referred to as the Finkelstein test.
Intersection Syndrome, or Rower’s Wrist
As its name implies, this is frequently seen in rowers and weightlifters and is caused by repetitive flexion and extension of the wrist. The swelling and pain are identified more proximal in the forearm where the first compartment intersects and crosses the second compartment on the back side of the wrist. This results in irritation of the second compartment. Pain is elicited by flexing and extending the wrist in this region. Crepitus can be palpated at this site as the wrist moves from flexion to extension.
Drummer’s Boy Palsy
Irritation of the third dorsal compartment (extensor pollicis longus) can occur with repetitive motion in racket sports. It can also be seen in skiers whose activity results in repetitive forced extension. It can occur as well after a nondisplaced distal radius fracture where swelling can pinch the tendon around Lister’s tubercle and in some cases cause rupture of the tendon. Tenderness is elicited over Lister’s tubercle when the thumb is lifted off a flat surface. If the tendon is ruptured, the patient will be unable to lift the thumb up or extend the thumb interphalangeal joint. If ruptured, the tendon needs to be reconstructed surgically. Steroid injections should not be used in this condition due to concerns regarding tendon rupture.
Treatment
Treatment is aimed at breaking the cyclical swelling and pinching. Splints to prevent motion may reduce swelling and irritation. Some physicians recommend warm heat to increase circulation and wash out inflammatory chemicals in chronic conditions and cold application if recent aggravation has occurred. Some physicians recommend alternating heat and cold to get the best of both modalities. Oral anti-inflammatories can also be helpful. If conservative measures fail, then surgical release of the affected compartment to reduce pinching is sometimes necessary.
Return to Action
If athletes try to play through the pain, they generally aggravate the condition. It is recommended that they wait to return to sports until pain and swelling have resolved.
CARPAL TUNNEL SYNDROME
Common Causes
Carpal tunnel syndrome is a compression of the median nerve at the wrist. The median nerve and finger tendons pass through the carpal canal on the palm side of the wrist. This is a canal created by the carpal bones and enclosed by the transverse carpal ligament. When the tendons of fingers swell in the canal they can pinch the median nerve. This results in pain, numbness, and weakness of the median nerve distribution. The median nerve supplies sensation to the palmar side of the thumb, index finger, and middle finger and to the radial side of the fourth digit. It also supplies the thenar muscles (palm of hand near the thumb), which allow us to oppose our thumb (bring the thumb toward the pinky finger). Any condition that increases the risk for tendinitis also increases the risk for carpal tunnel. The size of the carpal tunnel is reduced by flexion and extension of the wrist, which exacerbates the symptoms. Rowers or other athletes involved in prolonged wrist flexion or extension can develop this problem.
Identification
Patients will complain of numbness of the radial fingers while performing tasks in full flexion or extension for prolonged periods of time. They may develop night pain that awakens them since people often sleep with their wrist flexed. They feel better after shaking the hand because this reduces pressure on the nerve, which restores its circulation. Symptoms can be reproduced by holding the wrists flexed for a short period of time (Phalen’s test), or tapping on the center of the front of the wrist just proximal to the wrist crease, which generates electrical sensations in the median nerve distribution (Tinel’s test).
Treatment
In the initial stages of carpal tunnel syndrome, use a resting splint or brace (see p. 70) to prevent excessive motion of the wrist and to minimize the extremes of flexion and extension. Night splints are effective in minimizing extreme ranges of motion. Once the inflammation around the nerve has subsided, the pain may resolve.
If a resting splint does not eradicate the symptoms, the wrist should be evaluated by a physician. An injection of a steroid anti-inflammatory drug may be prescribed, which should gradually reduce symptoms over the next few days. Some athletes benefit from consuming vitamin B6 (about 50 to 100 mg per day for one month).
Electrodiagnostic testing (nerve conduction velocity and electromyography) can assess how well the median nerve is working and is an excellent means of quantifying damage to the median nerve and the muscles it supplies. Even if the electrodiagnostic test is negative, carpal tunnel syndrome could still be the problem; the test may just not have revealed it. If the electrodiagnostic test is positive, the problem is very likely carpal tunnel syndrome. If the condition is in advanced stages, or if the injection does not help, surgery may be required to create a larger space for the median nerve to travel in.
Return to Action
Patients can return to sports once symptoms are resolved. If patients undergo surgery, they can return once the skin is healed and comfort allows.
ULNAR NERVE ENTRAPMENT
Common Cause
Although there are multiple locations where the ulna nerve can be entrapped ,we will limit the conversation to the wrist. The ulnar nerve can be entrapped at the wrist at Guyon’s canal (pinky side of the wrist). It can frequently be seen in cyclists due to compression from the handlebars, called cyclist’s palsy.
Identification
This results in numbness in the ulnar nerve distribution (ulnar side of ring and entire pinky) on the front but not the back of the hand. The athlete will have weakness in the hand especially for grip strength, and in advanced cases, atrophy of the muscles innervated by the ulnar nerve. This can be associated with hamate hook fractures since this bone is close to the canal.
Treatment
Treatment consists of adjusting the seat and handlebars to avoid putting pressure on the canal, combined with intermittent splinting and nonsteroidal anti-inflammatory drugs as needed.
Return to Action
Patients can return to their sport with modifications to reduce recurrence once symptoms resolve. Depending on the degree of compression, this can range from several days to months. If symptoms do not resolve, surgical decompression is sometimes necessary.
CMC FRACTURES AND FRACTURE DISLOCATIONS
Common Causes
The joints that connects the carpal bones to the metacarpal bones are called the carpometacarpal (CMC) joints. Fracture or fracture dislocation can occur in any of the five CMC joints. The CMC joints and metacarpals can be injured during punching; by a blunt, forceful contact; or as a result of stress transferred through the fingers.
Identification
The metacarpal bones and joints are numbered one through five, starting with the thumb (#1) and ending with the little finger (#5). When a CMC joint is dislocated or a metacarpal is fractured, immediate and specific pain, swelling, and possibly deformity result. When the athlete makes a fist, each knuckle should be visible. When the fingers are relaxed and the wrist is in extension, the fingers should form a cascade, the index finger being more extended and the pinky being more flexed with the fingers pointing toward the scaphoid. Compare this to the athlete’s other hand to make sure the two are symmetrical. A physician should be consulted if symptoms of a fracture are present or if there is uncertainty.
Specific fractures and fracture dislocations include the following:
- Bennett’s fracture is a fracture dislocation of the thumb CMC joint.
- Reverse Bennett’s fracture is a similar injury to the fifth CMC joint.
- CMC fracture dislocation of the second through fifth can occur, with the fourth and fifth being most common. Clinical deformity in the area and massive swelling will be present.
- Metacarpal fractures can be identified by swelling and tenderness over the bone; and with displaced fractures, loss of the knuckle prominence or malrotation of the finger can be seen.
- Fracture to the fifth metacarpal neck is referred to as a boxer’s fracture since these generally occur with punching a solid object.
- Metacarpal head fracture can occur by direct force or by the ligament of the joint pulling pieces of the head off (avulsion fracture).
- Metacarpal fractures can be identified by swelling and tenderness over the bone; and with displaced fractures, loss of the knuckle prominence or malrotation of the finger can be seen.
Treatment
Nondisplaced fractures and some minimally displaced fractures can be treated with splinting or casting for four weeks. Significantly displaced fractures and dislocations need the bone to be realigned and either casting or surgical stabilization. These can take four to six weeks to heal.
Return to Action
Following immobilization, the hand is likely to be stiff and weak. Rehabilitation efforts should address these problems while protecting the hand from further injury. Strengthening exercises should be done for grip and wrist function. Once X-ray indicates that the fracture is well healed and mobility and strength are restored, the athlete may return to sports. Although some athletes may be able to return before healing if wearing a cast, most wait until bone healing has occurred and range of motion and strength are restored. This generally takes six to eight weeks. Refracture is a concern for the first three months after these injuries.
CMC BOSS
Common Causes
A CMC boss is a prominence over the second and third CMC joints. They develop in boxers from repetitive overload of the CMC joint.
Identification
The prominence is a combination of a bone spur and a cyst. These are caused by chronic overload of the joint from punching and will be tender to palpation when inflamed.
Treatment
Rest and splinting will quiet these injuries over time. Anti-inflammatories by mouth or a cortisone injection can speed the recovery. If recurrent or recalcitrant to conservative management, they can be surgically removed or the joint can be fused to prevent recurrence in severe cases.
Return to Action
Athletes can return to sports once swelling and tenderness resolve. This can range from several days to weeks. If surgery is undertaken, recovery is 6 to 12 weeks.
MP JOINT LIGAMENT TEARS AND DISLOCATIONS
The joint between the metacarpal and proximal phalanx is called the metacarpophalangeal (MP) joint. The ligaments that stabilize the MP joint from hyperextension is the volar plate. The radial and ulnar collateral ligaments prevent motion from side to side. When torn they can pull a piece of bone off either the metacarpal or proximal phalanx, resulting in an avulsion fracture or rip within its substance. These injuries are divided into three grades based on clinical exam. Grade I is a partial tear (sprain) with no instability detected on exam. Grade II has instability compared to the opposite hand’s corresponding joint, but a firm endpoint can be elicited on physical exam, and grade III is a complete rupture with gross instability and no endpoint.
THUMB LIGAMENT INJURIES
Common Causes
The thumb, especially the ulnar collateral ligament (UCL), is vulnerable to tears because of its mobility and position. It is located at the base of the thumb in the web space between the thumb and second digit. The UCL helps stabilize the MP joint and is commonly injured when an athlete falls onto the hand or when the thumb is torqued by contact. The thumb can be injured from a fall, especially on a ski pole, thus earning it the name skier’s thumb. If it stretches out over time it is called a gamekeeper’s thumb. Tenderness on the opposite side of the thumb is a radial collateral ligament injury.
Identification
When the thumb is injured, immediate pain and swelling follow. Compare the appearance of the sprained thumb to the other thumb. Excessive swelling, point tenderness, and an inability to use the thumb are signs of more severe injury or fracture and should be evaluated by a physician. The joint should not be stressed prior to obtaining an X-ray since this may displace a nondisplaced fracture and complicate the injury. Once a fracture is ruled out by X-ray the ligament can be stressed to assess the grade of injury.
Treatment
If the ligament is stretched or partially torn (grades I and II), a splint for the thumb is used so the ligament can heal. When the UCL is torn completely, the ruptured edge drops behind a muscle, and the ligament cannot heal without surgical repair. This is called a Stener lesion. These require surgical intervention.
Return to Action
During the healing phase, which generally requires four to six weeks, the athlete should wear a splint or athletic tape during stressful activities. As long as there is no pain and the thumbs are protected, the athlete may participate safely. When surgery is required to repair the ligament, the timing of return is dictated by the surgeon.
METACARPOPHALANGEAL DISLOCATION
Common Causes
If the ligaments fail, the joint can dislocate. This usually occurs when the finger is bent backward (hyperextension), which can occur during contact sports when the fingers are in an extended position and forcibly extended.
Identification
There will be swelling and deformity of the joint with limited range of motion.
Treatment
A reduction maneuver is utilized to realign the joint. The joint may not realign due to interposition of the volar plate into the joint. When this occurs, surgical intervention is required.
Return to Action
If the joint reduces and is relatively stable, then return to play can be immediate with buddy taping or splints. If surgery is necessary, return to play occurs when the joint is stable and range of motion is restored. This generally takes four to six weeks.
MP SAGITTAL BAND TEAR, OR BOXER’S KNUCKLE
Common Causes
Sagittal band tears occur from blunt trauma to an unprotected knuckle of the index through fifth digits frequently associated with boxing and martial arts. The third finger radial sagittal band is the most frequently injured since it is most prominent and absorbs most of the energy during punching.
Identification
The swelling and pain are localized over the same region as in the collateral ligament injury since the sagittal band overlies these structures. With stable injuries (grade I) there will be only swelling, but partial tears may result in subluxation of the extensor tendon (grade II) in a direction opposite the injury when the MP is flexed. The tendon centralizes to the top of the metacarpal head when the joint is extended. In grade III injuries, the tendon dislocates with a palpable snap into the valley between the metacarpal heads and snaps back with either active extension if possible or passive extension if needed.
Treatment
Treatment involves splinting with the tendon in a reduced position for four weeks followed by buddy taping. If splinting fails or injury becomes chronic or does not reduce with extension, then surgery is indicated.
Return to Action
If a splint and reduction can be maintained, the athlete can return to sports. In activities that involve punching, the swelling and pain should be resolved with restoration of range of motion. This varies according to the degree of injury and can range from days to months. If surgery is required, then splints are maintained for four to six weeks followed by formal therapy. Punching can resume once range of motion is restored and swelling is resolved. This generally takes three months.
FINGER FRACTURES
Common Causes
Finger fractures can occur from many sport activities, including baseball (commonly seen when a player slides into a base headfirst), hockey, basketball, and football. It is usually secondary to a blunt force or twisting injury.
Identification
The finger is composed of three bony segments called phalanges and three joints. These joints are the distal interphalangeal (DIP) joint, the proximal interphalangeal (PIP) joint, and the metacarpophalangeal (MCP) joint, which connects the finger to the hand. The connecting bones are thus the distal phalanx, the middle phalanx, and the proximal phalanx at the finger proper (note that the thumb has only two segments and thus one interphalangeal joint as opposed to both a DIP and a PIP joint). Injuries to these will cause the finger to swell and have a deformity depending on where the fracture has occurred. These injuries can involve the joint (intraarticular fractures) or not involve the joint (extraarticular fractures). The distal phalanx is the most commonly injured, and pain and swelling will be located at the level of the nail or pulp of the finger. Blood may be seen deep to the nail as well, indicating that there is a cut under the nail. Middle phalanx fractures may have a dorsal concavity or a convexity on examination when the deformity is examined. Typically, a proximal phalanx fracture exhibits a concavity dorsally on exam. These fractures are associated with swelling and bruising.
Treatment
Once the injury pattern has been recognized radiographically and clinically, a reduction may be attempted and buddy taping or casting can be implemented. Certain fractures, due to the muscle pull, will not stay in their reduced position and will subsequently require surgery.
Return to Action
Bony fractures usually need three to four weeks for solid healing.
SEYMOUR FRACTURES
Common Causes
In the younger athlete population who are yet to achieve maturity, there are still open physes where there is bony longitudinal growth. Seymour fractures are seen at the level of the distal phalanx after an axial load is exerted on the distal end of the finger. Because the physis is open, there can be a displacement of the physis with regard to the bony shaft and subsequent bleeding underneath the nail bed tear and interposition into the injury site. These are injuries that can be confused with an adult mallet finger (discussed later in the section).
Identification
At presentation, the young athlete will have pain and swelling at the tip of the finger. There will be blood underneath the nail because a concurrent injury to the nail bed may exist. There may also be a “drooped” fingertip appearance as the extensor tendon raises the physeal fragment into extension and the flexor tendon drops the distal shaft into flexion. Radiographs must be performed prior to any intervention.
Treatment
If a nail bed injury is suspected, repair must be included in order to prevent any infection and any chronic nail and finger deformity. Physeal separation must be reduced, and subsequent splinting for at least one or two weeks if stable or surgery if unstable is warranted. If the separation is not reducible, tissue interposition should be suspected, and surgery will likely be necessary to reduce the separation.
Return to Action
Typical return to sport is dependent on severity of injury. Athletes who have closed injuries with intact nail bed and reducible physeal separation may return to play at one week with a protective splint. Open treatment of fractures due to tissue interposition may benefit from at least three to four weeks of limited activity.
PIP AND DIP FINGER COLLATERAL LIGAMENT INJURY
Common Causes
Finger joint injuries, or jammed fingers, can also affect the collateral ligaments, which stabilize the sides of the finger or volar plate, which resists hyperextension. The name and function of these ligaments are similar to those of the MP joint discussed in the previous section This type of injury can be seen with a forceful grip or twisting on moving objects or blunt trauma to any finger from the side. If multiple ligaments fail, then the joint can dislocate. Assessment of stability can be similar to that for MP joints discussed earlier.
Identification
Usually there is swelling and tenderness over the affected ligament. Stability should be assessed as discussed for MP injuries after it has been determined that there are no associated fractures of the bone.
Treatment
After imaging and examination, efforts to maintain joint congruency and reduce further injury should be considered. The digit should be protected or splinted (or both) to avoid dislocation or radioulnar deviation. Usually buddy taping is enough for simple partial or complete ligament tears for at least three to six weeks.
Return to Action
Players can return to sports immediately with the finger protected by buddy taping to an uninjured finger or by a protective splint. Protection should be continued until stability and range of motion are restored.
PIP AND DIP JOINT DISLOCATIONS
Common Causes
When force is applied to the finger joints, multiple ligaments can fail. This can result in a dislocation of the joint with or without an associated fracture. These injuries are typically seen in gymnastics, wrestling, and football.
Identification
Presentation for PIP and DIP joint dislocations is highly variable. It is important to keep in mind that some of these injuries can self-reduce immediately after the incident occurs, leaving only residual pain and mild swelling without noticeable deformity. In contrast, when the joint dislocates without fracturing there can be significant deformity at the joint with swelling and pain. Usually these are more obvious than in the case of the more difficult intraarticular fracture dislocation type where subtle deformity is present. When the joint is dislocated it will not be able to be flexed either actively or passively.
Treatment
With an isolated dislocation, a reduction can be attempted, and if achieved, the stability can be assessed. Stable dislocations can be moved early, while unstable or unreducible fractures may require special splints to maintain position or may warrant surgery.
Return to Action
When isolated dislocations occur, splinting or buddy taping for one or two weeks is recommended, with return to play depending on stability, range of motion, and comfort.
JERSEY FINGER
Common Causes
As the name suggests, this injury is typically seen when a player grabs an opponent’s jersey. When the opponent pulls away, the flexed finger is forcibly extended, which pulls the tendon off the bone, perhaps taking a small fragment of bone with it. The most commonly injured finger is the ring finger. The reason is that when the fingers are flexed, the ring finger typically has a longer configuration compared to the other digits.
Identification
On examination, the DIP joint will be resting in an extended position as compared to other fingers since unopposed pull of the extensor tendon is occurring. The athlete will be unable to flex the DIP joint actively but will have full passive range of motion of the finger. Once the tendon is detached from the bone it can retract proximally, sometimes reaching the palm. If the joint is dislocated, one will be unable to flex the finger either passively or actively; this is in contrast to a jersey finger, which can be passively flexed but not actively flexed.
Treatment
These injuries will need surgical treatment in that retraction inhibits the possibility of normal healing. Treatment may range from closed reduction of a bony tendinous avulsion (if minimally displaced and reducible) to open management in order to find the retracted tendon in the more proximal site in the finger or hand. After this, splinting with early passive range of motion may be initiated several days after surgery with progression to active range of motion at four to six weeks.
Return to Action
It is important to fully allow for healing, or re-tears may occur. With a bony fragment at the DIP joint that is closed reduced, healing will be quicker with less stiffness. If open repair is necessary, then the athlete may expect at least a two- to three-month recovery with progressive rehabilitation. Return to play can be expected at the two- to three-month mark.
MALLET FINGER
Common Causes
As the name suggests, this injury is named after the appearance of the finger once the deformity appears. This pattern of injury occurs when an extended finger is forcefully flexed at the DIP joint with a subsequent extensor tendon tear—for example, when a player is trying to catch a ball in basketball or football and has no glove protection.
Identification
When the injury occurs, the athlete will complain of pain and swelling at the dorsum of the DIP joint. There is typically a resting flexed distal phalanx when compared to the adjacent fingers, which is passively correctable. The athlete will also complain that the digit stays drooped and will not extend actively, and thus there is a tendency for the digit to bump into surfaces due to its inability to actively extend. Radiographs should be obtained to assess if the tendon pulled off a bone fragment (avulsion fracture). Larger fragments may result in loss of joint congruency.
Treatment
Treatment for these injuries can typically be nonoperative either if bony displacement is minimal or there is no bony fracture. Treatment usually consists of six weeks of 24/7 extended joint immobilization. If the splint is removed and the finger once again droops forward, then the end result may be compromised. If there is a large bony fragment or joint displacement (or both), surgery may be considered.
Return to Action
The athlete can return to activities if the splint can be maintained and does not interfere with performance.
SWAN NECK DEFORMITY, OR VOLAR PLATE RUPTURE
Common Causes
This type of deformity can be caused by many different injury patterns. It can result from acute trauma (in football, basketball, rugby, soccer) or chronic repetitive trauma. The PIP hyperextends, which relaxes the extensor tendon at the DIP joint, resulting in DIP flexion. The problem can be secondary to a volar plate rupture (acute or chronic) at the PIP joint or mallet-type injuries causing an increased extensor pull at the PIP joint with a flexed DIP joint or with rupture of the FDS (flexor digitorum superficialis).
Identification
When one is examining the athlete with a swan neck deformity, any of the scenarios just described must be contemplated because the deformity is a result of one or multiple injuries. It is important to rule out bone injuries with radiographs.
Treatment
Management should consist of a reduction of any isolated PIP joint by splinting in slight flexion. If a mallet-type injury is diagnosed, then treatment is required.
Return to Action
The athlete may return to sport while wearing protective splints when comfortable.
BOUTONNIERE DEFORMITY, OR CENTRAL SLIP RUPTURE
Common Causes
The characteristic deformity of a boutonniere finger is the opposite of a swan neck on clinical exam. The PIP joint acquires a flexed deformity while the DIP joint hyperextends. This injury pattern can be seen with any blunt trauma that causes an already extended PIP joint to flex and subsequently cause a tear in the central extensor tendon slip of the middle phalanx.
Identification
It is important to first rule out any bony injuries that may cause this type of deformity, and a radiograph should be the first modality. Volar PIP joint dislocations may cause a boutonniere due to the extensor tendon pulling off the middle phalanx central slip tear. On examination the patient will have limited flexion of the DIP joint due to overpull of the extensor tendon at the DIP joint. The Elson test may help elucidate if there is a central slip tendon tear by maximally flexing the PIP joint and passively putting the DIP joint through its range of motion. If there is fixed extension without suppleness to range of motion, then a central slip tear can be assumed.
Treatment
When a boutonniere is confirmed, the PIP is splinted in full extension for four to six weeks.
Return to Action
Athletes can return to action with the splint in place when comfortable.
*The authors would like to acknowledge the contribution of Frank C. McCue and Susan Saliba to this chapter.
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