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common hand injuries in sports
TRIA Sports Medicine Conference June 5, 2015 COMMON HAND INJURIES IN SPORTS WHAT TO TREAT and WHEN TO REFER THOMAS F. VARECKA,MD DISCLOSURES NO CONFLICTS WITH THIS PRESENTATION NOTHING OF VALUE HAS BEEN RECEIVED NO OFF LABEL USE PROMOTED THOMAS F. VARECKA, MD THE HOMUNCULUS CLASSIC MODERN THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS Objectives Introduce/Discuss the more common hand injuries seen in athletes “Jammed” Fingers, Thumb Injuries Review simple non-operative treatment methods Discuss reasons/indications to refer to your local orthopaedic surgeon THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS Objectives Introduce/Discuss the more common hand injuries seen in athletes “Jammed” Fingers, Thumb Injuries Review simple non-operative treatment methods Discuss reasons/indications to refer to your local orthopaedic surgeon NOT a technique talk THOMAS F. VARECKA, MD INCIDENCE OF HAND INJURIES IN SPORTS Upper extremity injuries common reported incidence: ~14% -- 85% depending on sport in question Causes of injury vary exposed, e.g., baseball, basketball used for protection, e.g., football, boxing involved in contact, e.g., baseball, hockey extension of racquet/club, e.g., baseball THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS THOMAS F. VARECKA, MD VULNERABLE AREAS Mobile and Supportive Structures most prone to injury FINGERS: PIP joint, DIP joint “the jammed finger” THUMB: MP joint (UCL), CMC joint WRIST: scaphoid, S-L joint, hamate Tubular bone less commonly injured Metacarpals, phalanges THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS JAMMED FINGER THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS Two Different Clinical Presentations Mallet Finger THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS Two Different Clinical Presentations Mallet Finger PIP Hyperextension THOMAS F. VARECKA, MD MALLET FINGER CLINICAL INABILITY TO EXTEND DISTAL JOINT OF FINGER MECHANISM: FORCED FLEXION THOMAS F. VARECKA, MD MALLET FINGER CLINICAL INABILITY TO EXTEND DISTAL JOINT OF FINGER STRETCHED TENDON TORN TENDON MECHANISM: FORCED FLEXION FRACTURE ± DISLOCATION THOMAS F. VARECKA, MD MALLET FINGER: TREATMENT THOMAS F. VARECKA, MD MALLET FINGER: TREATMENT THOMAS F. VARECKA, MD MALLET FINGER Splint for minimum of 6 weeks Add 1 week of splinting for each week of delay (6 + y = X) Splint for additional ½(X) weeks @ night DIP should not go unsupported during 6 week splinting period THOMAS F. VARECKA, MD 18 Y/O Male, Soccer Goalie (D-1), Took Ball Off Tip Of Finger Unable To Achieve Full Dip Extension; Pain, Tenderness THOMAS F. VARECKA, MD 2 yr. FOLLOWUP: No Pain, Full Rom, Slight Joint Incongruity 1st Team All-conference (A-10) THOMAS F. VARECKA, MD TREAT! 2 yr. FOLLOWUP: No Pain, Full Rom, Slight Joint Incongruity 1st Team All-conference (A-10) THOMAS F. VARECKA, MD 33 Y/O Major League Outfielder, Injured In Brawl At Home Plate Pain, Deformity, Unable To Fully Extend N.B.: This Injury A “Bad Actor” THOMAS F. VARECKA, MD Joint Volarly Subluxated 20 To Injury Treatment With Extension Causes Further Joint Subluxation Operative Treatment Almost Always Required THOMAS F. VARECKA, MD REDUCTION ACCOMPLISHED BY PUSHING (OR LIFTING) JOINT INTO PLACE PINNING THEN CARRIED OUT THOMAS F. VARECKA, MD REFER! REDUCTION ACCOMPLISHED BY PUSHING (OR LIFTING) JOINT INTO PLACE PINNING THEN CARRIED OUT THOMAS F. VARECKA, MD “SPECIAL” MALLET DEFORMITY FRACTURE BETWEEN ATTACHMENTS OF FLEXOR AND EXTENSOR TENDONS USUALLY REQUIRES PIN FIXATION THOMAS F. VARECKA, MD 16 y/o receiver, finger caught between ball and opponent’s leg as making catch Nail plate and germinal matrix everted over top of eponychial fold THOMAS F. VARECKA, MD THOMAS F. VARECKA, MD THOMAS F. VARECKA, MD REFER! THOMAS F. VARECKA, MD DISTAL INJURIES SOFT TISSUE uncommon, except with bone/joint injury BEWARE “JERSEY FINGER”: avulsion of FDP tendon from distal phalanx most often in football, basketball BONE fractures dislocations: PIP most common finger injury THOMAS F. VARECKA, MD JERSEY FINGER Traumatic Avulsion Of Flexor Profundus Attachment To Distal Phalanx Caused By Forced Passive Extension Of Flexed Finger History Of “Broken Tackle” Or Catching Finger On Opponent’s Shirt, Basket Netting, Etc THOMAS F. VARECKA, MD JERSEY FINGER THOMAS F. VARECKA, MD 1 2 JERSEY FINGER = ECCHYMOSIS (1) of Distal Phalanx, Subtle Extension Posture (2) THOMAS F. VARECKA, MD SURGICAL FINDINGS THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS PIP HYPEREXTENSION SPECTRUM OF INJURY NORMAL VP TEAR SUBLUXED THOMAS F. VARECKA, MD PIP JOINT BY FAR, MOST COMMON SITE OF FINGER INJURY INJURY TYPES Soft tissue “jammed finger” Collateral ligaments “jammed finger” Volar plate True dislocation Bone Volar lip Intra-articular THOMAS F. VARECKA, MD PIP JOINT Treatment Goals Stable Joint stability often greater than x-ray would suggest Pain Free Functional Range Of Motion flexion of ≥ 650 arc of flexion 300 to 950 THOMAS F. VARECKA, MD PIP INJURY “JAMMED” FINGER Longitudinal Loading Force To Tip Of Finger Hyperextension Of PIP Frequently Associated With Rotational/Twisting Mechanism Volar Plate/Collateral/Accessory Collaterals Partially Disrupted Often Results In “Pseudo-boutonniere” Deformity PIP Flexion Contracture and DIP Hyperextension THOMAS F. VARECKA, MD ANATOMY Check reign ligament Volar plate THOMAS F. VARECKA, MD 38 Y/O Man “Jammed” Right Index Finger Playing Volleyball THOMAS F. VARECKA, MD 3 1 2 4 SWELLING RADIALLY (1), ULNARLY (2), DORSALLY (3) AND VOLARLY (4) THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS Ecchymosis Frequently Noted At PIP Region PIP Jt Assumes a 200 Flexion Posture THOMAS F. VARECKA, MD PLAIN RADIOGRAPHS NO FRACTURES, BUT….. THOMAS F. VARECKA, MD PLAIN RADIOGRAPH NOTE FUSIFORM SWELLING THOMAS F. VARECKA, MD STRESS VIEW: JOINT LAX, BUT NOT UNSTABLE THOMAS F. VARECKA, MD TREAT! STRESS VIEW: JOINT LAX, BUT NOT UNSTABLE THOMAS F. VARECKA, MD PIP INJURY “JAMMED” FINGER = LIGAMENT + VOLAR PLATE INJURY Treat non-operatively splint for a few days in extension for comfort buddy straps Warn patients of lengthy resolution tenderness for 4 – 6 months swelling / thickening of finger may last indefinitely or even permanently THOMAS F. VARECKA, MD PIP INJURY 70 Y/O Man Injured Finger Playing Tennis Advised Simply “Jammed” Finger In Jammed Fingers, Be Careful Not To Miss Fracture THOMAS F. VARECKA, MD PIP INJURY TREAT! 70 Y/O Man Injured Finger Playing Tennis Advised Simply “Jammed” Finger In Jammed Fingers, Be Careful Not To Miss Fracture THOMAS F. VARECKA, MD PIP DISLOCATION Treat with closed reduction Reduction Tactics 1) Good Anesthesia 2) Hyperextend PIP 3) Push joint into place; no need to pull THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS Finger Grossly Deformed Typically, PIP Joint Cannot Be Flexed May C/O Sensory Disturbances In Finger Tip Permanent Neurologic Injury Unusual THOMAS F. VARECKA, MD PIP DISLOCATION Treat with closed reduction Reduction Tactics 1) Good Anesthesia 2) Hyperextend PIP 3) Push joint into place; no need to pull PURE DISLOCATIONS USUALLY STABLE THOMAS F. VARECKA, MD PIP DISLOCATION PURE DISLOCATIONS USUALLY STABLE Closed reduction Splint for minimal time necessary (PIP: about 7 – 10 days) Protect X 3-4 weeks, e.g., buddy tape most players can return to game THOMAS F. VARECKA, MD PIP DISLOCATION PURE DISLOCATIONS USUALLY STABLE Closed reduction Splint for minimal time necessary (PIP: about 7 – 10 days) Protect X 3-4 weeks, e.g., buddy tape most players can return to game N.B.: beware of splinting in flexion THOMAS F. VARECKA, MD DISLOCATION N.B.: Angle at which finger is immobilized is the degree of flexion contracture to be treated!!! THOMAS F. VARECKA, MD PREVENTION/TREATMENT OF FLEXION CONTRACTURE SPRING ASSISTED EXTENSION SPLINT THOMAS F. VARECKA, MD PIP DISLOCATION PURE DISLOCATIONS USUALLY STABLE UNSTABLE DISLOCATIONS Soft tissue – usually open injury Boney Volar fracture Condylar fractures Impacted articular fractures THOMAS F. VARECKA, MD PIP DISLOCATION Volar lip fragment frequently seen Small fragment indicator of injury Large fragment (> 30%) associated with dorsal instability 17 y/o H.S. baseball player, “jammed” finger diving into second base THOMAS F. VARECKA, MD PIP JOINT FRACTURE DISLOCATION Common Fracture Young patient population Treatment difficult Significant stiffness Redislocation NO GOLD STANDARD THOMAS F. VARECKA, MD PIP JOINT FRACTURE DISLOCATION Extension block splinting Mild flexion with adequate reduction THOMAS F. VARECKA, MD Extension Block Splinting McElfresh, Dobyns, O’brien. JBJS 1972 17 Patients: 16 acute, 1 chronic ROM: “90 to 105 degrees of flexion” Bulky splint, requires close monitoring Effective for small fractures Fracture size: only 10-30% of P2 THOMAS F. VARECKA, MD PIP JOINT FRACTURE DISLOCATION Dorsal subluxation of joint Watch for “V” sign THOMAS F. VARECKA, MD PIP DISLOCATION “V” SIGN 38 Y/O Man, Injured Playing Co-ed Softball “Jammed Finger” THOMAS F. VARECKA, MD PIP FX-DISLOCATION Joint reduced with extension block splint Angle of immobilization = angle of flexion contracture Recurrence of mild subluxation N.B.: recurrent “V” sign THOMAS F. VARECKA, MD PIP DISLOCATION REFER! “V” SIGN 38 Y/O Man, Injured Playing Co-ed Softball “Jammed Finger” THOMAS F. VARECKA, MD Joint Pinned Pip Congruent Mild Flexion Posture THOMAS F. VARECKA, MD ULNAR COLLATERAL LIGAMENT INJURIES SKIER’S THUMB (Gamekeeper’s Thumb) THOMAS F. VARECKA,MD UCL INJURIES Thumb MP Joint Motions Hinge Joint Allows Flex/Ext Normal: -50 ≤ 850 Ab/Ad–duction very limited Resisted by Collateral Ligaments Ave: ~ 220 @ Full Ext 50 or Less @ 150 of MP Joint Flexion THOMAS F. VARECKA, MD UCL INJURIES Thumb MP Joint Motions Hinge Joint Allows Flex/Ext Normal: -50 ≤ 850 Ab/Ad–duction very limited Resisted by Collateral Ligaments Ave: ~ 220 @ Full Ext 50 or Less @ 150 of MP Joint Flexion ALWAYS Compare to opposite side THOMAS F. VARECKA, MD THOMAS F. VARECKA, MD AVOID EXAMINING IN HYPEREXTENSION THOMAS F. VARECKA, MD “STENER’S LESION” THOMAS F. VARECKA, MD THOMAS F. VARECKA, MD THOMAS F. VARECKA, MD THOMAS F. VARECKA, MD UCL INJURIES Most Authors report “Satisfactory Results” regardless of methods of treatment Most reviews retrospective (Level IV, V) NO CONTROLLED SERIES!! Non-op treatment yields greater residual laxity Weaker Pinch? THOMAS F. VARECKA, MD UCL DIAGNOSIS Challenge: To Distinguish Complete Tear of UCL from Partial Tear or Stretch (GrII) Methods: Exam Imaging Studies Radiographs, Ultrasound, Arthrogram, Ct, MRI THOMAS F. VARECKA, MD COMPARISON WITH OPPOSITE THUMB THOMAS F. VARECKA, MD REFER! COMPARISON WITH OPPOSITE THUMB THOMAS F. VARECKA, MD THOMAS F. VARECKA, MD X-RAY FOLLOW-UP @ 6 MONTHS; NO PAIN, FAIR MOTION THOMAS F. VARECKA, MD FRACTURES Perfect Anatomic Alignment Not Absolutely Necessary For Good Hand And Finger Function e.g., Mild Shortening Or Flexion In Plane Of Motion Well Tolerated DO NOT ACCEPT ROTATIONAL OR ANGULAR DEFORMITIES THOMAS F. VARECKA, MD FRACTURE OF 5TH METACARPAL NECK RARELY REQUIRES ANATOMIC ALIGNMENT FOR GOOD RESULTS THOMAS F. VARECKA, MD FRACTURE OF 5TH METACARPAL WITH ANGULATION AND CLAWING OF SMALL FINGER SURGICAL TREATMENT RECOMMENDED THOMAS F. VARECKA, MD FRACTURE OF 4TH METACARPAL WITH SLIGHT SHORTENING THOMAS F. VARECKA, MD FRACTURE OF 2ND METACARPAL ALIGNMENT AND ROTATION ACCEPTABLE THOMAS F. VARECKA, MD NON-OPERATIVE TREATMENT SATISFACTORY EXCELLENT FUNCTIONAL RESULT THOMAS F. VARECKA, MD SOME “NO – NO’S” THOMAS F. VARECKA, MD 20 y/o COLLEGE FOOTBALL PLAYER WITH OBVIOUSLY MALROTATED PROXIMAL PHALANX FRACTURE THOMAS F. VARECKA, MD 20 y/o COLLEGE BASKETBALL PLAYER WITH OBVIOUSLY MALROTATED PROXIMAL PHALANX FRACTURE THOMAS F. VARECKA, MD 8 y/o GIRL INJURED PLAYING KICKBALL UNRECOGNIZED FINGER ROTATION THOMAS F. VARECKA, MD FINGERS TEND TO DEFORM INTO ULNAR DEVIATION i.e., HYPERPRONATION THOMAS F. VARECKA, MD FINGERS TEND TO DEFORM INTO ULNAR DEVIATION i.e., HYPERPRONATION THOMAS F. VARECKA, MD CLINICAL DEFORMITY SURGICAL CORRECTION NECESSARY THOMAS F. VARECKA, MD 14 y/o BOY CAUGHT FINGER ON OPPONENT PLAYING TOUCH FOOTBALL, NO DEFORMITY UNTIL REACHING GROWTH SPURT THOMAS F. VARECKA, MD FRACTURES: CMC 32 y/o DIRT BIKE RACER, PUT BIKE DOWN ON TURN, “PUNCHED” TURF SWOLLEN, PAIN ON ULNAR BORDER OF HAND THOMAS F. VARECKA, MD FRACTURES: CMC 32 y/o DIRT BIKE RACER, PUT BIKE DOWN ON TURN, “PUNCHED” TURF SWOLLEN, PAIN ON ULNAR BORDER OF HAND “REVERSE BENNETT’S” FRACTURE THOMAS F. VARECKA, MD FRACTURES: CMC SURGICALLY STABILIZED WITH PINS THOMAS F. VARECKA, MD 29 y/o FELL PLAYING BROOMBALL; PRESENTS WITH PAIN AND SWELLING OF HAND INITIAL X-RAYS DECEPTIVELY NORMAL THOMAS F. VARECKA, MD 29 y/o FELL PLAYING BROOMBALL; PRESENTS WITH PAIN AND SWELLING OF HAND INITIAL X-RAYS DECEPTIVELY NORMAL TRUE LATERAL SHOWS FRACTURE DISLOCATION OF 4TH/5TH CMC JOINTS THOMAS F. VARECKA, MD SUMMARY Hand Injuries Represent A Wide Range Of Trauma Most Displaced And/Or Unstable Injuries Will Require Athlete To Miss Some Portion Of Season If Playing “Skill” Games Or Positions Functional Recovery Most Important THOMAS F. VARECKA, MD SUMMARY Critical analysis of finger injuries needed to make accurate diagnosis “Jammed” finger ≠ Diagnosis Identify structures injured and treat accordingly Fingers useful because they move Encourage early return to motion Movement beneficial only if injured area has recovered stability THOMAS F. VARECKA, MD COMMON HAND INJURIES IN SPORTS A Final “Sobering” Thought: THOMAS F. VARECKA, MD Thousands of Sports Fans Drunk After Football, Baseball Games, Study Finds EIGHT PERCENT OF SPORTS FANS HAVE A BLOOD ALCOHOL CONTENT ABOVE THE LEGAL LIMIT AS THEY EXIT THE STADIUM AFTER FOOTBALL AND BASEBALL GAMES by Michael Heimann NY Times, Sept. 20,2007 THOMAS F. VARECKA, MD Thousands of Sports Fans Drunk After Football, Baseball Games, Study Finds THANK YOU EIGHT PERCENT OF SPORTS FANS HAVE A BLOOD ALCOHOL CONTENT ABOVE THE LEGAL LIMIT AS THEY EXIT THE STADIUM AFTER FOOTBALL AND BASEBALL GAMES by Michael Heimann NY Times, Sept. 20,2007 THOMAS F. VARECKA, MD
