Hand and Wrist Injuries in Athletes Barry S. Callahan, MD Director of Hand & Reconstructive Microsurgery Alabama Bone & Joint Clinic USA

Fingertip Injuries Nailbed Lacerations Amputations Combined

Nailbed Injuries

Nailbed Injury Subungual Hematoma Traditionally 25-50% involvement was indication for nail removal and nailbed repair Prospective 2-yr study of 48 patients had no deformity or complications with simple drainage regardless of hematoma size Base decision to repair on status of nailplate Edges intact- drain only Fragmented- remove fragments and repair

Digital Blocks 10cc volume 25 gauge 1.5” needle 5cc .5% marcaine plain 5cc 1% lidocaine plain 25 gauge 1.5” needle Use penrose drain or rubber band for tourniquet

Nailbed Injuries Stellate laceration Areas of exposed bone Debride, irrigate Oral antibiotic Keflex Cleocin if pcn sensitive Apply adaptic or xeroform and refer or graft/definitive management in 24-48 hours

‘Simple’ Lacerations Hand has a high propensity for infection Educate the patient that not all hand and digital wounds should be closed After local sharply debride wound margins Irrigate and digitally massage wound depth with 1-2 liters of saline Few or NO sutures Only close if tendon or bone exposed Loose approximation- 1 or 2 sutures and leave open and place non adherent dressing USE PLAIN GUT (5-0) ON KIDS!

‘Simple’ Lacerations Patient should remove dressing 24-48 hours later and begin BID warm water soaks and ok to cleanse with gentle soap and water NO NEOSPORIN or other ointments or lotions. Dress with telfa or adaptic and coban Cover ALL patients with oral antibiotic for 5-7 days F/U 5-7 days postinjury

Mallet Finger Usually due to axial load to a digit May involve minimal MOI Inability to extend DIP joint Extension splinting of DIP joint for 6-8 weeks Avoid PIP immobilization Except for physiologic PIP hyperextension

Mallet Finger Terminal extensor tendon injury Rupture Laceration Avulsion

Mallet Finger Large bony avulsion may require surgical fixation due to joint subluxation

Mallet Finger

Mallet Finger

Mallet Finger

Acute Boutonniere Deformity Passively correctable Variety of splints Alumiform and refer to Hand surgeon for f/u

Extensor Tendon Instability Results from sagittal band tear Can manage closed if caught early Surgery often necessary

Thumb MP collateral ligament Injury “ Gamekeepers Thumb Base decision to operate on degree of instability Block the thumb Flex MP 30 degrees If >40 degrees deviation possible then repair

Radiographs

Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpophalangeal joint. J Bone and Joint Surgery Am. Nov 1962;44B(4):869-79.

Volar Plate Injuries Hyperextension Injury Associated avulsion common Larger fractures may render joint unstable Treat as dorsal dislocation Often present as PIP contracture in athletes

PIP Dislocations Usually dorsal May reduce with adequate block and traction Dorsal splint in position of stability Rare palmar dislocation results in boutonniere deformity

Flexor Tendon Injuries Closed FDP avulsion- “Jersey Finger” May have associated bony avulsion Dorsal block splint Should be repaired before 2 weeks and unable to primarily repair after 6 Open Flexor tendon lacerations Debride/irrigate wound ‘Loose’ closure Refer for repair (Ideally within 5 days)

Case Discussion 17 yo High school senior who aspires to play division I football as a receiver sustains a Jersey finger (dominant ring digit) at the beginning of summer 2-a-days. Acute repair will allow restoration of near normal function/strength but no stressful use of hand for 2 months If repair delayed beyond 6 weeks, only a 2 stage reconstruction becomes available.

Phalangeal Fractures Distal Middle/Proximal Usually associated nailbed laceration Repair based on stability of fingertip Middle/Proximal Closed Usually cannot be managed closed Attempt at block and closed reduction reasonable

Wrist Injuries Wrist ‘sprain’ means you don’t know what the injury involves. Radial/ulnar extrinsic collateral ligament system ? Dorsal or volar extrinsic ligament system ? Intrinsic ligaments ? Ulnocarpal ligament complex ? TFCC Central, peripheral, ligamentum subcuetum? ECU sheath

Wrist Exam Swelling / Coloration Active/Passive ROM Diminished motion is the #1 predictor of significant intra-articular injury/disease EOM symptoms Provocative testing Areas of tenderness Watsons, Kleinman, Linscheid, etc.

Adjuvant Studies Plain films CT for bone detail Communicate with xray tech for what you want to see CT for bone detail MRI – consider adding an arthrogram if any suspicion of carpal dissociation Arthroscopy remains the gold standard diagnostic tool

Scapholunate Ligament Injury

Wrist Injuries Dorsal radiocarpal/intercarpal ligament avulsions Hyperextension injury Small ‘fleck’ on lateral (usually from triquetrum) Area of tenderness right over LT relationship MRI/arthrogram if suspected LT involvement Immobilization x 4 weeks then orthotics as needed Can be symptomatic for 3-4 months

TFCC Injury Class 1: Traumatic Prefer repair of all class IB-D A - central perforation B - ulnar avulsion with or without distal ulnar fracture C - distal avulsion D - radial avulsion with or without sigmoid notch fracture Prefer repair of all class IB-D IA lesions must be careful that dorsal and volar radioulnar ligaments are competent

Scaphoid Fractures Acute-displaced------surgery Acute-nondisplaced LAC vs SAC with avg 12-16 weeks immobilization ORIF if delayed union or displacement

Percutaneous screw fixation of Nondisplaced Scaphoid Fractures Bond et al, 2001 JBJS Prospective cast vs screw for acute nondisplaced scaphoid fractures in military recruits 25 random (14 cast, 11 acutrak screw) 100% union, Casted group avg 12 wks (return to duty 15 wks) Surgical group avg 7 wks (return to duty 8 weeks) At 2 years groups equal in motion, strength

Bottom Line I prefer percutaneous screw fixation but Union rate is not going to be 100% Surgery does not make bone heal ‘faster’ Cast or brace for sports at least 6 weeks Joint ‘soreness’ especially at EOM lasts for 3-4 months Screw placement must be perfect

Thank You!