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

3. Fingertip Injuries
Nailbed
Lacerations
Amputations
Combined

4. Nailbed Injuries

6. 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

7. 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

8. 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 hours

10. ‘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!

11. ‘Simple’ Lacerations
Patient should remove dressing 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

13. 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

14. Mallet Finger Terminal extensor tendon injury Rupture Laceration
Avulsion

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

16. Mallet Finger

17. Mallet Finger

18. Mallet Finger

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

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

21. 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

22. Radiographs

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

24. 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

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

26. 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)

27. 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.

28. 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

29. 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

30. 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.

31. 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

32. Scapholunate Ligament Injury

33. 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

34. 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

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

36. 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

37. 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

38. Thank You!