Sports Medicine Update

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1 Sports Medicine Update Volume 8 No 1 February 2015 Special Issue - Hand and wrist injuries Instabilities of the wrist TFCC Injuries: Assessment and Management Sport-related soft tissue injuries of the hand Common fractures of the wrist and hand * CPD accredited Design and printing of this newsletter generously sponsored by

2 Editorial Dr Ponky Firer Orthopaedic Surgeon Private Practice Linksfield Park Clinic Johannesburg This year s first edition of Sports Medicine Update covers the often forgotten injuries of sportsmen and women. They are not as glamorous nor as spectacular as knee injuries which are replayed in slow motion on TV, nor as common as shoulder injuries in collision sports, yet potentially as devastating to an athlete s career as a knee ligament injury or shoulder girdle dislocation. The hand and wrist injury can often present insidiously without obvious trauma and in sports in which player on player trauma does not occur. McIlroy getting his wrist taped for stability and support at the 2011 PGA Championshiip Hans Deryk/Reuters There are a number of professional golfers who have had wrist injuries from overuse or even incorrect biomechanics as well as self induced trauma. The more famous wrist injuries have occurred to Phil Mickelson, hitting out of thick rough and Rory McIlroy s celebrated shot during the 2011 PGA Championship at the Atlanta Athletic Club. With his ball against the root of a tree, and the commentators screaming: don t do it Rory played the shot and suffered a partial tear of his ulnar collateral ligament which kept him out of golf for some weeks. He did go on to win PGA the following year. Although treatment protocols call for conservative management in some hand injuries, the professional sportsman may require a different approach depending on his present playing situation. The celebrated 1995 World Cup winning full back, Andre Joubert, would not have participated in the rest of the tournament had Dr Mark Ferguson treated his un-displaced metacarpal fracture in the traditional conservative way. Andre would not have been allowed to play with a solid cast/splint and could not have played un-splinted. Careful minimally traumatic internal fixation stabilized the fracture so that he could, with good strapping support, play a key role in our victorious campaign. The most important message that comes out of this Sports Medicine Update is that hand and wrist injuries, especially in sportsmen and women, should be referred to hand specialists for assessment to avoid missing subtle, but crucial soft tissue injuries which are best managed acutely. I would finish by wishing our readers a great On behalf of Pfizer, Ann Lake Publications and the readers of Sports Medicine Update, we would like to extend our sincere thanks to Dr Mark Ferguson for his expert guidance of and contribution to Sports Medicine Update during his tenure as editor for seven years. His passion and dedication has contributed significantly to the success of Sports Medicine Update. We welcome Dr Ponky Firer as the new editor of this wellrespected newsletter. - Production Editors Ann Lake Publications The content contained in this publication contains medical or health sciences information and is intended for professional use within the medical field. No suggested test or procedure should be carried out unless, in the reader s judgment, its risk is justified. Because of rapid advances in the medical sciences, we recommend that the independent verification of diagnoses and drug dosages should be made. Discussions, views, and recommendations as to medical procedures, products, choice of drugs, and drug dosages are the responsibility of the authors. The views expressed by the editor or authors in this newsletter do not necessarily reflect those of the sponsors or publishers. Production Editors: Ann Lake Publications - Ann Lake/Helen Gonçalves Design: Jane Gouveia Sponsor: Pfizer SA Enquiries: Ann Lake Publications, PO Box 265, Gallo Manor, 2052 Fax to lakeann@mweb.co.za Website: CPD Accreditation As a Healthcare Professional, you can acquire CPD points with this newsletter by registering on www. annlakecpd.co.za at no cost. Once you have received your username and password, simply login and complete the online questionnaire relating to this article. Your CPD certificate will automatically be generated upon successful completion of the questionnaire and stored online in your CPD Vault. Should you have any queries, please contact E2 Solutions at: or neo@e2.co.za. Editorial Board Editorial Board Dr Ponky Firer Dr Mark Ferguson Dr Willem van der Merwe Dr Mike Marshall Evan Orthopaedic Sports Dr Mark Medicine Ferguson Surgeon UpdateOrthopaedic Dr Jon Patricios Surgeon Dr Orthopaedic Willem Page van Surgeon der 2 Merwe Sports Dr Mike Physician Marshall Speechly Voume 1 Evan No 1 Speechly June 2008 Johannesburg Sports Orthopaedic Medicine Surgeon UpdateJohannesburg Sports Physican Orthopaedic Cape TownPage Surgeon 2 Durban Sports Physician Physiotherapist Voume 1 No 1 June 2008 Johannesburg Johannesburg Cape Town Durban Johannesburg

3 Instabilities of the Wrist Patients with instability of the wrist present with pain, weakness and a variable amount of stiffness in the affected joint. Although some chronic conditions such as rheumatoid arthritis and Kienbock s disease may lead to wrist instability, the vast majority of cases occur following trauma. The most common mechanism of injury is a fall onto the outstretched hand. Late presentation of these injuries is common, either because patients delay in seeking treatment or because of misdiagnosis. Many referrals occur weeks or months following failed conservative treatment for wrist sprain while a significant number of patients present years later with established arthritis in their wrist. This delay in treatment limits the surgical options available to the patient and inevitably results in a poorer long term outcome. Anatomy and biomechanics of the wrist The integrity of the carpus is dependent on the osseous anatomy as well as the intrinsic and extrinsic ligaments of the wrist. Stability is provided by contact between the surfaces of the bones and occurs throught the entire range of movements. Ligamentous control provides stability only at the extremes of joint motion. The eight carpal bones are arranged in two transverse rows with the scaphoid bridging the two carpal rows. The pisiform does not contribute structurally to the wrist as it is a sesamoid bone within the flexi carpi ulnaris tendon. (Fig. 1) The intrinsic ligaments are entirely intracapsular and originate and insert on the carpal bones themselves. They are also referred to as interosseous ligaments. The extrinsic ligaments bridge the radius, the carpal bones and the metacarpals. They are individually indistinguishable at operation, lying within and intimately related to the substance of the joint capsule. The major ligaments are volar and intracapsular. (Fig. 2) Fig. 2 As arguably the most complicated joint in the human body several theories have been proposed to explain the kinematics of the wrist. These include the row theory of Watson, the oval ring concept of Lichtman and the various columnar theories of Taleisnik, Navarro, Weber and others. Although no unified theory exists, most agree with the link joint concept of Gilford (Fig. 3) which states that the lunate is held in some sort of unstable equilibrium springloaded between the scaphoid and the triquetrum. This would explain why the scaphoid, which acts as a stabiliser against compressive forces across the intercalated link (the midcarpal joint), is susceptible to fracture. No explanation is entirely satisfactory, however, because although instability may be defined as the inability to bear physiological load, this is not always associated with malalignment of the carpal bones. Similarly, many joints that are hyperlax clinically or appear malaligned radiologically are not always symptomatic. To add to this, one must further differentiate static instability from dynamic instability where symptoms and carpal malalignment occur sporadically and under certain loading conditions only. Classification of wrist instabilites Several classifications exist. However, the classification of Linscheid and Dobyns modified by Amadio (1991) is most descriptive. They classified wrist instabilities into four groups: 1. Dissociative carpal instability (CID) 2. Non-dissociative carpal instability (CIND) 3. Complex carpal instability (CIC) 4. Adaptive carpal instability (CIA). CID occurs when there is major dysfunction between bones of the same carpal row. This may occur due to fracture and/or ligament disruption. The structures most commonly injured in CID are the scapholunate ligament and the lunotriquetral ligament. An unstable non-union of the scaphoid is also one of the more common causes of CID. Simplistically, these may be recognised radiologically as dorsal intercalated segment instability (DISI) and volar intercalated segment instability (VISI) respectively. In DISI the lunate appears abnormally dorsally tilted and in the VISI pattern the lunate is abnormally flexed. Dr Michael Carides Orthopaedic Surgeon with a special interest in hand and upper limb surgery Netcare Rosebank Hospital Fig. 1 Fig. 3 Volume 8 No 1 February 2015 Page 3 CIND occurs where the dysfunction is between the carpal rows. These may be divided into proximal injuries which involve the radiocarpal joint Sports Medicine Update

4 or distal injuries which result in midcarpal instability. (Fig. 4) Fig. 4 CIC occurs when both CID and CIND happen together. These injuries are not uncommon, an example being perilunate dislocations. Many believe that the lunate, regarded as the keystone of the wrist, may be involved in one way or another in almost all of the wrist instabilities. Different patterns of varying severity of these perilunate instabilities exist, depending on the severity of the initial injury. These may also include associated fractures of the scaphoid or the radial styloid. (Fig. 5) degenerative arthritis in their wrist. These are often recognisable as SLAC (scapholunate advanced collapse) or SNAC (scaphoid non-union advanced collapse) deformities. Plain X-rays are diagnostic in almost all significant carpal pathology and CT or MRI scans are not necessary unless specific additional information is required. Routine initial radiographic examination must include an AP view, a true lateral view, an oblique and a clenched fist AP (stress) view. Gilula s lines (Fig. 6) are 3 smooth radiographic arcs. A break in any of these lines is strongly suggestive of carpal abnormality. The spilled teacup sign on a lateral view is diagnostic of lunate dislocation (Fig. 7) while the widened scapholunate interval and cortical ring sign of a volarflexed scaphoid (Fig. 8) is consistent with complete scapholunate dissociation and rotatory subluxation of the scaphoid. A scapholunate gap (Terry Thomas sign) of greater than 4 mm is suggestive but not diagnostic of a complete scapholunate ligament injury. Measurement of certain carpal bone angles may also be helpful in diagnosing some of the more subtle variations of instability, particularly the DISI and VISI patterns. (Fig. 9) These are calculated from a true lateral view of the wrist. The most useful measurements (normal values in brackets) are: 1. Scapholunate angle (30 to 60 degrees). 2. Capitolunate angle (less than 15 degrees). 3. Radiolunate angle (less than 15 degrees). Fig. 9 Fig. 10 shows an X-ray with a typical DISI pattern. The scapholunate dissociation has resulted in rotatory instability of the scaphoid with the typical appearance of a dorsally tilted lunate and a volarflexed scaphoid. The scapholunate angle in this case measures 90 degrees. Fig. 5 CIA occurs secondary to extrinsic wrist pathology, the commonest example being malunited fractures of the distal radius. Diagnosis Physical findings are often unremarkable and non-specific, particularly if presentation is delayed. Soft tissue swelling with tenderness may be present in the acutely injured wrist with limitation of movements due to pain. Median nerve symptoms are commonly present if swelling is severe or where an unreduced carpal dislocation persists. Watson s scaphoid shift test is positive in cases of scapholunate dissociation. Many patients present years following their injury with grossly altered kinematics and secondary Fig. 6 Fig. 7 Fig. 8 Fig. 10 Treatment of wrist instabilities The treatment of symptomatic carpal instability is almost always surgical. Even the low-demand wrist will develop secondary osteoarthritis if left untreated due to the abnormal kinematics of an unstable joint. There are many procedures that are available and these must be tailored to suit each individual patient. Several factors need to be considered, including aetiology, the healing potential of the injured ligament(s), the site of the injury and ability to correct any malalignment. (Table 1) Sports Medicine Update Page 4 Volume 8 No 1 February 2015

5 Table 1 SLD Stage I II III IV V VI Is the dorsal ligament intact? Yes No No No No No Can the dorsal SL ligament be repaired? Yes Yes No No No No Is scaphoid normally aligned (RS angle < 45 o )? Yes Yes Yes No No No Is the carpal malalignment easily reducible? Yes Yes Yes Yes No No Is the cartilage at radiocarpal and midcarpal joints normal? Yes Yes Yes Yes Yes No Surgical options may be subdivided as follows: 1. Ligament repairs. These provide good outcomes but must be performed early as the healing potential of ligaments reduces quickly with time. 2. Ligament reconstructions. These are performed using free tendon grafts or tenodesis. The most commonly used tendons are flexor carpi radialis and palmaris longus. Many different configurations and modifications have been described. These procedures are technically demanding and patient satisfaction is often unpredictable. 3. Capsulodesis. This is mostly used to augment primary ligament repairs or other soft tissue reconstructions. Here capsuloligamentous tissues are used to provide improved stability. 4. Limited wrist arthrodesis. Various carpal bones may be fused together to impart stability to the wrist. These are durable operations but they result in a variable amount of stiffness in the wrist, depending on which bones have been fused. These include scaphotrapezialtrapezoid arthrodesis, scaphocapitate arthrodesis, scaphocapitolunate arthrodesis and lunotriquetral arthrodesis. 5. Salvage procedures. Degenerative arthritis will occur in all joints with abnormal kinematics. As mentioned previously, this will usually manifest as scapholunate advanced collapse (SLAC) or scaphoid non-union advanced collapse (SNAC). Surgical options at this stage are limited, but would include total wrist arthrodesis and proximal row carpectomy, usually combined with some form of neurectomy. Primary ligament repairs performed within 2 weeks of injury yield the best long term results. Here, complete osteochondral avulsion of the scapholunate ligament with obvious dorsal subluxation of the proximal pole of the scaphoid (Fig. 11) has been repaired with micro-fragment screw and bone anchor fixation (Fig. 12). SLD Stage I II III IV V VI Fig. 11 Fig. 12 Treatment Table 2 In patients with delayed presentation, particularly in the high demand wrist and where there is established carpal malalignment, my preferred method of treatment is limited intercarpal arthrodesis, in this case scaphocapitate fusion (Figs. 13 & 14). Fig. 13 Fig. 14 Table 2 provides a simplified algorithm for the treatment of scapholunate dissociations. This approach may similarly be adapted to any of the other wrist instability patterns. References available on request. Non-operative treatment/arthroscopic debridement Scapholunate ligament repair ± capsulodesis Scapholunate ligament reconstruction (Brunelli/Garcia-Elias) Capsulodesis (Blatt), intercarpal fusions, RASL Convert to reducible deformity or salvage surgery Neurectomy, PRC, partial/total wrist fusion Volume 8 No 1 February 2015 Page 5 Sports Medicine Update

6 Evanthia Pavli BSc (OT) WITS, MOcc THER (hand therapy) UP Occupational Therapist, Linksfield Orthopaedic Sport and Rehabilitation Centre, Rosebank Centre for Sports Medicine and Orthopaedics Triangular Fibrocartilage Complex (TFCC) injuries: assessment and management Ulna-sided wrist pathology occurs commonly in individuals within the sporting arena. This is not surprising given the complexity of the wrist joint and the nature of demands placed on it during sporting activities. Unfortunately such injuries are often neglected and in many instances misdiagnosed. Timely and thorough evaluation as well as appropriate management of all wrist injuries is vital in order to prevent further damage and ensure optimal outcome. The TFCC, a fundamental structure within the wrist complex, is one of the more commonly injured ligaments in the wrist, accounting for a large percentage of ulna-sided wrist pathology. Fig. 1 Anatomy The TFCC is triangular in shape, extending transversely from the ulna notch of the distal radius, with its apex inserting at the base of the styloid process of the ulna. It is composed of several structures. (See Figures 1 and 2) Triangular fibrocartilaginous disc (articular disc). This is the central portion of the TFCC, which separates the carpus from the distal radio-ulnar articulation. It is avascular in nature, which compromises healing potential. The palmar and dorsal radioulnar ligaments (deep and superficial). These are the principal stabilizers of the distal radio-ulnar joint. They originate from the ulna surface of the radius inserting onto the ulna at two distinct sites. The superficial components insert directly onto the ulna styloid. The deep components insert into the fovea, adjacent to the articular surface of the pole of the distal ulna. These ligaments have a rich vascular supply and therefore a greater potential for healing. Ulnar collateral and disc - carpal ligaments Sheath of the extensor carpi ulnaris Biomechanics and function The complex has three primary functions: Stability of the distal radioulnar joint with rotation. The volar and dorsal radio-ulnar ligaments play a significant role in this process. The volar portion of TFCC prevents dorsal displacement of ulna and is tight in pronation. The dorsal portion of TFCC prevents volar displacement of ulna and is tight in supination. Axial load transmission from the carpus to the ulna Ulna-sided carpal stability Fig. 2 Mechanism of injury Injury to the TFCC often occurs as a direct result of axial loading. It is commonly seen following falls on an outstretched hand (fall from a mountain bike) or with gripping and forearm rotation. Other mechanisms may include the application of a strong distraction force to the wrist. Within the sporting arena, TFCC injuries are commonly noted in gymnasts (intensive axial loading as well as distractive forces applied to the wrist). It has also been identified in individuals who participate in racquet sports (repetitive gripping and rotation), golfers as well as weight lifters and boxers. Injuries to the TFCC have been divided into two groups, traumatic or repetitive/degenerative. Both groups are further subdivided according to the exact site of injury. (See Table 1 and Table 2) Sports Medicine Update Page 6 Volume 8 No 1 February 2015

7 TYPE 1- Traumatic 1A 1B 1C 1D TYPE 2 Degenerative Table 1: Classification of traumatic TFCC tears Classification Tear in the central portion Tear/avulsion in peripheral portion/insertion of the ulna Tear/avulsion of the ulno-carpal ligament Tear/avulsion from the radius attachment. Table 2: Classification of Degenerative tears Classification A. TFCC wear B. TFCC wear with lunate and/or ulna chondromalacia C. TFCC perforation with lunate and or ulnar chondromalacia D. E. TFCC perforation with lunate and/or ulnar chondromalacia and lunotriquetral ligament perforation TFCC perforation with lunate and/or ulnar chondromalacia, lunotriquetral ligament perforation, and ulnocarpal arthritis Table 3: Provocative tests for evaluation of TFCC integrity Test Method Result Piano key sign Fovea sign TFCC load test Testing ligamentum subcruentum Press Test Pressure is applied to the distal end of the ulna with the forearm in pronation Pressure is applied in the ulna fovea, located between the ulna styloid and flexor carpi ulnaris The wrist is deviated ulnarly and an axial load is applied in combination with rotation With the patient s forearm placed in full supination, the examiner, sitting opposite the patient, applies a volarly directed pressure on the distal ulna while pulling the radiocarpal unit dorsally. With the forearm in pronation a dorsally directed directed pressure is applied on the distal ulna while the radiocarpal unit is pulled volarly The seated patient pushes up off the chair using the affected wrist, thus creating an axial ulnar load. A positive sign is indicated when the head moves volarly and springs back when released resembling the action of a piano key. Positive sign is indicated by tenderness which replicates the patient s pain. Positive test elicits pain, clicking and reproduces the patients symptoms Positive test (pain) indicates injury to deep dorsal fibers of the ligamentum subcruentum injury, subluxation or gross instability Positive test (pain) indicates injury to deep palmar fibers of the ligamentum subcruentum A positive test produces ulnar wrist pain that replicates the patient s presenting complaint. Assessment The Assessment and appropriate diagnosis of ulna-sided wrist pain can be daunting at the best of times. A detailed history regarding the onset of symptoms and the circumstances thereof (including mechanism) is essential in guiding one s assessment. Typically patients with TFCC injuries will present with the following complaints: a clicking sensation on wrist movement reduced grip strength tenderness, pain and swelling over the ulnar aspect of the wrist Pain increases with forceful grip, with wrist flexion and ulna deviation Increased pain with extreme rotation (pronation and supination) Pain when turning a door handle, lifting heavy objects, pushing oneself up from a chair. Inability to bear weight in certain plains Objective assessment should include measurement of oedema, active and passive range of motion, strength as well as a neurological examination. In cases where a TFCC Volume 8 No 1 February 2015 Page 7 Sports Medicine Update

8 Fig. 3 Fig. 4 injury is suspected, then provocative manoeuvres can be performed in order to evaluate the integrity of the complex. Specific provocative tests are listed in Table 3. Radiological investigations including an X ray of the wrist are necessary in order to exclude a fracture. X-rays are also valuable in determining the degree of ulna variance (positive/negative.) In addition, Ultrasonography as well as MRI investigations are useful tools in determining the integrity of the TFC complex. Management Decisions regarding the course of treatment, following a TFCC injury, should be made in consultation with a hand specialist with appropriate management dependent on a number of factors including injury type (classification) and severity as well as the degree of functional impairment. Conservative management Conservative management of TFCC injuries involves a period of rest in which the complex is off-loaded, in order to reduce inflammation and allow for healing. This may be achieved with Immobilization of the injured wrist in a wrist brace/ ulna gutter splint for a period of up to 6 weeks. The wrist should be immobilized in neutral position (Figure 3). A programme of activity modification should also be incorporated further reducing load on the TFCC. In cases where no improvement is noted with initial splinting or in situations where forearm rotation continues to reproduce symptoms, patients can be placed in an above elbow splint (Figure 4 sugar tong splint) limiting such rotation. Additional modalities incorporated to reduce inflammation may include icing. A course of NSAIDs may also be indicated and should be discussed with the appropriate health care professional. Range of motion exercises should gradually be implemented in order to restore movement to the wrist. Initially, care should be taken to produce such movement in isolation of one another and in neutral rotation so as not to overtly load the TFCC complex i.e.: initiate extension and flexion, radial and ulna deviation ROM in neutral rotation. Mobilization exercises should slowly be progressed to incorporate movements in combination. As range of motion improves strengthening exercises should also be incorporated. During this time it is important to bear in mind that ulna deviation moves the load bearing axis over the TFCC. As such care should be taken to initiate strengthening in neutral deviation. Strengthening should be progressed slowly in order to prevent setbacks. The Incorporation of proprioceptive exercises is essential in the rehabilitation process and will help reduce the chances of additional injury in the future. In an athlete, wrist strengthening encompasses a major part of the rehabilitation process. The ability to load ones wrist either during weight bearing activities, or intensive gripping is essential when considering return to sports. As such therapists should have a thorough understanding of the necessary requirements and load placed on the wrist with specific sports and therapy should be adjusted accordingly. Surgical management Surgical management of TFCC injuries can be undertaken in patients where conservative management has failed. It is also often considered in individuals with symptomatic degenerative central TFCC tears (due to the limited healing potential of the central portion of the TFCC). In addition, professional athletes may only give conservative management two to three weeks before opting to undergo surgery. Post-operative management of TFCC injuries does vary and is largely dependent on the nature of the injury, procedure performed, as well as any precautions highlighted by the surgeon. In general post-operative care may include a period of immobilization followed by range of motion and then strengthening. Criteria for return to Sport Treatment plans selected when treating a sports professional will always consider facilitating a faster return to sport. It is important to note that one s progression through rehabilitation is dependent on several factors, including the nature and degree of injury, as well as rate of healing. It therefore becomes difficult to identify an appropriate amount of time before one can return to sport. Instead therapists need to ensure that appropriate outcomes have been achieved before allowing individuals to return to sport. Sports Medicine Update Page 8 Volume 8 No 1 February 2015

9 Sport-related soft tissue injuries of the hand Injury to the hand is disproportionately common in many sports. The spectrum of pathology is large but in relation to other perceived more severe injuries, the injured hand is often neglected, overlooked or unrecognized. This is unfortunate since most acute injuries are readily identifiable by good examinations and usually do well with early medical or surgical management. In practice the neglect of these injuries often leads to long-term and significant dysfunction out of proportion to the original problem and it s often straightforward management. Fractures of the hand are usually picked up early but often more significant soft tissue injuries go undetected. A sprained wrist or hand is an outdated diagnosis and its use should be avoided. Where possible a clinical/anatomical cause for dysfunction should be made even though this may be quite difficult in the excitement of the sporting contest. Accuracy of examination is often compromised in this situation and therefore once the basics of the first aid and primary-care have been applied, provision should be made for adequate diagnosis and follow up of the problem. Timeous and appropriate referral is important even where this may be perceived as unnecessary. Common things occur commonly and if the principles of treatment are sound, irrespective of whether it is a sporting injury or not, then the results will be favourable. The perception that sportsmen have a greater need or access to more sophisticated medical treatment often times leads to compromised results because of compromised management. There is always a pending contest in the mind of the athlete and while understandable should not dilute long-term commonsensical advice. and avoid trying to provide a comprehensive list of all conditions. It is also somewhat artificial to subdivide injuries into those involving the soft tissues or the underlying bones. In practice they obviously overlap and diagnoses and management cannot always be neatly pigeonholed. Mallet finger A mallet deformity occurs as a result of forced flexion of the distal interphalangeal joint (dipj) of a digit. This is often surprisingly painless and leaves the patient with an inability to extend the digit at this level. The deep digital flexor responsible for flexing the joint is not involved in the pathology and therefore distal flexion is not compromised. The ruptured extensor insertion into the dorsal base of the distal phalanx may cause an intra-articular avulsion, or rupture may occur within the substance of the tendon. A lateral X-ray will differentiate between these two possibilities and in many instances dictates their management. Not infrequently the patient presents with a so-called swan neck deformity secondary to the mallet with a compensatory hyperextension of the proximal interphalangeal joint. The tendinous disruption will generally be treated with splintage of the distal joint either using a mallet splint or a percutaneous K wire run across the joint for a period of about two months. The joint must be kept in an extended position should the splint be removed at any stage otherwise the healing tendon will be disrupted. Appropriate rehabilitation of the joint is indicated thereafter but if any extensor lag persists after the period of immobilization, then splintage may need to be extended. Where an avulsion fracture exists many surgeons would regard this as an indication for open reduction and internal fixation as well as a period of immobilisation post operatively. Deep Flexor (FDP) Avulsion of the finger This tendinous rupture occurs from forced extension of the distal interphalangeal joint while flexed under tension. It typically occurs when a tackler is grasping his opponent s clothing, a so called rugby jersey injury. The patient is unable to flex the distal joint but flexion still remains at the proximal joint due to the intact superficial flexor (FDS). This may result in failure to diagnose this significant injury. An avulsion fragment may also be present and this may be seen on the lateral X-ray either adjacent to the distal phalanx or retracted with the tendon proximally along the flexor sheath. It is important that this injury be diagnosed early since treatment is surgical and involves reattachment of the tendon into the volar base of the distal phalanx. Delayed presentation significantly compromises the result and these patients frequently end up with stiffness or compromised flexion as a result of this. Dr Walter Stuart Orthopaedic Surgeon Netcare Rosebank Hospital Craighall Park I will concentrate on some of the more common soft tissue hand injuries and their management Figure 1: Mallet Finger Figure 2: FDP avulsion of the finger Volume 8 No 1 February 2015 Page 9 Sports Medicine Update

10 Dislocation of the proximal interphalangeal joint (PIPJ) This is the most commonly dislocated joint in the hand and its diagnosis is usually obvious. Relocation usually takes place on the sports field and often times simplicity of this procedure leads all involved to think that no further management is necessary. An X-ray is important to document adequate relocation as well as the presence of any fracture fragments. Because a dislocation inevitably causes ligamentous damage to the joint a period of splinting and thereafter rehabilitation and mobilisation of the joint is crucial. Inadequate management often leads to contracture in the joint, which is a difficult problem to treat and which may eventually require a surgical procedure. Figure 3: Dislocation of the PIPJ Collateral ligament injuries The radial and ulnar collateral ligaments are strong triangular structures that provide lateral stability to the interphalangeal and metacarpo phalangeal joints. As with all ligamentous injuries, they can be totally ruptured or only partially so. A total rupture will lead to instability when the joint is stressed. Opening of the joint will be clear and clinically evident. Most collateral ligament injuries involve the proximal interphalangeal joints and most do not involve total disruption of the ligament. In general these are best treated conservatively with buddy strapping and mobilisation. The patient should be warned that these injuries take a long time to settle down and that persistent swelling over the ligament is common and often becomes chronic. They usually eventually settle down and general do not need surgical repair. The so-called gamekeepers or skiers thumb is an example of ulna collateral ligament injury of the metacarpo phalangeal joint of the thumb. This is a common injury and if unrecognised or badly treated can lead to significant longterm disability. The ligament is often totally ruptured and is frequently associated with an avulsion fragment from the ulna base of the proximal phalanx. The ulna ligament is situated in the base of the first web space and with normal hand function constant pressure on the ulna side of the thumb leads to pain and dysfunction. With complete ligamentous disruption, surgical repair generally has good results but when unrecognized, a poor result is probable and may require fusion of the metacarpo-phalangeal joint. Figure 4: Collateral Ligament injuries Volar plate injury The volar plate is a cartilaginous structure which prevents hyperextension of the interphalangeal joints. It constitutes a strong volar stabiliser. The injury typically involves the proximal interphalangeal joint and results from hyperextension at this level. Pain is situated volarly over the flexion crease and passive extension of the joint causes pain. An X-ray will reveal a congruent joint but often with a small avulsion fragment situated volarly at the base of the middle phalanx. These injuries are best treated by splintage of the joint. If neglected, a flexion contracture frequently develops since in the flexed position the tension is taken off the joint. Chronic flexor pain can also be a problem. As with dislocated joints these contractures can be difficult to manage and have compromised surgical results. Figure 5: Volar Plate injury Peripheral entrapment neuropathies Carpal tunnel syndrome is a common condition, the symptoms of which are generally recognized. It is commonly present in people who ride heavy motorbikes as well as in other sporting scenarios. The onset of sensory impairment in the median nerve distribution of the hand, as well as pain and weakness are not unusual. Less well-known is entrapment of the ulna nerve as it passes through Guyon s canal just adjacent to the pisiform bone in the ulna volar area of the wrist. The ulna nerve supplies sensation to the little and ring finger but more importantly is the main motor nerve to the hand. Compression of the motor branch of the ulna nerve just distal to Guyon s canal is a common problem in off-road cyclists and can lead to profound and rapid onset of motor weakness in the hand. Treatment of both conditions would rationally provide for removing the stimulus causing the neurological symptoms but should this not be considered feasible then surgical decompression and orthotics may become necessary. When dealing with the acutely injured hand one must be mindful of providing adequate primary care in the form of analgesia, splintage and elevation, since these conditions can be acutely painful. Adequate follow up and referral thereafter, provides for satisfactory complete management. Figure 6: Peripheral entrapment Neuropathies Sports Medicine Update Page 10 Volume 8 No 1 February 2015

11 Common fractures of the hand and wrist Fractures of the hand and wrist are common sports injuries and with increasing demand on sportsmen and women to maintain a high level of performance for most of the year it is essential to identify and treat fractures expediently and correctly in order to maximize the outcome of treatment and minimize the delay in return to sport. The key to this is correct identification of fracture patterns and appropriate initial treatment. In high demand athletes, a small intra-articular step or missed fracture dislocation can have devastating long term effects that may have been prevented by early initial diagnosis and treatment. Surgical techniques for fracture management and new fixation devices allow us to fix fractures that were previously not amenable to surgery, allowing early mobilization after surgery and avoiding long term immobilization after injuries. Radial inclination Volar tilt Figure 1: Acceptable Platform Parameters Dr Phillip Webster Orthopaedic Surgeon Sandton Upper Limb Unit Mediclinic Sandton Dr Roger Nicholson Plastic and Reconstructive Surgeon Sandton Upper Limb Unit Mediclinic Sandton In this article we will discuss three important fractures of the hand and wrist. 1. Distal radial fractures 2. Scaphoid fractures 3. Metacarpal and phalangeal fractures Figure 2: Colles Fracture Distal radial fractures Distal radial fractures are the most common fracture, constituting up to 15% of all fractures. They occur most commonly in osteoporotic women, with a peak age incidence between 60 and 70 years. It is important to note that typical Colles type fractures are occur as a result of low impact falls. On the other hand distal radial fractures occurring in sports are of much greater impact and associated injuries are common. The distal radius has three articular surfaces, the radioscaphoid, radiolunate and radioulnar facets. Radiographic parameters that must be assessed are radial length, radial inclination and volar tilt as these must all be corrected to maintain pronation and supination through the distal radio-ulnar joint (DRUJ). Aim to achieve 15 radial inclination, 1.5cm radial height and 0 to 15 volar tilt. Figure 3: Smith Fracture Although the Colles fracture is the most commonly described fracture of the distal radius, caused by a fall onto an outstretched hand, other fracture patterns are important in sports injuries. The Smith fracture occurs with a fall onto a flexed wrist and results in volar angulation with or without dislocation. Volume 8 No 1 February 2015 Page 11 Sports Medicine Update

12 Figure 4: Barton Fracture Figure 5: Chauffeur Fracture Figure 6: Die Punch Fracture Figure 7: Distal Radial Fracture Figure 8a: Scaphoid Fracture Figure 8b: Herbert Classification A Barton fracture is a fracturedislocation of the wrist with either a volar or dorsal dislocation. These fractures must be treated surgically and can lead to severe disability if not treated appropriately. A Chauffeur fracture is an intraarticular fracture of the radial styloid process after an abduction force to the thumb. Die Punch fractures are intraarticular fractures of the lunate fossa of the radius and are caused by axial loading of the wrist with impaction of the lunate into the radius with or without a split of the radial styloid. Any gap or depression of more than 2mm or an intra-articular step of more than 1-2mm will result in early arthritis if not treated operatively. There are many options available for fixation of distal radial fractures after reduction of fractures. These include cast immobilization, k-wires, external fixation and internal fixation. The good results achieved with locking volar plates has popularized their use for most fractures. Complications of distal radial fractures are uncommon, but can be devastating. These include carpal tunnel syndrome, stiffness, chronic regional pain syndrome, radio-carpal or distal radio-ulnar joint arthritis, malunion, infection and tendon rupture. In summary, distal radial fractures in sports are often more complex injuries than simple X-rays reveal in young, high-demand athletes. Sport physicians require a high index of suspicion for these injuries. Acute surgical treatment of these fractures with early mobilization and rehabilitation provides the best chance for return to sporting activities. Scaphoid fractures The scaphoid is the most commonly fractured bone in the wrist. Scaphoid fractures involve 60% of carpal fractures and 11% of hand fractures. These fractures are often misdiagnosed as sprains with disastrous outcomes. Early diagnosis and vigilant care of acute scaphoid fractures leads to good outcomes in most cases. The mechanism of injury in scaphoid fractures is a fall onto an outstretched hand with the wrist in extension and radial deviation. It is questionable as to whether failure is due to excessive compression along the concave medial articulation of Sports Medicine Update Page 12 Volume 8 No 1 February 2015

13 Figure 9: Types of Fixation the scaphoid or failure secondary to excessive tension. The diagnosis of scaphoid fractures relies on a high index of clinical suspicion. Patients present with pain or fullness in the anatomic snuffbox of the wrist. Clinical signs are pain on axial compression of the thumb, pain on percussion of the tip of the abducted thumb and pain on forced ulnar deviation and pronation of the wrist. X-ray examination may not show a fracture acutely after the fracture and X-rays must be repeated after 10 days if there is clinical suspicion of a fracture. The most sensitive test for diagnosis of acute fractures is an MRI scan. However, CT scans are more sensitive for established fractures and aid more in clinical decision-making. Fractures are classified according to the site of injury, proximal pole, waist and distal pole, fracture pattern and stability. The proximal pole is entirely covered in cartilage and relies completely on intraosseus blood supply, thus proximal pole fractures have a high incidence of non-union and avascular necrosis. Management of scaphoid fractures 75% of scaphoid fractures occur in the waist of the scaphoid, 20% in the proximal pole and 5% the distal pole. In children the distal pole is most commonly fractured. The true incidence of scaphoid fractures is not known because not all fractures present for medical treatment. Non-union rates for non-operative treatment are between 5 and 20%. Poor prognostic factors for scaphoid fractures are: Fracture displacement of more than 1mm Proximal pole fractures Avascular necrosis Vertical oblique fractures Smokers Distal pole fractures tend to heal well with cast immobilization for four weeks unless there is intraarticular displacement. Waist fractures, if truly undisplaced and stable unite with cast immobilization in 90% of cases. However, it is essential to assess the fracture with CT evaluation if there is any doubt of this. Surgery is indicated for all unstable waist fractures. Instability is indicated by: Scapholunate angle of >60 Radiolunate angle of >15 Interscaphoid angle of >35 Foreshortening Displacement of more than 1mm All displaced or unstable fractures must be reduced and fixed by either percutaneous or open fixation. Percutaneous fixation may be arthroscopically assisted. If the fracture is stable cast immobilization for 2 weeks, followed by mobilization in a futura splint for 4 weeks is appropriate. All proximal pole fractures require surgery because of the tenuous blood supply and high nonunion rates. Early stable fixation significantly reduces the incidence of avascular necrosis and non-union. Outcomes of treatment One can expect good outcomes in more than 90% of patients with non-operative treatment in stable scaphoid fractures. However, if the fracture is unstable or displaced or occurs in the proximal pole surgical intervention is required to prevent avascular necrosis or post traumatic arthritis. In high-demand athletes surgical treatment of even stable fractures results in an earlier return to competitive levels. Fractures of the metacarpals and phalanges General principles Fractures of metacarpals and phalanges are by far the most common fractures of the upper extremity. Over the past 3 decades, however, operative fixation of hand fractures has increased in popularity for a number of reasons. There has been an improvement in implant materials and designs as well as instrumentation. Today, titanium low profile plates (plates with locking screws) are available. Small cannulated screws make percutaneous fixation of certain fracture technically feasible. We also have a better understanding of mechanical principles of internal fixation, and improved hand therapy allows more invasive procedures Volume 8 No 1 February 2015 Page 13 Sports Medicine Update

14 Figure 10: Rotation deformity Figure 11: Extension Block Splint to be performed minimizing the deleterious effects of the associated scarring and stiffness. Although most fractures can be managed non-operatively, prolonged immobilization should be avoided because of risks of resultant stiffness. In general one should try and avoid placing K-wires across joints (except for CMCJ s) for the same reasons. Conversely aggressive open reduction and internal fixation, which may provide increased stability and therefore allow earlier mobilization, can result in increased oedema, scarring and tendon adhesions and joint stiffness. One must be aware of the fact that the indication for management, be it non-operative (splinting, closed reduction and splinting) or operative intervention (percutaneous pinning, percutaneous screw fixation or open reduction and internal fixation) is not generally to ensure union (except perhaps in scaphoid fractures), but to prevent a mal-union that would be of functional significance. Each fracture as well as each patient needs to be treated individually. Each fracture has its own personality and this dictates management. This fracture personality is assessed clinically and with X-rays (typically PA, lateral and oblique views). Remember to be aware of rotational deformity, particularly in oblique and spiral fractures. Metacarpal fractures Many metacarpal fractures can be treated non-operatively with splinting or closed reduction and splinting (particularly neck fractures) and then careful clinical and X-ray follow-up. In general when appropriate post operative hand therapy is available, open reduction and internal fixation with plates and screws is well tolerated in shaft fractures, since dorsal placement of plates and screws is less likely to scar the extensor mechanism. However, as fractures extend towards the metacarpal neck and head, scarring and adhesions to the extensor mechanism and sagittal band become a problem, and stiffness, extensor lag around the MCP can be problematic. The more proximal metacarpal base fractures and fracture dislocations are often best fixed with percutaneous K-wire fixation. Adequate cortical screw fixation in very proximal fractures is difficult and might not provide additional stability compared to percutaneous cross K-wire fixation or K-wire fixation across to the adjacent metacarpal. Boxer fracture Metacarpal neck fractures are common in little and ring finger and are usually associated with an axial loading force from a punch. These fractures are usually impacted and stable and can be managed conservatively with careful mobilization. There is much debate on how much flexion can be accepted from a functional point of view. More than degrees of flexion will result in the loss of knuckle prominence and a cosmetic deformity, which if not concerning to the patient can be treated non-operatively. Most surgeons would agree that up to degrees would not cause a functional disability but patients may feel prominence of the metacarpal head in the palm resulting in pain and discomfort on forced gripping and gripping firm objects. Some surgeons feel that as much as 70 degrees is acceptable in a little finger. Phalangeal fractures Mallet finger may be often present as a closed rupture of the terminal extensor tendon, which may or may not be associated with a phalangeal fracture. The injury is often innocuous and may be missed initially until sagging (extensor lag) of the terminal phalanx is noted. This commonly occurs with axial loading on an extended finger in ball sports. Doyle classified Mallet injuries into four types: Type 1 is the most common type where patients have a closed injury with or without a small dorsal avulsion fragment. The vast majority of these can and should be treated with splinting of the DIP joint in full extension for between 6-8 weeks followed by progressive weaning of the splint. It is my opinion that commonly used stack splints are inadequate as the finger needs to be held in slight hyper-extension, so would generally recommend that patients get a custom made mallet splint fabricated by an appropriately trained hand therapist Should compliance with splinting be an issue, then a single axial K-wire can be passed down the finger as an internal splint for 6 weeks, followed by gradual weaning of an external splint. Type 2 fractures occur as a result of an open injury resulting from a laceration of the tendon. Type 3 is an open injury with loss of skin, subcutaneous tissue as well as tendon substance. Type 4 injuries consist of a Mallet fracture with a large dorsal fragment. These are divided into 3 groups. Type 4A are trans-epiphyseal fractures in children. Type 4B fractures involve between 20% and 50% of the articular surface. Type 4C injuries involve greater than 50% of the articular surface and are often associated with subluxation or dislocation of the distal phalanx. Most Type 3 and 4 fractures require Sports Medicine Update Page 14 Volume 8 No 1 February 2015