Hand & Wrist Injuries. DR MA Manjra

Transcription

1 Hand & Wrist Injuries DR MA Manjra 1

2 Background Up to 25% of all athletic injuries General population Sport people Sport specific Position specific

3 Multifaceted Time of season Level of athlete Parents Ability to play while protected Coaches PHYSICIA N Hand dominance

4 History and examination Hx: Direct blow Indirect Twisting Extreme ROM LOCATION of pain DURATION Neurological symptoms Exam: LOOK/FEEL/MOVE Neurological exam of limb

5 Approach: Wrist Fracture Radial Sided Soft Tissue Acute Fracture Ulna sided Wrist Soft Tissue Radial Sided Tendonopathy Chronic Ulna Sided BLACK BOX

6 Acute: Radial sided Scaphoid fracture Distal radius fracture Peri-lunate injury

7 Scaphoid fractures Most commonly injured carpal bone FOOH Pronation + Radial deviation Examination Tenderness Snuff box Axial loading Pincer

8 Scaphoid fractures X-rays Acute Delayed CT Scan MRI Herbert Classification Management Conservative Surgical

9 Peri-lunate injury Commonly missed (25%) Extension + Ulna deviation Greater vs Lesser Arc Sequence of failure SL ligament CL Ligament LT ligament Dorsal RC ligament Lunate rotates and dislocates

10 Peri-lunate injury Mayfield Classification Stage I: scapholunate dissociation Stage II: + lunocapitate disruption Stage III: + lunotriquetral disruption, "perilunate Stage IV: lunate dislocated from lunate fossa (usually volar) associated with median nerve compression

11 Scapho-lunate dissociation Terry-Thomas sign Clenched fist view >5mm widening Signet Ring Sign

12 Management SURGERY Universally better outcomes BUT Return to full function unlikely Decreased grip strength

13 Assess Giloola s Lines

14 Lateral C-lines Distal radius Proximal lunate Proximal scaphoid Distal lunate Proximal capitate

15 Acute: Ulna sided Ulna styloid fracture TFCC injury Hamate fracture Pisiform fracture ECU injury

16 TFCC injury TFCC: soft tissue complex that supports DRUJ Extension of radial articular surface Hyperextension and pronation of the axially loaded, ulnar deviated wrist

17 TFCC tear Can be acute or chronic Commonly seen in with repetitive bat swinging A painless functional TFCC is critical for swinging a bat

18 TFCC injury Deep pain Grip Fovea sign Piano key sign Management Initially conservative Immobilisation NSAID s

19 Hamate Fractures Can be body or hook Common: golf/hockey/baseball Direct blow Clinically Decreased grip strength Pull test NB: Check ulna nerve for Guyon canal entrapment

20 Investigations

21 Management Conservative Acute injuries Undisplaced No neurology ORIF Excision of hook Delayed presentation

22 Pisiform fracture Pea shaped sesamoid bone within FCU tendon Direct impact/fooh 50% incidence of concurrent carpal bone # Wrist pain/grip weakness

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24 Management Conservative EARLY immobilisation 30 degree wrist flexion and ulna deviation Excision Persistent symptoms Non-Union

25 ECU injury Flexion, supination, and ulnar deviation Non-dominant hand in a double-handed backhand in tennis Leading hand in the downward phase of a golf stroke Tendonosis/subluxation/dislocation, or rupture Can be ACUTE OR CHRONIC Pain and mechanical symptoms Resisted extension & Ulna deviation Snapping (Snapping ECU Syndrome)

26 ECU injury US MRI: Check TFCC Management Immobilisation: pronation & radial deviation for 4 MONTHS Surgery

27 Chronic: Radial sided de Quervain s tenosynovitis (most common) Intersection syndrome Tendonitis of the flexor carpi radialis Gymnasts wrist

28 de Quervain s tenosynovitis Thickening/inflammation of 1 st dorsal compartment Abductor pollicis longus/extensor pollicus brevis Repetitive thumb extension and abduction Tenderness 2cm proximal to radial styloid Finkelsteins test

29 Intersection syndrome Also called Oarsman s wrist Friction at the crossing of the tendons of the 1st extensor compartment over 2nd extensor or a stenosing tenosynovitis Pain extension and radial deviation 4 8 cm proximal to the radial styloid. Can be misdiagnosed as de Quervain s tenosynovitis.

30 FCR tendonitis Repetitive wrist flexion or acute overstretching volleyball or water polo develops from tendon thickening as it runs in its tunnel Pain radial palmar wrist crease to base of 2nd metacarpal worse on resisted wrist flexion.

31 Management Conservative Avoiding inciting events Immobilization, stretching techniques, ice NSAID s Anesthetic/corticosteroid injections diagnostic and of therapeutic benefit Surgery

32 Gymnasts wrist Overuse syndrome in skeletal immature gymnast Can lead to premature close of growth plate Present with Wrist pain Swelling Tenderness Decreased motion

33 Gymnasts wrist

34 Gymnasts wrist NSAID s Immobilisation for 3-6 months Surgery Resection of physeal bridge Ulna epiphysiodesis and radial shortening

35 Chronic: Ulna sided wrist pain (The black box)

36 HAND INJURIES

37 Thumb injuries Fractures of the metacarpal: Extra-articular Intra-articular Bennetts Rolando Dislocation CMCJ/IPJ Thumb collateral ligament injury

38 Bennetts Deforming forces Volar oblique ligament APL, Adductor pollicis Closed reduction Traction/extension/pronation/abduction Surgery

39 Dislocation of CMCJ/IPJ Mostly dorsal Relatively rare VERY NB: Method of reduction Do not apply traction in IPJ Management Conservative: stable close reduction Surgical

40 Thumb collateral ligament injury (Radial: rare) Ulna: most common Skiers thumb: Acute Gamekeepers thumb: Chronic Hyper-abduction injury Instability in flexion & extension Compare to uninjured side

41 Management X-ray Bony avulsion Stress view MRI Management Immobilisation 4-6 weeks: <20 degrees instability Surgery

42 FINGER INJURIES

43 Finger injuries Mallet Finger Jersey finger Pulley Injuries Sagittal band rupture Metacarpal fractures Base Shaft Neck Phalangeal fractures

44 Mallet finger Avulsion distal extensor tendon Bony vs soft tissue Acute vs chronic Forced flexion Splinting: most No joint subluxation 6-12 weeks Surgery

45 Jersey Finger Rupture of FDP Bony vs soft tissue Acute vs chronic Forceful hyperextension Can still have flexion in bony avulsion SURGERY ASAP Preserve vascular supply

46 Pulley ruptures Rock climbers Forceful flexion A2 or A4 pulley History of a pop Swelling Tenderness Management Taping or pulley rings Surgery: multiple pulleys

47 Sagittal band rupture Known as boxers knuckle Leads to dislocation/subluxation Index and middle in professionals Ring and little in amateurs Mechanism: Forceful resisted flexion/extension Laceration Direct blow

48 Sagittal band rupture Management Extension splinting No dislocation/subluxatio n Surgery Professionals

49 Central Slip rupture Volar dislocation of PIPJ or forced flexion Basketball and volleyball Leads to Boutonniere deformity Lateral migration lateral slips

50 Central Slip rupture History of DIPJ dislcoation Pain at central slip insertion Check DIPJ: Elson s test Management Early: conservative extension: DIPJ free Surgery: bony avulsion Chronic injuries with fixed deformity: POOR outcome Encourage early consultation

51 Neurological conditions Bowlers thumb Neuroma ulna sided digital nerve of the thumb Usually with spinners Ulna nerve dysfunction/guyons Canal syndrome Difficulty with pinch, coordination Cyclists: padded gloves/handle bars/adjust seat