5/8/2017. Finger Injuries in Football. Tendon Injuries of the Hand and Wrist in Football Steve Kronlage, MD Andrews Institute Gulf Breeze, Florida

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1 Finger Injuries in Football Tendon Injuries of the Hand and Wrist in Football Steve Kronlage, MD Andrews Institute Gulf Breeze, Florida A jammed finger is an injury (at very least a torn ligament) A swollen or painful finger needs to be evaluated Things to rule out (things that will get us in trouble) Fractures Dislocation Mallet finger Boutonniere (Central Slip Avulsion) Jersey finger Phalanx Fracture Presentation Check rotation by flexing fingers Check other side Check motion Check tendon function Mallet Boutonniere Tendon Injuries to the Hand Sagittal Band Tendon Injuries of the Wrist Extensor Carpi Ulnaris Tendon Injuries of the Wrist Extensor Tendon Injuries of the Hand Mallet Terminal tendon insertion Boutonniere Central slip (forearm extensor tendon) insertion at PIP joint Sagittal Band At the MCP joint 1

2 Extensor Mechanism Finger Extremely complex Tendons are more like sheets than cables Forearm Extensor Tendons extend at the PIP joint Lateral Bands Extend at the DIP joint INTRINSICS Extensor Tendon Anatomy Imbalance anywhere can cause a dysfunction Intrinsics Small muscles of the hand Make up the LATERAL BANDS Flex MP Extend the PIP and DIP Intrinsic Function Finger Terminal Extensor Tendon Injury Blow to extended finger Usually full PROM, often dorsal pain over tendon disruption Can have and acute swan neck deformity due to relative lengthening of the extensor mechanism Always x-ray Mallet Finger Treatment Mallet Finger Treatment Acute= non-operative Chronic = salvage Splint 6 weeks all the time compliance is issue Then 6 weeks night/sports splinting We use a non-removable splint made by the hand therapist Changed weekly or if breaks Can play all sports, shower use for anything Compliance with this is mandatory 6 weeks of constant splinting Wean out over then next month 2

3 Never normal If painful, something is wrong If you are concerned about a finger check other fingers Some young people are very loose jointed Swan Neck Mallet Fracture Commonly missed jammed finger Often presents late controversial Hofmeister, et al JHS 2002 Hussein, et al JHS 2007 >30% articular surface and no subluxation=splint Subluxation, large articular component=fixation The type of fixation doesn t matter Needs post op splinting Mallet Fracture treatment Hofmeister, et al JHS 2002 Epiphyseal Fracture of the Distal Phalanx- Seymour Fracture Hyperflexion Injury Open mallet fx Nail laceration Needs operative fixation Nailbed is in the fracture site Repair of nail bed Keep nail on as helps hold the repair Green s Operative Hand Surgery, 2011 Avulsion of the Central Slip insertion on the middle phalanx OFTEN MISSED Chronic does BAD, BAD, BAD Acute will have a normal result if treated within 3 weeks Boutonnière Injury Classic deformity due to loss of central slip integrity and lateral band subluxation/shortening Pain on central slip insertion site Swollen PIP No resistance to PIP extension Pain with active DIP flexion If confused/concerned MRI Always XRAY Boutonniere Presentation 3

4 Early Splint made by a hand therapist for 6 weeks, all the time Cannot play in the splint Return taped at 6 weeks Chronic Need central slip reconstruction Results inconsistent Treatment Boutonniere Sagittal Band Injury Saggital Band Injury The sagittal band hold the terminal extensor tendon in the midline If it is incompetent or injured the extensor tendon will sublux Middle finger most affected Often due to blow to dorsum of extended finger If caught early (1-2) weeks, immobilization of the MCP in extension for 6 weeks Late requires reconstruction followed by immobilization for 6 weeks It would be ok to wait until the end of the season to reconstruct as splinting would be difficult Sagittal Band treatment Complex and Unforgiving Flexor Digitorum Superficialis (FDS) Superficial flexor, attaches base of middle phalanx Flexor Digitorum Profundus Deep, major flexor, avulsion is jersey finger Annular Pulleys (5) Important for flexion A2 and A4 needed to prevent bowstringing Flexor Tendon Anatomy 4

5 Often missed in kids/adolescents Swelling and pain Jammed Finger Loss of motion Sometimes difficult to tell due to intact FDS tendon Almost always the ring finger is longer when flexed Make sure any swollen finger can do this Leddy Classification I.Tendon retracts to palm reattach 7-10 days II.Tendon retracts to PIP joint (long vincula attached) most common III. Large chunk of bone attached, least common Green s Operative Hand Surgery, 2011 Type 1 needs to be fixed as if it were a flexor tendon laceration. Sooner the better My belief that all should be fixed immediately. Can be fooled with fracture and then tendon retraction into the palm All treated with tendon reattachment to bone, Flexor tendon rehabilitation No sports for 3 months after repair Green s Operative Hand Surgery, 2011 Extensor Carpi Ulnaris (ECU) Instability Extensor Carpi Ulnaris(ECU) Instability Pain over the ECU tendon Can be mis-diagnosed as TFCC tear Loss of Extensor Sheath restraint to tendon subluxation Painful snapping 5

6 Treatment for ECU instability MRI first to ensure no intra-articular problems (TFCC tear) Acute: Cast in Pronation, may continue to snap, but pain will be gone Chronic: Stabilize with direct tissue repair, or local sling Very slow recovery over 3-4 months Much more common than instability Chronic ulnar sided wrist pain Very difficult to distinguish from TFCC tear in an athlete ECU tendonitis Pain over the ECU tendon Pain with EXTENSION and ULNAR DEVIATION at the wrist against resistance Synergy Test Xray/MRI essential ECU tendonitis evaulation ECU tendonitis treatment Steroid injection Rest Immobilization Therapy Chronic cases in low demand patients get release Thank You 6