Hand & Wrist Casey G. Batten MD Assistant Clinical Professor UCSF Sports Medicine Topics: Scaphoid Fracture Scapholunate Separation TFCC Injury Thumb Ulnar Collateral Lig (UCL) Injury Extensor Injury / Mallet Finger Hook of the Hamate Fracture Scaphoid Injury Most commonly injured carpal bone (70%) FOOSH TTP SNUFFBOX 10% have associated wrist Fx / elbow fx 41% wrist malpractice cases!
Early Dx! Distal blood supply Complications: Malunion Delayed-Union Non-Union AVN Imaging X-ray, repeat if negative and + TTP in 2 wks Order Scaphoid views! Bone Scan - Less often utilized MRI - Do not use to follow healing, Use AVN CT - Excellent to assess healing Dont Be Fooled... Pseudofracture NON-UNION X-ray Hallmarks: Sclerosis Cystic Changes TTP Displacement Lucent Line Considered unstable CT...NOT MRI? Early arthritis
Fixation or Not? Stable or Unstable? ligament Injury? Scaphoid Review Look for associated fractures Make the diagnosis early to avoid complication X-ray initially, then CT or MRI if suspicion Early (within 4 weeks) Referral if unsure Scapholunate Dissociation Most Common major ligamentous injury of the wrist FOOSH May be associated / confused with Scaphoid fracture Not always acute, present later TTP jxn, + Watson test Imaging
Treatment Non-operative if dynamic instability - AM, Splinting Usually early operative fixation is best to prevent further damage to wrist Scapholunate Review Usually does not present acutely Be suspicious if negative xray for Fx Correct views, may not show DYNAMIC instability EARLY REFERRAL for operative repair TFCC Injury (Triangular Fibrocartilage Complex) Stabilizes DRUJ and ulnar carpus Ulnar sided pain with click Piano Key, TFCC compression, painful UD Imaging X ray MRI 80% sens, 70% spec Arthroscopy is gold standard
TREATMENT -If isolated, 8-12 wk conservative Tx Flex/UD cast 4-6 weeks Removable splint PT MANY DIFFERENT TYPES OF INJURY TFCC REVIEW Major stabilizer of ulnar carpus and DRUJ MRI ARTHROSCOPY IS GOLD STANDARD (DX & TX) TYPICALLY SURGICAL TREATMENT Thumb UCL Injury (Gamekeeper s Thumb) Valgus force at MCP with thumb AB Skiers Thumb Grade 1, 2, 3 STRESS TEST FLEX MCP TO TIGHTEN LIGAMENT
Stener Lesion Obtain X-ray prior to stress, to avoid worsening injury Palpable lump ulnar aspect of MCP Treatment Grade 1 and 2, non-op mgt with thumb-spica cast for 4 weeks Complete tears and Stener lesion should be evaluated by hand surgeon Surgical repair within 3 weeks advised, within 1 week optimal UCL INJURY REVIEW Grade 1, 2, 3 X-ray before stressing Test with 0 and 30 deg of MCP Flexion Grade 1/2 - Spica Cast All others eval by hand surgery for repair Mallet Finger Loss of extensor tendon congruity at DIP Due to forced flexion with eccentric contraction of extensor Unable to actively extend DIP
Treatment Splint DIP in extension 6 weeks CONTINUOUSLY, then 6 weeks at night Free PIP Up to 3-6 months after injury may still splint Refer Dorsal Pressure Sore Mallet Review Lack of ACTIVE extension of DIP Continuous splint for 6 weeks, free PIP May still try splint if late presentation (up to 3-6 months) Look for dorsal pressure sores Hook of Hamate FX May be from direct blow Golf / Baseball Forms radial border of Guyon Canal
Exam Pain with axial loading 4th and 5th MC s TTP 1cm distal and radial to pisiform Fx Hook (I) more common than Body (II) fx s AVN may follow Non-union 50-90% Weak / painful grip NV exam Imaging Difficult on routine Xrays Carpal tunnel view Hook of Hamate view CT scan Treatment of Hook Fx If caught early (< 1 week), may tx with short-arm cast Recommend all evaluated by hand surgeon ORIF vs. Excision ORIF for Body Fractures Hamate Fx Review RARE, 2% of carpal fractures Evaluate for neurologic and vascular injury High rate non-union Order special view, CT in suspicious REFER ALL TO HAND SURGERY
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