Mr Mike Hayton BSc (Hons) MBChB FRCS (Trauma & Orth) FFSEM (UK) Mr Mike Hayton is a Consultant Orthopaedic Hand and Wrist Surgeon at the Wrightington Hospital in Lancashire where he has a tertiary complex hand and wrist practice Over the last 10 years, Mike has developed a special interest in hand and wrist injuries that occur in elite sport. He has several publications in this area and regularly lectures on this and other subjects internationally and in North America in particular. Mike currently receives hand and wrist referrals from over 40 professional sports teams and national sporting organisations. He has treated over 20 Olympians, many of whom have gone on to achieve podium success at the highest level. Mike has been awarded the status of a Founding Fellow in the Faculty of Sports and Exercise Medicine (FFSEM UK) and he is an examiner for the Intercollegiate Board of Examinations for the FRCS (Trauma and Orthopaedics).
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Wrightington Hospital, UK
Sir John Charnley Never operate on a bone that you can swallow
Some things have changed
Some things have changed
Hand - Sports Medicine Mike Hayton 7
In US - everyone is a sport med doc! 8
this gastroenterologist took things too seriously 9
My background Rugby Finger dislocations Ankle fracture Knee ligament rupture Cauliflower ear Thumb dislocation Thumb ligament injury Knee meniscal tear
C6/7 bifacet fracture dislocation
Sometimes - just get up and do it 12
Sometimes - just get up and do it 13
Pitfalls in Sports Injury Surgery stick with what you know 14
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Skiers thumb 16
Skiers Thumb UCL tear of Thumb MP joint Forced abduction Immediate pain over UCL Less pain if complete Lax 17
Adductor Aponeurosis UCL avulsion distally Flips outside adductor aponeurosis Will not heal 18
Assessment Tender over thumb MPJ UCL? Lump ( Stener lesion) Laxity - no end point 19
Laxity 20
Investigations Xray Stress xray USS MRI 21
Investigations Xray Stress xray USS MRI 21
Investigations Xray Stress xray USS MRI 21
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Need surgery Repair Interposed adductor hood Otherwise Wont heal Weak pinch 23
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Rehab Immediate Motion Radial blocking splint Low profile Thermoplastic 25
Series with accelerated rehab 15 professional thumbs 13 Athletes 11 rugby 4 soccer GK Mean FU 28 months (7-65)
affected thumb opposite thumb 150.0 150 140 112.5 75.0 37.5 0 62 59 59 50 17 18 10 10 MPJ flex RD Kapandji Hand Span Lat pinch 27
Return play = 4.4wks (2-10) No Re-ruptures 28
If not treated
Scaphoid 30
Clinical Features Trauma Energy
History Reduced ROM (esp. EXTENSION) Pain Scaphoid - ASB - Proximal pole SL rupture - Mainly dorsal RC in the midline ( 1cm distal to Listers tubercle) 32
History Reduced ROM Pain Scaphoid - ASB - Proximal pole SL rupture - Mainly dorsal RC in the midline ( 1cm distal to Listers tubercle) Unable to load - Press ups / Cleans 33
Examination Reduced ROM (particularly extension) Swelling Pain ASB dorsal RC joint line tubercle Axial load thumb 34
Examination Reduced ROM (particularly extension) Swelling Pain ASB dorsal RC joint line tubercle Axial load thumb 34
Examination Reduced ROM (particularly extension) Swelling Pain ASB dorsal RC joint line tubercle Axial load thumb 34
Examination Scaphoid Tubercle
Examination Scaphoid Tubercle Radial deviate Flexes Prominent
Examination Scaphoid Tubercle Radial deviate Flexes Prominent
Examination Scaphoid Tubercle Ulnar deviate Extends Less Prominent
MRI Show fracture within a few hours Show ligament injuries oedema may show the tear abnormal inter-carpal angles 39
Scaphoid in Sport Same bone Do they heal any differently
Office Worker Rugby League Prop
Why dont they heal? Delay in treatment Location Blood Supply Displacement Carpal instability Instability fracture Smoking
Blood Supply
Blood Supply Obletz & Halbstein 1938
Investigate X-ray CT scan MRI scan (Isotope Bone Scan)
Wrightington classification Ramamurthy C 2007 JBJS 89B : 627-632 46
Treatment Operative or Non operative 47
Any suspicion Xray Wrist if normal treat as a fracture in POP and re-xray 10 days or get MRI 48
Does surgery diminish time to fracture union?
Does surgery diminish time to fracture union? 2 prospective randomized studies Bond, Shin et al JBJS A 2001 Union at 7 wks (screw) vs 12 wks in (cast) Xray/clinical eval every two weeks Adolfsson et al, J Hand Surg B 2001 Union 10 wks (screw) vs 12 wks (cast) Xray at 10 weeks, 16 weeks
Fixation quicker return work?
Fixation quicker return work? Waist Fractures Adolfsson et al: 6 wks ( screw) vs 10 wks Bond, Shin et al: 8.2 wks (screw) vs 15 wks Mixed Location Inoue & Shionoya: 5.8 wks (screw) vs10wks 5 wks earlier return to activity
Treatment in athletes Is there a role for non operative?
Treatment in athletes Is there a role for non operative? Location of fracture Time of season
Non Operative Cast 6-8 weeks 12 weeks proximal pole Until healed!! Muscle wasting
My thoughts in general public Distal pole POP 6 weeks Undisplaced Waist Mini-open Fix or POP Displaced Waist Fix Proximal pole Fix (Mini-open)
My thoughts in sports Distal pole Thermoplastic 4-6/52 Undisplaced Waist Mini open Fix (Dorsal) Displaced Waist Fix (Garcia-Elias approach) Proximal pole Mini open Fix (Dorsal)
Surgery Not without risks Screw in poor position Screw too long Screw too short Infection Tendon injury etc etc Performed by experienced user and the risks much less
Treatment - Volar 59
Treatment - Dorsal 60
Rehabilitation 61
Rehabilitation Put in under load Mobilise early if Happy with fixation
Return to play 63
Traditional views Only return when healed 15% NEVER heal therefore give up career!!! Many players play with estab non unions 64
Return to train / play Geissler 2010 (personal communication) Well placed screw Immediate when pain allows Slade 2009 (personal communication) 50% union and well placed screw stronger than normal scaphoid 65
My rehab Fracture - simple Quality of fixation Early ROM and pain free Allow return in heavily strapped wrist 4-6 weeks if xray satisfactory Early CT 66
Splint for scaphoid ORIF
Return to drive? When safe to control a vehicle What about motor sport? Huge financial rewards 68
Return to drive 69
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Scapho-lunate ligament ruptures in the athlete 71
Scapholunate Dissocia on Most commonly recognized carpal instability Presents in a similar way to scaphoid fracture Many present late (6 12 months)
Acute or Chronic? 73
Acute < 8 weeks Assume healing potential of ligament 74
Chronic >12 weeks no healing potential of ligament 75
Fix or leave Explain the injury Show anatomical models Explain the natural Hx Treatment and rehab 76
Fix or leave Timing of season Timing of career Who are we to dictate? 3-4/12 rtn to sport We are there to work with the player to make the right decision for them 77
Direct Repair Presupposes healing potential of ligament remnants 6-8 weeks
Confirm diagnosis
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Chronic Tri- ligament tendodesis Brunelli I-IV Stanelli 82
2.9mm drill hole
Half FCR passed along tunnel
X X X X IV
Rehab Acute - wires out 6 weeks Chronic - Stanelli Splint 4 weeks Mobilise dart throw 4 weeks Return when fxn ROM pain tolerable strapping 89
Outcomes of Modified Brunelli Procedure in Professional Athletes with Scapholunate Instability Williams A, Ng Cy, Hayton M Br J Sports Med. 2013 Nov;47(17):1071-4.
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Results Patient demographics Number of operations 16 Age Mean 30 years (range 18-42) Gender All male Dominance of hand operated on 9 dominant, 7 non dominant Level of competition before injury 9 international, 7 national Time to surgery after injury Mean 30 weeks (range 2-78) Follow up Mean 24 months (range 3-43) www.wrightington.com
Subjective outcome measures Mann-Whitney U test p value Instability 0.047 VAS pain score at REST <0.001 VAS pain score ACTIVITY <0.001 Preoperative 0 2.5000 5.0000 7.5000 10.0000 Postoperative VAS (Visual Analogue Score) Error bar showing SEM (standard error of mean) www.wrightington.com
Functional scores at final review Quick DASH 7.66 SEM 2.11 (range 0-25) Wrightington activity of daily living, assessment for wrist function 2 (8 is normal 32 most abnormal) 9.25 SEM 0.38 (range 8-13) 2 Talwalkar SC, et al. J Hand Surgery (British and European Volume) 2006; 31: 110-117. www.wrightington.com
Modified Brunelli procedure in professional athletes generally Relieves wrist pain with (p<00.1) Appears to improve stability (not significant) Improves functional outcome scores But for other injuries 12 out of 15 (80%) returned to playing www.wrightington.com
TFCC 96
TFCC made easy
Triangular Fibro Cartilagenous Complex
Function Transmit load Stabilise the DRUJ
Anatomy Group of several anatomic structures Triangular fibrocartilage (articular disc) Meniscus homologue UCL ( ulnar capsule) Volar and Dorsal DRU ligaments ECU subsheath Prestyloid recess
TFCC 101
Vascular supply Supply periphery only Synovial fluid bathing Implications for repair
Biomechanics Ratio radius to ulnar length TFCC perforations in 73% matched or ulnar plus
Natural History Cadaveric study No Hx trauma <20 years no TFC perforations >60 years 50% had TFC perforations
Biomechanics Pronation Ulnar +
Biomechanics Pronation and Ulnar Deviation Increase ulnar load to 150% of neutral Pronation increases ulnar variance 1mm Gripping increases ulnar variance 4mm
Biomechanics of the hand-off
Biomechanics of the hand-off
Biomechanics of the hand-off
Symptoms Ulnar sided wrist pain Quite well localised Usually with ulnar deviation Sudden pronation activity Clicking on rotation Instability is rare
Signs Pronation Ulnar deviation Axially load Rotate
Ulnar column stability Test the DRUJ AP stability With wrist in Neutral Radial deviation Ulnar deviation
Ulnar column stability
Unstable DRUJ
Investigations Plain Radiographs Ulnar variance MRI Arthrography Wrist arthroscopy
Investigations MRI vs arthroscopy Accuracy Arthroscopy gold standard
Arthroscopy - normal
Palmers Classification Divides TFCC lesions traumatic and degenerative TFCC injuries Further into location
Class 1- traumatic radial
Treatment Conservative and activity avoidance Steroid injection (10mg Kenolog) if DRUJ is stable Surgery DRUJ stable and failed conservative Debride arthroscopically DRUJ unstable Repair
Surgery Arthroscopic Repair Debridement Shavers Radiofrequency (Vapr) keep the heat down Open Repair Ulnar Shortening
Arthroscopic : Repair
Open Repair
Arthroscopic : Debride
Ulnar Shortening
Case 23 old RL Pronation injury Pain Clunking
Unstable DRUJ
6 weeks post op
The Boxers Hand Extensor hood injuries CMCJ Instability 131
Boxers - MPJ Ext hood tear Make the diagnosis Flicking tendon Exposed MC head Pain on impact Ishizuki M: Traumatic and spontaneous dislocation of extensor tendon of the long finger J Hand Surg [Am] 15:969, 1990,
Clinical Subluxation 133
Imaging 134
Any digit - usually Index / Middle 135
Any digit - usually Index / Middle 135
Any digit - usually Index / Middle 135
Boxers - Ext hood tear Repair Easy Direct But do in full flexion (Deficient) use ext retinaculum
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Rehabilitation Back Slab 140
Rehabilitation @ day 2 - Dorsal thermoplastic splint MPJ 80 / PIPJ free 141
Rehabilitation @ day 10 - early active ROM @ 4 weeks leave free @ 8 weeks allow speed ball / water bags @ 12 weeks increase impact @ 16 weeks full contact 142
Current study 13 Knuckles in 11 elite level boxers (May 2006 Dec 2012) Many more since 7 Olympic GB squad and 4 professional Post-operative DASH score Range of flexion Time to return to sport
Return to sport Time to return Average 5.05 months (range 3 8) Success following surgery Olympic Gold 2 Olympic Bronze 1 Turned professional 2 Professional record Won 33, lost 2, drawn 2
Boxers CMCJ
Boxers - CMCJ instability 5000 punches / day Reactive Bossing Continued +/- injs Frank instability Occasionally spontaneous stiffen
Boxers - CMCJ instability
Boxers - CMCJ instability
Boxers - CMCJ instability History Hand Collapses Hand Buckles Its not my wrist doc
Boxers - CMCJ instability Examination Bossing obvious Isolate the CMCJ
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Investigations
Dynamic - Xray or USS 153
Treatment Activity modification - give up Occasionally spontaneously stiffen consider waiting if possible Taping Surgery (Ligament reconstruction) CMCJ Fusion 154
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Splinting for training 156
CMCJ Fusions 157
Which to fuse? The symptomatic and unstable on screening Usually index and middle CMCJc Very rarely the ring and little 158
Rehabilitation @ 2-5 remove back slab thermoplastic splint in neutral allow pin site cleaning (not buried in this case) @ 6 weeks Xray remove wires - usually under GA @ 8 weeks allow speed ball / water bags @ 12 weeks increase impact @ 16 weeks full contact 159
Results Combined joint fusion for index and middle carpometacarpal instability in elite boxers Nazarian N, Page RS, Hoy GA, Hayton MJ, Loosemore M. J Hand Surg Eur Vol. 2013 May 6. 160
Finger Fractures Most common 5 th MC Boxers fracture 161
Indications for fixation Shortening Rotational deformity Intra-articular Marked angulation Multiple (esp 2 nd 3 rd ) 162
Shortening 163
Rotational abnormality 164
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Intra-articular 166
Anatomic reduction 167
Marked angulation 168
Multiple fractures 169
Beware the fight bite 171
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mikehayton@gmail.com 173