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Sports Surgery Surgical Management of Upper Limb Injuries in Cyclists

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Sports Surgery Surgical Management of Upper Limb Injuries in Cyclists SPORTS SURGERY SURGICAL MANAGEMENT OF UPPER LIMB INJURIES IN CYCLISTS – Written by Richard Knight, Len Funk, Adam Watts and Mike Hayton, United Kingdom Upper limb injuries are extremely common ULNAR NERVE COMPRESSION (‘HANDLE- palsy at the wrist causes pain and altered in cycling and can be separated into non- BAR PALSY’) sensation to the little and ring fingers, if traumatic conditions, such as peripheral The ulnar nerve passes along the volar/ the compression is exclusively affecting the nerve compressions, and acute traumatic ulnar aspect of the wrist, passing through motor branch, cyclists may present with injuries, such as scaphoid and clavicle Guyon’s canal and into the hypothenar painless wasting of the interossei muscles fractures. This article aims to give an eminence and hand. This makes it between the metacarpals, wasting of the first overview of these injuries and injury particularly susceptible to compressive web space and clawing of the little and ring patterns which commonly affect elite injury in cyclists while they are gripping on fingers. Although predominantly a clinical cyclists, how to minimise their impact and the hoods or on the drops, as this applies the diagnosis, nerve conduction studies can how they can be managed surgically. most direct pressure at the Guyon’s canal1. confirm the diagnosis and localise the site Non-traumatic pathologies which The ulnar nerve supplies sensation to the of compression. The majority of cases settle commonly affect the hand of the cyclist are ulnar portion of the hand and the little and with non-operative management, although ulnar nerve compressions at the Guyon’s ring fingers. Its motor branches supply the surgical decompression and exploration canal, median nerve compressions at the intrinsic muscles of the hand (hypothenar is required as a matter of urgency when carpal tunnel and hypothenar hammer muscles, adductor pollicis, the interossei there is motor nerve involvement. It should syndrome. Figure 1 shows the superficial and the fourth and fifth lumbricals). It is be noted however that in some severe location of both the median and ulnar nerve important to remember that depending cases, particularly with motor symptoms, and also the ulna artery at the wrist. In on which zone of Guyon’s canal is affected, the symptoms and muscle loss may not this axial 3T MRI the ulna nerve is actually symptoms can be motor only, sensory fully recover despite decompression. This seen to be split into the sensory and motor only or a mixed pattern. This means that highlights the need for increased awareness branch as it passes through Guyon’s canal. although classic presentation of ulnar nerve and early operative measures when motor 476 Median nerve in the Ulna nerve and artery Flexor retinaculum carpal tunnel in Guyon's canal Figure 1: 3T MRI axial section of the wrist showing the superficial position of the nerves. Both the sensory and motor branches of the ulnar nerve can be seen. symptoms and signs of weakness and be more extended in these riders, but artery aneurysm or thrombosis. This is wasting are identified. Non-operativeaffected patients are not limited to these usually related to repeated blunt trauma measures for sensory involvement include grip patterns. Typical symptoms include to the hypothenar eminence, although a thicker, padded handlebar tapes and padded reduced sensation and pins and needles single, significant blunt trauma can cause gloves to minimise the contact pressures at affecting the thumb, index and middle sufficient damage to the vessel to cause Guyon’s canal. One study showed a decrease fingers, rarely with weakness or wasting of subsequent thrombosis or aneurysms. These in peak pressure over the palm by 10 to 29% the thenar eminence. Again, the diagnosis changes frequently lead to distal ischaemia, simply by using protective gloves1. Where is often clinical in classical cases but nerve ulceration and ultimately necrosis. As well possible, adoption of a cycling position conduction studies can confirm the site of as cyclists, sports which involve repeated which minimises the weight through the compression in equivocal cases. Although trauma to the hypothenar eminence, such upper limb should be encouraged. All riders likely to be a localised compression as golf, hockey, volleyball and baseball, should also be aware of their hand position neuropathy, other medical causes and can be affected. Patients can present with and to change this periodically throughout more proximal lesions at the elbow and a sudden acute event or a more gradual a ride. Despite the perception that ulnar cervical spine should always be excluded. picture. Symptoms generally consist of pain nerve/handlebar palsies are a ‘chronic’ The majority of cases resolve with non- over the hypothenar eminence and any of condition, it should be remembered that operative measures, similar to those for the fingers, although the ring finger tends to permanent ulnar nerve damage can occur ulnar nerve compression. An image-guided be more commonly affected. Cold sensitivity within hours or within a single ride and as steroid injection around the median nerve and paraesthesia are also common. Clinical a result, cyclists should be aware of these may improve symptoms but tends to have examination may reveal subtle blanching of strategies to reduce the risk of permanent a transient effect. If symptoms do not the digits with splinter haemorrhages, up to injury. improve with non-operative measures, a digital ischaemia, ulceration and gangrene. surgical release of the carpal tunnel should Rarely, a palpable mass representing an MEDIAN NERVE COMPRESSION be considered. ulnar artery aneurysm can be identified. Median nerve compression at the carpal Treatment depends on the acuteness of tunnel also frequently affects cyclists. It HYPOTHENAR HAMMER SYNDROME presentation and the severity of symptoms. tends to affect mountain bikers and road This is a rare and probably under- In mild cases presenting chronically, activity cyclists who prefer to ride on the tops reported condition which causes digital modification and non-surgical treatments of the handlebars, as the wrist tends to ischaemia as a consequence of an ulnar can be sufficient. In acute cases with SPORTS MEDICINE IN CYCLING TARGETED TOPIC 477 SPORTS SURGERY digital ischaemia some form of surgical intervention in the form of fibrinolysis or embolectomy is required, occasionally with complete excision of the affected ulnar artery segment and subsequent reconstruction. SCAPHOID FRACTURE Although many injuries in the hand and wrist occur due to falls by cyclists, one of the commonest and potentially most serious is a fracture of the scaphoid bone. Precise mechanisms of injury can vary, but any fall onto an outstretched hand in which there is pain around the wrist should raise the suspicion of a scaphoid fracture. Initial symptoms are radial-sided wrist pain, lack of wrist extension and difficulty loading the wrist in extension. The three most reliable Figure 2: Plain radiograph of a non-union proximal pole scaphoid. Increased sclerosis of the and reproducible areas to test scaphoid proximal pole is also visible, suggesting avascular necrosis that will eventually fragment. tenderness are: • The anatomical snuff box. necrosis leading to arthritis. Figure 2 shows with a compression screw. Displaced • Over the greater tuberosity on the volar a scaphoid proximal pole non-union. The scaphoid waist fractures should also be surface of the scaphoid. proximal pole has become sclerotic and fixed surgically, but evidence is divided on • Pain on performing the scaphoid will eventually fragment due to avascular the management of undisplaced scaphoid compression test. necrosis. waist fractures, with much research Lack of wrist extension compared to the Scaphoid fractures can broadly be placed ongoing. Given no clear consensus in the opposite side is a particularly important into three categories: distal pole, waist and management of undisplaced waist fractures, clinical sign and should alert the clinician proximal pole fractures. This is a reflection many surgeons treating elite athletes would to wrist internal derangement that may be of the relatively poor blood supply to the advocate fixation of these fractures to permit a scaphoid fracture or intrinsic ligament scaphoid bone which flows in a retrograde early return to training and/or competitions injury. direction from distal to proximal. Any and avoid the problems that prolonged Plain radiographs often reveal a fracture of the scaphoid potentially immobilisation may cause in the athlete, scaphoid fracture, however radiographs disrupts the blood supply and can lead to such as skin maceration due to sweating may be normal, even with a fracture and, avascular necrosis of the proximal scaphoid. under the cast. Although advice regarding if suspected, should be repeated after Traditionally distal pole fractures have been return to sport varies, many surgeons who 10 days of immobilisation. MRI is now treated in plaster for 6 to 12 weeks. A thumb fix fractures would not require prolonged commonly used to exclude or diagnose extension does not need to be incorporated casting postoperatively and an early return an acute scaphoid fracture and will show in this plaster. Proximal pole fractures have to non-contact or low-impact activities may the fracture and oedema immediately. A a poor union rate and can develop avascular be offered. However, these activities are timely diagnosis is important to reduce the necrosis. They are therefore almost always likely to be restricted until bony union is risk of scaphoid non-union and avascular treated via an open or percutaneous fixation confirmed, usually via CT scan. THE ELBOW Fractures around the elbow Typical fractures seen following a fall from a bike are radial head fractures, that Any fracture of the scaphoid may be part of a fracture dislocation and olecranon fractures. These injuries may be potentially disrupts the blood open and are often heavily contaminated supply and can lead to avascular with grit from the road. This requires immediate attention with surgical cleaning necrosis of the proximal scahpoid to reduce the risk of infection.
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