Sports Related Hand and wrist Injuries

Diagnosis and Management Stephen Olmsted, MD

No disclosures to report. Sport Specific Injuries

 Ball sports --- Finger avulsion fractures  Gymnastics --- Physeal stress fractures  Golf --- Hook of the Hamate fractures  Boxing --- Metacarpal fractures  Skiing --- Thumb fractures  Snowboarding- Wrist Fracture/dislocation  - high energy injuries  Contact Sports– Scaphoid Fx & Radius Fx

Return to Sports

 Pressure to return  athlete, team, parents and coaches

 Athlete can physically perform (no hands)  Soccer, Snowboard, Track, Football

 Adequate protection –  cast, splint, tape

Return to Sports

 Risk/Benefit ratio  Prolong injury, re-injury, worse injury  Benefit to the team and/or athlete

 Individualize the decision  Type of Fracture – Joint, unstable, location  Age, Level, Sport, Financial  Make sure everyone knows the consequences

Decision Making

 Early Diagnosis – crucial  Joint Involvement  Fracture Stability  Type of Sport  Ability to protect adequately  Age and Level of Play  Off season vs Peak season  Risks of re-injury or irreparable damage Boney Mallet Fracture

 Treatment depends on joint involvement  Most with small avulsion treated closed ◦ Stack splint – extension splint for 6 wks ◦ Early return to sports in splint  If 50% joint involved often needs pins

Volar Plate Avulsion Fracture

• Stable injury – brief splinting for comfort • Early Range of Motion Ideal - full motion in 1-2 weeks • Joint reduced, congruent • Early return to activity and sport as comfort allows Volar Plate Avulsion Fracture

Unstable injury - comminution Joint incongruency Needs more aggressive treatment Condylar fractures

Joint step-off and incongruency Vertical fracture - unstable Poor results with immobilization Condylar fractures

 Rotational Deformity – requires correction

Extra-articular fractures

Many treated closed, protected activity Unstable, angular deformity, tendon imbalance

Proximal Phalanx Middle Phalanx Metacarpal Fractures

 Common injuries in many contact sports  Often seen with punching, may see signs of old injury  Many treated closed with early return to sport Metacarpal Fractures

Look closely for rotational deformity Excessive angular deformity or shortening should be corrected Multiple metacarpal fractures often require surgery Some that look unstable heal with normal function Ulnar Collateral Avulsion Fx Skier’s Thumb Mechanism Ulnar Collateral Ligament Instability Joint involvement with joint incongruency Requires surgical reduction and fixation Ulnar Collateral Avulsion Fx

Collateral Ligament stability restored Joint congruency restored Hook of the Hamate fracture  Golf, Baseball, Hockey  Impact associated with Grip,Ulnar Deviation  May begin as a stress fracture  Often treated with excision, acute fx may heal

Scaphoid Fractures

 Common injury from fall in sports  May not have much pain or swelling  Often UN-diagnosed or MIS-diagnosed  Frequently diagnosed as Sprain  Radial Wrist Pain (snuff box tenderness)  Should be ruled out before returning  May consider MRI to R/O

Scaphoid Fractures

- Tubercle fractures – stable return to sport protected - Distal Pole Fx - Flexion Deformity, carpal malalignment - Waist Fx – most common, AVN or flexion deformity - Proximal pole Fx – High Risk AVN, Alignment Perserved - Untreated Scaphoid fx – Lead to Non-unions - Untreated nonunions – Lead to Arthritis

Scaphoid Fractures

 Distal Scaphoid fractures  Often lead to Flexion Deformity and Carpal Malalignment : Less risk of AVN  Comminution makes less stable Scaphoid Fractures -Waist  Scaphoid Waist Fractures - most common  Avascular Necrosis or Flexion deformity  Non-displaced-Cast or Percutaneous Screw  Displaced – ORIF  Non-Union – ORIF with Bone Graft Scaphoid Fractures-Proximal Pole

 Carpal Alignment Maintained  Avascular Necrosis Poor healing  Bone resorption, cystic changes  Often Require Surgical Treatment

Diagnosis ? Power Clean weight lifting injury Trans-Scaphoid Perilunate dislocation

Trans-scaphoid Perilunate Dislocation –ORIF scaphoid Gymnastics Distal Radius Physeal Stress Fractures Distal Radius Physeal Stress Fx Rest, Immobilization, reduce impact and stress Prognosis – excellent with early diagnosis Untreated can result in Physeal accellaration or arrest Ulnar positive or Ulnar negative variance Distal Radius Fractures

 Most Common Fracture

 Fall onto Outstretched Upper Extremity

 Can be Stable or Unstable

 Can be Extra-articular or Intra-articular

 High Energy Injuries - unstable

Distal Radius Fractures

Snowboarding and Terrain Parks – More High Energy Injuries Salter II Distal Radius Fractures

 Common Pediatric Injury - Fall  Tx - depends on age, displaced, stability  More conservative : wait to return to sport Distal Radius Fractures

May appear stable but can displace in cast Distal Radius Fractures