Coaches Manual
10 Tips on Sports Hand and Wrist Injuries
Sunjay Berdia, MD, MS
Adjunct Assistant Professor, Department of Surgery, Uniformed Services University of
The Health Sciences
1) The inability to completely extend the tip of your finger is called a mallet finger.
a. An injury to the extensor mechanism on top of the distal finger joint results in a mallet finger. The person then cannot completely make the finger straight. This droop is referred to as a mallet deformity. Usually there is a stretch injury to the tendon but sometimes there can be an avulsion fracture of the distal bone. The tendon attaches to the bony fragment and results in the inability to extend the joint normally.
b. The injury occurs when the distal joint is being extended straight and is suddenly subjected to forced flexion. Examples include a basketball or baseball jamming the tip of the finger that is extended to catch the ball. Usually the droop is immediately noticeable but can take days to develop.
c. In the work up of this injury, radiographs are necessary to rule out this type of fracture. Treatment is usually non-operative and consists of full-time extension splinting or casting for 6-8 weeks. Afterwards, there is a 2-4 weeks period of weaning off the splint. Surgical management is reserved for certain fracture patterns and for soft-tissue mallets that fail conservative treatment.
2) Jersey finger results from the closed spontaneous rupture of the tendon that flexes the distal finger joint.
a. Avulsion of the tendon that bends the distal joint is a called a Jersey finger. This injury occurs when the finger is forcibly extended during maximum contraction of the muscle, as with a strong gripping. This is a closed injury with no actual open wound or laceration. It is not uncommon for this injury to initially ignored because loss of active flexion of the distal joint may be missed because of initial pain and swelling.
b. This injury most commonly occurs in young men involved in football, flag football, and rugby. The player is usually trying to make a tackle and gripping their “jersey.” The finger gets caught in the jersey and is forcibly extended. It can occur in any finger including the thumb. Sometimes there is an associated bony fracture of its insertion.
c. Although radiographs are important in the work-up of this injury, the diagnosis is usually made on a clinical basis. Magnetic resonance imaging can be used to determine the level of the u of the tendon in the finger, hand, or wrist. Operative management for acute avulsions is recommended in order to achieve best functional results.
d. If the treatment is delayed or diagnosis is missed, there is no consensus on the ideal treatment. Primary operative repair may not be possible. As secondary reconstruction of the tendon may require two operations with less than optimal results, some patients may elect for a permanent loss of function with either no treatment or fusion of the distal joint.
3) An injury that results in an inability to extend the proximal finger joint is called a boutonniere deformity.
a. A stretch injury to the tendon that extend the proximal finger joint can result in an inability to completely straighten out the joint. The injury results from a sudden forceful flexion of an extended proximal finger joint. This functional loss of extension is often not initially seen and the diagnosis can be delayed. Finger is just initially swollen, bruised, and painful.
b. Treatment consists of extension splinting or casting of the proximal finger joint for up to 6 weeks. After which, there is usually a period of weaning the splint and possible therapy. If the treatment is delayed, splinting, casting, and/or therapy is usually still tried although results may be less successful. Operative management is indicated only after all conservative options have been tried.
4) Fractures in the hand can be easily missed.
a. There are a lot small bones in the hand. There is a lot of soft tissue covering these bones and many ligaments that serve as secondary supports to these bones. A subtle non-displaced fracture can be easily missed because there may be little pain, deformity, swelling, and bruising. The ligaments will hold the fracture is good alignment resulting in less pain. A diagnosis of wrist sprain may be given and medical attention may not be sought out
b. An example is a scaphoid fracture. The scaphoid is one of the most important bones of the hand. A fracture can occur falling from a standing position on a outstretched wrist. A non-displaced fracture of this bone has a 85-95% chance of healing if diagnosed promptly and immobilized in an cast. If not immobilized promptly, the healing rates are much lower. If the scaphoid bone does not heal, arthritis will ensue leading to pain, weakness, and loss of motion.
c. Another examples is a fracture of the hook of the hamate. Although a relatively rare injury, this bone is fractured from a direct impact while holding a racket or golf club. With proper cast immobilization, a non-displaced fracture will usually heal. Operative management may be recommended for large fractures that are significantly displaced.
d. These examples illustrate the need for players to seek medical treatment. A full work-up with appropriate radiographs. Computed topography and/or magnetic resonance imaging may be helpful. Referral to an orthopaedic surgeon with subspecialty interest in the hand injuries could also be indicated.
5) Beware of a wrist sprain.
a. In addition to missing hand fractures, significant ligament injuries may be missed. Although most wrist sprains result in small microscopic incomplete ligament tears and probably heal without any residual sequelae, some injuries can result is complete tears to important wrist ligaments. These ligament provide stability to the wrist and loss of this stability can result in eventual arthritis.
b. An example is the scapholunate interosseous ligament. This ligament connects the scaphoid and lunate bones in the hand. A complete tear of this ligament can occur with a fall on the outstretched wrist. Diagnosis can be easily delayed as there is usually minimal pain, swelling, and ecchymosis. Medical evaluation is mandatory with dynamic radiographs and possibly magnetic resonance imaging. Operative repair is usually recommended for acute complete tears so as to prevent eventual arthritis, loss of motion, pain, and weakness.
c. There is no clear guidelines which a wrist sprain must be referred for medical evaluation. It is author’s opinion that wrist pain that does not fully resolve to one week of rest, ice, compression, and elevation should undergo further evaluation. Also, certain injuries should probably undergo immediate evaluation based on the amount of force causing the injury and/or the degree of pain, swelling, or bruising.
6) Gamekeeper’s thumb refers to ligament injuries at the proximal thumb joint.
a. Gamekeeper’s thumb, also called Skier’s thumb, is a common injury that occurs to the inside ligament at the thumb proximal joint. Besides occurring during skiing, this injury is also common in basketball and football. A force that pulls the thumb away from the rest of the hand can result in either a partial or complete tear of this important stabilizing ligament of the thumb.
b. Diagnosis is usually based on a clinical examination. Pain, swelling, and decreased motion are common findings. Magnetic resonance imaging may be helpful. Partial tears are treated conservatively with splint or cast immobilization. The ligament may need to be protected up to 6 weeks for complete healing. Most hand surgeons recommend operative repair for complete tears to maximize functional outcome, especially in the young athlete.
7) Joint dislocations should not necessarily be reduced on the field.
a. Dislocations of finger joints are relatively common sport injuries. With enough force, any joint can be dislocated. A concomitant fracture is sometimes present. In addition to pain and swelling, a deformity is usually evident.
b. There is often an intense desire either by the player, trainer, or coach to reduce the dislocation. Although this reduction can be successfully carried out, important information about the direction of dislocation will be lost. If the player is taken to the nearest emergency room, radiographs can be done with the joint dislocated and this information is retained as it can impact later treatment. Unless there is vascular compromise, which is exceedingly rare in dislocations, reduction is not an emergency.
c. In addition, attempted reductions may actually be harmful if done on the field. An example are dislocations of knuckle joints. These are commonly very difficult to reduce without surgery. Usually, one reduction should be attempted and probably should be done by the treating hand surgeon. If the first reduction is done improperly, soft-tissue can be pushed into the joint instead of out of the joint and doom all subsequent reduction attempts. If the joint is unable to be reduced by closed means in the emergency room, they are taken to the operating room and a formal incision is made to perform an open reduction.
8) Gymnasts are prone to wrist problems because of overload.
a. As part of their routine, many gymnasts perform frequent, high-repetition, high-impact, weight-bearing on a dorsiflexed wrist. Tension forces during bars and rings also add to the forces seen across the wrist joint. Conditioning and technique also play a role. Relatively weak wrist flexors and extensors are commonly found in gymnasts with overload wrist problems.
b. Overload problems of the wrist include dorsal wrist capsulitis, dorsiflexion jam syndrome, distal radial physis stress syndrome, triangular fibrocartilage complex tears, carpal impingement, and carpal scaphoid stress fractures. Work-up includes history and physical examination and a set of plain radiographs. Further tests such a MRI may be ordered.
c. Initial treatment may include 1-2 weeks of rest from axial loading. Splinting and/or casting may be recommended. Anti-inflammatories may be also recommended. After the period of rest, a strengthening problem is started and then a gradual return to gymnastics. In order to prevent full wrist extension, some have recommended a protective brace or a foam taped of the back of the wrist.
9) Coaches’ finger is stiff, painful, and deformed.
a. Minor injuries to the ligaments at the proximal finger joint can result in significant functional deficits long-term. Initially, the functional loss after the injury may not be very significant. The player may still be able to participate in sports and so the injury maybe overlooked and not treated. However, after 2-3 months, as the finger remains swollen, stiff, and painful, management is then sought. Restoration of function in this “Coaches’ finger” may be difficult.
b. The key to prevention is prompt diagnosis and treatment. Radiographs are necessary to rule of fractures. A majority of patients can be treated by non-operative means. Treatment usually consists of rehabilitation, which may need to be supervised in some depending on the severity of the injury. Some break from sports may also be necessary.
10) Nerve compression problems can occur in athletes but are usually different than in the general population.
a. Nerves in the arm can be compressed either from trauma or from chronic irritation and overuse. Patients will present with pain, numbness, tingling, sensory loss, and/or weakness.
b. While carpal tunnel syndrome, which is compression of the median nerve at wrist, is the most common peripheral nerve compression in the general population, the proximal forearm is the more common location of compression in the athlete. Compression of the median nerve in the forearm is called pronator syndrome and can occur in sports such as tennis and baseball. Patients present with an achy forearm especially after activities that gets better with rest. Treatment consists of splints, physical therapy, and activity modification. Rarely is surgery necessary.
c. Carpal tunnel syndrome, although less common in sports, can be seen in cyclists, throwers, and tennis players. Ulnar tunnel syndrome, which is compression of the other major nerve at the wrist, is sometimes found in cyclists. Repetitive pressure on the nerve results in a compression neuropathy. Treatment is again conservative which includes padding, splinting, and activity modification.
The author can be contacted at sberdia@yahoo.com .