4/13/2016. Steven C. Kronlage, MD. Injuries of the Wrist. Football Related Injuries of the Wrist. Disclosures. Scaphoid Fractures.
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1 Injuries of the Wrist Injuries in Football Course April 21, 2016 Steve Kronlage, MD The Andrews Institute Gulf Breeze, Florida Steven C. Kronlage, MD Orthopaedic Surgeon with additional training in hand and upper extremity surgery (CAQ-Hand) Orthopedic Residency at Charity Hosptial New Orleans Hand and Upper Extremity Fellowship: Mass General/Boston Children s/bwh/harvard Practice in Gulf Breeze, Andrews Institute Hand, Elbow and Upper Extremity Surgery, Sports Medicine and Complex Reconstruction Disclosures Royalties: Arthrex Corp., Naples, Fl Football Related Injuries of the Wrist Bone Carpal bones Scaphoid Hamate Tendon ECU subluxation ECU tendonitis Ligament TFCC tear SL ligament LT ligament Perilunate Most commonly fractured carpal bone 59% from sporting event MC males, avgage 25 Often missed in this population Fall on outstretched hand Scaphoid Fractures Spans proximal and distal row tie rod for normal carpal motion Scaphoid Anatomy Blood Flow Retrograde 1
2 Examination Scaphoid fracture Clinical suspicion Fall, forced hyperextension Swelling, limited motion, pain over scaphoid (snuff box) 25% of fractures not visible on initial radiographs Negxray, cast/splint, recheck 2 weeks or check MRI If still painful after 2 weeks= MRI Diagnosis Scaphoid Fracture Radiographs, including scaphoid views CT, MRI, Bone Scan? MRI best at diagnosis CT best at monitoring healing Types of Scaphoid fractures Wow Remember STABLE or UNSTABLE Unstable is any displacement What is a stable scaphoid fracture? NO DISPLACEMENT AT ALL!! Should be difficult to see fracture If treating non-operatively, often a good idea to verify displacement with a CT scan Non-operative treatment Scaphoid Fractures Distal pole Non-displaced waist fractures Prox-pole are usually considered unstable by location alone No agreement in casting method, LAC, thumb spica Operative Fixation of Scaphoid Fractures Rigid internal fixation no fracture callus central axis of scaphoid Percutaneous screw ORIF dorsal volar Bone graft 2
3 No pain CT scan confirmation Stable fracture with a percutaneous screw can play in a cast/cast brace *monitor closely Return to Play Scaphoid fracture Scaphoid Fractures Surgery or Cast? I generally cast the ones that are difficult to see. I like to get a CT to verify Almost all football players will opt for percuatneous screw fixation so they can play I tell the patients they may be in a cast for 2 or more months, even with surgery. Monitor healing with CT scans Scaphoid non-unions will never be the same Most Hamate fractures occur in athletes Almost always it is the hook of the hamate Occurs from a direct fall on the palm in football Hook of Hamate Fracture Pain, base of hypothenar eminence Ulnar nerve parasthesias Weak grip Pain worse with grasp Pain with resistance to flexion of ulnar digits Hook of Hamate Fracture Presentation Hook of Hamate Fracture Diagnosis Usually can t see on standard radiographs Carpal tunnel view May be difficult with someone in pain CT scan Hook of Hamate Fracture Treatment Acute truly non-displaced treat with casting almost never see Most that present are displaced and/or chronic Recommendation is excision of fracture fragment Theoretical advantage for ORIF, although unproven If left untreated, can get tendon rupture, ulnar nerve problems 3
4 Wrist Sprain What is a sprain? When is it more than just a little bit of pain? When does it need to be worked up? Wrist Sprain Who needs a work up? Low mechanism, minimal swelling, normal ROM: removable brace, activities as tolerated as long as pain free in within a week WORK UP: High Energy Loss of motion BONE PAIN: especially snuff box Mechanical Symptoms: clunk, catch, pop Significant swelling Foveal pain, pain with supination These ARE injuries Extrinsic Ligaments to the wrist are torn They will usually heal without any type of treatment Benefit from bracing/taping Low Mechanism? Wrist sprain Work Up Exam Radiographs, include: PA, UD, RD, Clenched fist, latof BOTH WRISTS If x-rays negative and still significant pain, loss of motion or swelling can cast 2 weeks or MRI--diagnostic Pain at 2 weeks, MRI Arthrogram usually not needed on acute injuries Pain over the ECU tendon Can be mis-diagnosed as TFCC tear Loss of Extensor Sheath restraint to tendon subluxation Painful snapping Extensor Carpi Ulnaris (ECU) Instability Treatment for ECU instability MRI first to ensure no intra-articular problems (TFCC tear) Acute: Cast in Pronation, may continue to snap, but pain will be gone Chronic: Stabilize with direct tissue repair, or local sling Very slow recovery over 3-4 months 4
5 Much more common than instability Chronic ulnar sided wrist pain Very difficult to distinguish from TFCC tear in an athlete Xray/MRI essential ECU tendonitis ECU tendonitis treatment Steroid injection-once Rest Immobilization ok to play in a brace Watch the free weights! Therapy TFCC Scapholunate ligament Lunotriquetral Perilunate Ligamentous Injuries of the Wrist Intrinsic Ligaments Most common cause of ulnar sided wrist pain Pain after fall on outstretched wrist, forced supination Pain with gripping Often the wrist sprain that failed to get better Decreased Grip Ulnar nerve symptoms TFCC tear Major Stabilizer of the DRUJ TFCC Anatomy Acute TFCC tear Classification Consists of: TFC Proper PRU ligament DRU ligament ECU subsheath Acute tears involve the dorsal portion (DRU ligament and ECU subsheath) Blood Supply in Peripheral 30% only Far and away most common are 1B tears for acute injuries 5
6 Ulnar sided wrist pain Pain with grip Pain at end range supination Foveal pain R/O ECU pain TFCC tear diagnosis Radiographs usually normal look for Ulnar Positive Wrist MRI essential Acute much more accurate Can be negative up to 50% of chronic tears (3 moor more) MRI arthrogramcan be helpful, but usually not needed TFCC Tear Diagnosis Acute < 1-2 weeks can try long arm cast 4-6 weeks Otherwise most will present later, need repair Arthroscopic is treatment of choice LAC 4-6 weeks Return to sport with taping 3 months TFCC tear treatment Yin and Gilula defined three smooth, curved lines Need to line up on PA view Radiographic Examination Carpal Bones Clenched fist PA Lateral Clenched Fist RD UD I take both wrists on same plate Comparison MRI Arthrogram will give best clue on intrinsic ligament injury Not clear if arthrogram is needed for TFCC as long as magnet good and there is a wrist coil ALL MRI machines are not the same Radiographic Examination Carpal Bones Scapholunate ligament tear Most common intrinsic ligament injury to the wrist Fall on outstretched hand-just like the mechanism for scaphoid fracture In older patients without a definite cause of injury may be first presentation of arthritis can be in the 30 s 6
7 Pain after fall Dorsal wrist pain, swelling Clunking Pain at radius/scaphoid articulation ROM Scapholunate ligament tear Presentation Scaphoid shift test Watson Clunk J Hand Surg 2008;33A: parts of the ligament Dorsal, Volar and Proximal portions (260 N, 118 N, 63 N respectively) Very short (1-3mm) in length Dorsal Portion is repaired in acute setting Scapholunate Ligament Anatomy Extrinsic Ligaments J Hand Surg 2008;33A: SLIL or intrinsic ligament Acute Good history, after fall, hyperextended wrist Swelling Pain Limited ROM Dynamic X-Rays, Always XRAY both wrist on same plate MRI-definitive Scapholunate ligament Injury Diagnosis Clenched fist J Hand Surg 2011;36A: Radiographic Studies SL ligament tear J Hand Surg 2008;33A: Always surgical Partial Ligament tear does well arthroscopic stabilization Acute Complete needs open repair before 6 weeks Rohman EM, AgelJ, Putnam MD, Adams JE. J Hand SurgAm Chronic Salvage or ligament reconstruction with graft Scapholunate ligament Injury Treatment Lunotriquetral ligament injury Rarely isolated Often associated with ulnar sided problems like TFCC tear/ulnar impaction issues Controversial treatment ATS debridement pinning ulnar shortening 7
8 Perilunate dislocation Disruption of SL ligament and LT ligament Can be associated with CTS 25% missed in ER X-ray not quite right Although can be quite obvious Fall on outstretched hand Significant loss of motion Significant pain Lots of swelling Can have carpal tunnel symptoms Perilunate Dislocation presentation ORIF, repair of both SLIL and LTIL, usually with small suture anchors Surprisingly does well better than SL lig alone Can even do well chronically PerilunateDislocation Treatment Football Injuries in the Wrist X-rays should be taken often Pain after 1-2 weeks should not be ignored Mechanical symptoms usually need to be addressed surgically Earlier treatment does better than late treatment Thank You 8
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