Ligamentous (and Tendon) Injuries of the Hand & Wrist
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1 Ligamentous (and Tendon) Injuries of the Hand & Wrist Adam Bakker, M.D. Twin Cities Orthpedics May, 6 th, 2016 abakker@tcomn.com (952)
2 None Disclosures
3 Born: Seoul, South Korea Background Grew up: Walker, MN College: Concordia College
4 Background MD: University of Minnesota Orthopedic Residency: University of Washington Hand Fellowship: Mayo Clinic Twin Cities Orthopedics: 3 rd year of practice
5 the eye only sees what the mind knows History: 80-90% of the diagnosis Physical exam: 90-95% Imaging: X-ray CT/MRI???
6 Athletes: Special Considerations Optimize non surgical treatments Long Term Health Performance Immediate/Early return to play Career Scholarship Teammates Availability to accommodate/flexible
7 Sports Injuries History: Complaint Mechanism Anatomy of Injury PE findings
8 Sports Injuries Treatment options Conservative Surgical Return to play
9 Sports Injuries: Wrist SL (scapholunate) Ligament Disruption Ulnar sided injuries Snapping ECU (extensor carpi ulnaris tendon subluxation) TFCC (Triangular Fibrocartilage Complex) tear(s)
10 SL (Scapholunate) Ligament Tear History: Fall on hand/axial load Anatomy of Injury: disruption of the SL ligament primary dorsal aspect PE findings: Weakness in grip Pain Positive Watson s test
11 I SL Ligament Anatomy
12 SL (Scapholunate) Ligament Tear Treatment: Partial injury: Casting/Pinning Complete tear: Surgical repair vs. reconstruction Return to play 6 weeks cast 3 months full activity Year full strength
13 Ulnar Sided Wrist Pain Commonly referred : back pain of wrist & black box Multitude of structures complex Pain with rotation/grip, loss strength, & instability Focus: ECU snapping/subluxation TFCC tears Ulnar sided tears UT (ulno-triquetral) ligament split tear
14 TFCC ECU Ulnar Sided Wrist Pain: Differential Diagnosis LT (Luno-triquetral) ligament tear Arthritis Hook Hamate fracture/nonunion Ganglion cysts Tendonopathies
15 TFCC: Triangular Fibrocartilage Complex Tear History: Ulnar sided wrist pain s/p injury or fall Specific point & time Months/Years of sxs Anatomy of Injury: ligament tear Continuation of axis of rotation distal to ulna styloid
16 TFCC: UT (ulno-triquetral) Ligament Split tear
17 Fovea Test TFCC: UT (ulno-triquetral) MRI 50-60% sensitive Dx: Based on H&P Gold Standard: Scope Ligament Split tear
18 TFCC: Triangular Fibrocartilage Complex Tear Treatment Immobilization Arthroscopic surgery & repair Return to play Surgery is done primary in the off season Splint during season if possible
19 TFCC: UT (ulno-triquetral) Ligament Split tear Arthroscopic view of UT split tear & repair
20 Snapping Extensor Carpi Ulnaris (ECU) Tendon Subluxation History: Pain with rotation (golf/tennis) Anatomy: ECU tendon subshealth rupture PE: Snapping/subluxation of ECU with rotation, decrease grip
21 Snapping Extensor Carpi Ulnaris (ECU) Tendon Subluxation Diagnosis: PE place thumb ulnar ECU/MRI Treatments: Splint/cast ECU tendon subshealth reconstruction
22 Snapping Extensor Carpi Ulnaris (ECU) Tendon Subluxation Return to play no restrictions 3 months Excellent outcomes
23 Sports Injuries: Hand Thumb UCL: Skier s/gamekeeper s thumb Finger Dislocations Flexor tendon rupture: Jersey Finger
24 Thumb UCL Skiers/Gamekeepers Thumb History: Fall & catches thumb Mechanism: radial deviation of thumb at MCP Anatomy of Injury: rupture of the ulnar collateral ligament
25 Thumb UCL Skiers/Gamekeepers Thumb Importance: allows for grip/pinch PE: Unstable at MCP with radial deviation
26 Thumb UCL Gamekeepers/Skier s Thumb Historically: Scottish rabbit hunters Modern: Ski pole & thumb impact
27 Thumb UCL Stener Lesion Tear of ligament with interposed adductor aponeurosis Surgical treatment required Timing of treatment: varies Return to play: 0-6 weeks
28 Finger: PIP Dislocation History: Mechanism: axial load (primarily dorsal dislocation) Complaint: pain with deformity, loss ROM Anatomy of Injury: PE findings: Deformity Pain
29 Finger: PIP Dislocation Treatment option Immediate closed reduction: technique Buddy tape Immediate return to play
30 Finger: PIP Dislocation Irreducible Volar plate Lateral collateral Not a dislocation Fracture Stabilization: Splint vs. surgical Surgical treatment Irreducible Unstable: bony
31 Jersey Finger: Rupture of FDP History: Mechanism: finger forcibly flexing while hyperextended (eccentric contraction) Complaint: pain, loss ROM, decrease grip Anatomy of Injury: Muscle stronger than tendon insertion site PE findings Unable to flex at DIP joint Swelling & mass in palm
32 Jersey Finger: Rupture of FDP of Ring Finger Most common Jersey Finger Most distal with flexion: absorbs most energy Least independent motion of digits Weaker than FDP of middle
33 Jersey Finger: Rupture of FDP Treatment options Conservative: unfortunately poor option Surgical: reattached flexor tendon Return to play: full at 3 months
34 Thank You Ligamentous (and Tendon) Injuries of the Hand & Wrist Adam Bakker, M.D. Twin Cities Orthpedics May, 6 th, 2016 abakker@tcomn.com (952)
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