Jeff Husband MD
Objectives Evaluate, diagnose and manage common wrist injuries due to high energy trauma in athletes Appropriately use radiographs, CT scans and MRI Know when to refer patients for additional or definitive treatment Develop a rational approach to return to sport after injury Use casts and splints to facilitate early return to play
Fall on the outstretched hand and variations of this injury- jamming, hitting another player, rarely wrist is grabbed and twisted Because the same mechanism of injury can cause different injuries to different structures it can be difficult to make an accurate diagnosis without careful evaluation and appropriate imaging Therefore, knowing what to look for is important Mechanism of Injury
Mechanism of injury Swelling- may be relatively mild with scaphoid fractures and ligament injuries Neurovascular exam, especially with peri-lunate injuries Look for injuries in adjacent structures Clinical Evaluation
RADIOGRAPHIC EVALUATION Get specific x-rays of the injured part- don t x-ray the forearm if the wrist is injured Look for injury patterns, follow a routine to ensure completeness Correlate radiographic findings with clinical features Remember that radiographic healing lags behind clinical healing, often by 3-5 weeks Special views or imaging studies (CT or MRI) may be necessary in some cases
MRI Evaluation Remember that we treat patients not tests MR is a very sensitive imaging study Not all abnormalities seen on MR are clinically significant: central TFCC perforation seen in 50% of people over the age of 30, minor tears or holes in the membranous portion of the SLIL Make the MRI fit the patient, don t make the patient fit the MRI
Arriving at the Correct Diagnosis History, mechanism of injury, physical examination are the most important factors in making a diagnosis Ask yourself does it make sense? Avoid over reliance on MRI
COMMON CAUSES OF BAD RESULTS Misdiagnosis and missed diagnosis Under treatment Over treatment Incorrect treatment When bad things happen to good people
Fractures of the Distal Radius Most common fracture in both adults and children Fall on the outstretched hand Diagnosis is usually apparent clinically and radiographically Physeal injuries may be difficult to diagnose Most can be treated with immobilization
Distal Radius Fractures in the Adult Athlete Usually a high energy injury Deformity, swelling obvious Evaluate median nerve function Surgical treatment often necessary
Early mobilization after volar plating of distal radius fractures Dressing off at 5 to 7 days Edema control, custom splint, wound care Active range of motion Passive range of motion, strengthening (how soon can we mobilize these patients?) When to return to sports 3 weeks!
Accelerated Rehabilitation Compared With Standard Protocol After Distal Radial Fractures Treated With Open Reduction and Internal Fixation Brehmer, J and Husband, J. JBJS Am 2014, Oct 01, 96(19) 1621-1630
Wide receiver fell on wrist after leaping to catch a pass Marked wrist swelling and diffuse tenderness Limited ROM Neuro exam normal Wrist x-rays show triquetral fracture
Offensive lineman injures wrist, team mate falls on top of him. Marked pain and swelling
Casted for 3 months, fracture not healed, virtually no wrist motion and very tender
Perilunate Dislocations and Fracture Dislocations 7% of all carpal injuries Numerous injury patterns Mayfield s progressive perilunate instability Fractures often seen- trans-scaphoid, radial styloid, triquetrum Hyperextension, ulnar deviation, axial load Median nerve injury common with volar lunate dislocation All require surgery
SCAPHOID FRACTURES Most common carpal bone fracture Fall on the outstretched hand Ages 15 30, most often in males 5 10% not visible on initial x-ray Non-union leads to traumatic arthritis (SNAC wrist)
DIAGNOSIS OF SCAPHOID FRACTURES High index of suspicion Minimal wrist swelling, snuffbox tenderness X-rays should include wrist and scaphoid views Thin cut CT scan* MRI, bone scan Volume rad tomography
Tuberosity fracture- cast Proximal pole fracture- surgery Treatment of Scaphoid Fractures Unstable, displaced, comminuted fracture- surgery Associated with other injuriessurgery Undisplaced waist fracture- cast or surgery
SCAPHOID FRACTURE 14 year old boy fell during a basketball game Seen in one week, mild pain and tenderness, x-rays normal, no treatment Presents 4 months later with ongoing pain
SCAPHOID NONUNION
The case for acute screw fixation of undisplaced scaphoid waist fractures Increased rate of union Quicker healing Splint postoperatively with early range of motion Return to play with a protective splint
Return to sport after scaphoid fracture Usually for screw fixation without bone graft Not for proximal pole fractures Cast or splint for sports. Can they play without either?
Wrist Anatomy
Hamate Fractures
Triquetral Fractures Dorsal avulsion fracture 2 nd most common carpal fracture Hypertextension injury Avulsion by dorsal ligaments or shear by ulnar styloid Splint, return to play as pain allows Discomfort may last several months
Triquetrum Fractures MRI- high incidence of of dorsal ligamentous injury- dorsal radiocarpal, dorsal intercarpal and ulnotriquetral ligaments
Scapholunate Dissociation FOOSH injury: intercarpal supination Pain and swelling may be relatively mild to moderate Tenderness dorsally over the scapholunate interval Positive Watson (scaphoid shift) test: sensitive but not very specific Radiographs: increased gap, scaphoid flexion, increased scapholunate and capitolunate angles MR arthrogram Refer for evaluation and treatment
Scapholunate Dissociation Disruption of all three components of the scapholunate interosseous ligament Loss of normal carpal kinematics Symptoms of carpal instabilitypain, clunking, weakness
Scapholunate Dissociation
The Natural History of Scapholunate Dissociation- Osteoarthritis (SLAC wrist)
Treatment of Scapholunate Dissociation The ligament will not heal with immobilization It is not possible to perform a direct repair of the ligament that works Ligament reconstruction: Blatt capsulodesis, Brunelli procedure, 4 bone weave, RASL procedure, SLIC procedure and many others all with a long recovery Results are variable. We have not significantly improved the outcomes of SLIL ligament reconstruction in the last 50 years Should we just treat these patients in season symptomatically and allow them to play?
Summary Look for specific fractures and associated injuries High energy injuries can cause serious fractures and dislocations that are often not easily diagnosed CT is very helpful to diagnose and define the injury Apply the principles of fracture management to maximize outcomes
Summary Look for specific fractures and associated injuries High energy injuries can cause serious, at times not easily diagnosed fractures and dislocations CT is very helpful to diagnose and define the injury Apply the principles of fracture management to maximize outcomes
Return to play after injury
Important Considerations Most athletes will not play beyond high school. Very few will even participate in college. The number one issue to consider is patient safety. Do not jeopardize long term health for a game or a season. For elite athletes and professionals there are other factors involved- the current season and the next, scholarships, pending free agency, post career health and disability and financial issues related to the team s investment and revenue. Do not assume that the player or the parent will look beyond the next game. Parents may not always make decisions that are in the best interests of their children.
Questions to be answered When do you treat? Can the athlete play with the injury? If you do treat when can the athlete return? Will playing affect long term health or disability?
What do the experts have to say? There is no literature that clearly defines when it is safe to play after injuries in the hand and wrist Most recommendations are based on small series or expert opinion and anecdotal experience Elite Athlete Hand and Wrist Study Group (members of the ASSH that act as consultants to professional and college sports teams) Elite Athlete s Hand and Wrist Injury: Hand Clinics 28, Number 3, August 2012
Sport and Position Specific Differences Certain injuries may allow a player to return to play in one sport but not another. Hand fractures in a basketball player usually precludes playing while a soccer player can play soon after injury A quarterback with a metacarpal fracture in his dominant hand cannot play while a lineman can
Factors that affect return to sports The time required for bone, ligaments, tendons, nerves and cartilage to heal Pain Range of motion Strength Psychological recovery
How long does it take a bone to heal? It depends! Age of the patient: skeletally immature bone heals more quickly than adult bone Which bone is broken: phalanges, metacarpals 3-4 weeks, distal radius 4-6 weeks, scaphoid 6-16 weeks What part of the bone is fractured: metaphyseal (cancellous) bone heals more quickly than diaphyseal (cortical) bone
How do we determine that a fracture has healed? Radiographic healing: fracture line disappears Biomechanical healing: bone is as strong as it was before fracture and would require the same amount of force to break it again Pathologic healing: microscopic bridging of bone across the fracture line Clinical healing: fracture site is non-tender and there is no pain or instability with stress of the limb Radiographic healing lags behind clinical healing in the phalanges and metacarpals. *Do not wait for the radiologist to tell you that the fracture has healed.
What can we do to return the player to action? Casting Splinting Buddy taping Injections- Corticosteroid in certain tendon or joint injuries. Local anesthetic alone to relieve pain- rarely and be very cautious Surgery
Managing Wrist Injuries Take a history and carefully examine the player Use the right imaging studies and correlate them with the player s symptoms and examination Treat appropriately and refer as needed Return the player to sport when it is safe to do so using protective splints and casts as indicated