Hand and Wrist Injuries in The Baseball Athlete

Hand and Wrist Injuries in The Baseball Athlete Brian A. Schofield M.D. Clinical Assistant Professor Florida State University College of Medicine Hand and Wrist Injuries in The Baseball Athlete Participants shoulder be able to perform a basic wrist and hand examination upon completion of this talk. They shoulder be familiar with the diagnosis and treatment of some of the more common injuries associated with baseball. These include scaphoid fractures, scapholunate ligament injuries, TFC tears, hook of the hamate fractures, ECU tendon problems, PIP dislocations and mallet deformities. Hand and Wrist Injuries in The Baseball Athlete The literature suggests that 3-9% of all athletic injuries involve the hand and wrist Hand/Wrist Injuries in The Baseball Athlete: Evaluation and Treatment Examination of the hand and wrist Diagnosis of common baseball injuries Treatment DeHaven KE, et al. Am J Sports Med 1986 Rettig AC, et al. Hand Injuries in Athletes. Philadelphia: WB Saunders; 1992 History of the injury Inspect both upper extremities Assess ROM (active and passive) Palpation Neurovascular Exam (vascular, sensory and motor) Provocative testing History When? Where? How? 1

Inspection Bilateral upper extremities Wounds Ecchymosis Deformities ROM Assess active and passive Bilateral UE s From the elbow to the digits Palpation Assess from elbow to digits Target anatomic structures (SL lig., scaphoid, etc ) Concentrate on areas that are tender Neurovascular Exam Vascular Radial and ulnar pulses Capillary refill Radial and ulnar Allen s tests Neurovascular Exam Sensation to fine touch Radial nerve - dorsal first web space Ulnar nerve small finger Median nerve index finger 2

Most commonly fractured carpal bone (annual incidence 38/100,00 men) Most common mechanism of injury is a fall on the outstretched hand (FOOSH) Fracture is often missed on initial X-rays History Radial sided wrist pain after a FOOSH May complain of weakness Many continue to play with pain Physical exam Swelling and ecchymosis are often present in the anatomic snuffbox ROM esp. wrist extension, radial deviation and flexion are diminished and painful Tenderness can be elicited over the snuffbox and throughout the scaphoid bone NV exam should focus on the radial artery and median nerve Physical exam Scaphoid shift test Imaging Plain radiographs CT scans MRI Types of scaphoid fractures Distal pole fractures Waist fractures Proximal pole fractures Stable fractures and unstable fractures 3

Distal pole fractures Usually stable Most heal with 6-12 weeks of casting Waist fractures Most common type of scaphoid fracture 90% of stable fractures heal with casting Often waist fractures are unstable fractures and require operative fixation ( screws, pins, etc ) Proximal pole fractures Often missed on x-rays Usually require fixation or excision Controversy Most complete or displaced acute proximal pole and waist scaphoid fractures are best treated with internal fixation in competitive athletes Allows the athlete an earlier return to sport because of better healing and return of function McQueen,MM et al JBJS Br 2008 Rehabilitation Post operative splint until the athlete s pain is comfortable Early ROM exercises begin within the first two weeks post op Splinting is continued for 4-6 weeks Hitting is delayed until healing is evident on a CT scan Return to play is usually 8-12 weeks Scapholunate Ligament Injuries Often are a result of a FOOSH injury Athlete complains of a sprained wrist Initial X-rays can be read as negative May or may not be associated with other fractures Classified as partial or complete and acute (< 3 weeks), subacute (3-12 weeks) or chronic (> 12 weeks) tears 4

Scapholunate Ligament Injuries Scapholunate Ligament Injuries Physical Exam Inspection of the wrist may reveal dorsal swelling or appear normal ROM is usually limited especially wrist extension Pain is elicited with palpation over the ligament and with extreme radial / ulnar deviation Watson s maneuver Imaging X-rays of both wrists including clenched fist views Flouroscopic examination of the wrist kinematics MRI or MRI arthrogram Scapholunate Ligament Injuries Partial tears with stable wrist kinematics Splinting / casting NSAID s and anti inflammatory modalities Cortisone injections Arthroscopic debridement with or without pinning Serial Exams Physical exams Flouroscopic exams Scapholunate Ligament Injuries Complete or tears with altered wrist kinematics Arthroscopic or open reduction w/or without repair of the ligament and pinning Open reduction and repair of the ligament with capsulodesis RASL (Reduction and association of the scaphoid and lunate) procedure Rosenwasser MP, Tech Hand Up Extrem Surg, 1997 Scapholunate Ligament Injuries Rehabilitation Post op splint and sutures removed at 2 weeks Short arm thumb spica splint is placed for 4 weeks Pins and cast are removed at 6 weeks post op A removable splint is placed and ROM exercises are initiated 12 weeks post op all splints are discontinued and strengthening is begun Full return to play is allowed when motion and strength are restored and the athlete is relatively pain free Hook of the Hamate Fractures Represent 2-4% of all carpal fractures Acute or non acute (Stress fracture) Direct or indirect traumatic force 75% of fractures occur through the proximal third of the hook or the junction of the hook with the body of the hamate Stark, HH JBJS, 1989. 5

Hook of the Hamate Fractures Athlete may c/o pain and numbness in his hand when batting The pain may be volar and/or dorsal Minimal to no swelling or ecchymosis Tenderness over the hypothenar area and hook volarly Pain can be elicited with flexion of the ring and small fingers Ulnar Allen s testing is crucial to r/o ulnar artery thrombosis Hook of the Hamate Fractures Imaging Plain X-rays including a carpal tunnel view CT scan MRI Hook of the Hamate Fractures Treatment is excision of the fracture fragment in the majority of baseball athletes Splinting is continued for 7-10 days post operatively Rehabilitation begins immediately Most players return to sport between 6-8 weeks TFCC Fibrocartilage and ligaments on the ulnar side of the wrist overlying the distal ulna Consists of the articular disc, dorsal and palmar radioulnar ligaments, meniscal homologue, ulnar capsule, ECU tendon subsheath, and ulnolunate and ulnotriquetral ligaments Functions of the TFC Stabilizes the DRUJ and ulnar carpus Load bearing structure between the carpus and ulnar head (20% of the total load across the wrist) 6

Palmer classification: Injury can be from a FOOSH or swinging a bat Chronic injuries can be from repetitive loading of the ulnar side of the wrist Athletes c/o pain, weakness and clicking or locking Palmer AK, J Hand Surg Am 1989. Inspection can reveal swelling in the ulnar side of the wrist ROM and grip strength are often decreased, especially in ulnar deviation Palpation is positive for tenderness over the ulnar side of the wrist just distal to the ulnar head The Press Test described by Lester and colleagues. DRUJ instability testing Imaging X-rays (Determine ulnar variance) MRI MRI arthrograms Wrist arthroscopy (The Gold Standard) Treatment Conservative Immobilization, NSAID s, Cortisone injections, and Occupational therapy 7

Treatment Surgical Arthroscopic debridement and/or repair with or without an ulnar shortening Open debridement and/or repair with or without an ulnar shortening Open reconstruction Rehabilitation Debridement Splint for 1 week 1-3 weeks post op ROM exercises 3-6 weeks strengthening Return to play is between 4-8 weeks Rehabilitation Repair with or without ulnar shortening 2-6 weeks of immobilization in a splint or cast 6-12 weeks ROM and strengthening Return to play is 8-12 weeks Tendon is situated in the sixth dorsal compartment of the wrist It is located in the ulnar sulcus and covered by the extensor retinaculum and ECU subsheath It is intimately involved in wrist extension and ulnar deviation Disorders can range from inflammatory tendonitis, subluxation/dislocation and rupture Athletes c/o ulnar sided wrist pain, swelling, snapping and loss of extension and ulnar deviation Inspection can reveal swelling over the tendon and visible tendon subluxation / dislocation Loss of ulnar deviation and wrist extension Tenderness over the tendon to palpation Active resisted wrist extension and ulnar deviation should produce pain Passive wrist ulnar deviation and flexion from extension can produce subluxation and or dislocation of the tendon 8

Imaging Plain X-rays Ultrasound MRI Treatment 5-14 days: Immobilization in a short or long arm splint with the wrist in neutral and slight radial deviation 14-28 days begin A/AAROM program with ECU taping When ROM exceeds 75% begin strengthening program When strength exceeds 75% begin sport s specific training Most players RTP at 8 weeks Graham TJ, Hand Clinics 2012 Surgical Treatment Players that have failed conservative treatment Typically involves reconstruction of the sixth dorsal compartment using an ulnar based flap of extensor retinaculum Rehabilitation after reconstruction 2 weeks post op in a long arm splint 2-6 weeks begin A/AAROM and convert to a short arm splint When ROM exceeds 75% begin strengthening phase When strength exceeds 75% begin sport specific training Most players RTP 12-14 weeks post op Graham TJ, Hand Clinics 2012 Jammed finger Often overlooked Most commonly caused by an object striking the tip of the finger causing an axial load Injury can range from a simple dislocation to a fracture dislocation Missed injuries can rapidly develop into a fixed joint deformity Diagnosis True lateral radiograph is essential to assess the join for fractures and subluxations Physical exam findings can be subtle Swelling, decreased ROM of the joint, pain, and ecchymosis 9

Fracture dislocations are classified based on fracture pattern and stability Palmar lip, dorsal lip and pilon fractures 40% or greater involvement of the joint surface is an unstable joint Treatment is based on stability of the joint Options include immobilization, protected motion, traction, open reduction and internal fixation and reconstruction Immobilization ( no longer than 3 weeks ) Splinting K-wire fixation Protected motion Buddy taping Ring splints Dorsal block splinting Traction Force couple technique Open reduction internal fixation (ORIF) Plates and screws K-wires 10

Reconstruction (Salvage procedures) Volar reconstruction Hemi Hamate autografting Simple dislocation Reduce immediately (do not attempt multiple reductions) Buddy tape 2-3 weeks Return to play (immediate to several weeks) Unstable dislocation or fracture dislocation Reduce immediately Splinting thru ORIF Return to play 4-8 weeks Depends on severity of the injury, stability of the joint, handedness and player position Mallet Finger Most common closed tendon injury seen in athletes Often referred to as baseball finger Aronowitz ER, et al Clin Sports Med 1998 Mallet Finger Mallet Finger Defined as a disruption of the terminal extensor tendon at its insertion on the distal phalanx Two types: soft tissue and bony mallets Most often caused by an object striking the extended fingertip Diagnosis Pain, swelling, tenderness, ecchymosis and flexion deformity of the DIP joint 11

Mallet Finger Treatment Benign neglect Extension splinting for 6-8 weeks K-wire pinning ORIF Mallet Finger Treatment Can be delayed if necessary All or none Swan neck deformity Hand and Wrist Injuries in The Baseball Athlete Common area of the body to be injured Be suspicious for more serious injuries Evaluate and treat early to avoid long term problems Thank You 12