Just A Sprain?
Tendonitis
Finger joint injury
Extrinsic ligament injury
Intrinsic ligament injury
TFCC injury
Tendinopathy
• de Quervain's Tenosynovitis
• Intersection Syndrome
• EPL Entrapment
• Extensor Tendinitis
• FCR Tendinitis
de Quervain Tenosynovitis
• Entrapment of APL & EPB in the 1st dorsal
compartment of the wrist
• Cause: Repeated thumb abduction with
simultaneous wrist ulnar deviation
• Symptoms: Radial wrist pain aggravated by
thumb movement
• 6:1 women; Age group 40-60
de Quervain's Tenosynovitis
de Quervain Tenosynovitis
• Splint - 30% effective
• Splint + corticosteroids - 50-80% effective
• Surgery - 90-99% effective
• 20% textbook anatomy
• Separate EPB Compartment or >1 APL slips
de Quervain Tenosynovitis
Post-op
• Thumb Spica Splint for 14 days
• Localized soreness for 4-6 weeks
Intersection Syndrome
• Tendon entrapment in 2nd dorsal
compartment
• Cause: Repetitive Wrist Motion
• Common in athletes
• Weightlifting, Rowing, Racquet sports
• Symptoms: Pain & Swelling 4 cm proximal to
wrist joint at intersection of APL, EPB, and
wrist extensors. Possible crepitus
Intersection Syndrome
Intersection Syndrome
• Modification/cessation of aggravating activity
• NSAIDs
• Wrist splint in 15 degrees extension
• Corticosteroid injection
• 2nd dorsal compartment release
Intersection Syndrome
Post-op
• Wrist splint 10-14 days
• Strengthening after 5-6 weeks
EPL Tendinitis
• Entrapment of EPL in 3rd compartment
• Cause: Watershed area disrupted by
undisplaced distal radius fracture or
rheumatoid arthritis
• Symptoms: Tenderness, swelling, & crepitus
at Lister's tubercle
EPL Tendon Entrapment
EPL Tendinitis
• EPL tendon transposition after 3rd
compartment release
EPL Tendinitis
Post-op
• Splinting not needed
• Use as tolerated
ECU Tendinitis
• Entrapment of ECU tendon in 6th
compartment
• Cause: Twisting wrist injury or excessive
ulnar deviation
• Symptoms: Ulnar wrist pain & swelling with
extension & ulnar deviation; Nocturnal pain
• Differentiate from TFCC disruption
ECU Tendinitis
Diagnosis
• MRI - Differentiates:
• ECU Subluxation
• peritendinous synovitis
• longitudinal splitting of tendon
• shallow ECU groove
• anomolous tendon anatomy
• Confirmed with Lidocaine injection into ECU sheath
ECU Tendinitis
• Wrist splint, NSAID, ice
• Corticosteroid injection
• 6th dorsal compartment release
• Excise septum
• Repair retinaculum
ECU Tendinitis
ECU Tendinitis
Post-op
• Ulnar gutter splint 2-4 weeks
• Progressive use as tolerated
FCR Tendinitis
• Entrapment of FCR in tight fibrosseous tunnel
• Occupies 90% of cross-sectional area
• Cause: Most cases insidious/neighboring
degenerative process
• Repetitive flexion/extension or trauma rare
• Symptoms: Pain at scaphoid tubercle
aggravated by resisted wrist flexion/radial
deviation
FCR Tendinitis
• Wrist splint, NSAID, ice for 4 weeks
• Corticosteroid injection
• FCR sheath release
• Excise frayed fibers
• Debride trapezial groove spurs
FCR Tendinitis
Post-op
• Wrist splint for 2 weeks
• Gradually increasing activity after 14 days
Finger Joint Injury
• Skier's Thumb
• Thumb Radial Collateral Ligament Injury
• Finger Collateral Ligament Injury
Skier's Thumb
• Acute Ulnar Collateral lLigament injury at the
thumb MP joint
• 10x more common than RCL injury
• Cause: Sudden forced radial thumb deviation
• Symptoms: Ulnar thumb MP joint tenderness,
ecchymosis, and swelling
• Signs: Ulnar thumb MP joint tenderness with
radial deviation
Skier's Thumb
• Complete tear
• Radial deviation > 30 degrees in extension or in 40
degrees flexion
• Radial deviation > 15 degrees greater than other thumb
• Stener Lesion
• Associated proximal phalanx ulnar base
avulsion fracture possible
• Distal tear more common
Stener's Lesion
Skier's Thumb
• Partial Rupture
• Hand-based thumb spica splint for 6 weeks
• AROM last 2 weeks
• Resisted thumb activity after 3 months
• Aching pain can last > 6 months
Skier's Thumb
• Complete Rupture
• Operative Repair
• Hand -based thumb spica splint
for 6 weeks
• MRI or Ultrasound to rule out Stener
lesion
Skier's Thumb
Post-op
• Hand-based thumb spica splint for 6 weeks
• Controlled AROM 4x daily last 2 weeks
• UCL stress (pinch, grasp) avoided for 12
weeks
• Vague aching expected up to 1 year
Thumb Radial Collateral
Ligament Injury
• Cause: Forced adduction of flexed MP joint
• Proximal & distal tears equally
• Symptoms: Symptoms: Radial thumb MP
joint tenderness, ecchymosis, and swelling
• Signs: Radial thumb MP joint tenderness with
ulnar deviation
Thumb Radial Collateral
Ligament Injury
• Complete tear
• Ulnar deviation > 30 degrees in extension or in 40 degrees
flexion
• Ulnar deviation > 15 degrees greater than other thumb
• Associated proximal phalanx radial base
avulsion fracture possible
• Proximal and distal tears equally common
• MP joint volar subluxation more common
Thumb Radial Collateral
Ligament Injury
• Partial Rupture
• Hand-based thumb spica splint for 6 weeks
• AROM last 2 weeks
• Resisted thumb activity after 3 months
• Aching pain can last > 6 months
• Complete Rupture
• Operative Repair
Thumb Radial Collateral
Ligament Injury
Post-op
• Hand-based thumb spica splint for 7 weeks
• Controlled AROM 4x daily last 2 weeks
• RCL stress avoided for 12 weeks
• Vague aching expected up to 1 year
Finger Collateral Ligament Injury
• Classified by stability
• Grade I: Pain, no laxity
• Grade II: Laxity, firm endpoint,
stable arc of motion
• MP tested in 60 degrees
flexion
• Grade III: Grossly unstable,
no firm endpoint
Finger Collateral Ligament Injury
• Grade I & II
• Buddy taping, early ROM
• MP: 30 degree flexion splint 3
weeks, then buddy tape
• Grade III
• Surgical repair
• MP: 45 degree flexion splint
6 weeks, then buddy tape
• PIP: Extension splint 6
weeks, then buddy tape
Extrinsic Ligament Injuries
• Palmar radiocarpal
• Palmar ulnocarpal
• Dorsal radiocarpal
Intrinsic Ligament Injury
• Scapholunate Interosseous Ligament
• Dorsal component stronger
• Lunotriquetral Interosseous Ligament
• Volar component stronger
• Dorsal Intercarpal Ligament
TFCC Injury
• Radioulnar ligaments stabilize DRUJ
• Articular disk supports carpus and
absorbs compressive forces
TFCC Injury
• Cause: Axial load on wrist with pronation (fall
on outstretched hand or forceful rotational
injury)
• Symptoms: Ulnar wrist pain (with/without
clicking) exacerbated by ulnar deviation or
forceful rotation
• Signs: Tenderness at ulnar wrist between
FCU and ECU
• Piano key sign
TFCC Injury
Palmer's Classifications of Triangular Fibrocartilage Complex
Lesions
Class 1: Traumatic
A: Central perforation
B: Ulnar avulsion
With styloid fracture
Without styloid fracture
C: Distal avulsion (from carpus)
D: Radial avulsion
With sigmoid notch fracture
Without sigmoid notch fracture
Class 2: Degenerative (Ulnar Impaction Syndrome)
A: TFCC wear
B: TFCC wear
Plus lunate or ulnar head chondromalacia
C: TFCC perforation
Plus lunate or ulnar head chondromalacia
D: TFCC perforation
Plus lunate or ulnar head chondromalacia
TFCC Injury
• Immobilization 4 to 6 weeks
• Long arm if peripheral tear
• Arthroscopy if not improved after 3 months
• Arthroscopy
• Repair if peripheral
• Debride if central
• Add wafer resection or ulnar shortening for ulnar
positive variance
• Open repair
TFCC Injury
Post-op
• Ulnar gutter splint with early motion exercises
following debridement
• Long arm splint/cast for 4 weeks following
repair followed by short arm splint for 2 weeks
• PROM and gentle strengthening
• Full activities at 12 weeks
TFCC Injury