Common Hand and Wrist Injuries
Andrew Getzin, MD
Cayuga Medical Center
Sports Medicine and Athletic Performance
agetzin@cayugmed.org
www.cayugamed.org/sportsmedicine
Ithaca College
How I Will Approach Each Problem
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What is it?
Does it need any special imaging?
How do I treat it?
What are the indications to refer?
Finger Injury Pearls
• Treatment should restrict motion of the
injured structures while allowing uninjured
joints to remain mobile
• Patients should be counseled that it is not
unusual for an injured digit to remain
swollen for some time and that permanent
deformity is possible even after treatment
Finger Pathology
• Ligament/tendon injuries
– Mallet Finger
– Jersey Finger
– Central slip extensor
tendon injury
(Boutonniere
Deformity)
– Collateral ligament
injury
– Volar plate injury
– Skier’s thumb
• Fractures,
Dislocations
– Distal Tuft
Fractures/Crush injury
– Phalange fractures
– Metacarpal fractures
• Boxer’s fracture
– Dorsal PIP
dislocations
Finger Anatomy
Finger Case 1
During infield practice a high school
baseball player injured his dominant
right pinky while covering his glove to
field a grounder. The ball longitudinally
hit his right 5th finger. He developed
pain but kept playing. After practice, he
noticed that he was unable to fully
extend his distal phalange. He buddy
taped it over the next few weeks but
ultimately developed an extension lag
that limits his ability to type but with no
other functional limitations from the
injury.
Mallet Finger (Baseball Finger)
• Injury to the extensor
tendon at the DIP joint
• Most common closed
tendon injury of the finger
• Mechanism: object
striking finger, creating
forced flexion
• Tendon may be stretched,
partially torn, or
completely separated by
a distal phalanx avulsion
fracture
Mallet Finger Presentation
• Pain at dorsal DIP joint
• Inability to actively extend
the joint
• Characteristic flexion
deformity
• On exam, very important
to isolate the DIP joint to
ensure extension from
DIP and not the central
slip
• If can’t passively extend
consider bony
entrapment
• All of these need x-rays
Mallet Finger Treatment
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Splint DIP in neutral or slight
hyperextension for 6 weeks
Cochrane review- all splints same
results
Surgical wiring does not improve
outcome
Office visit every 2 weeks
If not extension lag at 6 weeks,
splint at night and for activity for 6
weeks.
Conservative treatment effective
up to 3 months delayed
presentation
Handoll. Interventions for treating mallet finger
injuries. Cochrane Database 2004
Mallet Finger Referral
• Bony avulsion >30%
of joint space
• Inability to achieve
passive extension
• Despite proper
treatment permanent
flexion of the fingertip
is possible
• No fracture reduction
in the splint
Finger Case 2
19 year old Ithaca College football player,
defensive back was holding onto the
running back by his jersey trying to tackle
him but the back broke the tackle. The
defensive player developed sudden distal
4th finger pain and was unable to fully flex
the DIP joint.
Jersey Finger
Flexor Digitorum Profundus Tendon
Injury (jersey finger)
• Athlete’s finger catches
another player’s clothing
• Forced extension of the
DIP joint during active
flexion
• 75% occur in the ring
finger
• Force can be
concentrated at the
middle or distal phalanx
Jersey Finger Presentation
• Pain and swelling at
the volar aspect of
DIP joint
• Can often feel
fullness proximally if
tendon retracted
• Need to isolate the
DIP to properly test
Jersey Finger Physical Exam
Jersey Finger Treatment/ Referral
All need to be referred for surgery
immediately
Central Slip Extensor Tendon
Injury- Boutonnière deformity
• PIP joint is forcibly flexed
while actively extended
• Volar dislocation of the
PIP joint
• Examine with PIP joint in
15-30 degrees of flexion,
can’t active extend but
can passively extend
• Tenderness over dorsal
aspect of the middle
phalanx
Central Slip Extensor Tendon Injury
Treatment
• A delay in proper
treatment will cause
boutonniere deformity
• Deformity can develop
over several weeks or
occasionally acutely
• Splint PIP in extension for
6 weeks
• Can still play sports
Central Slip Extensor Tendon
Injury Referral
• Avulsion fracture involving more than 30
percent of the joint
• Inability to achieve full passive extension
Collateral Ligament Injuries
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Forced ulnar or radial deviation
Can cause partial or complete tear
PIP is usually involved
Present with pain at the affected ligament
Evaluate with involved joint at 30 degrees
of flexion and MCP at 90 degrees of
flexion
Collateral Ligament InjuriesTreatment
• If joint stable and no large fracture- can
buddy tape
• Never leave the pinky alone
• ?Physical Therapy- if joint stiff
Collateral Ligament InjuriesReferrals
• Unstable joint
• Large associated fracture
• Injury in a child
Volar Plate Injury
• Hyperextension, such
as dorsal dislocation
• PIP is usually affected
• Collateral damage is
often present
• The loss of joint
stability can cause
hyperextension
deformity
Volar Plate Injury- Diagnosis
• Maximal tenderness at
volar aspect of affected
joint
• Bruising, swelling
• Full extension and flexion
possible if joint stable
• Collaterals should be
tested
• Radiographs may show
an avulsion fracture at the
base of involved phalanx
Volar Plate Injury- Treatment
• Progressive splinting
starting at 30 degrees
flexion
• Followed by buddy
taping
• If less severe, can
buddy tape
immediately
• Can play sports if
splinted
Volar Plate Injuries- Referral
• Unstable joint
• Large avulsion
fragment
Finger Case #3
Ultimate frisbee player
tried dove to block an
opponents disc and
he jammed his thumb
on the ground. He
was able to keep
playing but it swelled
and became
ecchymotic.
Ulnar Collateral Ligament Injury
of the Thumb (Skier’s
Thumb)(GameKeeper’s Thumb)
• Caused by forced
abduction of the 1st
MCP joint
• Left untreated the
joint will be unstable
with weak grip
strength
Skier’s Thumb- Diagnosis
• Difficulty opposing
pinky to thumb
• Swelling and black
and blue over thenar
eminence
• Can’t hold an OK sign
• Consider digital block
and to facilitate
ligament testing
Stener Lesion
Skier’s Thumb Grading/Treatment
• Grade 1
– Pain without instability with stress
– Splinting 1-2 weeks
• Grade 2
– Pain with mild instability: gapping <20 degrees
– Casting 3-6 weeks
• Grade 3
– Stenner’s Lesion
– Instability: gapping > 20 degrees or > 35 degrees
compared to unaffect thumb
– Early surgical intervention within 2-3 weeks
Skier’s Thumb Treatment
Skier’s Thumb Referral
• Fracture
• Unstable joint
• Stener lesion
Distal Tuft Fractures
• Common due to crush
injuries
• Painful
• Splint in extension for 3
weeks
Fraction Alignment
Proximal and Middle Phalange
Fractures
• Most common in
athletes
– Fall or direct blunt
trauma
• More difficult than
metacarpal fractures
• Close relationship
between fractured
bone and pulley
system
Phalanage Fracture Treatment
• Early motion (3-5 days)
• Splint and take out
• Can buddy tape
Proximal Phalange FracturesReferral
• Inability to maintain
proper alignment
• Rotation
• Irreducible Injury
• Any intra-articular
fracture
Finger Case 4
16 year old baseball player had a
frustrating discussion with his coach about
playing time so punched a locker. He
immediately developed pain over the
outside aspect of his right hand and lost
the normal morphology of the 5th knuckle.
Metacarpal Fractures
• Most common hand
fracture
– 30-35%
• Usually involves the
neck
• Fight or fall common
mechanism
• 4TH and 5th most
common fractures
Metacarpal Fractures Diagnosis
• Present with edema over
the dorsum of the hand
• Point tender
• Ecchymosis
• The distal fragment
usually displaces volarly
due to the interosseous
muscles
• Radiographs: AP, lateral,
oblique
Metacarpal Fracture Treatment
• Angulation up to 40+
degrees can be
tolerated
• Attempt reduction?
• Different cast types
Statius, Arch Orthop Trauma Surg 2003;123:534-7
Metacarpal Fracture-Complications
• Malrotation
• Common with spiral or oblique fractures
• Greater than 10% malrotation leads to
scissoring effect of the fingers
• Metacarpal head
– Loss of knuckle
Metacarpal Fracture Referral
• Rotation
• Angulation > 70 degrees
• Preference
Proximal PIP dorsal dislocation
20 year old Ithaca College football defensive
lineman ran to the sideline with right 4th finger
pain and deformity. He clearly had a dorsal PIP
dislocation. Gentle longitudinal traction resulted
in joint relocation. No visible deformity was
apparent after relocation and he had passive
FROM at DIP and PIP. The finger was buddy
taped and the athlete returned to play. X-ray
following the game revealed soft tissue swelling.
He was buddy taped and finished his season.
Proximal PIP dorsal dislocation
(Coach’s Finger)
• Most common
dislocated joint in the
body
• Can injure the volar
plate or cause an
avulsion fracture of
the middle phalanx
Proximal PIP dorsal dislocationrelocation
• Reduce via gentle
longitudinal traction
• If initially
unsuccessful should
hyperextend the distal
portion to unlock
• If not done <1 hour
consider a digital
block
Post Reduction Care
• Radiographs should be obtained to ensure
joint congruity
• Examine collaterals
• PIP should be splinted in less than 30
degrees
Proximal PIP Dorsal
Dislocation- Referral
• Avulsion fracture > 1/3 of joint space
• Irreducible fracture
• Instability post-reduction
WRIST
Wrist Pathology
• Fracture
– Scaphoid
• Ligament-Tendon
Injuries
– TFCC tear
– Scapholunate
dissociation
– DeQuervain’s
– Intersection Syndrome
– Ganglion Cyst
• Nerve Injury
– Carpal tunnel
• Other
– Kienbocks
Wrist Case 1
• 24-year-old male
FOOSH (fell on
outstretched hand)
while skiing over the
weekend
• Seen at the mountain
clinic and told “wrist
sprain”
Scaphoid Fracture
• Most common
fractured bone in the
wrist
• Peanut shaped bone
that spans both row of
carpal bones
• Does not require
excessive force and
often not extremely
painful so can be
delayed presentation
Scaphoid Fracture Presentation
• Pain over the anatomic snuff box
• Pain is not usually severe
• Often present late
Scaphoid Fracture
Pathoanatomy
• Blood supplied from
distal pole
• In children, 87%
involve distal pole
• In adults, 80% involve
waist
• Treatment depends
on location of fracture
Imaging
• AP, lateral, oblique
and scaphoid view
• Radiographs can be
delayed for up to 4
weeks
• ?MRI, bone scan, or
treat and repeat film
Scaphoid Fracture Treatment
• Cast 6-12 weeks
• Short arm vs. long
arm
• Follow patient every 2
weeks with x-ray
• CT and clinical
evaluation to
determine healing
• Consider screwing
early
Non Operative TreatmentDisadvantages
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Nonunion rate 5-55%
Delayed union
Malunion
“cast disease”- joint stiffness
Prolonged immobilization- sometimes >12
weeks
• Loss of time from employment and avocations
Scaphoid Fracture - Referral
• Angulated or
displaced (1mm)
• Non-union or AVN
• Proximal fractures
• Late presentation
• Early return to play
desired
Union Rates 100%
Wrist Case 2
Soccer player
has pain in
ulnar side of
wrist after a
fall
Triangular Fibrocartilage
Complex (TFCC) Tear
• Fall on dorsiflexed
and ulnar deviated
wrist
• Axial load with
forearm in
hyperpronation
• Positive ulnar
variance predisposes
to injury
TFCC Tear Diagnosis
• Exam
– Ulnar sided wrist pain
– Often experience a
click
• Imaging
– Radiographs
– MR arthrogram
TFCC Tear Treatment
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Splinting
Time
Injection
Surgical treatment
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Debridement
Repair
Open vs. arthroscopic
Ulnar shortening
osteotomy
TFCC Tear Referral
• Pain
• They take a long time to get better- 3-6
months of splinting
Wrist Case 3
25-year-old
tennis player
twists wrist as he
falls backwards
reaching for a
lob
Scapholunate Dissociation
• Most common ligamentous
instability of the wrist
• Patients may have high degree
of pain despite apparently
normal radiographs
• Physicians should suspect this
injury if patient has wrist
effusion and pain seemingly
out of proportion to the injury
• If improperly diagnosed can
lead to chronic pain
• Located proximal axial line
from 3rd metacarpal
Scapholunate DissociationDiagnosis
• Exam
– Watson’s test
– Scaphoid shuck test
– Pain/swelling over
dorsal wrist, proximal
row
• Imaging
– Plain films: >3mm
difference on clenched
fist view
– Scaphoid ring sign
Scapholunate Dissociation
Treatment
• If discovered within 4
weeks, surgery
• After 4 weeks,
conservative
treatment reasonable
– Bracing
– NSAIDS
– Consider evaluation by
hand surgery to
confirm no surgery
needed
Scapholunate Ligament
Dissocation Referral
• All will go onto to cause some problem
• Allow the specialist to make the ultimate
decision
Wrist Case 4
The Ithaca College
starting softball
shortstop presented
with pain at the base
of her left thumb. It
was aggravated by
hitting when she
rolled her left hand
over the top.
DeQuervain’s Tenosynovitis
• Pain due to
inflammation of the
short extensor and
abductor tendons of
the thumb
• Repetitive or
unaccustomed griping
and grasping causes
friction over the distal
radial styloid
DeQuervain’s Tenosynovitis:
Diagnosis
• Swelling and pain
over 1st dorsal
compartment
• +Finkelstein’s test
DeQuervain’s Tenosynovitis:
Treatment
• Splint
• Injection- 1st line
– up to 90% are pain
free if injected within 6
months
• Splinting performs
poorly in comparison
to steroid injection
Coldham F.. British Journal of Hand Therapy.2006
DeQuervain’s Tenosynovitis:
Referral
• Recurrence despite repeated injections
Wrist Case #5
An Ithaca College crew
athlete presented
following spring break
training trip in Georgia.
She reported pain distal
dorsal medial forearm,
accompanied by swelling,
and palpable/audible
crepitus. Her pain was
exacerbated by
feathering her oar.
Intersection syndrome
• Friction point where muscle
bellies of 1st compartmentAbductor Pollicis Longus and
Extensor Pollicis Brevis cross
2nd and 3rd dorsal
compartments
• Inflammatory peritendinitis
• Common with rowers due to
clenched fist and thumb
abduction
• Friction and crepitus felt 4-5cm
proximal to radial styloid with
rest flexion and extension and
radial deviation
Intersection Syndrome Diagnosis
• Pain and swelling about 2-3
finger breadths proximal to
dorsal wrist joint
• Palpable crepitus (“squeaker’s
wrist”
Intersection Syndrome Treatment
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Splinting
Activity modification
Icing
Nsaids
Corticosteroid injection
Intersection Syndrome Referral
• Failure of
conservative
measures
• Tenosynovectomy
and fasciotomy of
abductor pollicis
longus can be
performed
Ganglion Cyst
• Account for 60% of soft tissue,
tumor-like swelling affected the
hand and wrist
• Develop spontaneously in 2050 year olds
• Female to male, 3:1
• Cyst filled with soft, gelatinous,
sticky, and mucoid fluid
• Location
– 65% dorsal scapholunate joint
– 20-25% volar distal aspect of
the radius
– 10-15% flexor tendon sheath
Ganglion Cyst Diagnosis
• Usually obvious on
exam- may be helpful
to flex and extend
wrist
• Radiographs,
ultrasound, or MR not
usually indicated
Ganglion Cyst- Treatment
• Watchful waiting- most resolve
spontaneously over time
• Bible treatment- not recommended
• Aspiration/Injection
– No recurrence in 27-67% of patients
Ganglion Cyst Referral
• Patient preference
• Pain
• Cosmetic?
Carpal Tunnel Syndrome
• Most common nerve
entrapment disorder
• Pain and parasthesias
from high pressures in
the carpal tunnel causing
compression and
inflammation of the
median nerve
• Carpal bones dorsally
and transverse carpal
ligament (flexor
retinaculum) ventrally
Carpal tunnel syndrome
Hand Diagrams
Sn = 0.64; Sp = 0.73
NPV = 0.91
Tinel + hand diagram –
PPV = 0.71
Ann Intern Med 1990 Mar 1;112(5):321-7.
Carpal Tunnel Syndrome
Sensitivity and Specificity
• For both Phalen’s and Tinel’s is LOW
– Phalen’s – Sn= 0.75 ; Sp = 0.47
– Tinel’s – Sn= 0.60; Sp= 0.67
Ann Intern Med 1990 Mar 1;112(5):321-7
• Combine with hand diagram and history
Nerve Conduction Study
• Can be painful and costly
• Reserve for patients who
– have failed conservative therapy
– diagnosis is uncertain
– late presentation with thenar wasting and motor
dysfunction
• False negative rates as high as 10%
J Hand Surg [Am] 1995 Sep;20(5):848-54
Carpal Tunnel Syndrome Diagnosis
– Pain involves thumb, first two fingers and
radial half of the fourth finger
– Palpation: thenar eminence wasting
– ROM: thumb weakness and difficulty pincher
grasping
– Diagnostic Tests or special maneuvers
• Nerve conduction studies
• Tinel’s
• Phalen’s
Carpal Tunnel Syndrome
Treatment
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Ice
Activity modification
Workspace modification
Splinting
Injection
Surgery
Carpal Tunnel Injection
• Short term efficacy:
RCT, 70% vs 34% at
2 weeks (steroid vs
sham)
– NNT = 2.8
– Long-term benefits are
more variable
• 43% of patients above
required referral to
surgery
Muscle Nerve 2004 Jan;29(1):82-8
Injection technique: 23-25g
needle; 1-2 cc of lidocaine plus
20-40mg Methylprednisolone.
Injected radial side of palmaris
longus tendon
Carpal Tunnel Syndrome Referral
• Constant numbness and tingling
• Thenar eminence wasting
• If get EMG, moderate to severe carpal
tunnel or dennervation
Kienbock Disease
• Avascular necrosis/vascular insufficiency
– ?repetitive microfractures of lunate
• Young adults 15-40 years old
• Risk factors: negative ulnar variance
Kienbock Disease: Diagnosis
• EXAM
– Wrist pain that
radiates up the
forearm
– stiffness, tenderness,
swelling over lunate
• passive dorsiflexion of
middle finger produces
characteristic pain
• Radiographs, MRI
Kienbock Disease
• Stage I – IV
– Stage I: MRI only
– Stage II: Sclerosis
– Stage III: Some
collapse
– Stage IV: Total collapse
Kienbock Disease: Treatment
• Primarily surgical
– EARLY: Radial shortening, ulnar lengthening
– LATE: proximal row carpectomy, arthrodesis
Thank You!