Functional Anatomy of the Hand and Wristforms.acsm.org/16tpc/PDFs/20 Osbahr.pdfFunctional Anatomy of...

Functional Anatomy of the

Hand and Wrist COMMON SPORTS INJURIES

Daryl C. Osbahr, M.D. Chief of Sports Medicine, Orlando Health

Chief Medical Officer, Orlando City Soccer Club

Orthopedic Institute

Thank you Dr. Kenneth Means!

Hand & Wrist Anatomy: Bones

Hand & Wrist Anatomy: Tendons

Hand & Wrist Anatomy: Nerves

Hand & Wrist Anatomy: Vascular

http://www.chosun.ac.kr/~jdakim/lecture/gradu/hand.htm

Wrist Radiographic Anatomy

http://www.chosun.ac.kr/~jdakim/lecture/gradu/hand.htm

Normal Radiographic Paramaters

• Things to check for on every X-ray:

• On the A/P:

• Gilula’s lines

• Scapholunate gap

Scaphoid appearance

A good lateral x-ray should have palmar pisiform edge lying between palmar scaphoid and palmar capitate edges

Also, the metacarpals should be parallel to the forearm

Normal Radiographic Paramaters

• Things to check for on

every X-ray:

• On the lateral:

• Scapholunate angle

• Nl 30-60 degrees (avg.

47 degrees)

• Capitolunate angle

• Nl 0 +/- 15 degrees

• Radiolunate angle

• Nl 0 +/- 15 degrees

Hand & Wrist Sports Injuries

• Hand

• Baseball “Mallet” Finger

• Jersey Finger

• Gamekeeper’s / Skier’s Thumb (UCL)

• Bennett’s Fracture

• Metacarpal Neck Fractures (Boxer’s)

• Metacarpal Shaft Fractures

• Trigger Finger

• Wrist

• Scaphoid Fracture

• Hamate Hook Fracture

• Distal Radius Fracture

• Wrist “Dislocation”

• Hypothenar Hammer Syndrome

• ECU Subluxation

• TFCC Injury

• Hand

• Jersey Finger

• Trigger Finger

Baseball “Mallet” Finger

• Appearance: Flexed DIP joint with

inability to extend.

• Cause: Loss of integrity in the extensor

mechanism at the base of the distal

phalanx

Baseball “Mallet” Finger

• Pathology

• Laceration / Avulsion of

distal extensor tendon

• Fracture involving

extensor tendon insertion

• Treatment

• Closed injuries: DIP Extension

Splinting unless a Large

Fracture w/ joint subluxation

• Open injuries: Repaired

• Hand

• Jersey Finger

• Trigger Finger

Jersey Finger

• Not Named After New Jersey…

• Mechanism of Injury

• Cause: Loss of flexor mechanism

integrity at the distal phalanx

Jersey Finger

• Pathology

• Tendon tear or avulsion fracture

involving insertion at distal phalanx

• Treatment: Repair

• Hand

• Jersey Finger

• Trigger Finger

Gamekeeper’s / Skier’s Thumb

• Pathology: Thumb UCL Injury

• Acute Injury

• Skiing

• Fall on outstretched thumb

• Struck by ball / opponent

• Chronic Injury

• Football linemen

• Gamekeepers

Gamekeeper’s / Skier’s Thumb

• Treatment

• Partial Tear: Non-op

w/ Thumb Spica

Splint then PT

• Complete Tear:

Surgical Repair in

less than 3 wks

• Hand

• Jersey Finger

• Trigger Finger

Bennett’s Fracture

• 23 y.o. M baseball player

• Injured right thumb diving for a ball

• Pain, tenderness, and swelling at base

of the metacarpal

• No gross deformity

Bennett’s Fracture

• Fracture Pattern

• Oblique fracture line with a triangular

fragment at ulnar base of metacarpal

• Triangular fragment remains attached to

trapezium w/ proximal displacement of

the metacarpal

• Associated w/ metacarpal

subluxation/dislocation

• Opposing Forces

• Metacarpal shaft is displaced dorsally &

radial direction due to force of abductor

pollicis longus and adductor pollicis

• Treatment

• Surgery with CRPP vs. ORIF

• Hand

• Jersey Finger

• Trigger Finger

Metacarpal Neck Fracture

• Appearance: Intrinsics flex MC head

• Finger Specific Evaluation

• Ring & Small (Boxer’s) Fingers

• Studies suggest up to 70°flexion tolerated

• Index & Middle Fingers

• No more than 15-20°flexion ok

• Treatment

• Cast if no malrotation or pseudoclawing

• If Surgery, CRPP or “bouquet pinning” if border digit (IF/SF)

• 26 y.o. M professional baseball pitcher involved

in altercation with a wall

• Right index finger pain, tenderness, swelling,

and rotation deformity

Reduction Maneuvers

CRPP: Bouquet Pinning

• Hand

• Jersey Finger

• Trigger Finger

Metacarpal Shaft Fracture

• Non-operative w/ Cast, if possible

• Operative Indications:

• Open fractures

• Multiple fractures

• Any malrotation

• Unstable fx’s – border metacarpals

more often unstable

• Multiple operative options: K-wires, IO

wires, IM pins/rods, lag screws,

plate/screws, transverse pinning

• Hand

• Jersey Finger

• Trigger Finger

Trigger Finger

• i.e., Stenosing Tenosynovitis

• Fishing Analogy

• Like Having a Knot in Your

fishing line

• Knot gets caught in fishing

rod hooks

Trigger Finger

• Risk factors for developing a trigger digit:

• Repetitive power grip, e.g. golf, baseball, tennis

• DM, RA, other inflammatory arthropathy, tendonopathy, etc.

• Treatment options

• Splint PIPJ in extension

• Corticosteroid injection – will typically try a total of 2; does not need to be injected into the sheath/tendon

• Surgical release

Trigger Finger

Surgical Treatment: Release A1 Pulley

• Wrist

• ECU Subluxation

• TFCC Injury

• Wrist

• ECU Subluxation

• TFCC Injury

Scaphoid Fracture

• Most common carpal

bone fracture

• sometimes initial XR’s

negative for 1-2 weeks

• Avascular Necrosis &

Nonunion are concerns

especially for waist or

proximal pole fractures

Scaphoid Fracture

• Typically from a fall onto an

outstretched hand (FOOSH)

• Young patient (as opposed to

most distal radius fractures)

• May initially seem relatively

benign

• Delayed presentation not

uncommon because patient

not seeking treatment or

missed at initial presentation

Scaphoid Fracture

• What is not controversial?

• Surgery for Displaced &

Unstable fractures

• What is controversial?

• How to reduce/stabilize?

• Open / CRPP / Scope

• How to treat Nondisplaced

fractures?

• Immobilization vs.

operative fixation

• Wrist

• ECU Subluxation

• TFCC Injury

Hamate Hook Fracture

• 24 yo 2nd baseman pro

baseball player

• 12 months of vague ulnar

sided hand/wrist pain and

sense of weakness

• No neurovascular

symptoms or signs

• Flexor tendons intact

Hamate

hook fx-

nonunion

fragment

Opposite

left side

intact

hamate

Ulnar nerve

branch to SF

ulnar digital

Ulnar nerve

branch to RF-

SF common

digital nerve

Ulnar artery

Deep ulnar motor

nerve branch

Hamate hook

removed through

this space

Hamate

nonunion

excised

Base of

hamate now

smooth after

hook excision

• Wrist

• ECU Subluxation

• TFCC Injury

• Colle’s- dorsal displacement

• Stable, extraarticular cast

(VT < -20° RL < 10mm)

• Unstable, intraarticular

(VT > -20° RL >10 mm)

CREF +/-ORIF +/- ICBG

Distal Radius Fractures

• Smith’s: volar displacement

• Volar ORIF with 3.5mm

locking plate

• Chauffer’s: radial styloid

• AARIF

• Beware of Greater &

Lesser Arc injuries

Distal Radius Fractures

• Wrist

• ECU Subluxation

• TFCC Injury

Wrist “Dislocation”

…just mindin’ my own business

• 49 y.o. playing rugby

• Right wrist injury while at the bottom of

a pileup

• Presents to ED with pain, swelling, and

median nerve symptoms

Wrist “Dislocation”

• Wrist

• ECU Subluxation

• TFCC Injury

Hypothenar Hammer Syndrome

• 52 y.o. M baseball bullpen coach

• Several months of ulnar sided wrist

pain now with increasing pain in ring

and small fingers

• X-ray and MRI negative for hamate

hook fracture or nonunion

After 24

hours of

thrombolytics

Operative intervention

• Trifurcate vein graft from dorsal hand

• Wrist

• ECU Subluxation

• TFCC Injury

ECU Subluxation

• 32 y.o. F professional golfer

• Several months of wrist pain

• Now with mechanical symptoms at the

ulnar dorsal side of the wrist

• Nonoperative options (splinting, activity

modification, NSAIDS, corticosteroid

injection) failed to relieve symptoms to

her satisfaction

• Wrist

• ECU Subluxation

• TFCC Injury

TFCC Injury

• 22 y.o. M baseball player Right ulnar

sided wrist pain for several months

when batting

• Tenderness at palmar/ulnar wrist

• No instability of the distal radioulnar joint (DRUJ) with pronation/supination or stress maneuvers

• MRI shows central tear of the triangular fibrocartilage complex (TFCC)

• Activity modification, NSAIDS, splinting, corticosteroid injections trialed all with temporary relief

TFCC Injury

TFCC Tear

More chronic TFCC tear at

peripheral margin of central disc

More acute central TFCC tear with

unstable flap

Debriding the more chronic tear

Debriding the more acute tear

Central TFCC after debridement to

stable rims (volar, radial, and

dorsal rims visible on this photo)

• Very Complex Anatomy & Pathology

• Be Afraid of What you Don’t Know…

• Critically evaluate X-rays & Consider

MRI when indicated

• Sport Associated Injury Recognition

2016 ACSM Team Physician Course

Orthopedic Institute

Functional Anatomy of the Hand and Wristforms.acsm.org/16tpc/PDFs/20 Osbahr.pdfFunctional Anatomy of...

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