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

Mechanism of Injury 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

Clinical Evaluation 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

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 perilunateinstability

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

Treatment of Scaphoid Fractures Tuberosity fracture- cast

Proximal pole fracture- surgery

Unstable, displaced, comminuted fracture- surgery

Associated with other injuries-surgery

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 scaphoidwaist 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 2nd 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 scapholunateinterosseous ligament

Loss of normal carpal kinematics

Symptoms of carpal instability-pain, 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