Ben Hogan Newsletter

Optimal
Performance
THE TRAINING TABLE
Sports-related wrist and hand injuries
Wrist and hand injuries account for 3% to 9% of all sports injuries. Although
not as common as other sports-related musculoskeletal diagnoses, wrist and
hand injuries can limit an athlete’s ability to throw, catch, and perform other
essential movements. In youth football, injuries to the wrist and hand account
for approximately 10% of all injuries, second only to the knee. While the majority
of these injuries are mild sprains and contusions, fractures and more serious
ligamentous injuries do occur, often causing missed time from practice and game
participation. This article will review several common, sports-related wrist and
hand injuries and discuss diagnosis and treatment options.
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IN THIS ISSUE
The Training Table
Myth vs. Fact
A common football-related wrist injury is fracture of the scaphoid. Fractures of
the scaphoid account for 60-70% of all wrist fractures, with an estimated incidence
of 1 in 100 college football players. A scaphoid fracture typically results from a
fall on the outstretched hand with the wrist dorsiflexed. This type of fracture is
notorious for not being readily visible on initial radiographs, requiring prolonged
immobilization for adequate healing, and having a high rate of complications.
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A fractured scaphoid has a limited ability to heal due to a narrow surface area
for contact, poor vascular supply, and the potential for synovial fluid to pass
between the fracture fragments. Healing times range from six weeks to four
Continued
Ben Hogan Sports Medicine
usually apparent on radiographs at two weeks postinjury, but a bone scan, computed tomography (CT)
scan, or magnetic resonance imaging (MRI) can also
be used to further evaluate a possible fracture.
Casting is the gold standard for nondisplaced
scaphoid fractures with union rates of 90-95%
reported. Casting position and method depends on
what portion of the scaphoid is fractured. In general,
short or long arm-thumb spica casts with the wrist in
slight flexion are used, and radiographs are obtained
every three to four weeks to assess fracture healing.
Surgical stabilization is required with failed healing
of nondisplaced scaphoid fractures. Internal fixation
of scaphoid fractures is also indicated for fractures
associated with carpal instability or displacement of
1 mm or 15 degrees of angulation. Displaced fractures
are unstable with a high likelihood of nonunion and
the potential for avascular necrosis. The surgical
approach for scaphoid fractures depends on the
fracture pattern, associated injuries, and prior
surgery. An open palmar approach, open dorsal
approach, and arthroscopically guided fixation
techniques are described in the literature.
months depending on the location of the fracture.
For instance, 80% of scaphoid fractures occur at the
midportion of the scaphoid, which disrupts the blood
supply and often leads to nonunion or avascular
necrosis. This death of bone tissue can lead to chronic
wrist pain and disability if left untreated.
Following surgery, athletes require immobilization,
rehabilitation, and eventually a protective playing
splint for return to contact sports. The rehabilitation
program should follow the basic principles of tissue
healing with initial focus on active range of motion
exercises for the elbow, wrist, forearm, thumb, and
hand followed by gradual progression to resistive
and sport-specific exercises.
Accurate and prompt diagnosis of scaphoid
fractures is crucial for proper healing. An athlete
with a scaphoid fracture typically complains of
radial wrist pain, especially with forearm rotation,
and tenderness at the anatomical snuffbox. However,
as mentioned previously, initial radiographs may
be negative in the case of a nondisplaced scaphoid
fracture. Delayed immobilization increases the
incidence of nonunion. Immobilization is therefore
critical for athletes who present with radial wrist
pain and tenderness but normal radiographs until
a firm diagnosis is established. A fracture line is
Although rare in the general population, fractures of
the hook of the hamate may occur in sports such as
golf, tennis, and baseball, due to stress impaction of
the hook of the hamate on the hypothenar eminence.
Athletes typically complain of chronic pain at the base
of the hypothenar eminence, ulnar nerve paresthesias
into the ring and small finger, and weakness in grip
strength. The dominant hand is usually involved in
racquet sports and the non-dominant hand is usually
involved in golf, baseball, and softball athletes.
Tenderness to palpation can be identified over the
hook of the hamate, located 2 cm distal and radial
to the pisiform. Diagnosis may be delayed due to
difficulty visualizing hamate hook fractures on
standard antero-posterior and lateral radiographs.
A carpal tunnel view or a CT scan may be necessary
to confirm the diagnosis. Management of hamate
hook fractures is similar to treatment of scaphoid
fractures. An acute nondisplaced fracture diagnosed
early may be immobilized with the wrist in slight
flexion for 8-12 weeks to allow full healing to occur.
Surgical intervention, either excision of the hamate
hook or open reduction and internal fixation, may
be recommended with displaced fractures, delayed
diagnosis, or even with acute nondisplaced fractures
since healing time is equal to the time required with
conservative treatment. Residual tenderness along
the hypothenar eminence is common and well-padded
gloves may be beneficial for return to competition.
Gamekeeper’s thumb refers to a sprain or avulsion of
the ulnar collateral ligament (UCL) at the base of the
proximal phalanx of the thumb. The UCL stabilizes
the metacarpalphalangeal (MCP) joint of the thumb
and is necessary for the stability of the thumb-index
finger pinch. Early detection of UCL injuries is key to
avoid prolonged pain and disability. Injury to the UCL
usually occurs with abduction, hyperextension, or
a torsion force to the thumb. Athletes will complain
of pain, swelling, and tenderness in the web space at
the base of the thumb and also along the UCL. The
stability of the UCL can be tested by flexing the MCP
joint to 30 degrees and applying a radially-directed
(abduction) force to the thumb tip. Pain with abduction
and laxity compared to the uninvolved side or lack of
a firm endpoint is an indication for immobilization
or surgical repair. Stress and plain films can also be
useful in identifying instability in abduction and UCL
avulsion off the proximal phalanx.
Taping techniques or a volar splint can be used to
stabilize first-degree and mild second-degree sprains.
Continued
SAVE THE DATE
Immobilization in a thumb spica cast is
necessary for the majority of seconddegree sprains and after surgical
repair for acute third-degree sprains
or chronic instability. The casting
period is followed by several weeks
of removable splint wear that reduces
stress on the ligament but also allows
the athlete to perform thumb, wrist,
and hand range of motion exercises.
The thumb should be protected during
sports participation for at least three
months following UCL injury.
pain and disability and allow athletes
to return to play with normal wrist and
hand function.
Ben Hogan
Sports Medicine
Symposium
March 25-27, 2011
NATA
June 19-22, 2011
new orleans, LA
REFERENCES
Adickes, M.S., & Stuart, M.J. (2004). Youth football injuries. Sports
Medicine, 34(3), 201-207.
Geissler, W.B. (2001). Carpal fractures in Athletes. Arthroscopic Surgery
for Athletic Elbow and Wrist Injuries, 20(1), 167-188.
Irvin, R., Iversen, D., & Roy, S. (1998). Sports medicine: Prevention,
assessment, management, and rehabilitation of athletic injuries. (2nd
ed). Needham Heights, MA: Allyn & Bacon.
SWATA
July 13-16, 2011
Houston, tX
McCue, F.C., Hussamy, O.D., & Gieck, J.H. (1996). Hand and wrist injuries.
In J.E. Zachazewski, D.J. Magee, & W.S.Quillen (Eds.), Athletic Injuries
and Rehabilitation (pp.585-598). Philadelphia, PA: W.B.Saunders.
Injuries to the wrist and hand are often
overlooked because they do not always
prevent athletic participation. Prompt,
accurate diagnosis during the early
stage of injury is crucial for proper
treatment and favorable outcomes.
Early injury detection, stable alignment
of the involved anatomy, protective
immobilization,
and
thorough
rehabilitation help prevent chronic
CONTACTS
Brian Conway, ATC, LAT
Director, BHSM
brianconway@texashealth.org
www.texashealth.org/benhogan
Fort Worth location
800 5th Avenue, Suite 150
Fort Worth, TX 76104
Phone: 817-250-7500
Fax: 817-250-7501
Keller location
721 Keller Pkwy., Suite 107 A
Keller, TX 76248
Phone: 817-741-1700
Fax: 817-741-8030
Amy Goodson, MS, RD, CSSD, LD
Sports Dietitian, BHSM
amygoodson@texashealth.org
Kiley Cohen, MPT, CSCS, SCS, DPT
Physical Therapist, BHSM
kileycohen@texashealth.org
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