Wrist Injuries in the Competitive Athlete

Wrist injuries
in the competitive
athlete
P E T ER F R I CKE R OA M M BBS FACS P
A M S SM
APRIL 2014
DISCLOSURE
NEITHER I, PETER FRICKER, NOR ANY FAMILY
MEMBER(S), HAVE ANY RELEVANT FINANCIAL
REL ATIONSHIPS TO BE DISCUSSED, DIRECTLY
OR INDIRECTLY, REFERRED TO OR ILLUSTRATED
WITH OR WITHOUT RECOGNITION WITHIN THE
PRESENTATION.
Wrist injuries
Various reports in the literature indicate that injuries to the
wrist and hand comprise approximately 10% of all injuries
(Rettig AC, Sports Med., 1998)
Injuries can be acute (fractures, dislocations, etc.) or
overuse (stress fractures, tendon injury, etc.)
As always, history, careful examination for local or point
tenderness, functional exam (compare with the opposite
wrist), and imaging are the mainstays of good management
Early referral when in doubt!
Bony impingement
(www.hughston.com)
Bony impingement
Common in gymnasts, often in weightlifters
History of gradual onset, worse with training
Typically pain and tenderness dorsum of wrist as lunate abuts the radius
Unusual site of fracture but bone stress can be seen on imaging
Management by unloading the wrist in weight bearing dorsiflexion
Taping or strapping to limit impingement
Medication for symptom relief
Limited role for electrotherapy
(Remember other causes of similar pain such as
scaphoid fracture, scapholunate lig. injury, ganglion)
Stress injury of the lunate
Pain of the dorsum of the wrist during play (tennis)
ROM normal but tenderness of the lunate and pain on forced passive
extension of the wrist
MRI bone marrow oedema, no fracture
Management by semi-rigid immobilisation and symptomatic treatment
for 6 weeks and gradual return to play at 14 weeks
(Maquirriain J, Ghisi JP. BJSM 2007)
Grade-3 lunate stress injury of dominant wrist in a young male tennis player.
Maquirriain J , and Ghisi J P Br J Sports Med 2007;41:812815
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
Ulnar variance
Positive variance: ulna more distal
Negative variance: ulna more proximal
(Neutral: less than 2.5mm ulnar “shortening”)
Causes of variance:
*Trauma/mechanical (eg.Salter-Harris, DRUJ lig. injuries, surgery, bone
fracture with shortening/angulation)
*Congenital (Madelung, reverse Madelung)
Positive associated with ulnar impaction syndrome
Negative associated with Kienbock disease, ulnar impingement
Ulnar variance
Variance changes with wrist position
*More positive with maximum forearm pronation
*Negative with maximum forearm supination
Variance assessed by plain radiography with a PA view of the wrist in
neutral rotation, elbow flexed to 90 deg., and shoulder abducted to 90
deg.
(Goel A et al., http://radiopaedia.org/articles/ulnar-variance 4/01/2014)
Ulnar variance
Negative ulnar variance
Positive ulnar variance
Triangular fibrocartilage injury
J H Ko, T Wiedrich. Hand Clinics 28(3) Aug 2012 pp.307-21
Ishii et al. J Hand Surg 1996
Chidley LK. Oper Arthr 2ed.
Lippincott-Raven
Carlsen et al. Oper Teach Orthop 2009
Triangular fibrocartilage injury
Incidence of tears to the TFCC (triangular fibrocartilage complex) is
unclear
More likely to be symptomatic in younger athlete
Often associated with injury to other structures (eg. ECU, distal r/u joint,
lunotriquetral lig.)
Positive ulnar variance may predispose to injury
“Attritional” tears may be more common with ulnar deviation, power
gripping
(NC Chen et al., Sports Health 2009 Nov 1(6) pp.469-77)
ECU tendon
SPORTS PHYSICIANS ACT
Triangular fibrocartilage injury
Clinical signs include tenderness in the ulnar fovea and associated ECU,
RUJ tenderness and irritability,
irritability of the region with loading of the wrist and circumduction
(analogous to examining a meniscus of the knee),
Local pain on using wrist to lift self out of a chair
Usually no obvious swelling or significant loss of ROM
Radiography may show positive ulnar variance
MRI (arthrogram) may show tear(s) of the TFCC and
associated structures
Triangular fibrocartilage injury
Triangular fibrocartilage injury
Non operative management:
Splinting and modified training to minimise risk of further injury
NSAIDs and judicious intra articular injection of corticosteroid may be
helpful
For isolated TFCC tears (no joint or ECU instability) definitive
management may be deferred until out of season
Arthroscopy indicated for failed conservative therapy
Central tears often shaved (debrided)
Peripheral tears (vascular areas) may be repaired
(Chen et al., 2009)
Ulnar impaction syndrome
Central traumatic or degenerative defect in TFCC in patients with
positive ulnar variance
Chondral and subchondral oedema, impingement of articular disc,
chondromalacia of distal ulna, proximal lunate and proximal triquetrum
Management by unloading the wrist and arthroscopic ulnar wafer
resection (preferred to open resection or ulnar shortening osteotomy)
(Bickel KD,
J Hand Surg. 33(8) pp.1420-3, Oct 2008)
Recovery may take six months
TFCC surgery
(www.totalphysio.com)
Often central (avascular) TFCC debrided with shaver
Peripheral tears may be repaired
RTS weeks after debridement, maybe months after repair
Scapholunate ligament tear
(The Hand Center of Western Massachusetts)
(ericksonhandsurgery.com)
Scapholunate ligament tear
Mechanism typically a fall on the extended wrist in ulnar deviation (may
see gradual onset injury with weight bearing on dorsiflexed wrist)
Examination reveals local tenderness
Watson test for instability of the scaphoid:
Apply dorsal directed load on the scaphoid tubercle
As wrist is brought from ulnar deviation into radial deviation a painful
catch or click is detected (dorsal subluxation of the scaphoid)
Management:
Arthroscopy. If ligament not severely disrupted, pins across S and L
provide stability and support ligament healing. Gross disruption requires
repair or reconstruction. Return to sport can be difficult. Note loss of
dorsiflexion after reconstruction.
Scapholunate ligament tear
(AO Foundation v.1 2008-11-08)
Hook of hamate fracture
(lookfordiagnosis.com)
(Baseball Almanac )
Hook of hamate fracture
Hook of hamate functions as a pulley for the flexor tendons during “power
grip”
Pain presents over time or acutely (eg. golf club hitting the ground “fat”)
Local tenderness typical (just radial and distal to the pisiform)
Imaging with plain X-ray carpal tunnel view is useful, otherwise MRI or CT
scan
Beware median nerve (or ulnar nerve) involvement with haemorrhage,
oedema
Non union of fracture may be associated with FDP tendon rupture of small
finger
Excision of fragment effective, post-op wrist immobilisation for up to two
weeks advised, RTS at 6-8 weeks
Physeal injuries
Physeal injuries
(www.niams.nih.gov)
Physeal injuries
Chronic physeal injury:
Repetitive loading (eg. gymnastics) alters metaphyseal perfusion and
thus mineralisation of the hypertrophied chondrocytes (typically within
the zone of provisional calcification). The hypertrophic zone continues
to widen because of constant growth in the germinal and proliferative
zones.
This widening is usually temporary, but with impaired blood supply, may
develop localised changes of necrosis and deformity, or if entire physis
is involved, may see delayed or halted growth. Premature closure of
some or all of the physis may occur.
(Caine et al., Br J Sports Med 2006;40:749-760.doi: 10.1136/bjsm.2005.017822)
Physeal injuries
(
(www.healio.com)
Physeal injuries
Most common physeal stress injuries are of the distal radius in young
gymnasts
Presentation is with local pain, tenderness, loss of range of movement
Typical findings on X-ray are of widening and irregularity of the distal
radial growth plate, cystic changes at metaphyseal margin, premature
closure of the growth plate and positive ulnar variance
Physeal injuries
Management is by unloading the wrist as early as possible and
monitoring pain, range of movement, tenderness and radiological
change.
Early intervention is usually enough to see good recovery.
Established growth plate abnormality (eg. premature closure) is
irreversible and the athlete must be aware of the risk of repeated stress
on the wrist (with positive ulnar variance for example)
Remember young athletes are most at risk during growth spurts
Thank you