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Extensor Tendon Injuries
• Injury can be caused by lacera&on, trauma, or overuse
• Most commonly injured digit is the long finger
Most commonly seen injuries in athle&cs: • Zone I
“Mallet Finger” • Zone III
Central slip avulsion • Zone V
Sagi8al band rupture
Zone I: Mallet Finger
Injury to terminal extensor tendon distal to the DIP joint of the finger
• Mechanism: trauma&c blow to &p of finger • Presenta&on: inability to extend at DIP joint • XR may show bony avulsion or pure soS &ssue injury
Treatment
Nonopera&ve • Indica&ons:
• Acute (<12wks) soS &ssue injury • Nondisplaced bony injury
• Technique: • Extension splin&ng of DIP joint • Must wear 6-‐8 wks • Maintain PIP joint mo&on
Opera&ve • Indica&ons:
• Volar subluxa&on of distal phalanx • >50% ar&cular surface involved • >2mm ar&cular gap
• Technique: • CRPP vs ORIF
Zone III: Central Slip (“Boutonniere Deformity”)
Disrup&on over the PIP joint of digit • Mechanism: lacera&on or trauma&c avulsion
• Presenta&on: PIP flexion, DIP extension – Elson Test
• XR oSen normal; may have bony avulsion
Elson Test • Bend PIP joint 90° over the
edge of a table
• Ask pa&ent to extend middle phalanx against resistance
• In presence of central slip injury: • Weak PIP extension • DIP will go rigid
• In absence of central slip injury: • DIP joint will remain
floppy because the lateral bands are not ac&vated
Treatment Nonopera&ve • Indica&ons:
• Acute closed injuries (<4wks) • Technique:
• Splint PIP in full ext for 6 wks • Then part-‐&me splint x4-‐6wks • Allow ac&ve DIP mo&on
Opera&ve • Indica&ons:
• Acute displaced avulsion fx • Open injury that needs I&D
• Technique • Primary central band repair • Can be done with suture anchor
Zone V: Sagi8al Band Rupture “Boxer’s Knuckle”
Disrup&on over MCP joint of digit • Mechanism: Forced extension of a flexed digit or lacera&on
• Presenta&on: Extensor lag and flexion loss
• XR oSen normal
Treatment Nonopera&ve • Indica&ons:
• Acute injuries (within 1 week)
• Technique: • Extension splint x4-‐6 wks
Opera&ve • Indica&ons:
• Chronic injuries (more than 1 wk)
• Professional athlete
• Technique: • Direct suture repair
Flexor Tendon Injuries
Injury caused by lacera&on or avulsion
Most commonly seen injury in athle&cs: • Zone I
FDP avulsion “Jersey finger” Most commonly the ring finger
Zone I: Jersey Finger Avulsion injury of FDP from inser&on at base of distal phalanx • Mechanism: maximal contrac&on of FDP during forceful DIP extension
• Presenta&on: – pain/tenderness over volar distal finger – finger lies in slight extension rela&ve to other fingers – no ac&ve flexion of DIP
• XR may show avulsion fragment
Treatment
Nonopera&ve • Not recommended
Opera&ve • Indica&ons:
• All zone I FDP injuries
• Technique: • Direct tendon repair or direct reinser&on with a bu8on if no bony avulsion
• ORIF with wire or screw for bony avulsion fragment
Thumb Collateral Ligament Injury Most commonly Ulnar Collateral Ligament “Skier’s” or “Gamekeeper’s” thumb • Mechanism: hyper abduc&on or extension at the MCP joint
• Presenta&on: – Pain/swelling at ulnar aspect of thumb MCP joint – Laxity with stability tes&ng
• XR may show bony avulsion; stress XR may show gapping on the ulnar side
Treatment Nonopera&ve • Indica&ons:
• par&al tears with < 20° of side to side valgus instability
• Technique: • Immobiliza&on x4-‐6 wks
Opera&ve • Indica&ons:
• > 20° side to side valgus instability • >35° of opening • Stener lesion-‐ avulsed ligament displaced
above adductor aponeurosis
• Technique: • May use suture, suture anchors, or small
screw to repair ligament
PIP Joint Disloca&ons Dorsal disloca&on most common May be purely ligamentous injury or may be a fracture-‐disloca&on Involves injury to volar plate and at least one collateral ligament Presenta&on: pain and deformity at PIP joint XR will show fracture in fracture-‐disloca&ons
Treatment Nonopera&ve • Indica&ons:
• Reducible disloca&ons • <40% joint involved if fx
• Technique • Reduce and buddy tape x3-‐6 wks • Dorsal ext block splint if fx
Opera&ve • Indica&ons:
• Failed reduc&on • >40% joint involved if fx
• Technique: • Open reduc&on and volar plate
extrac&on if no fx and can’t reduce • ORIF vs CRPP for fx’s
Common Fractures in Athletes
Hand
• Phalanx • Metacarpal
Wrist
• Scaphoid • Hook of Hamate • Distal Radius
Phalangeal Fractures Distal, Middle, and Proximal phalanges Sports is the most common cause of phalangeal fractures in the 10-‐29 age group Proximal phalanx: deformity usually apex volar Middle phalanx: deformity will be apex dorsal if proximal to FDS OR apex volar if distal to FDS
Distal Phalanx Fx Treatment
Nonopera&ve • Indica&ons:
• Most cases
• Technique: • Reduce and splint
Opera&ve • Indica&ons:
• Associated nail bed injury
• Technique: • Remove nail, repair nail bed,
and replace nail
Middle & Proximal Phalanx Fx Treatment
Nonopera&ve • Indica&ons:
• extraar&cular with < 10° ang or < 2mm shortening and no rota&onal deformity
• Technique: • Buddy taping with 3 wks immobiliza&on, then
mo&on
Opera&ve • Indica&ons:
• Irreducible or unstable fx • > 10° ang or 2mm shortening or rota&onally
deformed
• Technique: • CRPP vs ORIF with wires or screws
Metacarpal Fractures May be fractures of the head, neck, or shaS Acceptable angula&on depends on fx loca&on Mechanism: direct blow to hand or rota&on with axial load Presenta&on: Pain, swelling, deformity XR to show fracture 30° pronated view for 4th & 5th MTC fx 30° supinated view for 2nd & 3rd MTC fx
Metacarpal Fractures • Criteria for nonopera&ve management: – Acceptable angula&on and shortening – No rota&onal deformity • May assess by lining up the fingernails in flexion
Acceptable Sha8 AngulaDon
Acceptable Neck AngulaDon
Acceptable Shortening
Index & Long 20 15 2-‐5mm
Ring 30 35 2-‐5mm
Small 40 55 2-‐5mm
Treatment Nonopera&ve • Indica&ons:
• Stable pa8ern • No rota&onal deformity • Acceptable ang & shortening
• Technique: • Splint/Cast immobiliza&on with
MCP’s flexed 70-‐90°
Opera&ve • Indica&ons:
• Ar&cular fractures • Unacceptable alignment • Mul&ple shaS fractures
• Technique: • CRPP vs ORIF
Scaphoid Fractures Most commonly fractured carpal bone Waist-‐ 65% Proximal 1/3-‐ 25% Distal 1/3-‐ 10% (most common in kids)
Mechanism: axial load across hyperextended, radially deviated wrist Presenta&on: anatomic snurox tenderness
dorsally scaphoid tubercle tenderness
volarly
Scaphoid Anatomy • 75% covered by ar&cular car&lage • Major blood supply enters dorsally and supplies proximal 80% • Minor blood supply enters distal tubercle and supplies distal 20% • AVN rate increases with more proximal fractures
Scaphoid Fractures
XR may show the fracture if displaced XR may also appear nega&ve acutely if nondisplaced If clinically suspicious, treat as a fracture and re-‐XR in 2-‐3 weeks MRI most sensi&ve to diagnose occult fracture acutely
Treatment Nonopera&ve • Indica&ons:
• Stable, nondisplaced fracture
• Technique: • Thumb Spica Cast • Longer immobiliza&on for more proximal fx’s • Return to play only when imaging shows a
healed fx
Opera&ve • Indica&ons:
• Displacement > 1mm • Proximal pole fx’s • ORIF may allow faster &me to union and
return to play
• Technique: • ORIF vs perc Screw
Hook of Hamate Fractures OSen seen in golf, baseball, hockey Mechanism: typically caused by a direct blow
grounding a golf club checking a swing
Presenta&on:
hypothenar pain pain with &ght grip
XR: Need carpal tunnel view to see it
Treatment
Nonopera&ve • Indica&ons:
• Most acute fractures
• Technique: • Short arm cast x 6 wks
Opera&ve • Indica&ons:
• Chronic painful non-‐unions
• Technique: • Excision of fx fragment vs
ORIF
Distal Radius Fractures
One of the most common orthopaedic injuries In athle&cs, most commonly will be seen in skeletally immature athletes Commonly apex volar angula&on (Colle’s fx) or physeal injury
Distal Radius Fractures
Mechanism: fall onto outstretched hand Presenta&on: pain, swelling, deformity about the wrist XR to demonstrate the fracture
Adult Treatment Nonopera&ve • Indica&ons:
• Extra-‐ar&cular • < 5mm radial shortening • < 5° dorsal angula&on
• Technique: • CR and SAC
Opera&ve • Indica&ons:
• Intra-‐ar&cular fx • > 5mm radial shortening • > 5° dorsal angula&on • Loss of reduc&on
• Technique: • CRPP • ORIF • Ex-‐Fix
Pediatric Treatment
Nonopera&ve • Indica&ons:
• Extra-‐physeal • < 9yo; < 30° dorsal angula&on • > 9yo; < 20° dorsal angula&on
(These numbers are controversial and decision is based on age, fx loca&on, and type of deformity)
• Technique: • Cast, +/-‐ CR
Opera&ve • Indica&ons:
• Any fracture that cannot be reduced and held with cas&ng within acceptable limits
• Technique: • CR and cas&ng vs CRPP
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