Managing hand and finger injuries in ball sports

Mar 30, 2008

Many hand and finger injuries in ball sports are misdiagnosedor mismanaged, possibly leading to disability. Primary carephysicians who obtain a detailed history, conduct a focused examination,and know the indications for referral can manage themeffectively. The chief complaint is pain. In mallet finger, a finger is"jammed" during sports participation; nonoperative treatment oftenis indicated. The ring finger is involved in most reported cases of jerseyfinger; surgical intervention is the treatment of choice. Managementof boutonnière deformity helps patients regain full strengthand range of motion. Collateral ligament injuries may occur at anyinterphalangeal joint. Finger fractures are the fractures most oftenseen in the primary care setting. Malrotation with phalangeal fracturesis unacceptable. (J Musculoskel Med. 2008;25:198-204)

 

Hand and finger injuries account for up to 9% of sports injuries, and the hand is the most frequently injured part of the athlete's upper extremity.1 These injuries are particularly common in ball sports, perhaps because athletes tend to avoid use of protective equipment that may limit dexterity.

Up to 30% of hand injuries are misdiagnosed or mismanaged.2 This problem may have long-term ramifications, because if they are not managed properly and efficiently, these injuries-especially those to the dominant hand-can be disabling.

Primary care physicians are capable of managing many sports-related hand and finger injuries effectively, as long as they obtain a detailed history, conduct a focused examination, and know the indications for referral. In this article, we discuss diagnosis and management of the traumatic injuries that are common in ball sports. We also describe the criteria for referral to ensure that patients receive the best possible care and achieve a safe return to sports activity.

 

HISTORY

Taking a thorough history of the injury is key to making an accurate assessment, ordering the proper ancillary tests, and formulating an appropriate treatment plan. First, identify the sport or activity that the patient was involved in at the time of injury; also ascertain his or her hand dominance, which may affect the injury mechanism and recovery or disability. Determining the mechanism of injury also helps the diagnosis. For example, did the injury involve a fall? Was the athlete holding a piece of equipment? Was he or she grabbing a jersey or trying to catch a ball?

 

The chief complaint with most hand injuries is pain.The location, quality, and onset of pain, as well as the precipitating and alleviating movements or positions all are important aspects of a thorough history. Is there swelling and ecchymosis? Was there an immediate or delayed onset? The presence of pallor or paresthesia could mean there is neurovascular involvement that requires immediate intervention. The patient's age is important, because injuries often occur at locations of greatest weakness (open growth plates are more likely to be involved in younger patients vs ligaments and tendons in adults). Learning what the athlete cannot do with the injured hand helps focus the clinician in formulating his diagnosis and treatment plan. Also helpful is an understanding of the complex anatomy of the hand (Figure).

 

EXAMINATION OF SPECIFIC INJURIES

Mallet finger

This injury, also known as baseball finger, results from ligamentous disruption of the extensor tendon at the distal interphalangeal (DIP) joint. A mallet finger may be a tear of the ligament itself or a small avulsion of its bony attachment on the distal phalanx. There is a loss of full extension (5° to 20°), also known as an extensor lag, at the DIP joint.3 A mallet finger often occurs when a finger is "jammed" during baseball, basketball, or football participation. While the athlete is attempting to catch a ball, his DIP joint is actively extended.The ball hits the finger, causing forced flexion and injuring the extensor tendon.

 

Physical examination shows swelling and tenderness to palpation on the dorsal aspect of the DIP joint of the affected finger. There is full passive range of motion, but the athlete cannot fully extend the finger at the DIP joint.

The best way to test the extensor tendon is to isolate the DIP joint. Hold the proximal interphalangeal (PIP) joint in full extension and ask the patient to extend the distal phalanx. Plain radiographs of the injured finger should be obtained in 3 views (posteroanterior, lateral, and oblique) to rule out an avulsion or other fracture.

Nonoperative treatment is indicated if the clinician can obtain passive full extension, there is no bony involvement or subluxation, and an avulsion involves less than one-fourth of the joint.4 Treatment involves splinting the DIP joint in full extension with an aluminum or stacked splint. Isolate the DIP joint, leaving the PIP joint free.

The splint must be worn at all times for 6 to 8 weeks. If the patient does not adhere to the treatment, an additional 6 weeks is added. If the patient has regained full active extension, the splint is continued for an additional 2 to 4 weeks at nighttime and during sports activity.5 The athlete may participate with the splint as long as the finger is protected from further injury. If extension lag persists, continuing to use the splint up to 6 months after injury still can help. Beyond this period, nonsurgical intervention is not useful and referral for operative treatment is indicated.6

 

Jersey finger

This injury, which often occurs in football, is named after its common mechanism, a player grabbing an opposing player's jersey while trying to make a tackle. Again, obtaining an accurate history should raise the clinician's suspicion for this injury, and it may be missed if this is not done. A disruption of the flexor digitorum profundus (FDP) tendon occurs because the DIP joint is actively flexed and then forced into extension. The ring finger is involved in up to 75% of reported cases, but any digit may be injured.7

 

Examination often reveals tenderness over the volar side of the DIP joint, which may extend proximally along the tendon sheath because of FDP tendon retraction.4 To test for injury, hold the patient's PIP joint in extension and ask him to actively flex the injured digit at the DIP; inability to do so indicates injury. Radiographs should be obtained to rule out avulsion fracture.

Timely surgical intervention is the treatment of choice for jersey finger. The finger should be splinted with a dorsal aluminum splint (with 30° of flexion at the PIP and DIP joint) and the patient referred to a hand specialist. The surgery should be performed within 7 to 10 days, especially if the FDP tendon has retracted a great distance.8 The recovery period is about 2 to 3 months. In the chronic presentation of this injury, functional impairment often is minimal; therefore, benign neglect by the physician and athlete may be the best treatment, because the chances of full correction with surgery are greatly reduced.9

 

Boutonnire deformity

This injury involves the same mechanism as mallet finger but at the PIP joint; the joint is in active extension and is forced into flexion. Boutonnire deformity also may occur with volar dislocation of the PIP joint, resulting in a disruption of the central slip of the extensor tendon at the PIP joint.10

 

On physical examination, the athlete experiences tenderness and swelling over the dorsal aspect of the PIP joint and cannot extend the digit at the joint. If the clinician cannot fully extend the finger at the PIP joint passively, referral should be made for surgical intervention. Radiographs should be obtained to rule out avulsion fracture; referral is indicated if avulsion fracture involves more than 25% of the joint.4

Treatment usually is nonsurgical. The goals are to regain full strength and range of motion and avoid a deformity. Treatment involves splinting the PIP joint only, in full extension for 6 to 8 weeks. Surgical referral is indicated for persistent deformity.

 

Collateral ligament injuries

Partial or complete collateral ligament tears, often referred to as "jammed fingers," may occur at any interphalangeal joint with an ulnar-directed or a radial-directed force. They occur more often at the PIP joints than at the DIP joints.11

 

Physical examination reveals swelling of the affected joint and pain over the injured ligament. When examining joint integrity, the clinician should flex the associated metacarpophalangeal (MCP) joint to 90°, and the involved joint should be at 30° of flexion; apply valgus and varus stress and compare the joint with the same joint on the contralateral hand. The positioning of the digit places the collateral ligaments in relaxation to prevent a false-negative result.6 A radiograph may show a small avulsion fracture at the ligament's insertion site.

Nonsurgical management of collateral ligament injuries is almost always successful. For the patient's comfort, apply a splint or use buddy taping (taping the injured finger to an adjacent finger). Remind him that swelling may take upwards of 6 months to resolve and that there may be a persistent deformity.

Range of motion and strengthening exercises also are important in returning the joint to full function. Athletes may continue to participate in their sport as pain and function allow. If the joint remains unstable with active range of motion after 8 weeks of conservative treatment, referral is indicated; referral also should be considered for young children if there is concern for growth plate injury.

 

Phalangeal fractures

Finger fractures are the fractures most often seen in the primary care setting.4 They may be transverse, oblique, spiral, or comminuted and may occur in various locations; the type and location vary with the mechanism.

 

Malrotation with phalangeal fractures is unacceptable.To assess for malrotation, flex all the patient's digits at the MCP and PIP joints. All fingers should point toward the area of the navicular bone. If there is rotation and it cannot be reduced, the patient should be referred to a hand specialist.

 

Nondisplaced fractures that involve less than 10° of angulation may be managed conservatively.12 Immobilization-until the finger no longer is sensitive to palpation-usually lasts 3 to 4 weeks. Athletes may return to sports activity at this point.

A U-shaped aluminum splint should be used for general distal phalanx fractures to protect the digit from incidental axial loading trauma. The DIP joint should be kept in full extension unless the FDP tendon is injured. Immobilization is recommended until the finger is no longer sensitive to palpation, usually 3 to 4 weeks, and then athletes may return to play.

Some distal phalanx fractures involve the nail bed, and a subungual hematoma results. If the hematoma involves more than 50% of the nail bed, it should be drained with a cautery pen or by boring a hole with an 18-gauge needle. If the nail is lacerated, it should be removed and the nail bed repaired after thorough irrigation. After repair, the nail should be placed back under the nail bed and anchored with sutures to prevent formation of adhesions between the nailfold and matrix. The patient should be informed about the possibility of future nail deformity.4

Angulation of middle phalanx fractures varies with the location of the fracture in relation to the flexor digitorum superficialis (FDS) tendon.The FDS attaches to the distal two thirds of the volar aspect of the middle phalanx; as a result, fractures at the base of the middle phalanx angulate apex dorsally and the rest angulate ventrally. If fractures are nondisplaced, treatment with buddy taping for 4 weeks is sufficient. If reduction is necessary, ulnar or radial gutter splinting for 4 weeks is indicated. Reduction may be attempted, but if rotation is noted, referral to an orthopedic or hand surgery specialist is recommended. Management of proximal phalanx fractures is similar to that of middle phalanx fractures.

 

Boxer's fracture

This fracture, which occurs just proximal to the fifth metacarpal head, often is seen after a person punches a hard object. The metacarpal head usually is displaced volarly.

 

On inspection, the clinician will notice a "loss" of the fifth knuckle because of the angulation. Up to 40° of angulation in the fifth metacarpal is acceptable.The area also will have pain and swelling. Most important is assessing for malrotation. No rotation is acceptable. If it is present, the patient should be referred for fixation.

If there is no rotation, reduce the fracture to less than 40° of angulation and splint the fourth and fifth digits at 70° to 90° of flexion at the MCP joints with an ulnar gutter splint. Repeat radiography at 2 weeks to check for worsening displacement. Immobilization is required for 4 to 6 weeks, followed by aggressive rehabilitation with flexibility and strengthening exercises. Patients should be reminded that the knuckle may not return to its previous appearance.

 

Gamekeeper's thumb

This injury may occur in any sport when an athlete falls onto the hand with forceful abduction and extension of the thumb. This mechanism causes the ulnar collateral ligament (UCL) to tear or avulse at its attachment on the first proximal phalanx.

 

Examination reveals pain over the UCL, as well as swelling. To assess UCL integrity, stabilize the metacarpal and radially deviate the thumb (at 0° and 30° of MCP flexion because there is inherent stability of the first MCP joint at 0°).4 Increased laxity or a soft end point in comparison with the unaffected thumb is a positive finding.

X-ray films are useful. Nonoperative treatment is indicated if there is a nondisplaced avulsion fracture off the proximal, ulnar aspect of the first phalanx that involves less than 25% of the joint.4 Conservative therapy starts with immobilizing the joint in a thumb spica splint for 2 weeks. Then, the UCL must be reexamined for laxity. Persisting laxity is an indication for referral to a hand specialist.7

A Stener lesion-displacement/trapping of the proximal end of the UCL outside of adductor aponeurosis-may occur in up to 29% of UCL injuries; it requires surgical intervention. There is no consensus about whether an accurate diagnosis of this lesion may be made with MRI; most often a diagnosis is made only at the time of surgery. If there is no laxity (or suspicion for a Stener lesion) at the time of reexamination, continue immobilization with a thumb spica splint for 6 weeks and then start rehabilitation.

 

Dislocations

PIP. The PIP is the most frequently dislocated joint in the body.5 PIP dislocation is caused by an axial force to an extended digit. The joint usually dislocates in a dorsal direction and involves disruption of the volar plate. A lateral or volar dislocation, much less common, often is reduced by the athlete or the coach, hence the designation "coach's finger."7

 

A dorsal dislocation has an obvious deformity and, usually, pain over the volar plate. Check the neurovascular status of the digit before and after reduction. Obtaining radiographs before and after reduction is ideal.

Reduction of a dorsal PIP dislocation is achieved with gentle hyperextension at the PIP joint to free the middle phalanx from the dislocated position, then axial traction, and then moving the joint into flexion. Reduction may be accomplished acutely without anesthesia, but after about 1 hour, a digital block usually is needed for pain.5 If reduction cannot be achieved easily, a tendon, bony fragment, or ligament may be interposed in the joint, requiring surgical intervention. This situation is rare in dorsal dislocations but more common in volar ones.6

After relocation, the joint should be assessed for stability of the collateral ligaments and active range of motion. If the joint is stable, the athlete can return to play with buddy taping. Radiographs should be obtained after relocation.

Treatment varies with the type of dislocation. Simple dislocations that involve ligament injuries and small avulsion fractures may be managed with immobilization of the PIP joint at 30° for about 1 week to allow pain and swelling to subside; then aggressive range of motion exercises may be started.13

Repeat x-ray films at this time. If the injury is stable, the athlete should receive buddy taping during sports participation for about 2 to 4 more weeks.

If there is a fracture dislocation that involves more than one-third of the joint, the dislocation is considered unstable and requires extension block splinting or the patient should be referred to a hand surgeon.11 Patients with volar dislocations also should be referred to a hand specialist. Complications that may arise from a chronically dislocated PIP joint or volar plate injury include swan-neck deformity (chronic hyperextension of a PIP joint with flexion of a DIP joint) and flexion contracture.7

DIP. DIP joint dislocations are rare. They almost always are dorsal and associated with crushing trauma and open wounds.4 Management is the same as that described for PIP dislocations.

MCP. The most frequently dislocated MCP joint-that of the thumb, the first MCP joint-may dislocate laterally, dorsally, or volarly.14 Relocation should be attempted as described above, and similar radiographic studies should be obtained.

It is important to note that this dislocation can be very difficult to reduce. If relocation is accomplished, assessing for lateral stability afterwards is very important in the management of an MCP fracture. If there appears to be a complete rupture of the UCL or radial collateral ligament on examination, surgical referral is indicated. If these ligaments are only partially torn, a thumb spica splint should be applied and the treatment plan for gamekeeper's thumb should be followed. If there is no associated ligament damage, the splinting procedure for other dislocations may be used.

 

 

References:

References


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