05/05/2007
INJURIES OF THE HAND AND
WRIST
By
Derya Dincer, M.D.
Hand injuries, especially the fractures of metacarpals and phalanges, are the most common fractures in the skeletal system.
Hand injuries are among the more frequently seen problems in boxing. The majority of these are soft–tissue injuries, sprains and strains but occasional fractures of the hand are also seen though infrequent. More hand injuries per hour of
participation occur during competition than during practice.
Wrist and hand injuries in boxing may be divided into acute traumatic injuries and overuse or stress type injuries. Acute injuries include fractures and dislocations, as well as injuries to ligaments and cartilage. Any misconception that these are “minor” injuries or treatment of these injuries by inexperienced members of the medical team may lead to unfortunate complications and prolonged functional disability. Nowhere in the body are motion and function more linked to anatomic structure than in the hand.
Physical examination is very important. Some fractures and dislocations will become obvious immediately because of local swelling and deformity. Tenderness is a clinical finding of soft tissue damage. Roentgenograms are important in most injuries of the hand. This is true even if no bone injury is obvious on clinical
examination. The goal of treatment is to return the boxer expeditiously to his sport and to restore the hand to the best possible function.
CARPAL FRACTURES
Scaphoid fractures are the most common and problematic fractures in boxers, they account for approximately %60 of all carpal fractures. Studies have shown that this fracture occurs if the wrist is in dorsiflexion with application of threshold force of 500 to 900 Newton(Figure 1).
In the most common classification system,scaphoid fractures are divided into 1. Acute nondisplaced stable fractures (type A)
2. Displaced unstable fractures (type B) 3. Delayed Union (type C) 4. Non Union (type D)
Acute nondisplaced fractures may present a diagnostic challenge because in many cases that fracture line is not visible on initial radiographs. A bone scan 48 to 72 hours after the injury may establish the definitive diagnosis. Magnetic resonance imaging (MRI ) is also an important diagnostic tool. In addition to diagnosis, MRI may also be used to demonstrate the integrity of the carpal ligaments and articular surfaces.
A nondisplaced stable fracture is defined as a fracture with less than 1 mm of displacement or a fracture in which the boney cortex appears to be intact on the radiograph. The probability of successful union with cast immobilisation is %90 to %100. The usual time to achieve union is nine to 12 weeks if the fracture is treated acutely. Healing time may be shortened by percutaneus cannulated screw fixation. This more aggressive approach will enable the athlete to return to boxing in about six weeks (Figure 2).
Displaced acute fractures are defined as fractures in which 1 mm or greater displacement is present on the anterioposterior radiographs. These fractures should be treated with open Reduction and internal fixation (ORIF) (Figure 3).
Delayed union and non union scaphoid fractures are treated with open reduction internal fixation with a vascularized graft from distal radius.
Figure 2: Non –Displaced Scaphoid Fracture
FRACTURES OF THE METACARPAL SHAFT
These fractures are usually the result of a direct blows. The clinical symptoms are point tenderness, pain and local swelling, deformity if there is displacement of the fractured fragments.
Metacarpal shaft fractures should be evaluated for displacement, angulation, rotation and shortening. These fractures in boxers are best treated by percutaneus pinning to avoid scarring in the dorsum of the hand. Returned to boxing should be delayed for a minimum of 3 months (Figure 4 and 5).
Figure 5: Surgical Treatment of Metacarp Shaft Fracture
FRACTURES OF THE METACARPAL NECK
Fractures of the metacarpal neck are unstable because of their anatomy. In boxers the most commonly seen metacarpal neck fracture is the fifth metacarpal. This injury is known as a Boxer’s fracture. Since it is a unstable fracture the
treatment is closed anatomical reduction and fixation with Kirchner wires.If anatomic reduction is not possible by closed methods,open reduction and internal fixation becomes the treatment ofchoice (Figure 6 and 7). If perfect anatomic reduction of the metacarpal neck is not obtained, the palmer angulation of the metacarpal head results in a painful grip
Figure 6: Boxers Fracture
Figure 7: Boxers Fracture
FRACTURE OF THE BASE OF THE FIRST METACARPAL (BENNETT’S FRACTURE)
Bennett’s fracture is an intra–articular fracture of the base of the first metacarpal. It is usually unstable. The treatment is anatomic reduction and percutaneus K- wire fixation of the base of the first metacarpal to the trapezium. Repair should be protected by a thumb spica cast for 4 weeks(Figure 8 and 9).
Figure 8: Bennet Fracture
INTERPHALANGEAL JOINTS
Stability of the interphalangeal joints depends on bony cogruence, the integrity of the collateral ligament complexes, the volar plate and the extensor tendon
apparatus. Evaluation includes careful examination of the digit, neurovascular status, joint congruity, stability and function. Treatment is usually splinting.
DISLOCATION OF THE INTERPHALANGEAL JOINTS
Dislocations of the interphalangeal joints are two types the common posterior dislocation and the rare anterior dislocation. Clinical findings are acute swelling and pain accompanied by deformity. Treatment is anatomical closed reduction and splinting for a period of 3 weeks.
CHONDRAL LESIONS
Traumatic articular cartilage lesions may result from a single injury or occur with repetitive blows.Symptoms are localized pain, especially with motion under load conditions.Radiographs, arthrography and ligament tests are normally performed to evaluate this condition. Treatment consists of rest and the avoidance of impact and lifting for 3 to 4 months.
BOXER’S KNUCKLE
Boxers may injure their knuckle either as a single traumatic event or from repetitive blows. Most often such injury results in a longitudinal tear of the extensor digitorum communis tendons combined with disruption of the dorsal joint capsule involving the radial or ulnar sagittal bands. A split in the central tendon is the most common finding while tears in the radial and ulnar sagittal bands occur with equal frequency. (Figure 10).
A boxer presents with pain over the metacarpo phalangeal (MCP) joint.
Physical examination may show a palpable defect in the extensor mechanism or lag in active extension at the metacarpo phalangeal joint.Treatment involves surgical exploration and side-to-side repair of the defect. Repair is followed by 6 weeks of immobilization; then, an aggressive rehabilitation program. The boxer should not return to punching until normal motion and full strength have been restored(Figure 11).
Figure 11: Surgical Treatment of Boxers Knuckle
BOUTONNIERE DEFORMITY
Rupture of the central slip of the extensor tendon at its insertion at the base of the middle phalanx should be treated immediately. Any delay in treatment may result in a boutonniere deformity (Figure 12). Clinically, the patient presents with maximum tenderness on the dorsal surface of the proximal inter phalangeal (PIP) joint. Full active extension of the PIP joint may be lost.
Injuries presenting within three weeks of injury must be splinted for 6-8 weeks. The PIP joint should be splinted in extension while the DIP joint is allowed to flex
(Figure 13). Untreated injuries will result in a classic boutonniere deformity flexion contracture of PIP and extension contracture of DIP joints.
Figure 12: : Boutonniere deformity
TENOSYNOVITIS OF THE HAND AND WRIST
Tenosynovitis of the hand and wrist is quite common in boxing.DE QUERVAIN’S syndrome or tenosynovitis of the M.abductor pollicis longus and M.extensor pollicis brevis is one of the most common causes of the pain in the boxers. Treatment includes rest, splinting and corticosteroid injection. In case of recurrent symptoms or in the late stages of fibrosis, injection is less helpful, and surgical decompression is recommended.
DORSAL WRIST GANGLION
Dorsal ganglion, the most frequent soft-tissue tumor of the hand is common in the boxers. History of specific trauma has been noted in 15% of visible ganglions, although it is rare in patients with occult ganglions, which probably occur secondary to chronic stress. The clinical symptoms are with point tenderness over the ganglion (Figure 14). Symptoms usually worsened with extremes of palmer and dorsi flexion. Initial treatment may be with local injection of corticosteroids. The definite treatment is surgical excision.
