This document discusses various common wrist and hand injuries in athletes. It describes injuries such as De Quervain's tenosynovitis, carpal tunnel syndrome, ulnar nerve compression, sprains of the ulnar collateral ligament of the first MCP joint, mallet finger, jersey finger, and trigger finger. For each injury, it discusses symptoms, diagnostic tests, and treatment options including splinting, injections, and in some cases surgery. The goal of treatment is usually conservative management but some injuries may require surgical intervention.

1. Wrist & Hand Injuries
Dr. Usha (PT)
Assistant Professor

2. Contents
 De Quervain’s Tenosynovitis
 Carpal Tunnel Syndrome
 Ulnar Nerve Compression
 Sprain of The Ulnar Collateral Ligament of The First MCP Joint
 Mallet Finger (Baseball Finger)
 Jersey Finger
 Trigger Finger

3. De Quervain’s Tenosynovitis
 Also known as hoffmann’s disease
 De quervain’s tenosynovitis is an
inflammation of the synovium of the
abductor pollicis longus and extensor
pollicis brevis tendons as they pass in
their synovial sheath in a fibro-osseous
tunnel at the level of the radial styloid
(fig. 19.11).

4.  This is the most common radial-
sided tendinopathy in athletes
and occurs particularly with
racquet sports, ten pin bowlers,
rowers and canoeists. The left
thumb of a right-handed golfer is
particularly at risk because of
the hyperabduction required
during a golf swing.

6.  There is local tenderness and swelling, which may extend
proximally and distally along the course of the tendons. In
severe cases, crepitus may be felt.
 A positive Finkelstein’s test is diagnostic (Fig. 19.10b) but not
pathognomonic because flexor carpi radialis tendinopathy
also causes a positive test.

8.  Treatment includes splinting, local electrotherapeutic
modalities, stretches and graduated strengthening. Patients
often find a pen build-up (a rubber addition to enlarge the
diameter of the pen) useful as this reduces the stretch on the
extensor tendons.
 An injection of corticosteroid and local anesthetic into the
tendon sheath will usually prove helpful.

9.  In rare cases, surgical release is necessary. A recent study that
pooled the results of seven investigations concluded that
cortisone alone cured 83% of cases, injection and splinting
cured 61%, and splinting alone cured 14%. I
 t is noteworthy that no patients gained symptom reduction
from rest and NSAIDS.
 Unfortunately, the original studies did not compare injection
to another form of treatment; thus, further studies are needed
to determine the most effective treatment for this condition.

10. Splints for De Quervain’s Tenosynovitis

11. Carpal Tunnel Syndrome
 The median nerve may be
compressed as it passes
through the carpal tunnel
along with the flexor
digitorum profundus, flexor
digitorum superficialis and
flexor pollicis longus tendons
(Fig. 19.14).

12.  The condition may manifest as a
result of swelling of the flexor tendon
sheaths (tenosynovitis), as can be
seen from the repetitive flexion
actions caused by the wrist in sports
such as gymnastics, cycling and
weightlifting.
 The condition can also manifest itself
as a result of arthritic degenerative
changes from repetitive or previous
impact traumas, such as wrist
fractures.

13.  This condition is characterized
by burning volar wrist pain
with numbness or paresthesia
in the distribution of the
median nerve (thumb, index
finger, middle finger and radial
side of the ring finger).

14.  Nocturnal paresthesiae are
characteristic. The pain can
radiate to the forearm, elbow
and shoulder.
 Tinel’s sign may be elicited
by tapping over the volar
aspect of the wrist (Fig.
19.10c).

15.  The most important aspects in diagnosis are the history and
physical examination but nerve conduction studies can help
confirm the diagnosis and may predict how the patient will
respond to surgery.
 Diabetes mellitus should be excluded as it is a risk factor for
carpal tunnel syndrome.

16.  Mild cases may be treated
conservatively with NSAIDs and
splinting.
 A single corticosteroid injection
may provide relief but persistent
cases require surgical treatment.
Surgery may be either open or
endoscopic and systematic
reviews to date show no
difference between the two
techniques for symptom relief.
Splints for Carpal Tunnel Syndrome

17. Ulnar Nerve Compression
 Compression injuries of the ulnar
nerve can occur between the wrist
space formed between the
pisiform and the hamate, known
as the tunnel of Guyon, termed
“Guyon’s canal syndrome”.
 The ulnar nerve may be
compressed at the wrist as it
passes through Guyon’s canal.

18.  This injury is most commonly seen in
cyclists due to supporting body weight
over a long duration ride because of poor
bike fit or a failure to use several relaxed
handlebar grip positions.
 It also occurs in karate players, and a
recent study highlighted the risk of hand
neurovascular changes in baseball
players, especially catchers, from
repeated trauma associated with catching
a ball.

19.  Within Guyon’s canal, the nerve lies with the ulnar artery
between the pisiform bone on the ulnar side and the hamate
radially.
 The symptoms are caused by compression or friction of soft
tissue structures surrounding the ulnar nerve, resulting in
pain, tingling and numbness or paresthesia to the little finger
and ulnar side of the fourth finger.
 Weakness usually develops later.

20.  Conservative treatment involves splinting, NSAIDs and
changes in the cyclist’s grip on the handlebars. Surgical
exploration of Guyon’s canal may be required.

21. Sprain of The Ulnar Collateral Ligament
of The First MCP Joint
 Injury to the ulnar collateral ligament of the thumb is one of
the most common hand injuries seen in athletes.
 It is known colloquially as ‘skier’s thumb’ and usually results
from forced abduction and hyperextension of the MCP joint.
 The mechanism of injury is characteristic. The patient may
complain of weakness of thumb–index (tip) pinch grip (Fig.
19.26a).

24.  Examination reveals swelling and tenderness over the ulnar
aspect of the first MCP joint. Before testing stability,
radiography should be performed to exclude an avulsion
fracture.
 Stability of the ligament is tested by stressing the joint in a
radial direction. Pain occurs with both complete and partial
tears of the ulnar collateral ligament.

25.  If the injured thumb deviates 10–20° greater than the non-
injured side and there is no clear end feel, then complete
disruption of the ligament is likely.
 Deviation within 10–20° of the non-injured side indicates a
partial tear of the ulnar collateral ligament. This should be
treated with immobilization in a splint with the MCP joint in
slight flexion for six weeks.

26.  Further protective splinting is required during return to sport
and may be required for up to 12 months. The thumb may
also be taped with the index finger, which acts as a less secure
check rein to prevent hyperabduction.
 A complete tear of the ulnar collateral ligament (Stener
lesion) requires surgical repair because of interposition of the
extensor hood.

27.  A displaced avulsion fracture of the base of the proximal
phalanx also requires open reduction and internal fi xation
with Kirschner wires.
 Residual volar or lateral subluxation of the proximal phalanx
on the metacarpal head is also an indication for surgery, as is
a chronic injury to the ulnar collateral ligament with
functional instability, pain and weakness of thumb–index
pinch grip.

29.  After surgery, the thumb is placed in a thumb spica cast for
four to six weeks followed by protective splinting during
sporting activity for a further three months.

30. Mallet Finger
 Mallet finger is a flexion deformity
resulting from avulsion of the extensor
mechanism from the DIP joint.
 It commonly results from a ball striking
the extended fingertip, forcing the DIP
joint into flexion while the extensor
mechanism is actively contracting.
 This produces disruption or stretching of
the extensor mechanism over the DIP
joint.

31. Mechanism of Injury for Mallet Finger

32.  This is seen in baseball catchers, fielders, football
receivers, cricketers and basketball players.
 Examination reveals tenderness over the dorsal aspect of the
distal phalanx and an inability to actively extend the DIP joint
from its resting flexed position.
 If left untreated, a chronic mallet finger type deformity
develops. This flexion deformity is caused by the unopposed
action of the flexor digitorum profundus tendon.

33. Splints for Mallet Finger

34.  Radiography must be performed to exclude an avulsion
fracture of the distal phalanx or injury and subluxation to the
DIP joint.
 The avulsion fracture is considered significant if greater than
one-third of the joint surface is involved, in which case open
reduction and internal fixation is required.
 Any subluxation requires open reduction and internal
fixation. A fracture dislocation of the epiphyseal plate may
occur in children. This injury requires open or closed
reduction.

35.  Treatment of uncomplicated mallet finger involves splinting
the DIP joint in slight hyperextension for a period of up to
eight weeks, with regular monitoring.
 The splint is then worn for an additional six to eight weeks
while engaging in sporting activity and at night.
 Treatment is reinstituted at any sign of recurrence of a lag.
The splint may be made of metal or plastic and applied to
either the volar or dorsal surface (Fig. 19.28b); patients with
dorsal splints maintain pulp sensation. The finger should be
kept dry and examined regularly for skin slough and
maceration.

36.  When treating mallet finger, emphasize to the patient that the
joint must be kept in hyperextension at all times during the
eight weeks, even when the splint is removed for cleaning.
 If a patient is not prepared to do this, then the joint should not
be splinted.
 The consequences of not splinting are a chronic mallet finger
type flexion deformity with osteophyte formation and
degeneration of the DIP surface.

37. Jersey Finger
 A disruption of the flexor
digitorum profundus tendon, also
known as jersey finger, commonly
occurs when an athlete’s finger
catches on another player’s
clothing, usually while playing a
team sport such as football or
rugby.

38.  As the athlete pulls away, the finger is forcibly straightened
while the profundus flexor tendon continues to contract. The
ring finger is the weakest digit of the four fingers, accounting
for 75% of all reported cases.

39. Signs and symptoms
 An athlete with jersey finger will present with pain and swelling at the
volar aspect of the DIP joint, and will be unable to bend the tip of the
affected finger. Tenderness may also felt elsewhere along the finger or
hand, if the profundus tendon has become retracted.
 The digitorum profundus tendon can be evaluated by holding the
affected finger’s MCP and PIP joints in extension while the rest remain in
flexion flexion, and performing a concentric contraction of the affected
DIP joint. A positive sign for rupture to the digitorum profundus tendon
is that the DIP joint should not move.

40. Management
 Immediate management of jersey finger includes diagnostic imaging to
confirm suspicion of an avulsion fracture, as complications can quickly
arise in the case of tendon retractions.
 Athletes with confirmed or suspected jersey finger should also be
referred for medical consultation.
 Following medical intervention, rehabilitation should consist of passive
range of motion exercises followed by a return to normal activity only
after a period of several weeks, during which time movement is
restricted in order to promote wound repair.

41. Trigger Finger
 Trigger finger, is a common
name for finger tendon
disruption that causes the joints
to prevent from extending.
 The condition is more common
among athletes who play sports
involving repeated and forceful
gripping with their fingers and
thumbs such as Racket sports
(tennis, racket ball, squash)
and Golf.

42.  As the finger bends a nodule on the tendon passes out of the
synovial sheath coating the tendon and into the palm, but as
the finger straightens the nodule may not pass back into the
sheath, becoming lodged in its entrance.
 The athlete may attempt to forcibly straighten the finger but
this should be avoided in all circumstances.

43. Thank you