Hand Fractures
The biology and biomechanics of fracture and soft tissue healing are no different in the athlete. (Athletes do not heal any quicker because they seek the advice and treatment of a ‘sports doctor’). In general, fracture union in the upper limb occurs in about six weeks (in the adult, and about half this in a child, fracture consolidation takes twice as long). What is different is the attitude to injury. The demands of competition (especially at the elite level) may result in the athlete returning to training and competition too early, (so running the risk of further injury). Financial concerns may bear on this decision to return too early. The athlete will make the ultimate decision. It is the role of the sports medical team to advise what the risks are and how they may be minimized.
The clinical signs of fracture are important (pain, swelling, deformity and loss of function). Diagnosis is confirmed by x-ray. Early movement is the key for a swift return to full function (so the fracture must be of a stable pattern, or be rendered stable by splinting or surgical fixation). Outcomes deteriorate if active range of motion is delayed beyond three weeks.
A fracture is reduced under appropriate anaesthetic by closed or open means and rendered stable. (Confirm by x-ray and repeat one week post injury and later as necessary).
If the fracture cannot be made stable by splinting, surgical fixation is necessary.
In general, displaced fractures involving joint surfaces will require reduction and surgical fixation. Note the called ‘clip’ or avulsion’ fractures, the bony equivalent of a tendon or ligament rupture, will usually require surgical repair.
Distal phalanx fractures
These result from a direct blow, often with the finger being ‘crushed’ between the bat and ball. The hallmark is a subungual haematoma. The nail plate maybe lifted out of the nail fold, suggesting that the fracture was, displaced and that a significant injury to the nail bed has occurred. A painful subungal haematoma under pressure may be relieved by drilling the nail plate with a sterile 19 or 19G needle, x-rays should then be taken as such (surgical cleaning of the fracture site, with accurate repair of the nail bed, magnification, and fracture fixation where appropriate give the best result; some surgeons feel a haematoma involving more than 25% of the nail plate is an indication for its removal to allow nail bed repair).
Bony mallet
Catching a finger on the ground ball, or opponent may result in avulsion fractures of the extensor tendon (bony mallet) or less commonly avulsion of the flexor tendon (this latter one is more serious and usually less recognized). Almost always require surgical treatment. Note: occasionally the tendon will pull away from the bone chip and be found in the palm.
The bony mallet (if no more that 30% of the joint surface is involved and no joint subluxation) is treated in a hyperextension splint (maintain for at least 6 - 8 weeks,) Instruct patient in skin care and changing splints.
Middle and proximal phalanges, metacarpals
Transverse fractures of the middle phalanx (distal to the insertion of flexor superficialis) result in extension of the distal fragment, those proximal to its insertion are flexed. Transverse fractures of the proximal phalanx usually result in the interossei flexing the proximal fragment. Transverse fractures of metacarpals tend to have the distal fragment flexed by the long flexors. Reduction and neutralization of the deforming forces may be possible using buddy and extension block splinting.
However short oblique, and spiral fractures of the phalanges and metacarpals may shorten/rotate and so require surgical fixation. Rotation is assessed with the fingers in flexion. The fingers should not cross and the tips should individually point to the tubercle of the scaphoid.
‘Boxer’s fracture’
Boxers fracture (a fracture of the neck of the small finger metacarpal and a result of bar-room brawling) is usually best treated in a resting splint with the hand in the safe position until pain and swelling subside (7-10 days) followed by active mobilization. Such fractures generally do not require fixation despite what appears to be marked x-ray deformity.
Dislocations and collateral ligament injuries
Dorsal dislocation of the PIPJ is common. Closed reduction (direct traction) is possible immediately, on the field, or later, under digital block. Following reduction joint then gauge stability. (The volar plate is avulsed from the middle phalanx, possibly with a bony fragment). Splinting straight for seven to ten days then ‘buddy taping’ (or dorsal block splint) for three weeks is recommended and during strenuous activity (for a further six to eight weeks).
If a dislocation will not reduce easily because of soft tissue interposition or entrapment of the dislocated phalangeal metacarpal head. Then open reduction required.
For partial collateral ligament ruptures, start immediate motion, protect with buddy taping for six to eight weeks (depending on residual tenderness).
Complete ruptures (controversial) either splint or surgically repair.
Metacarpophalangeal joint dislocations (rare) require open reduction as are thumb, collateral ligament injuries.
Skier’s thumb (Game keeper’s thumb)
This common injury occurs from sudden forced radial deviation (with/without hyperextension) of the thumb phalanx on the metacarpal with disruption, partial or complete, of the UCL/MCP (ulnar collateral ligament of the MCP) of the thumb; often seen in skiers (the ski stock handle door not protect from it) and football. Present with ulnar sided pain, swelling and instability. Xrays may show a bony avulsion. Graded as Type I (sprain, splint for 6 weeks in S-Thumb [Johnson and Johnson] and then when return to vigorous sports), Type II (partial tear, same splint) and III (complete tear, >30° abduction possible, needs surgical repair and protect postop. in S-Thumb for 6 weeks and in vigorous sport). Athletes seem reluctant to seek treatment for such ‘minor’ injuries. Rupture of UCL/MCP (Grade III) thumb often requires open exploration and repair as it is almost impossible to tell whether or not the avulsed ligament has come to lie superficial to the adductor aponeurosis (Stener lesion). However most surgeons will not explore where stable ( <30° abduction) injuries. (Exploration of older Injuries similarly shows the ligament folded back on itself beneath the adductor aponeurosis).
Mallet/baseball finger
Closed rupture of the distal extensor tendon results in the ‘mallet’, or ‘baseball’ finger. (Provided no joint subluxation, or fracture one third or less of the articular surface) splint the DIP joint in slight hyperextension for six to eight weeks (even if present after 7-19 days). In supple fingers if a swan neck deformity develops at the PIPJ include this joint in the splint for three to four weeks (in slight flexion). Commercial splints are available.
Rupture middle slip
Rupture of the middle slip of the extensor mechanism over the PIPJ is commonly missed and results in a boutonniere deformity ( difficult to correct).
Suspect in a ‘jammed’ PIPJ, when the joint is swollen, and tender over its dorsum. Specific tests; inability to actively extend the last 10-15 degrees at the PIPJ and the Elson test (flex the PIPJ to a right angle, ‘over the edge of a table’ ask the patient to extend the PIPJ, a central slip rupture will display no movement of the middle phalanx and the distal phalanx will tend to extend). Lack of full extension, although full passive extension of the PIPJ by tenodesis when the wrist and metacarpophalangeal joints are fully passively flexed, indicates rupture. Later signs are fixed flexion of the PIPJ with decreased passive DIPJ flexion with PIPJ fully extended.
Splinting is the most effective treatment. First correct PIPJ flexion and then DIP flexion (may take a minimum of eight weeks or longer to achieve the desired results).
Ruptures of the extensor mechanism at the level of the MPJ may occur (a ruptured sagittal band, on the radial side of the long finger). There is localized pain, swelling and an inability to actively extend the MPJ. Note the patient can maintain full extension of the joint if it is passively extended.
Triggering (extensor tendon subluxing between the metacarpal heads) of the finger at MPJ rather than PIPJ level may later present. If seen early these injuries respond to splinting the MPJ in extension for three weeks. Other joints are left free. If seen late the tear is best repaired.
Rarely may see at MPJ level a longitudinal split in the extensor tendon and rupture of the dorsal MPJ capsule (result of a direct blow, as in boxing martial arts). Surgical repair is indicated.
Flexor tendon avulsion (‘Jersey’ finger)
Flexor tendon avulsion is not common and not well recognized (from an attempt to grab the jersey or equipment of an opposing player (‘jersey’ finger). Not able to flex DIPJ bruising is present and a tender lump in the palm. The ring finger commonly affected. Players of ‘Oztag’, a variation of touch football in which a ‘tackle’ is effected by ripping a velcro fastened tag from the shorts of an opponent, incur this injury.
Early repair is best. Later repair is difficult because of swelling and collapse of the flexor sheath; If there is no pain and little functional deficit leave; Hyperextension of the DIPJ with or without ‘weakness’ in the finger may be treated by DIPJ fusion; Two stage tendon reconstruction is difficult.