Sports and Occupational Injuries to the Wrist and Hand

Disease/Disorder

Definition

The Occupational Safety and Health Administration (OSHA) defines occupational injury as abnormal condition or disorder resulting from a non-instantaneous event or exposure in the work environment.¹ There is no universal definition of sports injury but most studies examining sports injury consider an injury to be a loss or abnormality of structure or function sustained during an athletic activity that alters athletic performance.²

Etiology

In sports activities, acute hand and wrist injuries are often the result of falls, blunt force (e.g., helmet, ball, stick, or other player), rotational forces, and flexion/extension forces (e.g., grasping another player).³

Epidemiology including risk factors and primary prevention

Wrist injuries account for 5.5% of work-related injuries with an incidence of 2.54/10,000 full time workers and an average of 16.75 days off work. Hand injuries account for 2.76%, with an incidence of 1.18/10,000 and an average of 16.08 days off work.⁴

A majority of occupational illnesses are due to repeated trauma and injuries remain unrecognized and/or under-reported by athletes. Overuse injuries constitute between 25-50% of these hand and wrist injuries the remaining being traumatic injuries which are most in full contact sports.⁵ 

Hand and wrist injuries are common among athletes and many of these injuries remain unrecognized and/or under-reported by athletes. Overuse injuries constitute between 25-50% of these hand and wrist injuries; the remaining are traumatic injuries which are mostly sustained in full contact sports.⁶

Athletes younger than 16 have rates of 14.8% for upper extremity injuries; 16% involving the hand and 9% the wrist.   Eighty-five percent of sport-related hand fractures occur from football, basketball, and lacrosse, with football accounting for 40% of these.³

Primary prevention of hand and wrist injury in sport may be accomplished by modification of risk factors. For example, there is potential for reduction in injury incidence through advances in equipment technology, rule changes, and improved technique and training protocols.

Patho-anatomy/physiology

Triangular Fibrocartilage Complex (TFCC) injuries involve tears of the fibrocartilage articular disc and tissue that connects the disc to the triquetrum and other carpals. The TFCC acts as the primary stabilizer to the distal radioulnar joint and cushions articulations between the ulnar head and the lunate and triquetrum.

The ulnar collateral ligament (UCL) of the thumb is an important stabilizer for the metacarpophalangeal (MCP) joint. The term “Gamekeeper’s Thumb” refers to a chronic injury of the UCL usually acquired through repeated low-grade hyperabduction. The term “Skier’s Thumb” refers to an acute tear or sprain of the UCL that often occurs with abrupt, forceful thumb stress in extension and/or abduction (i.e., skiing injuries, football, judo). A Stener lesion occurs when the UCL ruptures from the base of the proximal phalanx and retracts proximally. The proximal end of the UCL becomes entrapped by the adductor pollicis aponeurosis, preventing healing. Stener lesions are treated surgically to prevent permanent instability and associated sequelae.⁶

Finger tendon injuries can cause instability and deformities. A central slip injury to the extensor tendon at the proximal interphalangeal (PIP) joint results in a boutonniere deformity, causing lumbricals to function abnormally. Collateral ligament injury at the PIP causes instability in flexion and MCP flexion. Extensor tendon injury at the dorsal interphalangeal (DIP) joint leads to mallet finger, where the DIP cannot actively extend. Flexor digitorum profundus injury and avulsion (jersey finger) results in an inability to actively flex the DIP and requires an urgent surgery.

Scaphoid fractures are the most common carpal bone injuries, particularly in football players and increasingly in female athletes. These fractures often result from wrist hyperextension with a pronated, radially deviated hand. Symptoms range from severe wrist pain to mild swelling and limited motion. Scaphoid fractures are characterized by radial-sided wrist pain, tenderness in the anatomical snuff box, and pain with axial loading or a pincer grasp. Standard X-rays may miss subtle fractures. Advanced imaging such as CT scan, MRI, or bone scintigraphy may be necessary for accurate diagnosis.

Treatment of scaphoid fractures depends on the location and displacement. Distal fractures can often be treated nonsurgically due to retrograde blood supply. Proximal fractures are at increased risk for avascular necrosis and typically require surgical intervention. Fractures with >1mm displacement also have a higher risk of nonunion and typically require surgery. The most common surgical treatment is headless compression screw fixation, which supports a quicker return to sports. Nondisplaced fractures may be treated with a cast or temporarily immobilized to allow for return to play, depending on the athlete’s sport and specific needs.

Hook of the hamate fractures can occur from direct blows, such as from a golf club hitting the ground or a baseball bat during a swing. Repeated lesser impacts may also lead to stress fractures. Symptoms include hypothenar pain with palpation or forceful grip, and as the hook forms part of Guyon’s canal, ulnar nerve issues (like dysesthesias or weak grip) may also occur. A positive pull test involves pain with flexing the ring and small fingers while the wrist is ulnar deviated. Diagnosis requires a carpal tunnel radiograph along with standard PA and lateral views, and if these are negative, a CT scan may be used to better identify the fracture.

Distal radius fractures are typically caused by a fall on outstretched hand. The Colles fracture is one of the most common subtypes and describes a dorsally angulated and displaced extra-articular distal radius fracture. Metacarpal fractures also occur frequently from a fall on outstretched hand or direct blow from contact.⁶

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Disease progression of soft tissue injuries follows a trajectory from mild symptoms to potentially chronic issues if untreated. Initially, milder injuries are managed with protected activity, splinting, inflammation control, and a gradual return to activity. Some stiffness may remain, requiring stretching and motion exercises to prevent further mobility loss.

In the sub-acute phase, pain may be present with limited movement due to soft tissue stiffness, scarring, inflammation, or weakened muscles. Therapy is essential to prevent stiffness, strengthen muscles, improve range of motion, and reduce movement fears. Modalities like exercises, ultrasound, electrical stimulation, and massage aid recovery. Medications such as NSAIDs are used for pain and inflammation control. Gradual recovery of range of motion is expected.

If untreated, soft tissue injuries may lead to instability and cartilage degeneration. This can ultimately cause pain, stiffness, and swelling that can vary in severity. Chronic mild or intermittent symptoms are managed with splinting or bracing, activity modifications, and medications. Severe flare-ups may be treated with steroid injections.^6,7

Specific secondary or associated conditions and complications

Complications from hand and wrist sports injuries can lead to extended time away from sports and long-term disability, making accurate and timely diagnosis crucial. Iatrogenic injuries must be avoided during both surgical and non-surgical treatments.

• Distal radius fractures can cause extensor pollicis longus tenosynovitis or rupture.⁸
• Undiagnosed scaphoid fractures may lead to non-union and advanced collapse, potentially requiring arthroplasty.⁹
• Delayed diagnosis of hook of hamate fractures can result in complications like flexor tendon rupture and ulnar neuropathy, affecting sensory or motor function due to the anatomy of the ulnar nerve.¹⁰
• Intra-articular fractures at the CMC joint can lead to long-term pain or dysfunction, requiring CMC arthrodesis for thumb instability.^11,12
• Stener lesions of the thumb UCL need surgical intervention.⁹
• Untreated scapholunate interosseous injuries can lead to scapholunate advanced collapse, causing degenerative arthritis.¹³
• PIP ligament injuries and dislocations often result in poor outcomes if not properly recognized, and overtreatment with excessive immobilization can cause long-term dysfunction.
• Improper tendon injury management can lead to permanent deformity and dysfunction.⁶

Essentials of Assessment

History

The mechanism of injury is key to diagnosis, with a history of high-velocity or rotational stress injuries helping to narrow down the cause. For example, a fall on an outstretched hand (FOOSH) may cause scaphoid or distal radius fractures or damage the TFCC. Rotational stress could result in a TFCC tear.

Pain location (dorsal, volar, ulnar, or radial) and factors that aggravate it should be evaluated. Pain after repetitive movements with stiffness after rest suggests inflammation, while night pain may indicate carpal tunnel syndrome. Acute versus gradual onset of pain is also important for diagnosis, with gradual pain pointing to potential systemic conditions.

Swelling and its characteristics such as location, chronicity, and severity help distinguish between acute trauma and repetitive conditions. Previous injuries or surgeries can impact current symptoms. Changes in sensation and color may indicate neurovascular involvement. Other symptoms like crepitus, bruising, or joint clicking can be associated with specific conditions like carpal instability or TFCC tears.¹⁴

Important but often overlooked details include hand dominance, occupation, and recurrent wrist swelling.

Physical examination

Start by observing for swelling, ecchymosis, deformity, or atrophy (like thenar or hypothenar wasting). Note how the patient holds their wrist or hand, as well as any scars or skin changes. Test both active and passive range of motion to identify functional deficits, focusing on movements that cause pain or discomfort. Pain from stretching shortened tissues occurs at the end of passive motion. While active movements engage both contractile and inert tissues. Palpation is crucial, especially for suspected scaphoid fractures, Dupuytren’s contracture, trigger finger, or 1st carpometacarpal arthritis. Strength testing helps identify focal weakness, which may be linked to median or ulnar neuropathy.¹⁴

Special Tests

For Ligament, Capsule, Joint Instability

Finger/thumb collateral ligament stress test assesses digit ligamentous stability. Murphy’s sign is indicative of a lunate dislocation demonstrated by the patient making a fist and observing the distal end of the 3^rd metacarpal level with the adjacent 2^nd and 4^th. Supination lift test can help the examiner determine if there is TFCC pathology present. Axial load test identifies possible metacarpophalangeal joint arthrosis and possible fracture of the metacarpals or adjacent bones. Watson test and/or a Shuck test identify scapholunate dissociation.¹⁴

For Tendons and Muscles

Finkelstein’s test for De Quervain’s tenosynovitis or axial grind test for carpal metacarpal (CMC) arthritis evaluate for thumb pain. Elson’s test and Boyes test identify extensor digitorum central slip injuries. Sweater finger sign or flexor digitorum profundus test identify possible rupture of the tendon or avulsion of the tendon from the distal attachment.¹⁴

For Neurologic Dysfunction

Finger opposition to the thumb and opening and closing the hand requires normal joint function, normal functioning flexor and extensor tendons, and intact median and ulnar nerves. Carpal Compression, Tinel’s test at the wrist or Phalen’s test identify possible carpal tunnel syndrome. Froment’s sign or Tinel’s test at the elbow and Ulnar compression Test will aid in the evaluation of possible ulnar neuropathy.¹⁵Spurling’s maneuver assesses nerve root pain. Referred pain originating from the shoulder, cervical spine, or other proximal structures must be considered as well.

Functional assessment

A variety of outcome measures are used to assess patients with hand and wrist injuries, with only one systematic review of instruments being highly rated. The quality of clinical metrics improves using checklists like COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN). When designing a study, it’s essential to choose the appropriate instrument based on the research question. Region-specific measures, such as the Disabilities of the Arm, Shoulder and Hand (DASH), QuickDASH, and Michigan Hand Outcomes Questionnaire (MHQ), have been extensively studied. The DASH, a 30-item questionnaire, is the most widely tested for wrist and hand injuries, while the MHQ offers good value for hand injury patients. Although the Carpal Tunnel Syndrome Questionnaire (CTQ) is the most sensitive to clinical changes, the DASH and MHQ are responsive in outcome studies of carpal tunnel syndrome. The Patient-Rated Wrist and Hand Evaluation (PRWHE) also demonstrates good construct validity and responsiveness, slightly outperforming the DASH for assessing wrist injuries.¹⁶

Laboratory studies

If initial/conservative management fails, workup for other conditions needs to be considered. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are tests associated with inflammatory causes of pain. These labs are non-specific but may indicate inflammatory rheumatic disease, especially if only a modest degree of inflammation is present. Rheumatoid factors are often seen elevated in patients with Rheumatoid Arthritis but can also be seen in other disease processes such as Sjögren’s syndrome and Systemic Lupus Erythematosus.⁷

Imaging

For wrist injuries, X-rays in neutral, lateral, and PA views with both radial and ulnar deviation are recommended. Scapholunate instability may not be visible on initial X-rays as it can take months for the scaphoid and lunate to separate enough to be detected. Ultrasound is useful for quickly assessing soft tissue abnormalities, such as tendon issues, synovial thickening, ganglions, and cysts. MRI is more specific than a bone scan for fractures and provides detailed information about soft tissue structures.⁶

Social role and social support system

Poor coping can preclude recovery. Patients can develop new psychosocial needs that are not adequately addressed. Social support patterns can change with increased reliance on coaches, trainers and medical team members. Loss of confidence and emotional stressors may require different strategies (i.e., goal setting and mental imagery) to provide positive psychological support.¹⁴

Professional issues

A multi-disciplinary approach to treatment of hand & wrist injuries is often needed. The treatment team can include non-operative musculoskeletal specialists, Physical Therapists, Occupational Therapists, and in refractory cases, Orthopedic Surgeons. In athletes, athletic trainers and coaching staff can be valuable to the treatment team.  Working with the high-level athlete can present a unique challenge given organizational and sometimes financial incentive to return to play too soon. The priority should always be the well-being and safety of the athlete.

Rehabilitation Management and Treatments

Rehabilitation for hand and finger injuries requires specific care and protection upon returning to sport, as joints in this area do not respond well to immobilization, and it should be minimized. The decision to return to play is individualized, considering factors like the athlete’s health, sport risk, and external influences such as family, team, legal, and financial considerations.

Stable phalangeal and metacarpal fractures treated non-operatively may have protected return to play before 4 weeks, with unprotected return typically between 4 to 8 weeks depending on risks of the sport.  Imaging should be obtained to ensure adequate healing has occurred before unprotected return^, The same guidelines apply to surgically corrected fractures, but risk and benefits must be evaluated by the surgeon. Protective devices depend on the sport’s governing body.

Scaphoid fractures are an exception, requiring 8 to 12 weeks of immobilization for non-operative fractures before attempting an unprotected return. After surgical fixation, the return-to-play timeline varies from 2 to 12 weeks, depending on the sport’s risk factors.

Mallet finger injuries and ligamentous injuries, such as the UCL and scapholunate ligament, typically allow a return to sport with protection after 4 to 6 weeks. Jersey fingers require surgical treatment and up to 4 months of healing before returning to contact sports.¹⁷

At different disease stages

Functional rehabilitation requires mobility, stability, sensitivity, and freedom from pain. Coordinated management can effectively address these needs during different phases of recovery. During the inflammatory phase, edema and pain reduction are essential. Control of edema can be achieved through splinting, compression, ice, elevation, and electrotherapeutic modalities. In the regenerative phase, there is a proliferation of scar tissue. Therapists can use supportive splints and active exercises to maintain range of motion. In the remodeling phase, dynamic and serial splints as well as active assist exercises can be beneficial. Additionally, heat, stretching, and electrotherapeutic modalities can be helpful.⁹

Coordination of care

Patients with occupational and sports injuries often require input from various disciplines (medical, therapy, training and psychological intervention) to achieve optimal outcomes. Communication and sharing of information among all participants concerned with a patient’s care achieve safer and more effective care.¹⁸

Patient & family education

The patient and the social support network (family, friends, significant others) should play a part in the multi-disciplinary approach to helping achieve the goals and needs of the patient.¹⁸

Emerging/unique interventions

In recent years there has been increasing frequency of use of minimally invasive procedures for the treatment of carpal tunnel syndrome. These include hydro-dissection and percutaneous release. More research into these techniques is required as there is evidence for and against their use in the treatment of hand/wrist conditions.²⁰

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Return to work/play is often not based solely on pathology, but other factors including but not limited to job requirements, socioeconomic stability and patient preference. With regards to most diagnoses, non-operative management including taping/bracing, physical therapy/occupational therapy, and rest should be pursued initially.  In individuals who are refractory to initial treatment, consider surgical consultation.

Cutting Edge/Emerging and Unique Concepts and Practice

The use of Orthobiologics is an emerging paradigm for the treatment of wrist and hand conditions. Most orthobiologics being used for these conditions are platelet rich plasma (PRP), stem-cells and autologous blood. These agents are being injected into the hand and wrist for conditions including tendinopathies, arthritis, chondropathies as well as instability injuries.¹⁹

Recently the injection of steroids and anesthetic agents into and around cartilaginous structures has been called into question. There is some evidence to suggest that these agents are causing cartilage and tendon damage especially with repeated injections. Their use is being called into question especially with the rise of orthobiologics.²² With regards to large joints, there is evidence for and against the use of repeated corticosteroid injection and emerging but not conclusive evidence for the use of biologics in DJD.

Gaps in the Evidence-Based Knowledge

Although many athletes use taping and braces, there is little medical evidence regarding efficacy in injury prevention. The use of orthobiologics such as PRP and stem cell therapy to treat injuries of the hand and wrist shows promise. In small numbers of patients, PRP has reportedly produced improved outcomes for distal radius fractures and trapeziometacarpal osteoarthritis.  There are many potential uses for orthobiologics in treating hand and wrist injuries but more robust clinical trials are required to examine safety and efficacy.²¹

References

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3. Rettig, A. Epidemiology of hand and wrist injuries in sports. Clinics in Sports Medicine. 1998;17:401-406.
4. Nonfatal Occupational Injuries and Illnesses Requiring Days Away from Work. Washington, DC: Bureau of Labor Statistics, U.S. Department of Labor. https://www.bls.gov/news.release/osh2.htm Accessed April 25, 2018.
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6. Avery, D.M., Rodner, C.M. & Edgar, C.M. Sports-related wrist and hand injuries: a review. J Orthop Surg Res 11, 99 (2016). https://doi.org/10.1186/s13018-016-0432-8
7. Nagle D. Evaluation of chronic wrist pain. Journal of the American Acadademy of Orthopedic Surgery. 2000;8:45.
8. Roth K.M., Blazar P.E., Earp B.E., et al: Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures. Journal of Hand Surgery. 2012:37: 942-947
9. Jaworski C, Krause M, Brown J. Rehabilitation of the wrist and hand following sports injury. Clinical Sports Med.2010;29:61-80.
10. Matsunaga D., Uchiyama S., Nakagawa H., et al: Lower ulnar nerve palsy related to fracture of the pisiform bone in patients with multiple injuries. Journal of Trauma and Acute Care Surgery. 2002:53: 364-368
11. Fufa D.T., and Goldfarb C.A.: Fractures of the thumb and finger metacarpals in athletes. Hand Clinics, 2012:28: 379-388
12. Niechajev I.: Dislocated intra-articular fracture of the base of the fifth metacarpal: a clinical study of 23 patients. Plastic and Reconstructive Surgery. 1985:75: 406-410
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18. Deal, D. N., & Chhabra, A. B. (2013). Soft Tissue Injuries of the Wrist and Hand. In ACSM’S Sports Medicine: A Comprehensive Review (pp. 370–371). essay, Lippencott Williams & Wilkins.
19. Melone C, Polatsch D, Beldner S. Disabling hand injuries in boxing: boxer’s knuckle and traumatic carpal boss. Clinical Sports Medicine.2009;28:609-621.Steiner MM, Calandruccio JH. Biologic Approaches to Problems of the Hand and Wrist. Orthopedic Clinics of North America. 2017;48(3):343-349. doi:10.1016/j.ocl.2017.03.010.
20. Wang JC, Hsu PC, Wang KA, Chang KV. Ultrasound-Guided Triamcinolone Acetonide Hydrodissection for Carpal Tunnel Syndrome: A Randomized Controlled Trial. Front Med (Lausanne). 2021 Sep 13;8:742724. doi: 10.3389/fmed.2021.742724. PMID: 34589506; PMCID: PMC8475784
21. McAlindon TE, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial . JAMA. 2017 May 16;317(19):1967-1975.
22. Latourte, A. (2022, March 14). Do corticosteroids injections increase the risk of knee osteoarthritis progression over 5 years? Wiley Online Library. Retrieved April 4, 2022, from https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.42118

Original Version of the Topic

Kevin Komes, MD, John Alm, DO, Megan Clark, MD. Sports and occupational injuries to the wrist and hand. 9/20/2014

Previous Revision(s) of the Topic

Brian Toedebusch, MD, Benjamin Washburn, MD, Kristopher Marin, DO. Sports and occupational injuries to the wrist and hand. 7/3/2018

Brian Toedebusch, MD, Benjamin Washburn, MD, Duncan Bralts, DO, David Tramutolo, DO. Sports and Occupational Injuries to the Wrist and Hand. 6/1/2022

Author Disclosure

Brian Toedebusch, MD
Nothing to Disclose

Bryan Wacker, DO
Nothing to Disclose