Sports and occupational injuries to the wrist and hand

Author(s): Brian Toedebusch, MD, Benjamin Washburn, MD and Kristopher Marin, DO

Originally published:09/20/2014

Last updated:07/03/2018

1. DISEASE/DISORDER:

Definition

The Occupational Safety and Health Administration (OSHA) defines occupational injury as any injury that results from a work accident or a single instantaneous exposure in the work environment. Occupational illness is defined as any abnormal condition or disorder caused by exposure to environmental factors associated with employment.

There is no universal definition of sports injury. In general, 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 and produces time loss from participation.1,2  It should be noted that that this definition is often sport- and athlete-specific. For a given defect in structure or function, there will not be equal loss of performance or participation amongst all sports or individual athletes.

Etiology

Sports and occupational injuries may be broadly classified as occurring either from trauma or repetitive use. The underlying etiologic mechanism of injury is often dynamic, complex, and multifactorial.

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

Epidemiology including risk factors and primary prevention

Wrist injuries account for 3.6% of work-related injuries with an incidence of 3.8/10,000 full time workers and an average of 14 days off work. Hand injuries account for 12.5%, with an incidence of 13.0/10,000 and an average of 5 days off work.4

Although hand amputations account for 0.5% of all hand and wrist injuries, finger amputations account for 95% of all work-related amputations. The use of two-handed activation switches and guards to push materials into machinery has helped to reduce the incidence of amputation.5

A majority of occupational illness is due to repeated trauma, and of these, musculoskeletal disorders of the hand and wrist are associated with longest absence from work and greatest lost productivity and wages, The onset and severity of work related musculoskeletal injuries of the hand and wrist is associated with forceful and repetitive hand use. These disorders are worsened by poor ergonomics or performing tasks in the presence of vibration or cold, and are also affected by psychosocial and non-workplace factors.6

Hand and wrist injuries are common among athletes, with a rate of 3 to 9% among all sports.7 Many injuries remain unrecognized and/or under-reported by athletes, making it difficult to ascertain the true incidence. Overuse injuries constitute between 25-50% of hand and wrist injuries. Traumatic injuries vary by sport and position and are more prevalent in full contact and stick and ball/puck sports.8,9

Athletes under age 16 show injury rates of 14.8% for upper extremity; 16% involving the hand and 9% the wrist.3   Eighty-five percent of sport hand fractures occur from football, basketball, and lacrosse, with football accounting for 50% of these.10

Risk factors for sports injury include extrinsic factors such as playing surface, weather, equipment and protective gear, and other players as well as intrinsic factors such as training load, prior injury, and individual anatomy, biomechanics, and neuromuscular coordination. Primary prevention of hand and wrist injury in sport may be accomplished by modification of these 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

Subtle injuries can be missed without detailed knowledge of anatomy.

Triangular Fibrocartilage Complex (TFCC) injury involves 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. 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).11 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 lodged between the adductor pollicis aponeurosis, preventing healing. Surgery is required to prevent permanent instability.12

Scapholunate dissociations are seen following a fall onto an outstretched, dorsally extended and ulnar deviated wrist, causing scapholunate ligament tear and dorsal shift. With more forceful trauma, there can be disassociation between the capitate and/or triquetrum.13,14

The proximal interphalangeal (PIP) joint is a hinge joint that is stabilized by both the bony anatomy and by collateral, dorsal, and volar ligaments. Injuries of the PIP joint range from mild sprains to complex fractures. PIP joint dislocations occur when there is traumatic disruption of the thick volar ligament and at least one of the collateral ligaments. The volar ligament is the primary palmar PIP joint stabilizer preventing hyperextension, and dorsal dislocations are the most common.15,16

Finger tendon injuries can involve disruption to the pulley system, resulting in instability/imbalance. Central slip of the extensor tendon over the PIP joint leads to boutonniere deformity, with lumbricals acting as flexors at the PIP and extending the DIP without opposing forces. Collateral ligament injury, usually at the PIP, can leads to PIP instability when the PIP is in 30 degrees of flexion and the metacarpal phalangeal joint (MCP) is flexed. Extensor tendon injury at the distal interphalangeal joint (DIP) from sudden passive flexion when the finger is extended causes mallet finger. Extensor tendon rupture and avulsion from the distal phalanx results in no active extension of the DIP in mallet finger. Finger flexor injury to the flexor digitorum profundus (jersey finger) leads to inability to flex the DIP joint. Volar plate injury commonly involves the PIP and collateral ligament following hyperextension of a finger joint.

Scaphoid fractures and dislocations are important to recognize due to the vascular supply of the scaphoid. Blood supply is received from the dorsal vessels of the radial artery and from the palmar and superficial palmar branches of the radial artery. Seventy to 80 percent of the bone (including the entire proximal pole) is supplied from branched dorsal vessels. The tubercle and distal end of the scaphoid is supplied by palmar vessels. Fracture to the middle and proximal portions are at risk for nonunion and osteonecrosis.

Distal radius fractures are typically caused by a fall on outstretched hand. There are several subtypes of distal radius fracture that can be broadly classified as intra-articular, partially articular, or completely articular.  The Colles fracture is one of the most common subtypes, and describes a dorsally angulated and displaced extra-articular distal radius fracture.17

Hook of hamate and pisiform fractures occur with either repetitive stress or sudden, forceful impact. They are usually seen in athletes who handle a racquet, bat, club, or stick, almost exclusively in the leading hand.17

Metacarpal fractures occur typically due to trauma with a fall on outstretched hand or direct blow from contact.17

Median nerve entrapment syndromes can occur from anatomical reduction of carpal tunnel space. Dorsal or volar lunate dislocation from high energy injury, and distal radial fractures can affect the median nerve.

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

Treatment is guided by severity. Milder injuries may be treated with protected activity, supportive splinting or casting, inflammation control, and gradual return to activity. Occasionally residual soft tissue stiffness occurs. Stretching and motion exercises to minimize mobility loss is important.

Sub-acute pain may present with movement loss around the injured structure, caused by soft tissue stiffness from scarring, ongoing inflammation, or weakened surrounding muscles. Therapy is recommended to prevent stiffness, strengthen weakened muscles and improve range of motion and alleviate patient fears of moving the injured structure. Exercises, ultrasound, electrical stimulation, massage or other modalities help recovery. Medication can be used at to control pain or inflammation. Gradually range of motion may return to normal.18,19

Unrecognized or untreated soft tissue injuries may result in instability leading to progressive cartilage degeneration and arthritis. Arthritic changes may result in pain, stiffness, and swelling; symptoms may be intermittent and vary in severity. Chronic mild or intermittent symptoms may be treated with splinting, activity modifications, and analgesics or anti-inflammatory medications. Significant symptom flare may be treated with steroid injection.18,19

Specific secondary or associated conditions and complications

Complications of sports injuries of the hand and wrist can result in significant including longer time away from sport and potentially long-term disability. Accurate and timely diagnosis is important in establishing the correct treatment. Iatrogenic injury must be avoided during both surgical and non-surgical treatments.

Distal radius fractures may provoke extensor pollicis longus tenosynovitis or rupture. 20

Undiagnosed scaphoid fractures may lead to scaphoid non-union advanced collapse, resulting in need for arthroplasty.21

Delayed diagnosis of hook of hamate fracture may lead to complications, including flexor tendon rupture.11 Ulnar neuropathy may be associated with fracture of the hamate or pisiform. Due to the anatomy of the ulnar nerve around Guyon’s canal, this may present as a pure sensory, pure motor, or mixed sensory and motor deficit.22

Intra-articular fractures of the metacarpals at the CMC joint can cause long-term pain or dysfunction, even with operative management. Instability of the thumb following intra-articular fracture may require CMC arthrodesis for the athlete to regain stability.23,24

Stener lesion of the thumb UCL requires surgical assessment.21

Untreated scapholunate interosseous injuries may develop a pattern of degenerative arthritis known as scapholunate advanced collapse.25

PIP ligament injuries and PIP dislocation often result in suboptimal outcomes due to a lack of recognition of the seriousness of injury. Overtreatment with prolonged immobilization can also cause long-term dysfunction.17

Improper management of tendon injuries may result in permanent deformity and dysfunction.21

2. ESSENTIALS OF ASSESSMENT

History

Mechanism of injury is the most important in diagnosis. History of high velocity or rotational stress injury versus pain after repetitive strain quickly narrows the diagnosis.  For example, a fall on an outstretched hand (FOOSH) can cause scaphoid, distal radius fractures or damage the TFCC. Also, rotational stress to the wrist may cause a tear in the TFCC.

Pain location (dorsal, volar, ulnar, or radial) and aggravating factors should be assessed. Pain after repeated movements with stiffness after rest suggests inflammatory conditions. Night pain is often found in carpal tunnel syndrome. Pain exacerbated immediately following activities or increasing insidiously with activity should be noted.19, 26, 27  Acute onset versus gradual onset of pain can be helpful in further delineating the differential diagnosis. For example gradual-onset pain should make you consider systemic conditions causing pain in hand or wrist. 28

Presence, location (diffuse or localized) and severity of swelling and a history of acute swelling following an injury, versus gradual swelling, help to identify repetitive conditions from residuals of acute trauma.

A history of previous injuries or surgeries may affect the symptoms of the injury.

Complaints of changes in sensation and color may aid in determining neurovascular involvement. Crepitus, degree of pain, bruising, and/or loss of function must be documented. Joint clicking may be associated with carpal instability, triangular fibrocartilage tears, or extensor carpi ulnaris subluxation.

Other important, yet often forgotten, aspects of the history are hand dominance, occupation and presence of recurrent wrist swelling 28

Physical examination

First observe for any swelling, ecchymosis, gross deformity or atrophy (such as thenar or hypothenar wasting). Also observe for how the patient is holding the wrist or hand as well as any scars or skin changes. Often testing both active and passive range of motion of the wrist and fingers can show functional deficits that will help you focus your exam.29  Identify movements and positions that cause pain or discomfort. Pain from stretching shortened contractile tissues occurs at the end range of passive motion. Active movements employ contractile tissues, while also moving inert tissues in the process.19 ,26  Palpation of the wrist and fingers is imperative especially when there is concern for scaphoid fracture, Dupuytren’s contracture, trigger finger or 1st carpometacarpal joint arthritis. Strength testing will help elucidate any focal weakness that could be caused by carpal tunnel syndrome or ulnar neuropathy. 29

Special tests

For Ligament, Capsule, Joint Instability:

Thumb Ulnar Collateral Ligament Stress Test or Finger 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 3rd metacarpal in relation to the 2nd and 4th. 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. 28, 30, 31

For Tendons and Muscles:

Finkelstein test for Dequervain’s tenosynovitis or Axial Grind Test for carpal metacarpal (CMC) arthritis evaluate for thumb pain. Elson test and Boye’s 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 phalanx attachment. 28, 30

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 test at the wrist or Phalen test identify possible carpal tunnel syndrome. Froment sign or Tinel test at the elbow and Ulnar Compression Test will aid in the evaluation of possible ulnar neuropathy.26, 27, 30, 32, 33   Spurling’s maneuver for assessing nerve root pain. Referred pain originating from the cervical spine or other proximal structures must be considered.

Other Special Tests:

Testing grip provides an objective measurement of the integrity and strength of intrinsic hand and forearm muscles. A grip dynamometer is accurate and reproducible. 34

Functional assessment

Emotional reactions, such as a lack of confidence, apprehension, and fear can play a role in an athlete`s ability to return to play. These reactions may become problematic, interfering with performance, and increasing the probability of re-injury. The physician should not only evaluate physical factors in determining return to play readiness, but also consider psychological well-being.35

Laboratory studies

In patients recalcitrant to treatment, workup for other conditions needs to be considered. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are nonspecific tests that are 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.18, 36

Imaging

For wrist injury, X-ray in neutral as well as PA with both radial and ulnar deviation, are recommended.

Scapholunate instability cannot be ruled out on initial plain radiographs because it may take months for scaphoid and lunate to separate significantly radiographically. 13, 14, 26

Ultrasound is a quick way to assess soft tissue abnormality such as tendon issues, synovial thickening, ganglions, and synovial cyst. 19, 37

MRI may be equally sensitive to and more specific than a bone scan for fracture, and provide information about soft tissue structures. 38

Supplemental assessment tools

The Patient-Rated Wrist and Hand Evaluation (PRWHE) is a 15-item self-reported questionnaire about pain and disability that can be used to evaluate outcome after hand injuries. 39, 40

A dynamometer evaluates grip strength and helps evaluate for possible disuse atrophy, arthritis, carpal tunnel syndrome, epicondylitis, and decreased motor function due to radiculopathy. 41

A Purdue pegboard dexterity test can be used to measure dexterity for activities that involve gross movements of the arms, wrists, hands, and fingers. 42

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. 26, 35

Professional Issues

Injury Cause Symptoms Treatment Return to Play
Jammed Finger Striking the end of the finger while fully extended Pain, swelling at the joint, difficulty bending and tenderness over the joint Ice, rest, and buddy taping to adjacent finger As tolerated with buddy tape
Finger Fracture Force of contact overwhelming strength of bone (i.e., against ball, ground, or helmet) Pain, tenderness over the bone, and deformity Ice, splint, and radiographic imaging After reduction, and wearing appropriate protection until healed
Mallet Finger Impact on tip of finger leading to rupture of extensor mechanism of Distal Interphalangeal (DIP) joint Inability to extend DIP joint Splinting in extension for 8 weeks As tolerated in splint which must be worn at all times
Finger Dislocation Force on finger overwhelming ligaments and causes joint displacement Pain and deformity, most common at Proximal Interphalangeal (PIP) joint Reduction, may require local anesthesia, and radiographic evaluation. In some cases, the injury may require surgical repair. After proper evaluation, use of buddy tape or splint as determined by physician
Jersey Finger Force of grasp with object (i.e., jersey) pulling away, causing avulsion of the flexor digitorum profundus Pain and inability to flex DIP joint Operative repair Post-operatively with mitten-type splint, but without any active gripping for 10-12 weeks
Scaphoid Fracture Fall on outstretched hand Pain from wrist motion, tenderness at “snuff box” Splinting/casting for non-displaced fracture, but displaced fractures will require operative repair Proper protection to be worn until healed
Wrist Ligament Tear Impaction or twisting of wrist Pain in the wrist with gripping and/or rotation Based on injured ligament and extent of tear Early evaluation and treatment can expedite return
Skier’s Thumb Forced radial deviation of the thumb (i.e., falling on hand while gripping ski pole) Pain and instability of thumb with grasping objects Partial tears can be done with splinting/casting for 4-6 weeks, but complete tears will require operative repair May occur with cast protection
Tendonitis Repetitive activity of one specific movement Tenderness over the tendon with finger or wrist motion Rest, ice, limitation of repetitive action, and NSAIDs As tolerated
Stress Fracture Repetitive activity that overcomes the strength of the bones and leads to small fractures Pain with activity, most commonly seen in the lower extremities (i.e., from running, jumping) Radiographic imaging and nutritional evaluation; treated with rest and possible splinting/casting Once fractures have fully healed following a time period of rest and cessation of offending activity

3. REHABILITATION MANAGEMENT AND TREATMENTS

Many hand and finger injuries require specific rehabilitation and appropriate protection on resumption of sport. Joints in this area do not respond well to immobilization and therefore full immobilization should be minimized.

Decision when to return to play is individualized and depends a variety of factures including health status of individual, participation risk, and external influences.  Risks of return to play will vary with each sport, and external influences include family, team, legal and financial considerations.

Stable phalangeal and metacarpal fractures treated non-operatively may have protected return to play before 4 weeks.43  Whereas, unprotected return is 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 to play is allowed.18  Similar guidelines are followed for surgically corrected fractures but risk vs benefit must be considered by the surgeon. Acceptable protective devices vary and are determined by each sport’s governing body.

Exceptions for return to play following fracture include scaphoid fractures.  Return to play can occur 4 weeks after injury without increased risk of nonunion.44  Typically, between 8 to 12 weeks of immobilization is required before attempting unprotected return to play with nonoperative scaphoid fractures.  There is a wide variation of 2 to 12 weeks for return to play after surgical fixation of scaphoid fractures.45  This depends on risks related to each individual sport.

Ligamentous injuries have a similar return to play timeline as fractures.  UCL, scapholunate ligament, and mallet injuries may return to sport immediately with protection for 4 to 6 weeks.  Jersey fingers are treated surgically and require significant healing time of up to 4 months before return to contact sports.

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 edema 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 in addition to heat, stretching, and electrotherapeutic modalities are employed.18, 21, 46

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. 47, 48

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. 47

Emerging/unique Interventions

The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is a 30-item questionnaire that looks at the ability of a patient to perform certain upper extremity activities, allowing patients to rate difficulty and interference with daily life on a 5-point Likert scale.

The QuickDASH is an abbreviated version of the original DASH outcome measure and contains only 11 items. 49

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

Work-related prognosis often is not based on pathology but on other factors.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge 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. 50

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. 51

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

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 (SCT) 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. 50

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Original Version of the Topic

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

Author Disclosure

Brian Toedebusch, MD
Nothing to Disclose

Benjamin Washburn, MD
Nothing to Disclose

Kristopher Marin, DO
Nothing to Disclose

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