- December 20, 2019
I chose this topic just to go over a couple common sports type of injuries that one may encounter on a day to day practice. Even if you don’t only do hand, these are a couple injuries that I chose. So hopefully if you haven’t seen these If you do it will make it hopefully straightforward for you guys. So TFCC injuries, you learned about how to examine TFCC. It’s a Complex structure and we could talk about for hours about the anatomy and what it does. If an MRI report comes back abnormal what does it mean. Just like you’ve learned about neck and back problem just because an MRI report is abnormal doesn’t mean that the patient needs a fix for it. So again you have to correlate clinical exam history and other findings to confirm what’s going on. But here’s kind of a structure of what it is.
It’s pretty interesting but again we have degenerative type problems. We have acute injury type problems. So if someone says on our side at risk pain and they never had an injury then their tear or whatever then I don’t know why radiologists say the word tear in all honesty because wear and tear the word tear is in that.
I didn’t make that up.
That was Howard Routman. TFCC Evaluation. So owner said at risk pain is what they’ll come in complaining of and if they had an acute injury some sort of fall or twisting moment on their wrist and they had pain with supination pronation. That’s kind of what ties me into that. You can have pain on the owner side or your wrist to your tendon to your phobia to where TFCC is or you can just have pain over the snuff box or pain somewhere completely different. So more times than not I see a patient with abnormal MRI finding and they don’t even have owners set at risk pain or maybe they’ve been having an injury. So you kind of have to tie everything together you can have arthritis, you can have ECU tendon problems, or part of the most common diagnosis for owner side of risk pain.
So this is what it looks like on MRI. This is what it looks like when you operate on them and it’s not common or doing surgery to fix these unless it’s in an acute traumatic or setting where the distal rate on owner joint is actually unstable which again all those are fairly rare and these are different classifications of where it can tear and how it can tear whether it’s degenerative or something acute where you can consider doing a repair so similar to the meniscus in the knee.
If you have a central tear that’s not something you’re going to suture or bring back. You’re just going to debride because of a blood supply issue. If the tear is peripheral then you’re able to do a repair and bring it back down to the insertion at the phobia.
So moving on to fingers. For those you up north you might call it a stoved finger. For everybody else in the world I think they say jammed finger. I jam my finger so. If you play baseball for the Rays and don’t know how to slide back into first you can dislocate your finger.
The best part of the talk, this video is for them.
Yeah. So Phams still plays left field and I don’t know it can’t slide back and it wasn’t even close but he dislocated his finger and then it was last year. And usually you see the trainer going out and trying to pop it back in on the field which in basketball I think they routinely do buddy tape and keep playing. But in baseball they’re not as tough. They Sit out for a couple of weeks.
So radiograph evaluation or football too, football though just do an amputation on the sidelines and then go back in.
So you’re going to you’re going to look at the fingers and look at the Cascade. You’re going to you know you guys might do a good exam you’re going to check out where they’re actually sore.
So just go somethings black and blue doesn’t mean it’s sore. And PIP joints from an evaluation standpoint there’s a lot of stuff that will be seen on an urgent care setting or primary care setting. These are things that we like to see. Sooner than later in a hand surgery practice because if it’s stable we’ll get him and the therapy will allow him to move it. We don’t know immobilized finger joints especially the PIP. DIP or mallet finger and such but PIP like an elbow you want to make sure you get moving so you don’t have stiffness so you want to get the good X-rays. Yeah in here this shows an X-ray from an unstable fracture subluxation. So these are things that you want to look at when you’re evaluating your X-rays. A lot of times you order X-rays of the hand and it’ll just show all the fingers and you can’t see the dedicated lateral of the fingers. So definitely you need that for a PIP injury whether it’s a dislocation or just a sprain. So clinical evaluation again I think you guys get that after last talk. You want to make sure there’s a concentric range of motion that’s stable.
So active stability. If someone has pain you can always numb them up and test until Elson’s Test test the central slip. That’s more for a volar dislocation of the PIP joint. So dorsal PIP dislocation This is most common this is what you’ll primarily see. Again a simple dislocation is not associated with the fracture. So this is something you should be able to reduce and Buddy tape and start active motion for some reason associated with the fracture. There are other treatment options. But again, even in this patient you reduce it if they’re seen within a couple of days or a week. We’ll confirm that and allow me to get back to their motion and rehab so they don’t get stiff. So these are the different types of injuries. You could just have a hyper extension, you can have a dislocation, or a fracture dislocation. So if you kind of break him down in either of these two, type one and type two, they’re going to be stable. They can do active range of motion even if there’s a small little volar plate fracture that doesn’t matter like this. You see this x ray here OK. It’s very small.
If the zoom in on your pack system this doesn’t matter.
This is not anything that needs surgery. They can do active range of motion. They don’t need to be splint PIP injuries or finger injuries.
The full finger splint option is not necessarily useful if you know they have a dislocation of the PIP joint which I’ll get to in a moment that’s volar.
You can splint just the PIP joint an extension because a central slip is injured if it’s just a mallet finger you can just splint the DIP joint. So again hyperextension injuries simple buddy tape range of motion dislocation. Okay. It’s fairly simple and straightforward to reduce that should reduce easy if not there’s other things that sometimes we have to do. So this kind of shows that early range of motion because these injuries get stiff and they hurt for three or six months. They’ll always notice there’s some swelling at their finger it’s not going to go away it’s just the injury. So you just educate people mainly for these injuries. So here’s a fracture dislocation these are unstable injuries. These usually require some sort of surgical intervention. So these are ones again. It’s nice to see these injuries within a couple of days of injury not six weeks out because six weeks out there’s kind of difficult to to fix.
So if it’s unstable we can send them to a hand therapist. We can make a splint. You do a dorsal blocking splint allowing flexion because it’s stable and flexion however preventing maximum extension and then dial it back in over time. You can do a pin so a pin acts like a splint you can do that that that works for majority of these that are very common in it you don’t have to open the joint up in theory maybe get a little less stiffness but again something’s being done for these again. If you look at the X-ray and the bottom left you see there’s dorsal subluxation or what they call the V sign. This is something we’re going to do something for in in this paper this just shows you if you do it just a pin and you follow patients over time the joint looks pretty good even though initially it did.
You can open them up and put screws. I mean they they work OK for for the right patient you can stabilize the joint if you’re going to have them open up and fix. From our standpoint we get him stable and we get him into therapy right away. This is not something we cast for a while. If you want to get fancy and you can’t fix it or in a later case this guy came up with this idea taking the hamate. There’s cartilage on the hamate where you can take a bone graft and then place it on the base of the metal phalanx providing you stable concentric PIP joint.
And if you do this you’re going to send a therapy and you’re going to allow motion. So these do OK you see something like this that might be six or eight weeks out.
It gives them an option over during a fusion so lateral dislocations. I think a lot of people see these.
Sometimes they can be fairly unstable chronically. I know some people I know even one surgeon orthopedic surgeon who has this and every time he puts on a glove at this locates and he just kind of pulls it back in. So I guess you can live with this. There’s someone in the room or has this. However if it’s stable then they’re usually OK. So this is a volunteer location so if you see this this is something that you’re not going to just buddy tape and do range of motion because a central slip or the extensive mechanism that inserts here is disrupted to shrink into a closer reduction.
Here’s a little avulsion variant. And then you’re going to splint the PIP and extension while allowing DIP active motion.
So you’re going to just split the PIP only allowing active DIP motion. I usually send them to a hand therapist. All right.
Another video. So never sliding to first base. I think they teach you that when you’re like six. But some people like Kiermaier say look he’s examining his thumb there. So you guys know what he injured there. So as owner collateral. So looking at the history of all these myths that people wear this guy in the top left this guy for the royals I forget his name because he’s not a famous guy but he came up with this idea of wearing this Mitt that you see everybody wear now. So I don’t know 100 percent if it prevents injuries I think it does. But I think there’s some in sports medicine in hand surgery literature that will follow if it hasn’t been already. You guys might know better than me.
So handmade fractures can occur when you’re batting or playing golf. This is something that you don’t want to miss. Again getting back to exam if someone has on her side at risk pain if they’re sore over the handmade they can get hurt by batting making your hurt by playing golf. There’s different types, different locations check swings potentially could occur if they’re sore over here. You do want to miss this fracture because they can have a tendon rupture of the profundis to the small finger. So it’s a very annoying injury to have people out pain over their owner side of the hypo thing are eminent. They can have ulnar nerve parasthesias, weakness, and grip. So this is the time you would get a carpal tunnel x ray along with the C.T. scan. So the C.T. will show it if their fracture didn’t heal with time say a couple months then we go in and excise this fragment.
So they don’t have a tendon rupture. So in overview again history and physical exam is everything you’re going to see these injuries come into your office. I’m sure no matter what specialty you do. Why. Because hand injuries are very common. If you see an injury to the finger like we talked about for PPD or even elbows and I didn’t talk about elbows but referral sooner than later is proved beneficial to the patient. A lot of times it’s education. Get back to moving and get back to your life get back to your sport when there’s times where they need something we can intervene and get them back right on track as well. Thank you.