Transcript for:
Lecture on Sports Hand Injuries

okay everyone all right so we'll go ahead and get started thanks for joining uh this installment of the national fellow online lecture series I'm Robbie Bowers at Emory Sports Medicine in Atlanta Georgia I will serve as the moderator for tonight's lecture before we get started with tonight's lecture going to plug the the next lecture next week which will be the final lecture of the 2022-2023 Academic Year and that's going to be June 21st next Wednesday 8 30 p.m eastern time it will be a caq review hosted by Melody rubish and Jason zarinski we will then start back up with the first lecture of the 2324 Academic Year the first week of August so tonight we have Dr Eric latska University of Washington uh who will give a lecture on Sports hand injuries before we get started with that just a couple housekeeping issues again this program is to serve as an adjunct to your individual programs didactics and not to take place if any of your educational content over the course of the year with your program we also want to provide fellows with access to a diverse group of speakers and mostly amsson members but at times invited guest speakers and overall this is really to help you prepare for caq exam now as far as tonight just mute your microphone turn off your video put any questions in the chat function I will then ask Dr laska at the end of this any questions and and we'll have a q a discussion after he is finished with his talk and then also there'll be a link to an evaluation that will be in the uh in the chat function as well so please click on that and provide your thoughts on the evaluation as possible so again tonight Dr Eric latsko will be giving our lecture on Sports hand injury so Dr laskas and Timmy physician and clinical assistant professor of Physical Medicine Rehabilitation and sports medicine at the University of Washington there he's been the director of the diagnostic ultrasound curriculum for the PM R family and pediatric Sports fellowships Dr Alaska earned his MD at Tufts University and completed Pima R residency at University of Washington and an acgme Sports Medicine fellowship at Swedish Medical Center in Seattle as well he's provided medical care across a broad broad range of Athletics from Mass events to professional Athletics to Collegiate Athletics he's a former Varsity track and field athlete at UNC Chapel Hill and this just happens to be his last week at University of Washington as he will be moving on to Boston to join Dr Walter Sussman at Boston Sports and biologic so with that said Eric go ahead and take it away thanks for having me Robbie just see if I need to share my screen again can you see it yeah good okay uh thanks for the intro and thanks for having me today uh it's really hard to separate the hand from the wrist for a lot of these uh injuries so I'll be touching on all of them I have no disclosures uh Robbie already touched on some of my training uh for those of you who don't know what a sports medicine physiatrist is because it's come up a little bit recently that some don't we do one year of internship and Internal Medicine followed by a three-year residency and those three years include at least 13 months of inpatient coverage with patients with tbis STIs polytrauma and then as you probably know we do a sports fellowship and take the same caq as family as emergency so that's a little bit about that and he also touched on my career I've been at UW now for five years and I'm leaving to go back home to Boston with my family uh and lucky that I got a good job working with Dr Sussman wouldn't be here without you know a lot of great mentors both in residency in my career and a fellowship and also the you know my trainees that I've had in the last five years have made me a much better doctor as well uh better or bigger thanks to my wife for letting me do this lecture and letting me always do these extra things I think she's getting sick of them especially this week as her house is being packed and we're on the way uh I'll try to get home soon there are a lot of other lectures that have been done recently on these injuries and in more depth and detail so I would recommend looking at some of them we're going to be covering so many that they will be much more superficial and but we'll try to touch on all the high-yield stuff that might be on your caq so to form this lecture I reviewed uh books like these and basically took out any diagnosis that might come out on your test next month it's only a month away so I assume anything that's not highly relevant for that exam you're not going to be paying attention to this is the outline for these injuries there's about 40 of them so in about 40 minutes I'll try to touch on all of them and we'll start with the distal forearm and the tfcc or triangular fibrocartilage complex this can be injured in various locations but will focus on the articular disc first because this doesn't create any instability in the disk the articular disc is injured with acute falls on outstretched hands or it can be chronically injured with repetitive ulnar deviation in sports like tennis baseball and gymnastics here we have a combination of those two with Mike Trout sliding into second base and tearing his tfcc on exam the sheer or dorsal Glide test is the one that's tested most often with opposing dorsal and bowler forces over the piece of form and on their head uh recreating the pain and recreating kind of a click a clicking sensation there are various other physical exam tests that all act to load the tfcc through ulnar deviation wrist flexion and extension but the shear endorsal Glide test is the one that's most commonly cited from a diagnostic standpoint here we have an MR arthrogram in the upper right hand the screen it's comparable to 3T MRI and still arthroscopy is the gold standard when it comes to tests x-rays can show a positive ulnar variance so that ulnar head a little bit more distal to the radius but uh otherwise ultrasound while you can see a tear as I've shown here it's not a good screening tool it's very operator dependent and this is a very hard image to get so if you do see a tear of the articular disc on the tfcc a neutral splint for four to six weeks followed by physical therapy and or a corticosteroid injection can be helpful repair is really more for the peripheral tears of the radial uh ligaments and we'll talk about those in a little more detail when we talk about drudge injuries and then ulnar shortening can be done if there's positive ulnar variants and that's done more often in the case of ulnar abutment syndrome and we'll talk about that as well so if you're concerned about stability of this joint uh the distal radial in their joint the piano key sign or the blotman test is the one that's kind of classic so you push down on the ulnar head and it should basically spring back up proximally once you release it and that's indicative of uh radial ulnar ligament tear if we go back to this image here those ligaments are the ones at the edges both volarly and dorsally so x-rays can show a widened joint and MRI can show a tear in the radial ulnar ligament these are more often repaired or reconstructed but if you do attempt non-operative treatment for a drudge injury you want to use a long sugar tongue cast to prevent supination inflection supination and pronation of the wrist one other thing that comes up on these tests is if it is combined with a distal radial fracture that's called a Galaxie fracture dislocation ulnur abutment and impaction syndrome will present similarly uh with ulnicided pain but it usually in older older athletes more degeneratively more chronically uh it has been reported in some younger boxers and MMA fighters but your exam is pretty uh similar to what you see with your tfcc tears from a diagnostic standpoint you should see a positive ulnar variances demonstrated here but your MRI is really what's going to differentiate it when you see signal in the lunate signal in the triquetrum or in the ulna itself and later in the disease process you can see subchondral sclerosis and subchondral cysts the treatment for this is the ulnar head resection or shortening procedure distal radius fractures have been covered extensively by Dr Lieber already I'd recommend looking at that lecture it was great uh what you should know at least for the test are the differences between Collies Smiths and Barton's fractures and it is there are a lot of nuances to when these are treated surgically versus non-surgically but to make it as brief as possible non-displaced extra articular fractures are going to be treated with splinting until the swelling resolves followed by a cast any of the other things of displacement combinated intra-articular highly angulated ulnar fractures drudge instability nerve injuries those more often go to surgery this came up in my review it's a little bit proximal to the wrist but I didn't really know what a green stick fracture was so I thought I'd throw it in here it's basically a Bend of the bone in pediatric patients where the cortex remains intact on one side so these are treated with casts and splinting and they heal very well uh finally the distal radial epiphositis or gymnast wrist this is unique to athletes during growth spurts who are doing a lot of repetitive axial loading uh of an extended wrist so that's primarily gymnasts who are performing over 35 hours of practice per week uh weight lifters have also been reported the exam is non-specific and so you need to have a low uh clinical or a high index of Suspicion and a low threshold for Imaging you want to get at least an x-ray with bilateral views so you can compare and see compare this to you know to the normal side and if inconclusive have a low threshold for getting an MRI because this isn't something you want to miss if you allow the athlete to continue practicing and competing it can lead to early growth plate closure uh more positive vulner variants and even a shortened radius called a madalung type deformity moving on to the true kind of carpal region uh first we've got carpal ganglion cysts so most often these are dorsal there's have been a few papers in the last few years saying that we might be underestimating volar uh dorsal polar ganglion cysts but the texts will you know thus far always say that dorsal is more common and the most common location is coming from the scaphoblenate joint usually and early on they're painless and asymptomatic but as they get larger they can limit wrist extension and become painful in that case an ultrasound or MRI can be useful to make the diagnosis or at least confirm the diagnosis I've seen plenty of what were sent to me as ganglion cysts ended up being various other things and tumors and tendon tears and retractions so uh always you know don't just go aspirating it before you've confirmed with an image if it is symptomatic though aspirating it and doing a cortical steroid injection is helpful surgery if is warranted if it recurs and here this we've got one video here just showing how this dorsal ganglion cyst tracks from The scapulinate Joint there's the stock going right to the scaffolding joint and those can occur with partial tears in the scapholunate or or full tears so the Escape balloon ligament and you're going to get see a similar theme a lot of these are injured with the same mechanism so an acute foosh injury uh or or a chronic axial loading during wrist extension now this occurs with a axial loaded wrist in ulnar deviation so weight lifting especially people who perform front squats or under heavy weight there's Tenors developation distal and ulnar to lister's tubercle with a positive Watsons test so they're The Examiner is taking the patient from a ulnarly deviated to a radial deviated position while applying pressure to the scaphoid if that reproduces a click and pain is positive on x-ray you're really only going to see a positive Terry Thomas sign if you have a full ligament rupture you're not going to see that with the partial rupture uh if you suspect if your clinical suspicion is for escape lunatarian or x-rays on bilateral uh clenched face scripts look normal I would recommend at least doing an ultrasound uh if you're not comfortable with ultrasound getting an MRI to look for a partial tear because those partial tears can be uh treated with splinting like a neutral wrist splint they can be treated with corticosteroid injections or PRP but typically the textbook especially if you get a question where you see widening of the joint uh those are going to be treated with open surgical repair and that is to present that's to prevent things such as dizzy and slack so what those are is as these ligaments tear the Bones start to move and the Escape aluminate angle can increase from 30 degrees once it increases Beyond 60 degrees that's called dizzy or dorsal intercalated segmental instability and once that happens you can have slack Advanced collapse of the oxy of advanced collapse osteoarthritis and this is another video showing that process where the capitate moves approximally from that instability foreign ligament is the next ligament uh it's again with axial loading during wrist extension but now with radial deviation ulnar pain so this is going to present similar to our ulnar abutment tfcc injuries uh and there's even a kind of similar test the climb and Shear test where you use opposing door symbol or force over the piece of form and lunate as opposed to the ulna and the lunate or all night and piece form excuse me and then there's another test called the Reagan's balotment or shuck they have a lot of names these tests but they all basically involve moving the lunate while also while either stabilizing the triquestrum in Reagan's or moving the piece of form and triquetrum together in climates Mr arthrogram can show some extension of contrast outside of that ligament arthroscopy though is the gold standard and in this case it doesn't lead to dizzy or dorsal instability at least to volar instability and this finding of bissy can be found in some normal hypermobile patients so it's not always pathologic unlike dizzy which is this is one I one of the more interesting I think diagnoses that you might be tested on uh and one of the trickier ones so a perilunate dislocation is not a lunate dislocation and and so differentiating these two things can be helpful uh they both occur with similar mechanisms so a high velocity foosh injuries usually motor vehicle accidents uh that cause hyperextension and ulnar deviation they are not common and oftentimes in the emergency room they can be missed a presentation uh the symptoms are pretty vague with wrist swelling and some carpal tunnel symptoms so they might be sent home with presumed carpal tunnel uh and lateral x-rays if you're not if you don't have these nice labels they can be uh hard to see and easy to miss so on a lateral x-ray a perilunate dislocation is the dorsal displacement of the capitate uh while a lunate dislocation is the volar displacement of the lunae and that's sometimes referred to as a spilled teacup so you can see in this position it's a teacup that could be you know filled and not spilling and then here it's tipped over CTS are often indicated uh or both of these injuries to rule out concomitant scaphoid fractures and both of these are usually repaired with open reduction in surgery urgently especially the lunate dislocation and this is a you know something you want to take away from from this talk that this is very uh you don't want to miss this lunate bowl or dislocation because it's going into the carpal tunnel and if you miss it then you can have uh your immediate nerve injury and oh let's see here kind box so this is a vascular necrosis of the lunate you can see on the picture here just of an x-ray you have some sclerosis of that lunate this occurs in males 20 to 40 years old most often but not from High Velocity trauma or foosh injuries it's more from just chronic repetitive minimal trauma so just regular people out there playing golf playing football uh they present pretty non-specifically too with just tenderness to the lunate and x-rays especially early on might not show this sclerosis or flattening of the lunate uh more advanced cases will show fragmentation and collapse so if you can't figure it out and the patient continues to have this dorsal lunate pain MRI is the gold standard so they probably will have gone to physical therapy before that and if they're not improving get the MRI this one thing that can clue you in on this disease is associated with negative ulnar variants so if the ulna is below the radius or proximal to the radius there isn't another injury that is associated with the negative ulnar variance as far as I know so this this distinguishes it from infection syndrome and tfcc tears the scaphoid fracture is what kept UNC from winning 2012 National Championship I think uh it is a foosh the mechanism is again a foosh and it's the second most common risk fracture more common in young people than older and that's because if an older person falls an outstretched hand they're more likely to fracture the radius and that gives before the Escape void does on exam while we always talk about tenderness to feel patient at the snuff box uh the exam is kind of unreliable and x-rays are also unreliable so if the story fits and the location fits uh and there's any palpation any tenderness depletion at the snuff box uh I would get an MRI and you may want to get one with IB contrast if uh if you're at all concerned for a proximal pull injury and we'll get to that in a second so a stable injury meaning it's non-displaced can be treated with casting and a thumb spike a splint for about three months but if there's any more displacement than one millimeter you're going to have to surgically fix that fracture if you want to get a athlete back faster on a lot of pro athletes will do this they'll they'll have their surgery and then they'll get a cast and they'll come back before they're fully healed and just rely on the cast to protect that bone uh the important part though to escape void fractures is where the fracture occurs because the scaphoid is getting its blood supply distally and so if you fracture you're not going to get proximal flow or flow proximal to the fracture fortunately most of these fractures are waste fractures so fractures that occur kind of in the middle of the scaphoid the ones that occur in the proximal pole are the ones that are most likely to lead to avascular necrosis or non-union so just have a if if you see a proximal full fracture on your X-ray I would also get that's one I would definitely add IV contrast to see if there's any early AVN already occurring uh wrist guards and snowboarding and skateboarding have been shown to be preventative of Escape of scaffold fractures the hammy hook fracture or a type 1 amate fracture occurs with uh acute and acute swing of either a golf club a baseball bat hockey stick and it presents as kind of a vague pain and tenderness at the bowler ulnar aspect of the hand there's it can also be associated with some ulnar neuritis given the hamates proximity to gian's Canal and the main exam finding that you guys should know about is the Hammett pull test so essentially what the examiner is doing here is applying pressure to the area of the Hami while resisting flexion of the fourth and fifth digit in ulnar deviation this is painful and in radial deviation it's not and that's because in ulnar deviation these tendons of the fdp tendons are basically rubbing up against the amate uh and in ulnar deviation the very sorry in radial deviation they aren't so for a Diagnostics this carpal tunnel view is the only way to really confirm it on x-ray and that can often be missed CT is better unless we're talking about a stress injury and that's a different presentation we'll get there in a second so if you do see a CT on CT you see a fracture there's a little debate about how to treat them they can be treated just with rest conservatively or surgical fixation but either way if they recur the hamate hook is often excised or recommended to be excised now one other way this can present is in rock climbers uh who have a slow subtle onset of worse and worse ulnar Palmer pain and this is in rock climbers who use an undercling grip so this is kind of an advanced grip but it highlights the path of the fdp tendons and how that position puts stress on the hamate uh if this is if so if you have this kind of pain in a rock climber I would suggest getting an MRI because just like a stress fracture if there's not a true fracture line you're going to miss it on other Imaging de querbeans or first dorsal compartment Tina synovitis involves the the APL and the EPB it occurs in athletes who are golfing fishing playing tennis rowing through and even in Esports the exam maneuver to test for it is Finkle stains so basically holding the thumb in a clenched Fist and ultimately deviating reproducing pain uh at the radial wrist that is more accurately called icoff's test but everyone talks about it as finkelsteins and I'm not going to get into that I think either of those would be correct on a board exam from a diagnostic standpoint ultrasound is very useful if you have it in the office both it and MRI can show a fit in a thickened ranaculum and here we have one that's 0.16 centimeters that's about three times as large normal uh and then it can also show tenosynovitis of the retinaculum or tendon sheath this is a little debate I don't know how to tell you guys what the answer is going to be for first line treatment for the queer veins on in a lot of textbooks it'll say rest in immobilization in and I can tell you in at least a few other exams that I've taken in my career the correct answer has been cortical steroid injection first first line and that's based on a study that showed an 82 cure rate back in the 90s and some studies that have shown even higher than that in my clinical practice that's what I do first thing first time I see it I do a cortical steroid injection with ultrasound guidance but it could be either of those based on this test and I'm not sure other things you should remember though that the APL and EPB can either share a tenant a sheath or they can travel in separate sheets so if you do an injection you need to look for that possibility to make sure that your flow is going into the symptomatic tendencies it's the most common genocivitis in athletes and in new moms at least involving the wrist enhance proximal intersection syndrome was just presented by my fellow Malia Cali a few weeks ago so I stole most of this from her it presents after repetitive wrist extension so classically in crew but can also occur in weightlifting and Racket Sports there's tenderness to palpation in the area of the intersection about four centimeters proximal the listers tubercle and some people will even it will describe a crepitus us and they'll describe it actually more as like a squeaking so I think some people turn this even as a squeaking wrist and that you can even hear audibly I've seen that once on ultrasound you can follow the compartment so here we have the first passing over the second uh and you can also look with Doppler to see if there's tenosynovitis in that region on MRI what you'll see is this increased signal uh peritendinitis edema and this is also liked aquariums treated pretty well with corticosteroid injection in between the uh at this intersection point I don't know of anyone doing surgery for this uh procedure or even what that surgery would be distal intersection syndrome involves a second and third compartment so we're moving now distal to lister's tubercle uh it's in more in drummers than athletes although I would say you know drumming requires a lot of uh athletic stamina and strength uh it can also be found in Esports cheerleading and tennis the tenderness is like I said distal to listers also can have that squeaking kind of crepitus and there will often be painful pain inhibited weakness on thumb extension similarly you can use ultrasound to follow the third compartment which is the EPL as it passes over the second compartment here this is in a normal patient and or you can get an MRI to look for these peritendinous edema in those second and third compartments uh this again is treated with kind of conservative measures rest spica splint and corticosteroid injections however if it's recurrent a synevectomy is recommended and in chronic cases it can lead to a rupture of the EPL which is you know not a good injury to have especially in a drummer ECU tendinopathy and or subluxation this is the sixth dorsal compartment it's common in Rocket Sports Club Sports High Impact Sports uh you guys probably know I mean the easy things are there's going to be tenderness along the ECU pathway there's going to be pain with wrist extension and ulnar deviation but the one exam test that's cited in a lot of the textbooks is the ECU Synergy test which is essentially resisted abduction in a deduction of the first and second digits and that reproduces pain at the ulnar at that ECU now this ECU if it's subluxing should sub locks with supination and reduce with pronation and MRI is not going to show that unless the tenant is subluxed while the image is taken ultrasound can be more useful because it can show Dynamic subluxation if you do confirm that and the patient has already tried conservative therapies and ECU sub sheath reconstruction may be recommended which is basically where they recreate this ligament here to hold the ECU down and if this occurs in a young person who's not an athlete you need to think about rheumatoid arthritis and other inflammatory disorders we all know a little bit about carpal tunnel syndrome at this point uh the takeaways are this happens in gymnasts weight lifters cyclists rowers and wheelchair athletes so all of those people are using their wrists extensively uh exam Maneuvers I think you guys know already I think one the one key always is that the numbness should only involve half of the fourth digit uh it should not go on to the ulnar side of the fourth digit EMG and nerve conduction studies I think those are just a great lecture by Dan by Dr Herman recently and uh from an ultrasound standpoint this is what a normal carpal tunnel looks like with the TCL over the top going from the piece of form to the scaphoid this honeycombed appearance of the median nerve I hope you guys can see my arrow or if you can't Robbie let me know I'll stop using my arrow so much uh the things you can see on ultrasound though in path to logic or in carpal tunnel syndrome are an increased cross-sectional area that's the main one we look for and so here's one in a patient who's got about almost three times a normal cross-sectional area uh I don't expect them to test you on what the normal uh is it's about 0.09 but it knowing that an increased cross-sectional area uh is indicative of carpal tunnel syndrome could be on it a positive Notch sign is basically looking at the nerve in Long axis and seeing that its thickness decreases by about 50 percent under the TCL uh I think you guys know that treatments of neutral wrist bracing during activity or sleep corticosteroid injections for temporary relief and carpal tunnel releases either uh on the textbook probably you know open or endoscopic but you know more recently ultrasound guided shown to be just as good these can occur you know as I've already pointed out with lunate dislocations and in that case it's a surgical kind of emergency cyclist palsy involves the ulnar nerve at eons Canal it's from handlebar compression but can also occur in weight lifters doing heavy bench press or wheelchair athletes this again will involve the ulnar aspect of the fourth digit as opposed to carpal tunnel syndrome EMG and nerve induction studies are indicated ultrasound can be helpful you can differentiate the TCL and volar collateral the bowler carpal ligaments as well you can follow that eons Canal from the proximal carpal tunnel to the distal aspect where the nerve splits into its superficial and deep branches this is useful if a patient's not getting better or presenting with weakness because sometimes you see things like this you can see hammock fractures you can see ganglion cysts this was a uh I think a rack ball player in what I saw in fellowship and we just drained the ganglion cyst and it didn't recur and their strength improved so it's an easy fix fortunately the typical treatment though if you're not seeing a cyst like this is a bike fit to make sure they're not putting too much load on their upper extremities uh gloves padded gloves changing the handlebar grip and if there is Progressive motor loss then surgical decompression the next neuropathy we'll talk about is mortenberg syndrome this is really just a pain in paresthesia problem it's not going to lead to weakness fortunately because it's a policy of The Superficial radial nerve this occurs in athletes wearing tight wristbands weight lifting bands or five million dollar watches like nadala is here the canal test at wartenberg's Point can reproduce the symptoms and interestingly ficklestein's test can be positive too and that's not because you have declare veins that's just because doing this is putting neural tension on The Superficial radial nerve so if you have a positive Finkelstein and that they pre they say oh that reproduces my tingling or numbness think about uh warrenburg syndrome this is usually a clinical diagnosis the treatment is removal of the compression and it usually does really well rarely requires injections or surgery but it's important to differentiate it from near to queerbanes and your intersection syndromes moving on to into the Palm in the hand the first thing we may see and most very commonly in our older athletes is CMC osteoarthritis of the trapezium metacarpal joint this can present with pain kind of throughout the Palm on the radial aspect at least it can be volar dorsal or radial it can cause pain with any kind of movement of the thumb or gripping pinching especially the CMC grind test is the classic one where you apply an axial load to the thumb and you're basically pushing down and rotating uh I've had residents suspect that the patients have had dislocated thumbs before for this so it if it's enlarged enough it can actually look like it's dislocated and out of the joint x-ray is all you'll need for the diagnosis uh early on a spike a splint or corticosteroid injections can be done but if you get to this severity uh a arthroplasty or metacarpal kind of resection it can be helpful and if it's a young patient with this you want to consider inflammatory disorders metacarpal thumb fractures the first we'll talk about is the Bennett fracture and this occurs with Force abduction so often in football players or in uh probably more MMA athletes than boxers uh it but I think the textbook says boxing now exam wise pretty non-specific swelling and limited range of motion but your X-ray you want to pay attention to that proximal aspect uh and this is a non-communuted fracture if it's combinated or more than two pieces then three pieces or more it's going to be a different type of fracture so for this closed reduction uh can be attempted plus a spike of brace but most are going to need open reduction and internal fixation this is a high rate of osteoarthritis afterwards Rolando fractures are common are essentially the same fracture but now combinated and this is much more common in men you know 10 to 1 ratio and that's because the typical mechanism is a fist fight and it's always treated with uh with surgery and it has a much worse prognosis for you know CMC arthritis and disability down the road medic moving more distally shaft fractures can be categorized into two ways either transverse or oblique and spiral now there are some similarities between these and some differences so a transverse fracture tends to fall on a clenched fist or uh or a blow to a helmet while oblique or spinal fractures or Falls onto an open hand so here we have Steph Curry falling onto his open and utterly deviated hand and he suffered I believe it was a camera represent oblique or spiral so that can occur with twisting of hands as well during sports like wrestling the main things to pay attention to are to look for shortening of the metacarpals in which you will lose essentially a knuckle or for Mal rotation of a digit where all of these digits should be pointing to a common like scaphoid location and if there's overlap that indicates rotation which is a surgical indication if there is no high degree of angulation or rotation then you can try to treat with body taping and splinting but if it's unstable or if there's rotation or shortening then often uh surgery will be needed these are some images of these so the X-ray of the transverse fracture not hard to see x-ray of the oblique fracture also not hard to see but the spiral fractures if they're non-displaced those can be pretty subtle so if you have the right history just make sure you look closely metacarpal neck fracture is moving a little more distally again these occur with fistfights and punching now in a 20 to 1 ratio of men to women there is some dorsal angulation of the metacarpal on X-rays and can also be seen on exam uh you should again look for the loss of the knuckle and the most commonly known one is the boxer's fracture uh that that's at least what it's called it's when as we're shown in these x-rays the fifth metacarpal neck has a transverse fracture that's non-communition interestingly though boxers fractures are not usually seen in boxers because boxers throw punches and try to strike with their second and third Knuckles and digits where they can get more power it's really Street Fighters or non-trained Fighters that strike with the outside of their hand which is a weaker area and more likely to injure so it's kind of paradoxically named that most boxers injure their second and third metacarpals and not sustained boxer fractures lumbrical tears uh this these are found in the third and fourth lumbricals and the reason for that is because they originate off adjacent tendons and in this because they originate off adjacent tendons this specific grip in rock climbers called a pocket grip where one finger is extended and the adjacent fingers are fully flexed causes a Shear force on this muscle uh and the muscle stretches and tears now this you kind of just have to know by history and have a low threshold for a high index of Suspicion if they come in with Palmer mid Palm pain after doing this grip this is going to be high on your differential and as long as it is you'll know to do an exam maneuver that's really only going to test the lumbricals and that's passively fully extending one finger and fully flexing the others so if you do that passively and you know that motion reproduces the pain there's not too many other things uh it's pretty you've pretty much made the diagnosis ultrasound can show a tear so here's a torn lumbrical distally versus a intact lumbrical and then here's a lumbrical with you know this is I think a chronic injury so it had a lot of muscle belly loss distally compared to the normal ones adjacent to it the key with lumbar injuries is you just want to make sure they rest and don't continue to climb and that they maintain the range of motion because these can Scar and cause the reflection contracture and finally to the fingers so skiers thumb starting at the mCP joint this is a abduction injury typically in skiers who are using poles and who fall onto their poles or in wrestlers who you know when you're trying to get your opponent's hand off of you and peel it off they're pulling their hand back by their thumb so after you've done an x-ray if you have a history for acute abduction injury in a ski or a wrestler I would advise get an x-ray early to rule out a fracture once you know there's no fracture then you can do some stress examinations and this abduction stress should be done in both full extension and full flexion and that's because these positions of flexion and extension test different parts of the ulnar collateral ligament and if you only do it in flexion you're going to be missing you're not going to be testing the entire ligament and you might get a false positive so once you have your X-ray and you've done your exam it is kind of useful to get an MRI or ultrasound early to rule out a Steno lesion and that's because stamina lesions are really common in these injuries I think some studies say up to 50 to 70 percent of UCL tariffs involve a standard lesion and that's when the UCL tears distally and kind of retracts and gets transposed by the overlying adductor aponeurosis so this is the adductor Neurosis here this is the short axis of the aponeurosis here and this is an intact UCL and an intact adductor apnosis over the top and then this is a torn UCL retracted now A Center lesion there's no way that this is going to get back down here because the uh adductor aponeurosis is preventing it from doing so and you can see that more clearly when I remove the labels so a spica cast and then a spica splint can be used to treat if it's stable and if there's no Center lesion but if it's unstable if there's a stener lesion or an avulsion fracture then open repair is recommended and game Keeper's thumb is essentially just The Chronic presentation of this injury a skier's thumb is the acute presentation boxer's knuckle not to be confused with boxer's fracture this is seen in boxers and also other martial artists it typically involves the middle knuckle because that's the one to strike first and it's a tear of the sagittal band The sagittal bands are what hold the extensor tendon in place dorsally so here you can see the sagittal band that's displaced ulnarly it can be diagnosed just on your exam with flexion and extension of the fingers you should be able to see this tendon Go from midline on the finger to either ulnar or radial MRI can also diagnose it and so can ultrasound and ultrasound can show it dynamically so if you do make this diagnosis you want to put the patient in an extension splint for six weeks if it's recurrent and chronic then sometimes they're treated surgically but most of the time they are not and again don't confuse it with the boxer fracture boxer's knuckle is a ligament injury moving a little more distally we have volar plate injuries for Polar plate tears typically these occur at the PIP joint more so than the dip or mCP they're from Forced hyperextension so a basketball kind of hitting or volleyball or any kind of ball suddenly hitting the finger and Hyper extending it on exam there's no end point on passive extension and from a diagnostic standpoint MRI or ultrasound can show the tear x-ray can show an evolved fragment as it does here and there are different ways of classifying these fractures whether they're uh associated with dislocations or if they're just associated with fractures this might be a little beyond what you need to know though for for boards if there's an evolved fragment that's greater than 40 of the articular surface though that is going to require surgery if it's less than 40 percent then an extension blocking splint is appropriate MC now we're going to move to dislocations starting with mCP then pip and dip uh all of these we're going to focus on the dorsal dislocations because that's the most common one volar dislocations and all of these are very rare uh so we're just going to skip them dorsal dislocation of the proximal phalanx it occurs after forced hyperextension on exam that digit is still going to hyper extend at the mCP joint you can see overlapping of the digits which you don't really see here but you do see they're closer together and you see some puckering of the skin here on the Palmer side on x-rays make sure you get La you pay attention to your lateral and obliques because on your APS it can be easy to miss this is of a thumb so it's not easy to miss but of the second through fourth digits on an AP will be easily missed uh these are treated with open or closed reduction and splinting for six weeks uh blocking the last 30 degrees of extension if the dislocation is complex meaning the volar plate gets torn and lodged in the joint or a sesamoid bone gets large lodged in the joint then they might be irreducible and those will require surgery at the mCP level this is a uncommon entry pip dislocations are much more common here's Steph Curry's a few years ago this occurs again jammed fingers catching or hitting a ball the exam shows uh can show a swan neck deformity this is an acute swan neck deformity with Pip extension and dip flexion and try to you know always ask or see if there's a picture or uh because the direction of the dislocation can tell you what ligaments are going to be injured diagnostically get x-rays early to allow for an evulsion fracture if there's an avulsion fracture that is small and the joint is stable then you can do a closed reduction in body taping and uh but the volar dislocations like I said those are more rare and oftentimes irreducible finally dip dorsal dislocations all these again hyperextension of the joint mostly when balls are hitting fingers and always obtaining x-rays to rule out volume fractures these are more easily treated traction just manual traction plus flexion can usually reduce them and they only need to be splinted for about three weeks Jersey finger on the other hand uh is not easily treated this is a tear of the FTP tendon it occurs when grabbing an opponent's Jersey or an open hand open grip rock climbing there's usually a sudden pop felt and acute pain patients present with the inability to flex their dip joints which is why he's extended at the dip here but fds flexion is intact so x-ray should be obtained to a valve for Evolution fractures which are common and there are a lot of different types and there are six types of f2p tendon tears depending on how far the tendon retracts to or if there's an Emulsion or not that might be a little beyond what you need to know for your caq but it is important to at least get the images to assess for that those things so you want an x-ray to look for the fracture and you want an MRI or ultrasound to a valve for tendon retraction because this is going to go to surgery and the surgeons are going to want to know how far that tendon is retracted it can also it's also called rugby finger mallet finger or Mallet fracture is a terminal extensor tendon tear at the distal Phalanx so this is now we're getting a hyperflexion injury or a flexion uh a resisted uh a passive flexion against active extension injury it occurs in basketball football baseball and patients present with the inability to extend their dip joint this was Russell Wilson uh a few years ago lateral x-rays are important to look for that avulsion fracture most of these can be treated by splinting in extension for six to ten weeks and if you do that you need to allow the PIP joint to still have free range of motion but if the fracture if there is a fracture that involves over 40 percent of the articular surface surgery is the treatment Kobe played a full season with one of these uh just taping it uh ten thousand two thousand nine or ten and if not treated this can lead to a chronic swan neck deformity as opposed to an acute one that we saw uh in the PIP dislocation the other extensor tendon injury is essential slip tear so this isn't a tear at the terminal tendon this is a chair at its insertion onto the middle phalanx again it's similar theme Here struck by a ball is uh res flexion against resisted extension and the the they present with the opposite of a swan neck deformity so now you're seeing pip flexion and dip extension the board test or the board that's on the boards often is this Ellison's test So the patient's fingers are gripping over a table with reflection at all of the PIP joints and then the symptomatic finger is attempted uh to be extended against resistance that's called elson's test x-rays are important we'll avulsion fractures if it's on cue injury it can be splinted as long as it's not displaced over two millimeters and chronically though they'll require a Serial casting to get them out of their boutonniere deformity prior to surgery this is just a brief summary on the different deformities that I've mentioned so far the I think the takeaway from this is that you know boutonnieres and mallet deformities are pretty clear and occurred usually from just the same injury every time swan neck is a little more complicated in that there can be an acute presentation of it with dorsal pip dislocations and Molar plate tears there's a chronic presentation of it with the untreated mallet finger and there's also atraumatic commonly atraumatic presentations of it in patients with rheumatoid arthritis psoriatic arthritis and lupus trigger finger is an injury that it's more often not in athletes uh it's just in our aging population that works with their hands but it can occur in uh athletes and that are involved in Racket and club sports and rock climbing uh it presents with tenderness at the bowler aspect of the uh mCP joint the uh classic you know that everyone knows it's just the catching the inability to extend against uh to extend from a flexed position without passively kind of forcing it open the way to diagnose this I mean I think clinically is enough but ultrasound can show a thickened A1 pulley so here we have a normal A1 pulley and here we have a thickened A1 pulley and this is in short axis on the finger the long axis on the pulley it'll also show Tino synovitis in this area of pulley and the tendon sheath so first line treatment you can try splinting but oftentimes cortical steroid injections in this area will be very helpful especially if you see Tino synovitis like this uh ultrasound guided or surgical releases can also be done for uh current cases however I would this might not be in any textbooks but I would not recommend a ultrasound any kind of release in a rock climber for the A1 pulley because you take away that A1 pulley and all of that force is now going to be transmitted to the a2a3 and A4 police I've seen that happen with patients who had A1 releases and go back to rock climbing and then suddenly have two three and four ruptures and require surgery A2 pulley ruptures speaking of that are injured in rock climbers in a specific crimp grip which loads the A2 pulley and puts a lot of force on the PIP joints they present with a pop felt during this position and tenderness of palpation on the volar aspect of the proximal phalanx they'll have pain with resisted finger flexion and ultrasound will show this classic kind of bow stringing of the tendon uh that is measured as tendon Phalanx distance the distance between the tendon and the bone now that's bolstering you can see on a dynamic ultrasound you can also see it on MRI clinically it's rarely seen the only way you're going to see bow stringing by looking at someone's hand is if they've torn their a2a3 and A4 police and that's more rare so these are classically treated just with rest a thermoplastic ring to help hold the tendon down to the bone while it heals and surgery if you have an A2 and A4 uh rupture at the same time the A4 Rock fully rupture occurs in a different kind of grip the open hand grip it's also been reported in a major league pitcher as well but it's an acute pain or pop and it can also occur in the same mechanism as Jersey finger tenderness palpation will now be at the middle phalanx volarly and there'll still be pain with resisted fdp flexion but not with resisted fds ultrasound will show an increased tendon bone distance here and here this is normal this is torn and the other thing you can take away from this is the tendon is very straight and horizontal running from proximal to distal whereas here it's depressed by and held down by the pull overlying pulley again same treatments rest thermoplastic Rings taping same indications for Tears only with multiple pulley ruptures nail bed injuries are from trauma or Crush injuries the nail bed can appear bruised swollen lacerated there's all sorts of presentations with this uh adjacent cyst called mixoid cysts can occur the key though is to get an x-ray to look for a fracture and don't jump right to draining this ultrasound can also show injuries to The Nail Matrix that you don't see uh that's deep to the nail and the typical treatment once you've ruled out a fracture is aspiration of this with a needle and if the if there's a laceration deep to The Nail the nail might actually have to be removed suture it and then replaced if there is a fracture with the nail bed injury those usually those will require antibiotics because of high rates of infection but I think the main key here is don't train before rolling out a fracture because if you do you're turning a closed fracture into an open fracture and there's one other injury called a Seymour uh fracture and that's when a habit that's when you have a mallet deformity from a growth plate injury uh and nail bed injury uh that's pretty rare I believe and I think this is our last diagnosis on the list bowler's thumb it's a digital neuropathy that's common in Bowlers from compression by the thumb hole and it's the medial digital ulnar nerve of the thumb and you can have a positive Canal sign at that area numbness the first web space and this palpable mass and the mass is the neuroma because the uh the current chronic trauma to this area causes perineural fibrosis which can be seen on MRI this thickening here or on ultrasound stickening here these are treated well with uh kind of conservative treatments resting thumb guards or changing your grip to be less deep I guess and more in the uh you know ending at the uh IP joint but essentially it's it's very similar to a Morton's neuroma just up the thumb those are a lot of diagnoses we covered uh so trying to wrap my head around all of them uh it can be difficult so these this is just another way to think about it uh ones that are common for which sports and then the other way to think about it is you know where do certain these certain things present in what part of the hand uh how far distally dorsally all that early readily uh those are references and I'm sure hopefully we have some time for questions awesome thanks Eric uh that that was impressive that you covered when I saw the list of the number of diagnoses I was like there's no chance we cover this in an hour so uh good job I can um be confident that I think of any of uh of the fellows or anyone researching that has a question on wrist or hand pathology specifically hand on their tests that it was just covered in this talk so um solid job going over uh everything you have one question in the chat as of right now if anyone else has questions please uh put it in the chat function hour and we will we'll go through so uh question is from uh Evan looking at the ultrasound of the nail bed injury can the concerning findings explain the con explained a little more extensively what to look for in the injury to the Matrix yeah so I had some other image that I didn't put in here so one thing you can often see here uh you can't see this part of the nail right because it's covered by skin so that can allow you to see if there's like a fracture in in the nail bed and you can oftentimes you'll see cysts and fluid tracking out of it uh that's what can form a what's called a mixoid cyst uh you can also see fractures of the bone deep to the nail bed on ultrasound if you haven't yet you know gotten your X-ray okay um do you have a a sense of and I don't know the answer to this question either um how much I just can't recall from from our test which is now five or six years ago um how much ultrasound for some of these kind of wrist hand pathology how much ultrasound has has permeated into the test as far as an option for diagnosis I'm so not sure how much you know ultrasound has gotten to this point Beyond uh you know from a diagnosis standpoint yeah I think there's some I can remember I think if if a question is giving you options probably with MRI and ultrasound I would I mean I'd probably go to be safe with MRI but there there might be some where they just give you ultrasound as an option and don't put MRI in and in that case I I can remember that I think dequariums uh has been commonly tested with ultrasound uh obviously ganglion cysts there are certain things that they're they're going to say can be diagnosed without an MRI scaphil lunate I think that's probably more my personal choice and that's probably better assessed with a Mr arthrogram yeah I agree I think that for those of us that use a lot of ultrasound we would we would answer ultrasound do a lot of the questions but I think for the purpose of the caq if they give you another Advanced Imaging modality that that may be the the answer to the question is kind of similar to you know as as we go along and there's more and more that we can can do from a diagnosis and treatment standpoint with ultrasound kind of look at it the same as with biologics on the board exam I'm not sure it's got to the point where that is it's going to be the the most common answer to the question so uh just wanted to ask that as far as if you had a sense of that as well um any other questions from anyone in the audience so I'll give a few more seconds to to put one in there uh if so but you know to be honest Eric I think you you covered mostly everything and I think all of the high yield information that will be needed for the boards is is right here in this talk so uh please review it I may have rushed through some of it so feel free to when you're reviewing it press pause and spend a little more time on each slide yeah those um the last couple slides that you had with just those images as far as how it broke down between sports and also location oh yeah uh maybe like those last two slides do you know where they can possibly find those or or you know y'all can take screenshots of these as well but I think these are good breakdowns as far as you know if you have a question and it's talking about particular Sports I think just having an understanding of of which sports these injuries happen in um can be a cue and a good clue for for some of these questions that you might have as well yeah okay oh yeah a few I left on at the end there I don't think are necessary right um okay so no other questions that are uh that are in there now so we will wrap it up and it's a little bit after 9 30. so we'll wrap it up you know Eric thanks a lot for giving that talk there's a ton of information and again thanks super high yield as far as questions that are going to be on the board so thanks again for doing it for tackling a big topic we appreciate it and uh for everyone else uh have a good night thanks for having me Robbie