Hand injuries are a common occurrence in impact sports and often under-appreciated on the field of play. Whilst there is tendency to \u201crelocate\u201d or \u201cstrap up\u201d and play on with a hand injury – early diagnosis, immediate care and treatment can help to preserve function in athletes.<\/p>\n
| \n Is this an acute or chronic injury?<\/p>\n<\/td>\n<\/tr>\n | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| \n Key questions<\/p>\n<\/td>\n | \n How will it help me ?<\/p>\n<\/td>\n<\/tr>\n | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| \n Is the wound open ?<\/p>\n<\/td>\n | \n Early antibiotic treatment, closure +\/- exploration<\/p>\n<\/td>\n<\/tr>\n | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| \n Is there a possible fracture ?<\/p>\n<\/td>\n | \n Arrange X-ray imaging<\/p>\n<\/td>\n<\/tr>\n | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| \n Is this a flexor or extensor tendon injury ?<\/p>\n<\/td>\n | \n This can help to assess timelines for healing<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n Table 1. Key considerations<\/p>\n Taking a clear acute injury history from the player can help you to diagnose and plan treatment early on after presentation. It will also help to guide your referral.<\/p>\n
Figure 1. Anatomy of extensor and flexor tendons, alongside some common injuries<\/span><\/i><\/p>\n Figure 2.<\/span><\/i> Extensor tendon anatomy<\/span><\/p>\n Figure 3.<\/span><\/i> Common extensor tendon injuries<\/span><\/p>\n Figure 4.<\/span><\/i> Flexor tendon anatomy<\/span><\/p>\n Figure 5.<\/span><\/i> Ultrasound scan of digit.<\/span><\/p>\n Table 2.<\/span><\/i> Breaking down extensor and flexor hand injuries.\u00a0<\/span><\/p>\n Mechanism of injury<\/b><\/p>\n Hand tendon injuries are common in both sporting patients and those undertaking recreational activities (DIY) or manual professions that put their hands at risk. Although ball sports <\/span>(football, rugby, basketball, cricket, baseball) <\/span>\u00a0are the most reported <\/span>sports for these injuries, they are also seen in contact and combat sports such as martial arts and boxing.\u00a0<\/span><\/p>\n In ball sports the fingers are typically exposed to sudden impacts or unsupported forced movements (1) whereas, direct blows or forced grip injury mechanisms are more predominant in contact sports. Manual professionals or those working with sharp tools, may be at risk of lacerations that can cause tendon ruptures and significantly impair grip, fine motor control and dexterity.<\/span><\/p>\n Recognising the mechanisms of injuries early and potential structures involved is key to preventing chronic disability (2) and involves an MDT approach.\u00a0\u00a0<\/span><\/p>\n Injury<\/p>\n<\/td>\n Mechanism \/ Force<\/p>\n<\/td>\n Typical Deformity Seen<\/p>\n<\/td>\n Healing Timeline<\/p>\n<\/td>\n<\/tr>\n Finger<\/p>\n<\/td>\n Forced flexion of extended DIP (e.g. ball striking at the fingertip)<\/p>\n<\/td>\n Drooping fingertip (loss of DIP extension)<\/p>\n<\/td>\n Splint DIP in extension for 6\u20138 weeks<\/p>\n Surgery if sub-luxed or large fragment<\/p>\n<\/td>\n<\/tr>\n Dislocation<\/p>\n<\/td>\n Axial load, hyperextension or twisting<\/p>\n<\/td>\n Finger angulated, obvious deformity, severe pain<\/p>\n<\/td>\n Closed reduction follow up buddy taping or splinting,<\/p>\n Surgery if unstable<\/p>\n *XRAY ( pre- and post-reduction)<\/p>\n<\/td>\n<\/tr>\n Jersey finger<\/p>\n<\/td>\n Forced extension while actively flexing (e.g. grabbing jersey)<\/p>\n<\/td>\n Inability to flex DIP (finger remains extended)<\/p>\n<\/td>\n Surgery ideally <10 days followed by 12+ weeks rehab<\/p>\n<\/td>\n<\/tr>\n Boutonniere<\/p>\n<\/td>\n Forceful blow to dorsal PIP joint while finger is flexed<\/p>\n<\/td>\n PIP flexion + DIP hyperextension<\/p>\n<\/td>\n Splint PIP in extension for 6 weeks.<\/p>\n Surgery if chronic or displaced<\/p>\n<\/td>\n<\/tr>\n Trigger finger<\/p>\n<\/td>\n Repetitive gripping, stenosing tenosynovitis at A1 Pulley<\/p>\n<\/td>\n Painful locking\/catching on flexion<\/p>\n<\/td>\n Weeks\u2013months (conservative),<\/p>\n Consider Steroid injection<\/p>\n A1 pulley release if refractory<\/p>\n<\/td>\n<\/tr>\n Extensor hood \/ sagittal band rupture<\/p>\n<\/td>\n Forced flexion against resistance, or direct blow (e.g. boxer\u2019s knuckle)<\/p>\n<\/td>\n Extensor tendon subluxation\/instability at MCP<\/p>\n<\/td>\n 6\u20138 weeks splinting,<\/p>\n Surgery if unstable<\/p>\n<\/td>\n<\/tr>\n Flexor tendon injury<\/p>\n<\/td>\n Laceration, forced extension, crush<\/p>\n<\/td>\n Inability to flex affected joint(s)<\/p>\n<\/td>\n Surgical repair \u2192 12 weeks+ rehab<\/p>\n<\/td>\n<\/tr>\n Volar plate injury<\/p>\n<\/td>\n Hyperextension at PIPJ<\/p>\n<\/td>\n Swelling, PIP instability, hyperextension<\/p>\n<\/td>\n 4\u20136 weeks splinting, progressive rehab<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n Table 3. Common injury patterns seen in the Emergency Department<\/p>\n<\/div>\n The Patient’s journey from injury to treatment usually involves care at the pitch side (where medical assistance is available) or presentation at the Emergency Department. It is important that immediate treatment is provided to stabilise the injury, start treatment (in suspected open fractures), and assess for neurovascular compromise.<\/p>\n DIP \u201cdroop\u201d (cannot actively extend).\u00a0<\/span><\/p>\n Swelling or tenderness to the DIP in Acute cases (often absent in chronic cases) but a <\/span>persistent extensor lag will be evident.<\/span><\/p>\n Imaging\u00a0<\/b><\/p>\n X-ray<\/b>: A 3-view radiographic series (anteroposterior, oblique, and true lateral) is recommended.<\/span><\/p>\n US<\/b>: extensor tendon discontinuity (consider where available)\u00a0<\/span><\/td>\n The patient will be asked to extend their finger whilst their finger is at the edge of a table. If the patient is unable to fully extend their finger independently, it indicates a mallet finger injury.<\/p>\n Pain and tenderness of the volar aspect of the injured finger\u00a0<\/span><\/p>\n Ask patient to make a fist \u2192 affected DIP won\u2019t flex. \u201cSweater\/Jersey sign.\u201d<\/span><\/p>\n Imaging\u00a0<\/b><\/p>\n X-ray<\/b>: <\/span>Plain radiographs to rule out fractures<\/span><\/p>\n US<\/b>: To assess for tendon retraction in both acute and chronic cases without fracture\u00a0<\/span><\/p>\n \u00a0\u00a0<\/span>\u00a0MRI<\/b> is rarely performed but can be used\u00a0 \u00a0 to determine the increased tendon-bone distance more accurately.<\/span><\/td>\n The clinician holds the patient’s proximal interphalangeal joint (middle joint) in full extension and asks the patient to bend (flex) the Distal Interphalangeal joint (DIP)<\/p>\n Intact FDP: If the patient is able to flex the DIP, the FDP is intact<\/p>\n Ruptured FDP: If the patient is unable to flex the DIP, the FDP if likely ruptured<\/p>\n <\/p>\n Pain and swelling of the PIP\u00a0<\/span><\/p>\n Elson\u2019s test<\/span>:<\/b> flex PIP over table, resist extension \u2192 weak at PIP, DIP hyperextends.<\/span><\/p>\n Inability to actively straighten the middle joint of the finger.<\/span><\/p>\n Imaging\u00a0<\/b><\/p>\n X-ray<\/b>: exclude fracture.\u00a0<\/span><\/p>\n US\/MRI<\/b>: central slip disruption, extensor hood injury.<\/span><\/td>\n The patient will rest their finger at the edge of the table, with the affected proximal interphalangeal joint (PIP) resting in 90 degrees flexion. The clinician presses on the middle phalanx. The patient is asked to extend their PIP against the clinician finger.<\/p>\n Positive test: The patient has a weak PIP and the DIP becomes rigid and or even hyper extension. This indicates the an injury to the central slip due to the extension force travelling to the lateral bands and extending the DIP<\/p>\n Negative test: The patient can extend the PIP against resistance and the DIP joint remains floppy and flexible suggesting the central slip is intact.<\/p>\n Palpable nodule at A1 pulley. \u201cLocking\/catching\u201d on flexion-extension cycle.<\/span><\/p>\n Imaging\u00a0<\/b><\/p>\n US : <\/b>dynamic ultrasound<\/span> can be used to look for tendon thickening and dynamic bunching underneath pulley<\/span><\/td>\n The clinician will ask the patient to move their finger to feel for any locking or catching. The clinician will feel the base of their finger or thumb to check for a palpable lump. The clinician may also try to passively extend or flex the finger to see how the tendon moves.<\/p>\n <\/td>\n<\/tr>\n Extensor tendon subluxation when flexing\/ extending MCP.\u00a0<\/span><\/p>\n Pain\/tenderness sagittal band.<\/span><\/p>\n Imaging\u00a0<\/b><\/p>\n US\/MRI<\/b>: discontinuity or subluxation of extensor tendon over MCP.<\/span><\/td>\n The patient will rest their at the edge of the table, with the affected proximal interphalangeal joint (PIP) resting in 90 degrees flexion. The clinician presses on the middle phalanx. The patient is asked to extend their PIP against the clinician finger.<\/p>\n Positive test: The patient has a weak PIP and the DIP becomes rigid and or even hyper extension. This indicates the an injury to the central slip due to the extension force travelling to the lateral bands and extending the DIP<\/p>\n Negative test: The patient can extend the PIP against resistance and the DIP joint remains floppy and flexible suggesting the central slip is intact.<\/p>\n Ask for isolated PIP\/DIP flexion \u2192 loss suggests FDS\/FDP injury.\u00a0<\/span><\/p>\n Assess neurovascular status.<\/span><\/p>\n Imaging<\/b><\/p>\n US \u2013 <\/b>loss of tendon<\/span> continuity<\/span><\/p>\n XR <\/b>\u2013 to rule out fracture\u00a0<\/span><\/td>\n The clinician holds the other three fingers in full extension to prevent the flexor digitorum profundus from working.<\/p>\n The patient is asked to flex their finger at the PIP joint.<\/p>\n Positive test: If the PIP does not bend or bends poorly it suggests an injury to the FDS.<\/p>\n Negative test: If the PIP joint flexes and the DIP remains lax or straight, it suggests the FDS is intact.<\/p>\n Jersey Finger Test (FDP):\u00a0<\/b><\/p>\n The clinician holds the patients proximal Interphalangeal joint (middle joint) in full extension and asks the patient to bend (flex) the Distal Interphalangeal joint (DIP)<\/p>\n Intact FDP: If the patient is able to flex the DIP, the FDP is intact<\/p>\n Ruptured FDP: If the patient is unable to flex the DIP, the FDP if likely ruptured<\/p>\n Tender at volar PIP, instability with hyperextension stress test.<\/span><\/p>\n X-ray<\/b>: avulsion fragment, joint subluxation.\u00a0<\/span><\/p>\n MRI<\/b> if uncertain ligament\/volar plate injury.<\/span><\/td>\n The clinician will apply directed force to test for instability. Increased laxity or a gross dislocation during the force suggests a tear or avulsion to the volar plate.<\/p>\n Table 4. Common tendon injuries,\u00a0 their clinical findings and relevant imaging.<\/p>\n Remember:<\/strong><\/p>\n Is there an open wound or visible tendon?<\/span><\/p>\n Is there loss of extension or flexion?\u00a0<\/span><\/p>\n Figure 6<\/span><\/i>. Key questions for hand injuries<\/span><\/p>\n Figure 7.<\/span><\/i> Flowchart of flexor or extensor tendon injuries<\/span><\/p>\n Figure 8.<\/span><\/i> Management of common flexor and extensor hand injuries<\/span><\/p>\n When to Image<\/strong><\/p>\n —————————————————————————————————-<\/span><\/p>\n Red Flags – Urgent Hand Surgeon Referral\u00a0<\/strong><\/p>\n Clinical Assessment and Imaging<\/b><\/p>\n When hand injuries present to the Emergency Department – a concise history that includes the mechanism of injury, handedness, and sporting\/occupational demands is advised. If there is a suspected fracture then plain film x-ray imaging in at least two views to rule out bone involvement (fractures, dislocations and subluxations) is essential<\/span><\/p>\n Checklist for hand injuries presenting to the Emergency department.<\/span><\/p>\n –<\/span> \u00a0 <\/span> History including mechanism of injury, handedness, hobbies<\/span><\/p>\n –<\/span> \u00a0 <\/span> Washout of wound (if present)<\/span><\/p>\n –<\/span> \u00a0 <\/span> Clinical examination<\/span><\/p>\n –<\/span> \u00a0 <\/span> Plain film x-rays (rule out concurrent bony injury)<\/span><\/p>\n –<\/span> \u00a0 <\/span> Discussion with hand surgery team<\/span><\/p>\n *(Plastics surgery or Orthopaedic surgery depending on local expertise) for further investigation and surgical planning within 24 hours.\u00a0 (BSSH, 2024).\u00a0<\/span><\/p>\n A focussed hand specific clinic assessment (table 4) can help to rule in or out complete ruptures but is less sensitive for (partial tears). Where a closed tendon rupture is suspected and the clinical exam is uncertain, imaging can help to confirm a diagnosis. MRI is the gold standard imaging for closed tendon injuries and has good sensitivity, but US is generally preferred as it allows the benefit of dynamic assessment of tendons, locating retracted tendon ends and more chronic conditions, such as tendinopathy or tendinosis (Figure 1-2).<\/span><\/p>\n Open injuries do not often need imaging and are usually explored surgically. Ideally, tendon injuries should be repaired within 4 days of the injury (BSSH, 2024) and if an US scan is not available during this time frame, then it is better to continue with surgical exploration +\/- repair.<\/span><\/p>\n Figure 9<\/span><\/i>. Ultrasound images of various tendinous pathologies.<\/span><\/p>\n Definitive Management<\/b><\/p>\n Treatment options differ slightly depending on the mechanism of injury. General rule of thumb is that traumatic tendon injuries, tendon injuries with fractures and tendon injuries that have failed conservative management require surgical repair. Tendon rupture requires surgical intervention called a <\/span>primary<\/b> repair<\/b>. More complex cases with missing tendon or post-operative complications may need a <\/span>tendon transfer<\/b> or a <\/span>two-stage repair<\/b>.<\/span><\/p>\n Table 5.<\/span><\/i> Definitive management of common extensor and flexor injuries<\/span><\/p>\n <\/p>\n Peripheral Nerve Blocks<\/b><\/p>\n Equipment<\/b><\/p>\n Equipment: 10mL syringe, 10mL lidocaine 1% vial, skin preparation wipes, drawing up needle, small needle (e.g 25G)<\/span><\/p>\n General Tips<\/b><\/p>\n –<\/span> \u00a0 <\/span> Needles are always inserted perpendicular to the skin surface<\/span><\/p>\n –<\/span> \u00a0 <\/span> |
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