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Wrist,-Hand-and-Finger-Injuries

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					Wrist, Hand and Finger Injuries
WITH ANDREW GARNHAM, MAUREEN ASHE AND PETER GROPPER

CHAPTER

19

T

he wrist and hand are frequently injured during sport.1 Sport-related injuries account for up to 15% of all hand injuries seen in accident and emergency departments.2 Upper extremity injuries are frequent; distal radial fractures are the most common fracture seen in emergency departments,3 and scaphoid fractures are the most common carpal fracture.4 Men are more likely to sustain a hand or wrist injury2 and children/adolescents are more likely to have a wrist injury compared with adults.5 Injuries to the hand and wrist range from acute traumatic fractures, such as occur during football, hockey and snowboarding, to overuse conditions, which occur in racquet sports, golf and gymnastics. Finger trauma is common in ball-handling sports and rock climbing. If wrist, hand and finger injuries are not treated appropriately at the time of injury, they can lead to future impairments that can affect not only sporting endeavors but also activities of daily living.6 In clinical practise, patients can present with either an acute wrist injury (usually as a result of a fall onto the outstretched hand) or because of longer-term (chronic, or subacute) wrist pain. When pain has been ongoing, it may have developed gradually, or there

may be a clear history of a past injury. We address each of those presentations in major sections. We then discuss conditions that affect the hand and fingers.

Acute wrist injuries
The wrist joint has multiple axes of movement: flexion–extension and radial–ulnar deviation occur at the radiocarpal joints, and pronation–supination occurs at the distal and proximal radioulnar joints. These movements provide mobility for hand function. Injuries to the wrist often occur due to a fall on the outstretched hand (FOOSH). In sportspeople, the most common acute injuries are fractures of the distal radius or scaphoid, or damage to an intercarpal ligament. Intercarpal ligament injuries are becoming more frequently recognized and, if they are not treated appropriately (e.g. including surgical repair where indicated), may result in long-term disability. The causes of acute pain in this region are shown in Table 19.1. The anatomy of the wrist and hand is complex, therefore, a thorough knowledge of this region is essential to diagnose and treat sports injuries accu-

Table 19.1 Causes of acute wrist pain Common Distal radius fracture (often intra-articular in the athlete) Scaphoid fracture Wrist ligament sprain/tear Intercarpal ligament Scapholunate ligament Lunotriquetral ligament Less common Fracture of hook of hamate Triangular fibrocartilage complex tear Distal radioulnar joint instability Scapholunate dissociation Not to be missed Carpal dislocation Anterior dislocation of lunate Perilunar dislocation Traumatic ulnar artery aneurysm or thrombosis (karate)

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CHAPTER 19 WRIST, HAND AND FINGER INJURIES

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rately (Fig. 19.1). It is helpful to know the surface anatomy of the scaphoid tubercle, hook of hamate, pisiform, Lister’s tubercle and anatomical snuffbox. The bony anatomy consists of a proximal row (lunate, triquetrum, pisiform) and a distal row (trapezium, trapezoid, capitate, hamate), which are bridged by the scaphoid bone. Normally, the distal carpal row should

be stable; thus, a ligamentous injury here can greatly impair the integrity of the wrist. The proximal row permits more intercarpal movement to allow wrist flexion/extension and radial and ulnar deviation. Here a ligamentous injury disrupts important kinematics between the scaphoid, lunate and triquetrum, resulting in carpal instability with potential weakness and impairment of hand function.

2nd MC 1st MC trapezium trapezoid scaphoid radius 5th MC capitate hamate triquetrum pisiform lunate ulna

adductor pollicis brevis muscle carpal tunnel flexor carpi radialis tendon

hook of hamate pisiform palmaris longus

(c) Surface anatomy, volar view

Figure 19.1 Anatomy of the wrist (a) Carpal bones (MC = metacarpal)
fibrous flexor sheaths 1st dorsal interosseous

lumbricals opponens digiti minimi adductor pollicis flexor pollicis brevis abductor pollicis brevis flexor carpi radialis brachioradialis tendon flexor pollicis longus flexor digiti minimi brevis abductor digiti minimi pisiform palmaris longus
(cut)

tendon of extensor pollicis brevis anatomical snuffbox radial styloid lunate

extensor digitorum tendons ulnar styloid

flexor carpi ulnaris flexor digitorum superficialis & profundus

(b) Surface anatomy, dorsal view

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