Wrist and Hand Injuries
From little fingers getting stuck in doors, to bigger fingers being bent back by baseballs, the hand and wrist are frequent sites both for acute injuries as well as overuse problems.
HAND AND WRIST ANATOMY
The hand and wrist are made up of many bones.
- Phalanges: Better known as the fingers, or digits. There are typically five digits, although many people can be born with 4 or 6. Finger fractures and dislocation are extremely common, and mroe information will be discussed below. The thumb has two phalangeal bones (proximal and distal phalanx), while each of the other fingers have three phalangeal bones (proximal, middle, and distal phalanx). The finger nail is located on the distal phalanx.
- Metacarpals: The metacarpal bones represent the middle portion of the hand in between the fingers (phalanges) and wrist. There are five metacarpal bones, as demonstrated in the diagram, and they are typically numbered 1-5, with 1 at the thumb and 5 at the pinky (aka small finger)
- Carpal Bones: There are a total of 8 carpal bones. They are less frequently involved in acute injuries except for the scaphoid bone which is located between the thumb and the forearm.
ACUTE WRIST AND HAND INJURIES
The scaphoid is the most commonly fractured carpal bone in children. Typically, it occurs as a result of a fall on an outstretched hand. While the wrist will typically not appear "crooked", it will be swollen, and your child will complain of pain at the base of the thumb. It is often confused as a “sprained” wrist. The blood supply to parts of this bone are more limited, and therefore, sometimes it is more challenging for this bone to heal with a cast alone.
Diagnosis: Typically an x-ray is all that is needed to make the diagnosis. However, there are times where the fracture can be difficult to visualize. It would not be uncommon to either repeat radiographs 1 week later, or proceed to a CT scan or MRI. Typically an MRI is preferred.
Treatment: If the fracture is closer to the thumb and your child is very young, the fracture likely to heal in a thumb spica cast without surgery. If the fracture is closer to the middle of the scaphoid or closer to forearm in areas with poor blood supply, the fracture may require surgery or extended casting
The Triangular Fibrocartilage Complex (TFCC) is a soft tissue complex located on the ulnar (pinky side) of the wrist that is involved with stabilizing the wrist joint. The TFCC is located between the carpal bones and the tip of the ulna bone (known as the ulnar styloid). These injuries can be acute or chronic. In the acute setting, TFCC injuries are typically due to falls on an outstretched hand in palm down position. It may be called a "wrist sprain". In the chronic setting, TFCC tears may also occur from overuse in high demand athletes like those participating in baseball, tennis, pole vaulting, or gymnastics
Diagnosis: Typically, the diagnosis can be made on a clinical history and physical examination. Radiographs are not as helpful except for ruling out other causes of ulnar-sided wrist pain. There may be a break of the ulna styloid in association with a TFCC tear. If the diagnosis is not as obvious, or the pain is not improving with traditional treatment methods, an MRI can be very helpful at making the diagnosis.
Treatment: Depending on the extent of the injury, treatment may include immobilization in a cast or splint, physical therapy, steroid injections, wrist arthroscopy, or sometimes open surgery. Please consult with your COA physician for further details.
A broken thumb usually presents with pain, swelling and/or bruising in the area. Radiographs are used to confirm the diagnosis. Treatment involves either setting the thumb (with or without pins) or merely immobilizing it with casting. Healing typicaly takes around 6 weeks.
Metacarpal fractures are characterized as articular (joint) vs extra-articular (not involving the joint) and by location (base, shaft, neck or head). Angular deformity ("crookedness") may be tolerated depending on which finger is involved. Typically, fractures of the 4th and 5th metacarpals can be allowed to heal more crooked vs fractures of the other metacarpals. This has to do with the increased flexibility in the hand in this area. While angulation is sometimes tolerated, rotational deformity is rarely tolerated.
Diagnosis: This is made with the physical exam along with an xray
Treatment: Typically, immobilization in a cast or splint for 2-3 weeks is all that is needed. If the fingers are not situated in a normal alignment, especially because of rotation, then surgery may be recommended. Other times when surgery may be recommended is if the fracture is open (compound), involve the joint and are displaced, or if the fracture is unable to be controlled by casting
Phalangeal (Phalanx) Fracture:
Dislocations of the phalanx can occur at any of the three joints along the finger including the metacarpophalangeal (MCP) joint, the proximal interphalangeal (PIP) joint, or the distal interphalangeal (DIP) joint. All dislocations will require some type of manipulation ("setting the finger") to put the joint back in place. Most of the time, this manipulation can be performed under sedation without making any incisions. In the rare circumstance, an incision may be necessary if the joint is "stuck" and just will not go back into its normal location. Once the finger has been set, short-term casting and/or splinting will be required.
CHRONIC WRIST AND HAND INJURIES
Ulnar Impaction Syndrome:
Separate from but may lead to TFCC injury (as mentioned above), ulnar impaction is one of the many causes of ulnar (pinky-sided) wrist pain. It typically occurs secondary to excessive loading of the wrist. Radiographs are helpful in the diagnosis, especially when comparing to other side. As with acute TFCC tears, treatment is often with bracing, injections, and physical therapy. Surgery is reserved for those children in which non-operative treatment fails
As the name implies, "gymnast wrist" is an overuse injury to the growth area of the radius bone near the wrist. It can occur in up to 40% of gymnasts, and is due to the enormous loads that a gymnast endures to this area with the wrist bent backwards (dorsiflexed), such as during vault and tumbling. It is not uncommon for this injury to occur when there is an increase in training hours, such as when moving from one competitive level to the next. Symptoms include wrist pain with impact activities. Sometimes, there are changes seen on radiographs, but typically, the diagnosis is made based on clinical history and physical exam.
Treatment involves a period of rest - i.e. avoiding pain provoking activities - in order for the growth area to heal. Wrist braces, such as "tiger paws" are particularly helpful with the symptoms. Return to sports can occur when symptoms permit.