Orthopedic surgeon Nikki Schroeder, MD, chief of UCSF’s hand, elbow and upper extremity service, shows providers how to pinpoint the problem when patients present with elbow, wrist or hand pain. Offering helpful flowcharts and diagrams, she notes how injuries are typically characterized, describes quick in-clinic tests to expedite diagnosis, and advises on appropriate counseling with regard to recovery and return-to-play.
All right. Hi. Good afternoon, everybody. Um, and thanks for coming. It's a pleasure to be here today to speak to you all. Um, I just wanna introduce myself. My name is Nikki Schroeder. I'm, uh, Part of the um chief of hand and upper extremity at UCSF, um, and, um, have given several of these talks over the past few years. But today, um, what I really wanted to focus on was sports injuries of the elbow, wrist, and hands. Um, and please feel free to unmute yourself, uh, interrupt me, ask questions at any point in time. If there's something that I went over too fast or something that you want me to go over, um, in more detail, please feel free to just ask and interrupt me. I'm completely fine with that. Um, and just one thing that I know that, uh, you all are San Francisco based, but, um, to let you know, kind of the exciting things that are happening in our hand pod is that, um, we actually now see patients at Redwood Shores. So Doctor Shapiro sees patients at Redwood Shores, and we also have expanded to Marin. So we're seeing, uh, patients in San Rafael at our clinic out there. So we are expanding to the Bay Area and we have, um, two new providers that started this fall, and we actually have One more new provider that we're just in the process of hiring that will be seeing patients in the East Bay starting this fall. So, that being said, we will move on with sports injuries of the elbow, wrist, and hand, and I have overall nothing to disclose. But, um, when I think about kind of what are the most common things that we see in terms of elbow, hand, wrist, Um, you can see the list of here. We'll talk a little bit about the elbow first and then we'll move down to the wrist, um, and hand to talk about injuries that I typically see when I see sports patients in our clinic. Um, so in order to get started, I think it's always uh pertinent to talk about the history when you think about somebody that comes in with an upper extremity injury. And typically when you come to a hand clinic, it's age, hand dominance, and occupation or sport. Um, and that's always pertinent to how we think about when we're treating patients only, only for the reason that sometimes, you know, if it's a professional athlete that we're treating, we have to figure out how to get them back to sport as soon as possible or Um, you know, if it's a pianist, we treat them a little bit differently than somebody that, let's say, you know, isn't working. Um, and so we start with age, hand dominance, occupation, and then really it's timing and mechanism of injury. And so what I, what I always tell my residents is you need to be really specific about the mechanism because oftentimes that actually dictates what else is injured, um, or the pattern of injury and shows us what else could be associated with the injury that we see on an X-ray or we see on an MRI, etc. Um, and so we do wanna know if it's a twisting, if it's a traumatic event, if it's just recurrent impact, um, and then when exactly it happened. And certainly, this is really pertinent in terms of if it's a traumatic injury, the date, obviously, but, um, when you think about other things in terms of you're seeing somebody like a pitcher, um, we wanna know what phase of throwing are they having pain in because that can actually help point to where the injury is. Um, location, one of the best things about hand is everybody, or almost everybody has two hands, and so we usually tell them to take one finger and point to the area that hurts. Um, that really helps us conne in on where the pain is or where the pathology is that we're looking at and how it affects their performance, because oftentimes it's really maybe it's just stiffness or maybe it's that their pitches are a lot slower or maybe that they don't get enough repetitions. Um, or maybe that they can't do certain things if they're gymnasts. So those are always good questions to ask and then obviously, how long it's been going on for, and then the typical questions that you ask for everything, is there anything that alleviates it or aggravates it? Um, when we think about elbow injuries, I think it's always pertinent to just review an elbow X-ray first. Um, and you can actually look at elbow X-rays and oftentimes you can look at, you know, hand, wrist, foot, whatever your, whatever pathology you're kinda looking for. And some of it will actually help you determine what, um, the cause of the injury is or, you know, what they might be complaining about. So when you think about it, if you look at the olecranon, and most lecranon is best visualized in the lateral. Um, you can see some osteophytes there that can be associated with valgus extension overload injuries, which you'll see in pictures. Um, they get the medial osteophytes from the, from pitching. Um, coronoid, which is the front of the elbow, um, you can see instability related to trauma, so typically a fall on an outstretched hand, which can cause elbow dislocations or elbow fracture dislocations. Um, the capatellum, uh, is the area right here that articulates with the radial head. Um, you can see OCD lesions like in pictures or in young children who are pitching. They'll get, um, chondral defects in the bone here. Um, and then the radial head, you can sometimes see this is a radial tuberosity where the biceps inserts and so you can see, um, some periosteal reaction associated with biceps tendonitis or you may see some swelling along the tendon on a lateral X-ray. And then in for, if you're evaluating epicondylitis, um, you can look at the medial and lateral epicondyle and typically on an X-ray, you don't see very much. Um, sometimes you can see some soft tissue swelling associated with it. Um, but that's really all that you will see on X-ray. Um, every once in a while, you can see some calcifications in like a chronic epicondylitis where maybe the, um, extensor of the flexor mechanism has pulled off and you may see some calcifications right there. So, a review of your anatomy. Um, remember that the elbow has, uh, a medial side and a lateral side, and they both help with the stabilization. Um, and when we talk about the MCL, which is on the medial side, there's the three bundles, the anterior being the most important. It's a valgus stabilizer and often can get injured in pitchers. You can see the injuries in tennis players. Um, and then the lateral side is the varus stabilizer. Um, and you see that most often in posterolateral rotary instability. So you see this oftentimes in traumatic elbow injuries like a fallen outstretched hand, and it's usually a pattern that starts from the lateral side of the elbow, works its way around the back, and then you can see a dislocation, and it can continue around to the medial side of the elbow in a really bad elbow fracture dislocation. But you can see, and I'll show you some images of this. You'll see it in trauma. Um, you can see it in break dancers when they dislocate their elbow. So first off, I want to talk about distal biceps ruptures. So you oftentimes will see it in strength training or weightlifting, bodybuilding, or any type of contact sports, and this is what it's sports related. Oftentimes, and probably more common than actually sports related, it'll be like a single traumatic event, like a sudden extension force applied to a flexed stubinated arm. Um, and you'll see this in people who, um, are like lifting heavy objects. So oftentimes we see this in like the weekend warrior, 40 to 60 year old male who's out there like moving something heavy, and they're lifting it up and it's very heavy, like moving a refrigerator or helping to move boxes, and they feel a sudden pop. Um, and it's the same kind of pop that they often say that they feel if you like rupture your Achilles. Um, risk factors for this. The really only main risk factor is the use of anabolic steroids. So that's why you oftentimes will see it in weightlifters or bodybuilders. Um, and then, uh, it can be associated with nicotine use. So, what's important to know is that spontaneous rupture of a tendon is usually preceded by degenerative changes in the tendon. So it's usually not just this like one acute event. It's that there's been some slow degeneration. So if you actually ask the patient, you may find out that they say, well, it was kind of bothering me intermittently for a while, and then one day I heard this pop. Um, And so what you can see here, this is an MRI. This is a sagittal MRI, so looking at the cuts from the side, and this is proximal and down here is distal. And so, what you'll typically see here, this is the humerus, and this is the biceps tendon with all this fluid around it. So not only has it ruptured, but then it's retracted and it's retracted far up. So that often does happen when it ruptures is that it kind of pops up the elbow. So you'll, the history is audible pop and weakness, and they'll, not, not that they'll tell you this, but they're mainly weak in supination cause if you remember, the biceps also helps with supination. And then, on physical exam, you can expect to see an acute injury. You'll see a lot of swelling in the forearm, um, particularly kind of right around the antecubital fossa or the front of the elbow. Um, in terms of exams that can be done, you can do the hook test, which is that with the elbow flexed, you should be able to take your index finger and grab right around the distal biceps, and you can try this on yourself. You should be able to do that and actually palpate that biceps as it's crossing the elbow and Pull it up. Now, the bicipital aponeurosis flex test, if you actually only flex your elbow about 70 degrees, the biceps, while it does go down and continues to insert on the biceps tuberosity, the aponeurosis is actually much more superficial, um, Uh, structure. And so you can actually with flexed about 70 degrees, you can also, it's just distal to the elbow, you can grab there and feel it. And so, if you don't feel either of these, you can be concerned for a, um, biceps rupture. And so you can assess this by getting an MRI here, um, more frequently, uh, people are getting ultrasounds as well, which can actually help to assess for this cause you can actually track the biceps and the biceps tendon all the way down to the biceps tuberosity. And then it's just acute or chronic. Um, treatment, so the way that we kind of think about managing these, so when you see these patients in clinic, typically in the athlete it's surgical, um, non-op, if you don't treat these with surgery, you can actually have a loss of your supination strength by up to 40%, which is a lot. Um, and a loss of flexion strength by about 30%. So that's oftentimes why you have discussions in the kind of younger population, yeah, we definitely should fix this. And then as you get into the, you know, older than like 60, then you, you talk to them about, you know, well, you may have a loss of supination and you may have, you know, some flexion strength loss. But the other thing is you can see here is this is actually a pretty long rehab. There's 3 phases of recovery and so, um, typically at the beginning, you're in an elbow brace and you're working on elbow flexion and, but not full extension. Um, and then, um, so you're allowed to do full flexion but not full extension, and you slowly increase extension. So it's about a 6-month recovery, right, where the kind of the most, the most, um, happens in the 1st 6 to 8 weeks, but you do tell people that you're not back to strengthening until at least 4 months. And just so you can kind of see what a biceps looks like, this is the incision. So over here, up here would be the shoulder, here would be distal. It's typically, um, you make this incision here if it hasn't retracted too far. If we have to cross the elbow crease, you usually cross it in line with the elbow and then come up proximally. And sometimes they retract pretty proximal, and the longer from the injury to the time of surgery, oftentimes not only will they retract, but they will scar down and you end up having to make a much bigger incision. And so what we go in and we try and go in safely and grab the tendon, as you can see the tendon here. Um, and you certainly worry about the nerves. So the, um, there's some cutaneous nerves that you worry about, um, uh, when you make your skin incision. And then, as you can see from the tendon here that it's not just like a clean tear. There's some degenerative changes. And so oftentimes, you actually have to clean off the end before you reattach it. So moving on to elbow dislocations, um, when we think about elbow stability, um, there's bony stability, and then there's the ligaments that we talked about before. And so you have the anterior bundle of the medial collateral ligament, which is the most important. You have the lateral collateral ligament. Um, and then you have the ulnar humeral articulation where, um, the ulna meets the humerus, and then you have your radial humeral articulation, and then you have your soft tissues which are kind of the dynamic stabilizers. So they form this kind of capsule. Um, and you can see that this is kind of your classic, it's a fall on the outstretched hand, and you can see what's happening here is, you know, the elbow is dislocating. Um, or you can see somebody that has presented to the emergency room with a posterior elbow dislocation. Um, and you can see here. So, again, remember when we talk about X-rays, we talk about the distal bone relative to the proximal bone. So that's why this is considered a posterior elbow dislocation. Um, and you can see this is most likely a simple dislocation cause it's posterior. You obviously need to see the AP as well, which is the front view. Um, but what happens is, you know, if you're gonna reduce this, you're basically kind of pulling on the elbow and pushing from the back to reduce it. Once it's reduced, the question is, is this elbow stable? Cause most elbow dislocations are simple. They happen, they pop back in, and they're stable through a full range of motion. But kind of what's your assessment when you see somebody in clinic is like, yeah, I was seen in the emergency room last night and I dislocated my elbow and I've been in a splint. What we need to do is we need to see them and take them through a range of motion to see if the elbow is stable. So, oftentimes, we'll take them under our, a live X-ray fluoro machine. And take the elbow through a full range of motion and take a look at it on a lateral view. So kind of looking at it like this, to make sure that through that full range of motion, they're stable. Because if they are stable, then we start them moving somewhere around 5 days, 5 to 7 days, because if you leave an elbow in a splint or a sling and tell them not to move, it just gets stiff. So, it's really important to make sure it's stable so that we can get them through a range of motion. One of the things also is, is the elbow congruent on X-rays. So if you guys read an X-ray report, if you look at an X-ray and it says, That they never, you know, the, the joint doesn't look congruent. What that should kind of ding in your head is like, gosh, I bet there's a, a ligament injury, something that we need to assess that might be surgical. And so as you can see here, when you look at the lateral, the elbow, here's the humerus, here's the ulna. And so you can see that there's kind of a nice congruent circle that you can see. However, you know, here's an elbow dislocation. It's the same one as the one before. It's been reduced. But then you look here and see if you can follow this line around. It's not congruent, right? There's not that kind of small circle that you saw on the one previously. So this makes you think, is there a ligament injury? This is not Not a congruent elbow. This is something that we would probably take under floral or get an MRI to assess kind of what the injury is. Is it just a lateral collateral ligament that needs surgery? Is it a lateral and a medial collateral ligament? But these are the kind of things that you should think about when you see somebody in clinic. Gosh, I got the, I need to get them in to see somebody. But also, is it something that I might need to get an MRI on because the um X-ray or the X-ray report shows that the joint is incongruent. And you can see the kind of the difference. So on the right side, you can see the concurrent joint. On the left side, it's not congruent. And while this is a lot of wording, I think it's actually a really nice diagram to kind of show you what we think about when we go through that algorithm of the elbow. If it's reduced and stable, great. Let's get him moving. If it's reduced and stable, can we keep him in a stable arc? If the answer is yes, then you can start therapy. If the answer is no, then we need to go ahead and repair it. And obviously, if it's unreducible, then they go to surgery. So when we talk about rehab briefly, one of the things in terms of getting people moving early is avoiding various loads. So we basically don't let them abduct their arm up to 90 degrees. They can do all kinds of motion in the forward plane, and they can even get it up over their head to do it. And those are great ways, and that's gravity loaded elbow rehab that you see in these two pictures below. So, ulnar collateral injuries, the lateral ulnar collateral injuries, the pivot shift test, it's really hard to kind of demonstrate here, but this is done on a patient. So, if you see somebody who's like, God, I dislocated my elbow a while ago, and, you know, every time I get myself up from a seated position, I kind of feel a pop in my elbow where I feel really unstable and I just don't want to do it, that usually means that they have some type of ligament injury in the elbow. And what we do in clinic, if we can get them to relax enough is to lie down, flex their elbow, um, and then we do the, a pivot shift test. And I think you can see it really well in this image here, but this is what a pivot shift test will look like. As you can see, as you bring them into flexion and then subsequently into extension, that's a radial head popping in and out. And so that tells you, and I'll play it one more time just so you can kind of appreciate it. And you can, you can honestly, if you have somebody who doesn't have a lot of pain when this happens, you may sometimes see this in clinic cause they'll show it to you. They're like, I don't know, my elbow's popping in, and they'll push themselves up from a seated position, and if you look at the outside of the elbow, you can see this happening. On the flip side, so that's a surgical. You know, that's something that we say, yes, we need to do surgical reconstruction. On the flip side, the medial ulnar collateral injury. So, remember, the medial side, the primary stabilizer to valgus stressing. So, you see a lot of injuries in pictures, as you can see here, and it's in the late cocking phase when they're back like this that puts stress on the medial side of the elbow. And so they may say they have an acute pop like that they felt or heard during overhead throwing, but oftentimes this is a chronic kind of injury of overuse, and they'll say, I just, you know, I'm losing speed. For a professional athlete, you may start to see that, you know, like the trainer or whoever has come in with, with you says that the patient has lost speed in pitching or they have like less control. So you check range of motion, you look at their shoulder cause oftentimes they have limited internal rotation, so they'll get very stiff at internal rotation. Um, and then they'll be tender on the medial side of the elbow. Now, the milking maneuver, so, what we're trying to do is to reproduce that instability. And so, there's a couple ways that we could do that. This is the moving valgus stress test. So, the provider is holding the thumb, and then the arm is up like this and out to the side. And basically, you're flexing and extending the elbow, and you have your hand over the medial side of the elbow. And you'll feel it kind of open up as you do that. And so, that's the moving valgus stress test, as you can see in this picture here. Um, And so that's another surgical reconstruction where we typically take the patient to the, it's the like Tommy John procedure that you've probably heard about. So lateral epicondylitis, and this is way more common, um, and particularly, I'm sure you guys are seeing a ton of this, um, particularly during COVID and like the poor ergonomics of working from home, we tend to see a lot of repetitive stress or strain that is in, you know, comes in either as cubital tunnel, carpal tunnel, lateral epicondylitis, medial epicondylitis, really bad ergonomics. So number one is, um, get them an ergonomic assessment, um, and start them on some physical therapy to work on, you know, better ergonomics. Um, but lateral peondylitis, also known as tennis elbow, is one of the most common overuse injuries. Um, and it's actually a tendinosis of the components of the extensor origin. So when I, you know, it's not really even an itis cause itis implies inflammation. Um, what this is, is a tendinosis. So basically, it's like Repetitive overuse, where the extensor tendon is inserting on the lateral aspect of the elbow. Over time, with a repetitive pull and strain, um, that you get from a repetitive wrist extension, the tendons kind of pull off the bone and then they just don't heal down. So it's not an itis, it becomes an osis. And when you look at this tissue, the tissue kind of looks gross. It looks almost snotty is how I explain it when I operate on it and tell patients about it. Um, but the tissue isn't as strong as it used to be. So from an epidemiology standpoint, it's pretty common, but it's about equal to male and female. It doesn't happen very often in tennis players. They really compromise very little of people that come in with tennis elbow. Only about 5% is attributed to playing tennis, but if you play longer and longer, um, you may, you have an increased risk of about 2 to 3.5%. Um. It is associated with harder surfaces, poor stroke mechanisms, and improper grip and racket weight. So kind of one of the first things if you see somebody that is playing tennis and they're saying, I have a tennis elbow, you know, yes, most likely it can be related to that, and you want to make sure that they've actually thought about having their grip reassessed so they can often increase the grip on their racket, and then they may need to get their racket restrung. Um, other risk factors outside of tennis, uh, you see it a lot in manual labor, repetitive activities. So oftentimes I will see it in people that have repetitive wrist extension, um, movements. I see it a lot of times in gardeners who will be out doing a lot of clipping. Um, you see it more common in the dominant arm. And then as with any upper extremity pathology, it's definitely associated with poor coping mechanisms or kind of somaticization of stress, um, and depression. So, um, for a specific tennis elbow, um, they have pain over the lateral epicondylitis, uh, over the lateral epicondyle. So that's like right where the bony protuberance on the outside of your elbow is, or slightly distal to that. And when I say just distal, it might be like one finger breadth, but not really more. Because when we think about lateral side of the elbow pain, Um, you have to make sure that it's not that, like if it's, you know, 4 finger breadths distally, that makes you think more about radial tunnel or the nerve actually getting compressed. So that's kind of the differentiation. For tennis elbow, it's right where the bony protuberance is of the lateral peondyle. They'll also have, um, they may have sharp burning pain that radiates or they'll say, it gets worse anytime I'm like doing lifting or something where they're having repetitive wrist extension, um, or any rotation with the elbow extended. Um, and as it progresses, they can continue to have night pain. And so on physical exam here, this is just a differentiating. So this is tenderness over the lateral bacondyle versus tenderness distal. So distal here is radial tunnel, which is a little bit different and it's more of a diagnosis of exclusion. It's much more common to see tennis elbow. Um, they'll have really point tenderness. So on palpation, that's kind of the first thing that you do. They will also have pain with resisted wrist extension. So with the elbow almost in full extension. I'll pull the wrist up and say, hold it up there and then I'll try and flex the wrist down and that usually repeats the pain, um, or repeats the, reproduces the symptoms. And then long finger extension. So they, if you ask them to give you the middle finger and hold it up, that will also reproduce pain in that same area. Um, just one thing is, um, Tennis elbow can actually manifest as wrist pain as well that radiates up the arm. So if you have somebody that has pain over the dorsal aspect of the wrist and also some elbow pain, that still can be tennis elbow. So, in terms of uh how we think about it, a lot of it is activity modification. A lot of it is setting expectations for your patients so that they know that it's actually like a really long recovery. I usually tell people this is about a 11.5 to 2-year thing that it takes to, to get better, and most of it is modifying your activities. Um, there's not much that we as physicians can offer people for tennis elbow except for therapy. Um, So you do wanna kind of start with activity modifications which include limit lifting and repetitive grasping. So trying to be more in the neutral position rather than the flexed or or the extended position. Um, no vibrational tools. So vibrational tools have been associated with tennis elbow. They've also been associated with carpal tunnel. So those are good to tell people to avoid those. Um, and then in terms of like from the athletic standpoint, equipment modification, so restringing your racket and increasing the grip size have been shown to help. Um, and gloves, actually, they can increase the gripping force which causes more pain. So, um, there, there are really kind of two ways to think about treatment for tennis elbow. And it honestly depends on almost which physician you have or how you guys have treated this in the past, but there's, excuse me, there's wrist there's just wrist braces, right, which pre, prevent wrist extension. And then there's these unloader braces, which are the tennis elbow braces that you can order online. So, the wrist brace will neutralize the wrist extensors, so prevent that repetitive wrist extension. Um, and then you can see the tennis elbow unloader brace. What it does is it actually transfers force to distal to the elbow. So it gives the, the elbow extensors a chance to heal where the common extensor is here. Um, ice. So typically what I'll tell my patients to do is take like a Dixie cup, one of those little small like water cups, fill it with water, stick it in the freezer. Take it out, rip the top off, and actually applying local ice helps a lot with that swelling and pain that they're having there. Soft tissue massage, some people really believe in cross frictional massage, and then patient education. I think that's probably the number one thing that, that we don't do well enough is really educating patients on lateral bacondylitis and how long it takes, and then it's really activity modification. So, other type of the exercises is primarily stretching the elbow like this with the wrist extended and the elbow extend, sorry, wrist flex elbow extended. Um, and then once you do work on the wrist extensors with the elbow extended, then you can progress to strengthening, but it's really mostly stretching at the beginning. So people do use cross frictional massage, ultrasound, ionophoresis, and then some people will do the ultrasound with NSAIDS. And then I think the question people always ask is, what about steroid injections? So the studies show that uh injection of a steroid, while it does make you feel better, it can actually lengthen the course of the disease. So the majority of hand surgeons recommend against steroid injections. That being said, we do have patients who come in the office and say, I've had one before and it helps and I just want another one. but I typically try and counsel my patients away from getting a tennis elbow injection with a steroid. The PRP data, uh, when you look at kind of all comers for PRP, um, tendonitis, particularly lateral tendonitis, is one of the ones that has responded best to PRP. Now, there's more recent data which is a little bit more controversial, but, um, I do tell patients that PRP can help. And then finally, surgery. So, maybe about like 2 to 5% of people with tennis elbow go on to need surgery. And what we do at the time of surgery, typically, depending on kind of how extensive it is, is we make an incision and we take away that tissue that I said earlier looks snotty. It's, it's usually a tendon, as you saw in that earlier picture, looks really white. When you have tendinosis, it kind of looks like it has that yellowish coloration to it, and we actually go in there and excise that. Um, and that's really the end of the surgery. Now, sometimes it's so extensive that you actually have to take it off, the insertion on the lateral bacondyle and reattach it, but that's very rare. So moving on to wrist and hand, um, you know, I think one of the most common questions, and you probably see this a lot in your clinic, is it, is it broken or is it just sprained, right? And it's really hard to tell, um, when you just have a really swollen finger, but there are a couple of things that can help. So, If there's any angulation like you see in this picture here, you can assume that it's either broken or it's dislocated. I think that's a fair assessment when the finger looks like this. And then the other thing that you can assess as you look at the motion. Now, obviously, people have injured their finger and they don't want to arrange it, but one of the things that you can look at is in that limited arc of motion, and what I tell people is, you know, I need to assess it once, so can you try and make a full fist? If they have a very hard block to that motion, meaning it's just a hard stop and they can't get past that at all, then that makes you worry about a dislocation or a fracture. But if it's just difficult, but they can kind of push past it, that's usually a sprain. And then, when you have excessive motion, meaning more motion than, you know, another finger has or another, another hand has, then that makes you think, is there a ligament injury? Um, and then, can you move each joint independently? So if you took your finger, there's many joints in the finger, but can you isolate that and have them do each joint? So you can say, can you bend your FTP? Can you bend, you know, FDS here. And so those are good to do if you're trying to kind of get a checklist. And obviously, you can also get an X-ray to look at this, but those are good ways to assess for this. So, 85, I, I found the statistic, but 85% of all hand fractures that occur in sports happen in, um, football, basketball, and lacrosse, and most of them actually happen in football. I thought that was pretty interesting. Um. And then, um, I think from this is, you know, most of the time when you're treating them, you have to work on range of motion before you get them back to strengthening. So obviously, when you guys see fractures, there's a lot of them out there and so in a, in an hour's time, I can't really go through all hand fractures and so each fracture is treated a little bit differently, but most of the time, you know, most hand fractures can be treated without surgery. And you have to get range of motion back before we allow strengthening, and range of motion often doesn't come back until the swelling comes down. And I think one of the hardest things as a hand surgeon is to tell people how long it takes swelling of a finger or hand to get better. So it's usually somewhere between 3 to 6 months that swelling actually gets better, whether or not it's an operative or a non-operative finger fracture or even a sprain. It takes a long time. Um, distal radius fractures, so these are actually pretty common in sports-related injuries. Sorry for the spelling error there, but, um, and so most of the time when you see it in a younger patient, it's either trauma-related or sports-related. Um, oftentimes here in the Bay Area, we see it mostly related to skiing injuries. Um, but, you know, they're more likely in young patients to be intraarticular and associated with soft tissue injury when it's related to sports. So, in terms of letting somebody get back to, like, return to play, when are they OK to get back? So, if it's an operative distal radius fracture, like you'll see in this one, and we go in and we put a plate on it, then the next question is, well, when can I get back to playing? And certainly it depends on, number one, what sport. Sometimes you can play with a cast on. So, sometimes we've operated on people, put them back in a cast, and they can go on to play. But return to play. It's mostly done when they have 80% of range of motion and, um, and they're able to make a full grip. So when we're thinking about how quickly do we let them get back to work, that's kind of what we're looking at. So I think probably one of the most common visits that you guys may get related to hand is the ulnar-sided wrist pain. Um, and you'll see here that, you know, the, the TFCC, which is the triangular fibrocartilaginous complex, is a bunch of the soft tissue stuff that you see here on the ulnar side of the wrist. When I talk about the TSCC, and you could talk about this for hours, but most of the time, that's when somebody comes and they have that non, non-trauma related, more of like a chronic overuse ulnar-sided wrist pain. It's very rare that you see somebody that was like, I was out playing tennis yesterday and I did one quick, you know, slice or one quick backhand or something, and then I had ulnar-sided wrist pain. It's usually kind of this gradual thing. But you do see it. You can see it as a fall on a prote outstretched hand or if you're swinging a bat or a tennis racket, and they'll say acute onset pain. But most of the time, it's a chronic repetitive thing. Um, and what they may complain about, number one is ulnar sided wrist pain. Um, and then they may also say that they have painful clicking or locking with pronation supination. Remember that, you know, a lot of people have cracking wrists or ankles or whatever, and that's normal. But if they have like a clicking when they pronate or supinate, that makes you think that it might be related to this TFCC. And so the TFCC, which is this whole complex that you can see here, is a combination of a bunch of ligaments, but the number 1 and 2 that are kind of important to talk about is this is the volar and the dorsal radial ulnar ligaments, and you can see one of them here and one of them here. And what these do is they actually connect the radius to the ulna. If you go back to like med school days, we're thinking about anatomy, the radius is connected to the ulna, but remember that the radius and the ulna actually rotate over each other as you go into pronation and supination, and the radius rotates around the ulna. And so this is actually a joint. This is a distal radial ulnar joint, although it's a really small joint relative to like the knee and the wrist joint. What happens as you go into pronation, supination, so palm down and palm up, is not only is there a rotation of the distal ulna, but it slides back and forth. Um, and this is what holds those together. It's the TFCC. It also is like the sling for the carpus as you go into ulnar deviation. So, if you're waving and you're doing your, you know, a wave like this, as you go into ulnar deviation, that's kind of is what's the sling for the ulnar side of the wrist. So, I, I describe the TSCC as like the meniscus of the knee, but it's the meniscus of the wrist. Um, and so ways that you can get tears. You can get tears from a fall or, uh, you know, if you like have a quick supinating injury, you can get a tear. Um, you can have a distal radius fracture where the ulna styloid fractures off, um, and then that's part of where the TFCC inserts. So there's a lot of ways that you can get it. Um, and what, and then there's just degenerative, which means, you know, repetitive use over time. And usually when we're looking at this, these get MRIs. Degenerative tears are like in the middle, and they're just kind of like the same as a meniscus of the knee, a degenerative tear, versus a traumatic, acute traumatic are usually often on the periphery, or they can be associated with an ulnar styloid fracture. And so, when you think about the wrist, just going back to the wrist in general, the way that I think about when you examine the wrist is you start on the radial side of the wrist, and then you can move to the dorsal, and then you move over to the ulnar side of the wrist. So, on the radial side of the wrist, so opposite of what I was just talking about, but there's a lot of things in sports or in repetitive use. So what I've drawn here, this is the distal radius, right? These are the extensor tendons that are coming into the thumb here. So this is the base of your thumb. Here's your metacarpal. So here's your first dorsal compartment. So if you get a tendonitis in the first dorsal compartment, that's the qua veins. You can palpate that here as it comes. They're called the outcroppers cause they come from the ulnar side of the wrist. Um, you can palpate the radial styloid, which is right here. You can palpate the snuff box, which in the setting of a fallen an outstretched hand, and, and X-ray is red as normal. You can see a sty, a um scaphoid fracture, and that's that snuff box, which is the space between the first dorsal and the third dorsal compartment right there. Um, and then oftentimes, if you have particularly like an elderly woman who's fallen, you get an X-ray. The X-ray is read as negative, but they have so much pain, so much pain. It's most likely related to the fact that they have CMC arthritis or basal joint arthritis of the thumb, and then they've just really exacerbated it by the fall. And so they'll be very tender at the base of the first CMC. So those are on the radial side of the wrist. Now, as you move across from the radial, you keep moving across. This is Lister's tubercle, which is that little bony protuberance on the back of your distal radius here. This is the EPL. So if you have your hand flat on the table and lift your thumb up in the air, that's where it can curve around. And then other things, you can see wrist sprains or ganglion cysts are often tender over the back of the wrist. Um, and so those are kind of the two main things on the backside of the wrist when you see tenderness. Now, you may have a distal radius fracture, a little bit dis distal. You may have a ganglion cyst in somebody that says, I don't have any trauma. Um, or you may have somebody who's like, yes, I have pain. It may be related to the scapholunate ligament. So again, this is the snuff box. Now, on the ulnar side, so now we've gone all the way around and we're on the ulnar side of the wrist. This dot that you see here, that's the fovea. So it's the spot right in between the front and the back on the ulnar side of the wrist. On the front side, you have your pisiform, and then the back side, you have the ulna, and it's a real soft spot in between as you take your arm into radial ulnar deviation. That's the fovea. And that's where they'll be tender. If, if you're worried about a TSCC injury, that's where they'll show you that they're very tender. This is the ulnar deviation and load test, which is another concern for um if you have a foveal injury or a TFCC injury. And when somebody has had a traumatic event, so this is a patient of mine, um, you can see, oftentimes when there's a full thickness tear on the TFCC, they get instability between the two bones. And so what you'll see here. And see how much motion there is in the ulna. How very loose that is and I'll show it again. So that's when you have an unstable TFCC injury and that's surgical because those two bones are no longer held together. So, another really common finger injury is the mallet finger, right? And this is oftentimes, you guys will see this. They'll come into your clinic and they've jammed their finger on something, um, and the finger will look like this. It looks like it's flexed, and they can't actively extend it. You can certainly passively extend it, but they can't hold it in extension. You can get an X-ray. An X-ray will either look normal, but the joint is flexed down, or you may see a little bony fragment. So this is called a bony mallet. This is the soft tissue mallet. Um, and physical exam, you'll see that drooped finger, inability to extend. They may be swollen or painful, right? So, As you know, there's, you know, when we classify it, we classify it on bone and based on the size of the fragment, so meaning, how big is this fragment relative to the articular surface. So this one comprises maybe about 50% of the articular surface. Is it closed versus open? Is it bony or soft tissue? And then what we really care about is, is the joint concentric? And by, what I mean by that is, can I draw a line straight up? The articulate all the bones here, or does it kind of fall off like you see in this X-ray here? This is the distal phalanx. Here's the fracture, and relative to the middle phalanx, see how much more volarly subluxated it is. This is what makes this potentially operative because you want the joints to be concentric. Now, most of the time, we don't ever, almost never do we operate on mallet fingers. We do, but in a splint, they are, they are not concentric. So I would put this patient in a splint. I would take an X-ray and say, did the joint reduce? If it did, great, I'm gonna treat you without surgery. If it didn't, that's when I take you to surgery. So for bone, for bony mallet, it just depends on the concentricity of the joint. For soft tissue mallet, the treatment is immobilize the DIP joint. So when you see this in clinic and you diagnose it, the number one and most important thing that you can tell your patient is, here's your splint, don't take it off, period, right? Not even a shower cause I think that's what people get really confused about. It's like, well, I took it off because it kind of hurt and I wanted to shower and I wanted to do this. The reason they leave it on full time is you actually have to let the extensor tendon scar back down. So they take it off the shower and then the finger drops down again. You've broken up any callus that may turn into a, um, into a scar which would then heal and then it starts back again. So when we see them, we really give them the ride active it's 24/7, so 24 hours a day, 7 days a week for 6 to 8 weeks. This is one of the splints that you can offer. This is a nice one that we make in one of our clinics. Um, the nice part about this is they can actually shower with this and then dry it off. Um, certainly, there are a million other ways. So other, um, hand injuries that you'll frequently see is finger dislocations. So the PIP joint is the most common joint that's actually dislocated. You can easily see it in the X-ray here. What I want you to see here is most of the time, it's dorsal. Again, remember that when we talk about dislocations or fractures, it's where the distal bone is relative to the proximal bone. So this is a dorsal dislocation. And this is what happens in the majority of time. So if you ever see anybody that says, you know, I injured myself, 90, you can say with 95% certainty that it was probably a dorsal PIP dislocation. But what happens is, so here's the middle phalanx. Here's the proximal phalanx. The middle phalanx usually dislocates dorsally, and when it does, it pulls off the volar plate, which is the thickening of the capsule. So oftentimes, if you guys read an X-ray report, you'll see that it says volar plate avulsion fracture. And all that it means is, as the finger dislocates, the volar plate is really thick. It pulls off a little piece of bone of the middle phalanx. So you would see like if you saw it on the picture here, you might see a little bone, a little piece of bone, and that's a volar avulsion. And so, um, it, when it does that, it also typically, as you can see, the accessory collateral ligament is right here, so that pulls off with it. So physical exam, this is where you'd see a really swollen finger like you would see in any sprain, but they're gonna have a block, meaning you can't flex them down cause it hits very hard, and they may have that angular deformity. So you may look at a finger and it may be pointed left or right. And then, you know, the question is, how do you reduce it? So we reduce this typically with just um traction and then some pressure over the middle phalanx to get it reduced. Um, and as you can see in the picture here, so this is a dislocation. So all you're trying to do is get this middle phalanx back to where it belongs to, to reduce it. So here's just an example of somebody when I was in clinic one day, I got a call from the emergency room about a patient they wanted to send out. Here's a dislocation and if you look at it, it looks like a simple dorsal dislocation. And then here was their reduction. Excuse me. And as you'll notice from this reduction, it looks a lot better, right? But it's still not congruent. And what I mean by that is this is a lateral of the finger here, but if you draw a line at the back of this bone here, it certainly isn't in line with these two bones. So, this is not acceptable because if you let this person go, this would cause arthritis very acutely because the joint is not concentric. So, they came to see me in clinic, and I said, I numbed them up and then I put this, which is an alumifoam splint. I'm sure you guys have all seen those or applied these in a flex position and that actually reduces the joint. And then what you can appreciate is that there was this little volar plate avulsion fracture. So most of the time when dislocations are, are, um, unstable, it's that they're unstable as they get into full extension. So if we bend them down a little bit, then they become congruent, and then we can treat them with therapy instead of needing surgery. So, when the last um Uh, injuries I want to talk about is the thumb ulnar collateral ligament. Um, and as you see here, the thumb ulnar collateral, um, it's essential to joint stability. So, you need it for pinching, and you need it for pain-free motion. Oftentimes, as you guys, uh, probably know and have seen from skiing, it's called the skier's thumb, um, or in the chronic situation, it's called the gamekeeper's thumb. And if anyone knows the history of it, it's gamekeepers is related to the way that they used to snap the necks of rabbits, um, and it was a deviation force to the thumb repetitively, which would cause chronic attenuation of the ulnar collateral ligament. But most of the time, it's a fall with the, the, um, With a pole of a ski, uh, the ski pole here, and it deviates the thumb radially. So patients will have swelling. Um, they may, you may have bruising in that area. Um, they may have pain and weakness and grip or instability. So if the swelling goes down, they may say, gosh, every time I try to grab something, it still hurts. And if you look at this X-ray here, You can see, and this is a younger person cause you can kind of see the thus here is still a little bit open, but you can also get an avulsion fracture cause that's where the ulnar collateral ligament inserts and so it can actually pull off a piece of the bone. So, when we think about ulnar collateral sprains, tears, etc. um, you can have just one where it's painful, but the thumb is still stable. Number 2 is, um, a grade 2 is increased laxity with a firm endpoint. And when we talk about assessing somebody, you assess the thumb in the neutral position. So, the, you basically hold the metacarpal and then assess the, the opening of the, uh, phalanx. And then you also bend it down 30 degrees and do the same thing. And the reason being is because from that picture that I showed earlier, there's an accessory collateral ligament which inserts on the volar side of the thumb on the volar plate. And then there's the proper. Which inserts transversely, and so you need to assess it. And then When you assess, like, if you check somebody's thumb, usually everyone has a firm endpoint, meaning it just stops opening up. It doesn't gap or anything, it just ends. If they have increased laxity and no endpoint, that's a full thickness tear. And what you can see in this picture here. This, I'm holding the forceps, and this is the collateral that's just fully pulled off the bone. So that's what we would call a grade 3. And if you look at the image here, so this on, on the left side, you'll see normal. On the right side, you'll see abnormal. So here's me checking it. And so you can see that this patient opens up, but it stops, right? There is a firm endpoint. I'll show it one more time so you can see it. So it opens about, I don't know, 20 degrees and then it stops, right? But if you look at the operative side, See how it just keeps going. So it almost looks like it could push the thumb off of the hand. That is a full thickness tear, right? And so that's the difference. And you can imagine trying to pick something up or having any fine dexterous grip with your thumb. That's actually, you would have no stability. And so that's why we operate on this. Um, and that is the last of my, um, injuries associated with sports, but please feel free to unmute yourself and ask any questions should you have them.
