HAND | WRIST | THUMB PAIN & PATHOLOGY + PHYSIO
a. Acute Wrist
Acute Wrist Fracture
1. Distal radius/ ulna
Distal radial fractures are commonly experienced during high-velocity sports. In younger individuals, the force to fracture bone is greater, often resulting in the combination of injury to surrounding ligaments. You can expect to experience local tenderness, combined with pain and weakness on grip strength. Management commonly includes reduction and immobilisation for 6 weeks in a cast over the wrist, hand and half the forearm. Regular two weekly imaging follow ups may be completed throughout the immobilisation period to ensure adequate reduction. Internal fixation may be required if reduction is not achieved early on. Longer term we look to commence range of motion
and strengthening following the immobilisation period, introducing return to sports protocol once achieved an appropriate base line.
Scaphoid fractures are the most common fractures in the hand. The fracture diagnosis if often delayed or missed and can have significant consequences long term. The scaphoid is a carpal bone at the base of your thumb and is most commonly fractured in those aged between 10-70 yrs old with a fall onto an outstretched hand. Young children and the elderly are more likely to break another bone – the radius.
The blood supply of the scaphoid is limited at the proximal pole so if it is fractured and poorly managed there is a high rate of non-union or poor healing. Despite a fracture being present the pain is often mild and experienced only with gripping or a pincer grip. There may be some swelling or bruising especially in a region called the anatomical snuffbox at the base of the thumb. Fractures can be indicated with physiotherapy tests but imaging is always required. An xray may or may not show a fracture as it is difficult to visualise until about 10 days after the injury, an MRI is more effective and can help determine if surgery is required to reduce the risk of non-union. A short arm cast with the thumb included is always required for these fractures.
After immobilisation, strengthening and mobility exercise is commenced, followed by graduated return to sport protocols.
3. Hook of hamate
Hamate is one of the eight carpal bones in your hand. It is a triangular bone consisting of a body and a hook. The hook of hamate can be fractured by a single trauma eg the golf club hitting the ground and the non-dominant hand absorbing the force of the club or in racquet sports such as tennis. It can also be fractured by repeated micro-stress being transmitted to the hook of hamate or via a direct impact eg falling on a hand whilst holding something.
A hamate fracture is diagnosed by tenderness over the region both on the palm and the back of the hand, reduced grip strength and local swelling/bruising. Follow up imaging is required to aid management – initially an xr-ay but if this is negative and suspicion of a fracture remains then a specific MRI imaging protocol is followed. Management involves casting/splinting and surgical review as poor blood flow to the region can lead to delayed healing. Post immobilisation rehabilitation is focused on mobilising the stiff segments in the wrist and hand, strengthening the muscles within the hand and wrist and building capacity to get back to normal
Acute Wrist Dislocation
1. Capral bones
Dislocation of the carpal bones is an uncommon result from severe ligament damage, commonly involving the lunate. Dislocation may occur due to a fall onto the outstretched hand, forcing the hand into dorsiflexion under force. You can expect to feel severe pain and present with a clear deformity. Initial management involves imaging of the dislocation to determine the severity.
Management of these injuries involves open reduction and ligament repair, with an eight-week period of immobilisation in a cast. Associated median nerve compression may be present, requiring surgical decompression in cases. Longer term management includes mobility, strengthening, proprioception and return to sports protocol.
b. Fractures (hand)
Metacarpal facture to the base of the first metacarpal is common trauma from a hard object. Two types of fracture exist, a Bennett’s fracture dislocation and an extra-articular transverse fracture of the base of the first metacarpal. A Bennett’s fracture dislocation presents where the first metacarpal has been forced proximally, creating the fracture near the base. This fracture should be referred to a hand surgeon for closed reduction and immobilisation in a cast for 4-6 weeks. The transverse fracture will lead to the thumb positioning flexed across the palm. Immobilisation in a short arm cast is recommended.
You can expect to feel acute moderate to severe pain depending on the fracture, with localised tenderness at the fracture site coupled with swelling and reduced grip strength. Following immobilisation joint mobilisation of the wrist and hand is important for return to sport. Protective braces may be worn if returning to contact sport.
Fractures to the phalanges are split into proximal, middle and distal fractures. Proximal fractures can lead to functional impairments, due to the disruption to the flexor and extensor tendons. Middle fractures may be associated with tendon avulsion of the flexor tendon. Distal fractures are commonly associated with crush injuries and typically slower to heal. You can expect to feel pain on movement, localised tenderness and swelling around the fracture. We initially manage these injuries with early immobilisation, followed by progressive mobilisation, dictated by the severity of the injury. Stable fractures are immobilised in a splint for 4-6 weeks. Unstable fractures may require orthopaedic review to determine surgical intervention. Longer term we look to include strengthening, range of motion and proprioceptive exercises, before return to sport is introduced.
iii. MCP joints
MCP joint injuries are commonly experienced at the first MCP joint (thumb). Ulnar collateral ligament sprains, also known as a skier’s thumb, are the result of an abduction and hyper extension stress to the thumb. A rupture to the UCL will result in gross laxity to the first MCP. You can expect to feel weakness in a pincer grip position (holding pen/ key). At rest, you can expect the thumb to rest in a slightly deviated position compared to the unaffected side.
We initially manage these conditions with immobilisation with taping or bracing for grade one or two UCL sprains, while a grade three rupture requires surgical intervention due to surrounding anatomy and blood supply to the area. Longer term we look to include strength, mobility and return to sport once 100%.
c. Ligament & tendon injuries
i. UCL/ RCL
Skiers thumb: The UCL of the Thumb is the acute injury of the base of the thumb on side closest to the palm. It occurs when the thumb is forcefully abducted or pulled backwards which can happen when a skier lands on an outstretched hand whilst holding a ski pole. It can also happen in football, rugby and more often in sports that require a stick or bat.
The pain is felt immediately on the inside of the base of the thumb and it often becomes swollen and bruised. It is difficult to move your thumb especially to make a pincer grip with the index finger. Injuries are graded 1-4 with grades 3-4 requiring referral to a hand surgeon. It can occur alongside an avulsion fracture where a small segment of bone is pulled off as the ligament ruptures. A more serious complication is a Stener lesion where the torn ligament gets stuck in soft tissue called the aponeurosis and is unable to heal without surgical input. Imaging will be directed by your physiotherapist and options include xray to look for fractures, ultrasound to see the degree of tear in the UCL or MRI if a Stener lesion is suspected. Management involves correct diagnosis, splinting, ice, referral onwards if required and education regarding hand rehabilitation post splinting/surgery. Hand therapy involves gradual strengthening without straining the ligament until proper healing has occurred.
ii. PIP joint sprain
PIP joint sprains involve the collateral ligaments of the PIP joints from force directed sideways to the joint. Distinguishable features of a partial tear include pain, however a end feel to the ligament. In comparison, ruptured ligaments present with no end feel. You can expect to feel pain on sideways/ lateral force to the joint. Both partial and completed ligament tears require 10 days of splinting, swelling management and exercise. Surgical management of complete tears is recommended, however conservative approach is also effective. Longer term we look to include mobility, strength and return to sport protocols.
iii. Mallet finger
Mallet finger is a condition that occurs when the fingertip is hit by an object (eg a ball) and the finger is forcibly bent forwards causing damage to the tendon that straightens the fingertip. It can also cause a fracture as the tendon pulls off the bone. The fingertip droops and is unable to straighten actively, there is sometimes swelling and bruising. The finger is often x-rayed to find out if there is a fracture and then splinted for 3-8 weeks to hold the fingertip straight and avoid allowing it to droop as this prolongs the healing process and increases your risk of long-term stiffness. Your physiotherapist will give you information about how to keep your joints moving and how to start strengthening the damaged tendon. In some circumstances surgery is required if there is a large fracture or the tendon doesn’t heal.
iv. Boutonniere deformity
A Boutonniere deformity can occur at both the fingers and toes. It occurs when the fingertip cannot bend and the joint at the middle of the finger/toe cannot straighten. It is associated with pain and swelling from the middle joint to the fingertip. It can occur immediately or a few weeks after an injury when the central slip of the tendon and disruption of the soft tissue around the fingers. This can also occur gradually in cases of rheumatoid arthritis or after full thickness burns.
Treatment includes specific splinting for about 6 weeks and the gradual resumption of movement of the fingertip and other joints of the finger. The longer it is left untreated the longer it can take to resolve. Surgery can be an option to improve function when splinting hasn’t fully resolved the condition and referral to a hand surgeon can be important when other injuries exist alongside Boutonniere’s.
v. Avulsion of the flexor digitorum profundus tendon
Avulsion of the flexor digitorum profundus tendon is commonly seen in the ring finger in sports where the shift of an opponent has been grabbed, consequently leading to a forceful extension of the finger while flexed. You can expect often to feel a snap on trauma. We often look for a finger in sustained extension compared to other flexed fingers. There is often a dysfunction to actively flex the finger. Imaging is recommended to clear an avulsion fracture. Management includes early surgical repair to reattach the tendon and must occur in the first 10 days of the injury. Longer term mobility, strength and return to sport protocol are implemented.
vi. Swan neck deformity
A swan neck deformity (SND) occurs when the fingertip is bent whilst bending the finger from the knuckle whilst being unable to bend the middle joint of the finger. It results in the finger looking like a swan’s neck thus the name. SND mostly commonly is associated with rheumatoid arthritis or neurological conditions but can also occur with trauma or post untreated mallet finger (see earlier). Treatment can be focused on splinting to reduce hyperextension of the middle joint of the finger and to improve the flexion deformity. Surgical review can be required depending on the cause of SND and follow up rehabilitation is required after splinting. At Evoker we will give you information about how best to manage and rehabilitate this hand condition.
Your diagnosis is: TFCC injury
- Pain arising from the cartilage complex of the ulnar (pinky finger) side of the wrist
It presents like this:
- A fall onto the wrist with an outstretched hand
- Increasing discomfort in response to repetitive tasks involving compression or traction of the wrist such as weightlifting or racket sports
It feels like this at rest:
- Often only a dull ache or no pain at all with complete rest in the early stages of overuse injury to the TFCC
- Activities like turning a key, using a can opener or lifting heavy pans often increases the pain
- Weakness and instability of the wrist are often reported
We look for this in assessment:
- Tenderness on palpation around the ulnar side of the wrist
- Reduction in grip strength
- A positive TFCC stress test or pain with resisted lift off increase suspicion
We initially manage TFCC injury by:
- Referral for an MRI in more severe instances – the most sensitive scan for diagnosing TFCC injury
- Fitting of a brace to prevent aggravation
- Wrist widget in minor cases – usually for lower grade degenerative injuries
- Full wrist brace for more severe injuries
- Firm releases of the wrist musculature can help to take pressure of the TFCC and reduce acute symptoms
Longer term management strategies to aid performance and prevention include:
- Specific strengthening programs aimed at improving wrist control and load tolerance, especially in positions of compression (such as push ups)
- Analysis of biomechanics and lifting techniques (including gym programs) to help manage risk factors for recurrence
- Referral to an orthopaedic hand specialist may be required for complex injuries
Trigger finger is characterised by inflammation and narrowing of the flexor tendon sheath in which the flexor tendons glide through to allow bending and straighten (flexion/ extension) of the fingers. Trigger finger may affect anyone; however middle-aged women and diabetics are more likely to develop the condition. A history of prolonged finger flexion will often be reported (prolonged writing, grasping, computer work, carrying bags etc.). Initially patients present with a painless clicking when moving their finger, with occasionally painful catching. Loss of range of motion and swelling may be present. A palpable thickening may also be experienced.
You can expect to feel stiffness and symptoms worse in the morning. Movement typical becomes more restricted with time. Waking at night with the finger bent may also occur. There may be some referred symptoms into the hand or forearm on the palmar surface.
We initially manage trigger finger by implementing gentle hands on manual therapy including soft tissue release, IASTM ‘tools’, mobilisation, ice/heat and splinting. Activity medication is important; stopping activities which aggravate the condition is important.
Longer term we look to strengthen the hand and forearm, re-introduce or increase previous activity and address any mechanical dysfunctions that may have led to the development of the condition.