ACUTE SOFT TISSUE

INJURIES AROUND
FOREARM, WRIST, AND
HAND.
Dr Riafat Mehmood
 Extrinsic Muscles of Hand and Wrist
 Intrinsic Muscles of Hand and Wrist
 Hand Function
 Zones of the Hand
 Acute soft tissue injuries
 TRAUMATIC INJURIES
 OVERUSE /CHRONIC INJURIES
Extrinsic Muscles of Hand and Wrist
Superficial Extrinsic Extensor Muscles
Extensor Carpi Radialis Longus
Extensor Carpi Radialis Brevis
Extensor Digitorum
Extensor Digiti Minimi
Extensor Carpi Ulnaris
Deep Extrinsic Extensor Muscles
Abductor Pollicis Longus
Extensor Pollicis Longus
Extensor Pollicis Brevis
Extensor Indicis
Extensor Retinaculum
Flexor Carpi Radialis
Palmaris Longus
Flexor Carpi Ulnaris
Flexor Digitorum Superficialis
 Intrinsic Muscles
 Thenar Muscles
 Abductor Pollicis Brevis.
 Flexor pollicis Brevis
 Adductor Pollicis
 Movements of Thumb
 Hypothenar Muscles
 Palmaris Brevis
 Abductor Digiti Minimi
 Flexor Digiti Minimi
 Opponens Pollicis
 Lumbricals
 Palmar Interossei
 Dorsal Interossei
Anatomical Relationships
Muscles of the Thumb and Fingers
Extrinsic Muscles
Intrinsic Muscles

 Intrinsic muscles have their proximal attachment

at, or distal to, the carpal bones and have a
function on the thumb or fingers.
 These muscles are responsible for the hand’s fine
motor control and precision movement. The
intrinsic muscles can be further divided into the
 thenar, hypothenar, and deep palm muscles.
 Hand Function
Functional position of the wrist and hand. Power grip. Accuracy grip.

Cylindrical grip. Spherical grip Cylindrical grip variation

Zones of the Hand.
Acute soft tissue injuries
Acute soft tissue injuries Athletes participating in
high intensive and contact sports will no doubt be
affected by acute soft tissue injuries.
The role of the sports rehabilitator, there fore, is to
work on minimizing those risks, while focusing on
rehabilitating those injuries.
The classification of acute soft tissue injuries can be
subdivided into sprains, strains and contusions.
Acute injuries are caused by a sudden trauma, such
as a fall, twist, or blow to the body. Examples
include sprains, strains, and contusions.

Overuse injuries occur gradually over time when an

athletic or other activity is repeated so often that
areas of the body do not have enough time to heal
between occurrences.
TRAUMATIC INJURIES

More likely for those who play sports that involve a

significant amount of contact with other players.
Sports such as hockey, football, or wrestling tend to
result in more traumatic injuries, including:
Muscle Strains.
Joint Dislocations.
Tendon Inflammation.
Ligament Tears.
Fracture Injuries in the Fingers.
 OVERUSE /CHRONIC INJURIES

 These injuries are more common in sports that require

repetitive motions. Baseball, tennis, and golf are sports
that carry a risk of chronic injuries.
 Tendonitis (Tendon Inflammation, Irritation, or Tear)
 Tendon Dislocation
 Nerve Injuries
 Stress Fractures
 While chronic injuries are less likely to result in long-
term disability than traumatic injuries, it is still vitally
important to assess and treat correctly.
 Gamekeeper’s thumb
 A common injury sustained by players in
football and hockey, the gamekeeper’s thumb is
a sprain of the ulnar collateral ligament, also
termed the ‘skier’s thumb’, for the mechanism
in which the injury is sustained
MANAGEMENT
In the immediate instance of injury to the ulnar
collateral ligament, ice packs and compression are the
best forms of treatment. RICE
Ultrasound can also be effective in the early stages to
diagnose injury.
followed by massage and mobilisation, to aid in
ligament repair and restore function.
Thumb strength and dexterity can also be improved.
grip and thumb strengthening devices may be useful in
restoring normal hand and thumb motion
Complications in healing.
in some cases the ruptured ligament may have become
entangled in the soft tissue at the base of the thumb, known as
a “Stener lesion”, which will further complicate the procedure
for conservative management and present a delay in wound
healing.

Injury prevention For football (soccer) goalkeepers and rugby

players, preventative taping can be effective in aiding thumb
joint stability and preventing further injury, and in sports
where no catching is required, a thumb brace can also provide
an alternative means to a permanent wrist support
 Mallet finger
 Another common injury
sustained in field and contact
sports is mallet finger. Mallet
finger is sustained from forceful
flexion of an extended distal DIP
joint, such as when a player has
mistimed a shot or catching the
ball.
Signs and symptoms
An athlete with mallet finger will present with pain at the dorsal DIP
joint, with an inability to actively extend the joint, demonstrating a
characteristic flexion deformity.
If the tendon is only partially stretched, then movement may be
restricted by 15–20 degrees extension. However, if a full rupture is
present, then movement will be limited by 30–40 degrees extension,
although full passive motion is typically preserved.
Management .
Ice packs
splinted
Treatment includes active DIP flexion exercises (making a full fist) that act to
regain strength and mobility of the injured finger.
Injury prevention

 In sports such as basketball, cricket, and rugby it

may be sensible to tape the fingers to provide
further support to the joints. In individuals with a
previous history, it is wise to wear a finger splint
as protection.
 Jersey finger
A disruption of the flexor digitorum profundus
tendon, also known as jersey finger, commonly
occurs when an athlete’s finger catches on
another player’s clothing, usually while playing
a team sport such as football or rugby.
As the athlete pulls away, the finger is forcibly
straightened while the profundus flexor tendon
continues to contract.
The ring finger is the weakest digit of the four
fingers, accounting for 75% of all reported
cases.
Signs and symptoms
An athlete with jersey finger will present with pain and swelling at
the volar aspect of the DIP joint, and will be unable to bend the
tip of the affected finger.
Tenderness may also felt elsewhere along the finger or hand, if
the profundus tendon has become retracted.
The digitorum profundus tendon can be evaluated by holding the
affected finger’s MCP and PIP joints in extension while the rest
remain in flexion, and performing a concentric contraction of the
affected DIP joint .
A positive sign for rupture to the digitorum profundus tendon is
that the DIP joint should not move
Management
Immediate management of jersey finger includes
diagnostic imaging to confirm suspicion of an avulsion
fracture, as complications can quickly arise in the case of
tendon retractions.
Athletes with confirmed or suspected jersey finger
should also be referred for medical consultation.
Following medical intervention, rehabilitation should
consist of passive range of motion exercises followed by
a return to normal activity only after a period of several
weeks, during which time movement is restricted in
order to promote wound repair.
Boutonniere deformity `

A common injury to the central slip

extensor tendon (boutonniere
deformity) occurs when the PIP `
joint is forcibly flexed while
actively extended.
It is a common injury among
basketball players. Volar
dislocation of the PIP joint can also
cause central slip tendon ruptures.
Sign and symptoms

clude pain and localised swelling to the PIP joint.

The PIP joint should be evaluated by holding the
joint in a position of 15–30 degrees of flexion.
If the PIP joint is injured, then the athlete will be
unable to actively extend the joint, however,
passive extension will be possible.
Tenderness over the dorsal aspect of the middle
phalanx will also be present.
Management
The PIP joint should be splinted in full extension for
the first six weeks of healing, and in cases where no
avulsion has taken place, or the avulsion involves
less than one third of the joint.
All available splints can be used to treat PIP
injuries, except for the stack splint, which is used
only for DIP injuries.
As with mallet finger, extension of the PIP joint
must be maintained continuously. If full passive
extension is not possible, then the rehabilitator
should refer the athlete.
Complications in healing If an avulsion fracture is present on
imaging then medical intervention may be necessary to prevent
future complications, as a delay in the proper treatment may
cause permanent deformity.
A boutonniere ` deformity usually develops over a period of
several weeks, as the intact lateral bands of the extensor tendon
slip inferiorly. However, a boutonniere de- ` formity will also
occur more acutely.

Injury prevention In sports such as basketball, cricket, and

rugby it may be sensible to tape the fingers to provide further
support to the joints. Athletes with PIP joint injuries may also
continue to participate in athletic events during the splinting
period, although some sports are difficult to play with a fully
extended PIP joints
Wrist sprains
Wrist sprains typically occur after a trip or fall,
resulting in stretching or tearing of the ligaments of
the wrist.
Common causes of wrist sprain include falls during
team sports, such as when a basketball player is
tackled during a jump shot, or a rugby player barged
from the side.
Moreover, if the tissues are inflexible and weak, the
risk of injury increases. However, the majority of these
injuries can be treated conservatively, and seldom
result in prolonged loss of sporting activity.
 Contusions

Contusions of the wrist and hand are a

common injury, because of the many
superficial tendons and bony prominences
that are exposed. Contusions are rarely
serious, and can be treated conservatively
over time.
However, care must be taken not to rule
out more serious injury, such as ligament
sprains, tendon injuries and joint
fractures.
 CHRONIC
AND OVERUSE
INJURIES
Repetitive actions can take their toll in team and action
sports, resulting in chronic inflammatory issues and
degenerative pathologies.
The repetitive cycle of injury that can occur from an acute
injury that is poorly managed is also a source of chronic
instability, resulting in faulty recruitment from scar tissue,
chronic inflammation and irritation from repetitive forces.
In sports such as tennis, gymnastics and rock climbing, the
wrists are exposed to a greater frequency of joint
irritation, from the dissipation of load through the upper
extremity.
De Quervain’s disease

 De Quervain’s disease (also

known as Hoffmann’s disease) is
an inflammation and thickening
of the synovial lining of the
common sheath of the abductor
pollicis longus and extensor
pollicis brevis tendons
Signs and symptoms The common sheath provides support to
the tendons to prevent bowstringing when the wrist is in
extension.
Therefore, space inside the sheath is limited. Thickening occurs
particularly at the distal portion of the radial styloid.
There is often pain in resisted thumb extension and abduction,
and while passively moving the wrist in ulnar deviation, keeping
the thumb fully flexed (Finkelstein’s test).
local tenderness on palpation, and with the tendon on stretch,
crepitus to repeated movements.
Management De Quervain’s disease responds well to frictional
massage with the tendons in a lengthened position, and
immobilisation of the thumb joint in a splint Corticosteroid
injections may also be prescribed for persistent case.
 Carpal tunnel syndrome
Carpal tunnel syndrome is a result of compression of
the medial nerve as it passes beneath the flexor
retinaculum and into the carpal tunnel.
The condition may manifest as a result of swelling
of the flexor tendon sheaths (tenosynovitis), as can
be seen from the repetitive flexion actions caused by
the wrist in sports such as gymnastics, cycling and
weightlifting.
The condition can also manifest itself as a result of
arthritic degenerative changes from repetitive or
previous impact traumas, such as wrist fractures.
 Ulnar nerve compression
Compression injuries of the ulnar nerve can occur
between the wrist space formed between the
pisiform and the hamate, known as the tunnel of
Guyon, termed “Guyon’s canal syndrome”.
The symptoms are caused by compression or
friction of soft tissue structures surrounding the
ulnar nerve, resulting in pain, tingling and
numbness.
The condition commonly affects cyclists, as the
wrist is compressed and extended against the
handlebars
Impingement syndrome
 This condition can manifest as a result of forced compression
of two carpal bones of the wrist.
 Such injuries include impaction between the scaphoid or, less
commonly, the lunate and radius with forced extension,
triquetrohamate impingement with forced extension and ulnar
deviation, and radial styloid impaction with forced radial
deviation.
 Impingement syndrome may also relate to chronic
instabilities, whereby increased accessory joint motion refers
to greater chances of impingement during physiological
movement.
 Trigger finger
Trigger finger, is a common name for finger
tendon disruption that causes the joints to
prevent from extending.
As the finger bends a nodule on the tendon
passes out of the synovial sheath coating the
tendon and into the palm, but as the finger
straightens the nodule may not pass back
into the sheath, becoming lodged in its
entrance.
The athlete may attempt to forcibly
straighten the finger but this should be
avoided in all circumstances.
BONE PATHOLOGY
 Scaphoid fracture
A scaphoid fracture is the most commonly
injured bone of the carpals. Often occurring
from sudden impact of a closed wrist or
during a trip or fall, with the wrist in full
extension.
The injury is particularly common in contact
sports, such as American football, rugby and
martial arts, but it may also occur in other
types of sports, such as gymnastics, skiing or
snowboarding.
Signs and symptoms
An athlete with a scaphoid fracture will present
with swelling at the base of the thumb, on the
outside of the wrist (anatomical snuffbox).
Palpation will elicit pain, particularly with passive
movements during pronation and ulnar deviation,
which will stress the scaphoid.
It is also not uncommon for a scaphoid fracture to
go undetected, and in the event, diagnostic imaging
is highly recommended.
 Management
Acute management of scaphoid fractures is immobilization of the wrist and
thumb where a support would extend from the wrist to the IP joint of the
thumb, but also sometimes from the elbow.
Rehabilitation in the early stage begins with maintaining range of movement in
the shoulder and the elbow, and, in less complicated fractures, healing can be
resolved in as little as four weeks.
In more complicated fractures, however, such as a fracture to the proximal
bone, healing may take several months. Therefore, maintaining muscle function
in the upper extremity is imperative, to prevent loss of movement.
Once healing has been approved, mobilization and strengthening exercises using
therapeutic putty and hand therapy balls can begin to restore full function .
During this period it may also be helpful to wear a wrist support when not
performing exercise to aid further support
 Metacarpal fractures
A punching type injury is the most
common cause of metacarpal fractures.
This may occur either when the hand
strikes another object (hand off), such as
in handball, or when a player falls with a
closed fist hitting another solid object.
Sports involving this type of injury
include American football, boxing,
basketball, soccer and in some cases
cricket.
 Bennett's fracture
A Bennett’s fracture of the thumb (first
metacarpal bone) is similar in mechanism to
an MCP fracture.
Except in this case impact is specifically
targeted at the thumb.
In this instance the pull of the abductors
muscle causes displacement of the
metacarpal bone, resulting in shearing of the
bone at its base.
Because this fracture occurs near the joint
line, it can also present with a false joint
with palpation and movement.
 Finger fractures
Finger fractures are very common in basketball, and
can be caused by a variety of mechanisms.
While finger fractures are often considered minor
trauma, without proper treatment they can also
cause major problems.
Conservative management involves buddy taping or
splinting while the injured bone heals, and to
prevent further injury.
These types of fractures are also sometimes
referred to as hairline fractures, small avulsion
fractures, and non-displaced fractures
PIP joint dislocations
Dislocation of the PIP joint is common in sports such
as handball, basketball and cricket.
The mechanism of injury can occur in axial loading
and hyperextension of the joint, lateral loading and,
more rarely, volar disruption of the PIP joint.
Lack of treatment may cause permanent joint
deformity, and in the case of more traumatic PIP
dislocations, fractures may also be present.
 Lacerations and infections of the hand

Lacerations to the fingers and hand occur frequently in

sport as a result of contact with equipment such as the
undersurface of a football boot.
All lacerations have the potential to become infected
and should, therefore, be thoroughly cleaned with an
antiseptic solution and observed closely for signs of
infection.
Tetanus toxoid should also be administered where
appropriate
A particular concern is a laceration of the hand,
often over the MCP/PIP joint, caused by teeth,
usually from a punch to the mouth. These injuries
should always be assumed to be contaminated and
an immediate course of a broad-spectrum antibiotic
should be commenced.
The wound should not be closed. Lacerations over
volar DIP or PIP joints may represent compound
dislocations. If this has occurred, the joint has been
contaminated and the patient requires hospital
admission for surgical debridement and repair.
Otherwise septic arthritis may follow.
Overuse conditions of the hand and fingers

Important but sometimes overlooked are the

overuse problems associated with the hand. These
include trigger finger, and other small joint injuries
that are commonly seen in rock climbers)-
Trigger finger is caused by a tenosynovitis in the
flexor tendon that is large enough to be impeded by
the proximal Al (annular) pulley located at the base
of the finger. Conservative treatment involves
splinting and local treatment to reduce the enlarged
tendon. Corticosteroid injection is often advocated
first, and then surgical release of the impeded AI
pulley.
EXERCISE AND RETURN TO PLAY