The examination must be comparative, especially when the patient has constitutional ligament laxity. AP and lateral views must be taken before stability testing to avoid displacing a fracture fragment and worsening a benign lesion Figure 9. Ultrasound can accurately demonstrate a Stener lesion, interposition of the aponeurosis of the adductor brevis muscle between the torn ligament ends. However, US does not replace clinical examination. MRI can confirm complete or incomplete ligament injury Figure The general classification of ligament injury divides them all into three types 11 :.
Most sprains heal favourably, but the lesion may remain tender for several months, especially on gripping. Intervention is necessary when there is grade III instability or a displaced bone fragment; the avulsed ligament is usually re-inserted at the proximal phalanx using a mini anchor, or rarely using direct suture or screw fixation. Postoperatively, the thumb is protected in a thermoplastic splint for 4 weeks followed by night splinting for 2 weeks.
Unrestricted return to sports is allowed 3 months after surgery 9. The extensor apparatus is complex and delicate.
Hand & Finger Injuries
In balance with the flexor apparatus, it is crucial in all acts of manipulation and grasping. The extensor tendons are thin and cover a broad surface which makes them vulnerable to injury and susceptible to the re-injury. Following closed trauma, the site of the extensor lesion will determine the type of deformity: a central tendon lesion on the back of the PIP results in boutonniere deformity, while rupture at the distal extensor insertion causes a mallet finger or baseball finger particularly common in handball.
Most commonly seen are closed mallet finger injuries which are known as a Type I injury. Mallet finger is more common in males, with significant trauma in younger males and minor traumas in older females. In most cases, mallet finger results from avulsion or less commonly section of the extensor insertion at the base of the distal phalanx of the fingers or thumb rare. Extensor avulsion at the base of the distal phalanx usually occurs during a forced extension of DIP in flexion A fracture dislocation usually occurs during axial trauma, with DIP extension or hyperextension, with simultaneous tension of flexors and extensors Figure Retraction of the extensor apparatus is less marked than that of flexor tendons but is nevertheless significant.
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The players often present late, several days later, having expected spontaneous recovery. The deformity is usually immediate, but can be delayed. The distal phalanx drops with spontaneous flexion of the DIP, loss of active extension with functional disability hooking. Sometimes there is hyperextension of the PIP by an imbalance between traction on the central and lateral tendons. There is little or no pain. There may be a small dorsal localised swelling or bruising if there is an associated fracture.
AP and strict lateral views of the DIP show the presence, size and displacement of a bone fragment and the presence of a palmar subluxation of the distal phalanx or osteoarthritis Figure Wilson 14 distinguishes four types of lesions Figure 14 :. Closed fractures Type 1, 2 and 3 are treated conservatively. Many immobilisation methods exist such as stack splints or glued splints to keep the DIP joint in neutral position or slight extension. I prefer a thermoplastic slab with a thin protective cloth to spare the skin, keep the pulp free and immobilise the PIP joint Figure In the absence of bony lesion Type 1 and 2 , the recommended period of immobilisation is 8 continuous weeks with an additional 4 weeks of night splinting.
The patient is instructed to remove the splint only to wash the finger, maintaining DIP extension all the time. Breaking these rules is the only cause of failure of conservative treatment! In handball players, percutaneous trans-DIP pinning is not indicated because of the potential risk of infection. Moreover, this technique does not exempt from wearing a splint. Surgical treatment of bony mallet is controversial because of the potential of this joint for remodelling. Operative repair also can be considered for failure of conservative therapy, whereby there is persistent subluxation despite splinting.
Many techniques are described: pinning, screws, cerclage, tension band wiring or mini anchors. This is a difficult operation that allows no margin of error due to the size and fragility of the fragment. After conservative or surgical treatment, gentle active flexion is recommended after 6 weeks in presence of a fracture or 8 weeks if no fracture.
If a flexion deformity persists, splinting should be continued. There is often a burning sensation or hypersensitivity that resolves with time.
Aspetar Sports Medicine Journal - Acute finger injuries in handball
In case of persistent extension deficit secondary mallet finger or recurrence of the deformity, it is permissible to impose a new period of immobilisation of 6 weeks. Moreover, the finger can stiffen gradually with inset of irreducible deformity. Secondary osteoarthritis is the result of untreated or inadequately reduced bone fragment. Hand injuries are very common especially in young players who are still developing their technique of receiving the ball.
Most often, treatment is conservative however in some cases, surgical treatment is needed such as in rupture of medial collateral ligament of the thumb. Very frequently handball players return to play too early with protection which means long-term results are not as good as they should be which is why we must protect young players with adequate, early treatment.
Image via Mindy Tan. PDF Version.
Acute finger injuries in handball
Sports Surgery. Mechanism The vast majority of lesions are benign sprains resulting from direct axial impact by a ball or contact during the game. According to the direction of the forces and the energy expended, one or more structures can be injured to varying degrees: Collateral ligaments.
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Volar plate Figure 4. Central slip of the extensor mechanism. Clinically After the trauma, the pain is the main feature associated with local swelling in these athletes. Investigations Plain anteroposterior AP and lateral X-rays of the finger are often sufficient. Treatment The treatment is almost always conservative. The indications of surgery are rare: Irreducible dislocation with soft tissue volar plate interposition especially after anterior dislocation.
Major instability after reduction. Open dislocation.
Associated neighbouring lesions fracture, tendon injury 8. Complications Flexion deformity after inappropriate and prolonged immobilisation in flexion.
Chronic Finger Injuries
Boutonniere deformity. Chronic instability after repeated injuries. Secondary osteoarthritis rare. Key points Sprains are very common in young handball players especially PIPs and benign if properly treated initially with adequate position and duration of immobilisation. Stability of the interpharangeal collateral ligaments must be tested in extension. Conservative treatment is the standard in most cases.
Mechanism and pathophysiology Lesions of the thumb MCP are common and vary in severity, ranging from mild sprain to dislocation. Clinical There is diffuse swelling of the MCP which is more pronounced over the injured ligament. Investigations AP and lateral views must be taken before stability testing to avoid displacing a fracture fragment and worsening a benign lesion Figure 9.
X-rays can show: Lateral or palmar avulsion or fracture base P 1. Classification The general classification of ligament injury divides them all into three types 11 : Grade I: Also known as a sprain and represents a small, incomplete tear. Tenderness is present over the site of injury but there is no laxity on stress examination.
Grade II: A larger but still incomplete tear with greater pain and swelling over the injured side. Asymmetrical laxity of the joint is present on examination but a firm end point is present. Grade III: Represents a complete tear of the ligament. There is marked laxity of the joint with no firm end point. Treatment Conservative treatment 11 In grade I ligament injury, 3 weeks immobilisation by thumb spica thermoplastic splint is indicated Figure After this period, no more fixation is required and rehabilitation is started to restore movement.
Handball activity is allowed 5 weeks after ligament sprain accident. In grade II injury, 4 weeks of immobilisation with a short-arm thumb spica cast is required. A strengthening protocol is started 6 weeks after injury. Return to active sport is allowed 10 weeks after trauma if there is no pain and severe limitation of movement, with protective tapping, if necessary. Surgical treatment Intervention is necessary when there is grade III instability or a displaced bone fragment; the avulsed ligament is usually re-inserted at the proximal phalanx using a mini anchor, or rarely using direct suture or screw fixation.
MCP joint stiffness. MCP joint osteoarthritis. Injury of dorsal sensory branch requires surgery. Clinical examination is key in diagnosing instability. Surgery is indicated for unstable lesions with complete rupture, conservative treatment for others. Sensory branches of the radial nerve must be protected during incision. Epidemiology Most commonly seen are closed mallet finger injuries which are known as a Type I injury.
Mechanism and pathophysiology In most cases, mallet finger results from avulsion or less commonly section of the extensor insertion at the base of the distal phalanx of the fingers or thumb rare. Rotator Cuff Injuries The three bones of the shoulder the humerus, scapula, and clavicle are held in place by the rotator cuff, a group of muscles that cover the head of the humerus and enable arm lifting and rotation.
Gilles Dautel, MD, Pr
The intense underhand motion of softball pitching can create stress, strain, and consequential wear-and-tear on the rotator cuff. If the responsible stressful activity is not reduced or halted, a rotator cuff tear may occur, which will be accompanied by symptoms of weakness, pain, and reduced arm mobility.
Strains refer to injuries of the tendons or muscles, and are more common among softball athletes. Anterior shoulder strains are common softball pitching injuries and will cause symptoms of pain in the front of the elbow. Repetitive high-impact shoulder usage and shoulder strains may result in chronic shoulder instability. Caused by overuse, tennis elbow describes inflammation of the forearm muscles and tendons. Ulnar Neuritis of the Elbow A final common elbow injury among softball pitcher is ulnar neuritis of the elbow.
Also called cubital tunnel syndrome , this condition occurs when the ulnar nerve in the arm is compressed or irritated. This can cause symptoms of numbness and tingling in the ring and little finger, as well as a weakened grip. Occasionally, a traumatic orthopaedic injury, such as a shoulder dislocation, may affect a softball player due to a throwing accident. Overuse injuries, however, are far more common among softball players. With that in mind, preventative methods should be aimed at preconditioning of the associated musculoskeletal components and the moderation of high-impact throwing activity.
Players are advised to work with a coach or trainer to identify and target anatomical areas of weakness that may be prone to injury in their strength training. Likewise, players who notice the emergence of pain, inflammation, or weakness in any of the muscles, bones, or connective tissues associated with throwing should immediately reduce the intensity and duration of their training and consult an orthopaedic specialist if symptoms persist. Rothman Orthopaedic Institute specializes in offering injured athletes the targeted Sports Medicine treatments needed in order to make complete recoveries, return to sports activity, and promote long-term orthopaedic health.
If you have experienced one of the above-listed common softball pitching injuries or an orthopaedic injury of any other type, Rothman Orthopaedic Institute can provide you with the care you need. To learn more or to schedule an appointment, please visit us here or contact us at Christopher C.