CLOSED TENDON INJURIES OF THE HAND AND WRIST IN ATHLETES

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Closed tendon injuries of the hand and wrist are very common in athletes. These injuries are often believed to be minor, and many go untreated during the playing season. A good result can usually be obtained if treatment is initiated early. If the injury goes untreated until the season is over, however, a permanent disability may result.67

This article discusses closed tendon injuries of the hand and wrist, which are common in the athletic population. This includes mallet finger deformity, boutonniere deformity, boxer's knuckle, dislocation of the extensor tendons at the metacarpophalangeal (MCP) joint level, and avulsion of the flexor digitorum profundus tendon from the distal phalanx.

Section snippets

MALLET FINGER

Mallet finger is defined as a disruption of the terminal extensor tendon at its insertion on the distal phalanx. It is the most common closed tendon injury seen in the athletic population.67 Mallet finger is also commonly referred to as “drop finger” and “baseball finger.”1, 67 It is most commonly seen in softball, baseball, basketball, and football.55 This injury is usually caused by a direct blow to the tip of the extended finger, which forces the distal phalanx into flexion. A mallet finger

BOUTONNIÈRE DEFORMITY

A boutonnière deformity occurs as a result of an injury to the central slip at or near its insertion into the base of the middle phalanx. The term boutonnière comes from the French word for buttonhole, which is what the head of the proximal phalanx can do through the defect in the extensor mechanism. In athletes, the injury may be caused by a blow to the dorsum of the middle phalanx that forces the PIP joint into flexion while the athlete is actively extending his or her finger. This results in

EXTENSOR TENDON INJURIES AT THE MCP JOINT LEVEL

The extensor hood mechanism overlying the MCP joint is vulnerable to injury during sports.67, 68 Two entities, subluxation/dislocation of the extensor tendon mechanism, and the “boxer's knuckle” or “soft knuckle,” are discussed.

SUBLUXATION/DISLOCATION OF THE EXTENSOR TENDON MECHANISM

Subluxation or dislocation of the extensor tendons occurs from a direct blow forcing the finger into flexion or with forced flexion and ulnar deviation of the finger.5, 94 It is a rare injury in athletes. Ulnar subluxation/dislocation is more common than radial, and it happens most frequently in the middle finger.39, 94 This was best shown in a study by Kettlekamp and colleagues.39 They demonstrated that the extensor tendon of the middle finger is more round than the other extensors, and

BOXER'S KNUCKLE

The term boxer's knuckle is used to describe an injury to the soft-tissue structures overlying the MCP joint. It was first described by Gladden26 in 1957. It is usually seen in boxers who give a history of a specific injury followed by repetitive trauma to the area. Patients complain of pain and swelling over the MCP joint, and occasionally there is weakness of full extension. There is no subluxation of the extensor tendon and radiographs are usually normal. The lesion is either a tear in the

AVULSION OF THE PROFUNDUS TENDON INSERTION

Avulsion of the flexor digitorum profundus tendon from its insertion on the distal phalanx is a relatively common injury seen in athletes. This injury was first described by Von Zander91 in 1891 when he described a rupture of the flexor pollicis longus tendon. Since then, several authors have reported on this injury.*

Tendon rupture most commonly occurs at the bony insertion. This was originally shown by McMaster59 in 1933.

TYPE I

The type I profundus avulsion is characterized by retraction of the tendon into the palm. The vincular system has been disrupted resulting in loss of blood supply to the tendon. There is no diffusion of nutrients into the tendon from synovial fluid. Clinically, the patient may have tenderness over the insertion area of the profundus on the distal phalanx, and there also may be tenderness and swelling in the palm where the tendon has retracted to near the lumbrical origin. It is important that

TYPE II

In type II profundus avulsions, the tendon retracts back to the level of the PIP joint, being held there by the intact long vinculum. As a result of the long vinculum remaining intact and the fact that the tendon remains in its sheath, nutrition through both perfusion and diffusion is preserved. Radiographs should be obtained because, occasionally, a small bony fleck is avulsed and can be seen at the level of the PIP joint. Clinically, patients have pain, swelling, and loss of motion at the PIP

TYPE III

In type III profundus avulsions, there is usually a large bony fragment that gets held in place by the A4 pulley. The vinculae remain intact as well as the tendon length, thus preserving nutrition to the tendon. Clinically, the patient has marked swelling, ecchymosis, and pain over the distal aspect of the middle phalanx just proximal to the DIP joint as well as no active flexion at the DIP joint. A lateral radiograph will show a large bony fragment just proximal to the DIP joint (Fig. 11).

SUMMARY

Closed-tendon injuries of the hand and wrist are very common in the athletic population. Most of these injuries, if seen acutely, can be treated successfully with nonoperative management, although some do require operative treatment. It is those injuries, however, that go undiagnosed until the end of the season, which may result in permanent disability.

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    *

    University of Medicine and Dentistry of New Jersey, Robert Wood Johnson University Hospital, New Brunswick, New Jersey

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    Copyright © 1998 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.