Welcome back to the mid year Blog. In Australia we are entering winter, and the football codes dominate. However many sports continue to train for competitions the whole year long. At the BSEMS clinic we are fortunate to maintain close ties to high profile sports like tennis, gymnastics, and kayak/canoe. One area which these sports have in common is overuse injuries of the wrist. The blog this time around focusses on injuries in this area.

Overuse Wrist Injuries

de Quervain’s tenosynovitis

Aetiology: This is an inflammation of the synovium of the abductor pollicis longus and extensor pollicis brevis tendons, as they pass in their synovial sheath in a fibro-osseus tunnel beneath the 1st compartment at the level of the radial styloid.

This is common in racquet sports, fly-fishing, bowling, rowing and canoeing. The left thumb of right-handed golfers is at risk as a result hyperabduction during the golf swing.

Examination: There is local tenderness and swelling, that may extend proximally and distally along the tendons. There may be a positive Finkelsteins test (the thumb is placed in the palm of the hand with flexion of the MCP and IP joints, while the wrist is deviated in the ulnar direction), but this can be positive with FCR tendinopathy.

Treatment: Rest, immobilization and NSAID’s may be of help in the very early periods. Trial splinting in 15º of wrist dorsiflexion with the thumb CMC joint in 40º of abduction, the MCP in 10º of flexion and the IP joint extended. Also modalities, stretches and graduated strengthening with mobilization of the carpal joints.

A pen build-up (rubber addition to build up the diameter of the pen) may help.

Corticosteroid injection into the 1st dorsal compartment has high cure rates. Chronic cases may have associated radial nerve tension. Surgery might be needed as a last resort with decompression of the dorsal compartment.

Intersection Syndrome

Aetiology: This is an inflammatory condition at the site where the 1st dorsal compartment (APL and EPB tendons) crosses over the extensor carpi radialis tendons (2nd compartment). It may be due to friction at the site of crossing or due to tenosynovitis of the extensor tendons in their synovial sheath. Seen in rowers, canoeists, weight lifters and racquet sports.

Examination: Tenderness is found dorsally on the radial side, proximal to the site of tenderness for de Quervain’s.

Treatment: Rest, NSAIDs and sometimes injection into a bursa. Splinting in neutral or slight dorsiflexion may be of help.

Surgical decompression is rarely necessary.

Triangular fibrocartilage complex tear

Aetiology: The TFCC lies between the ulna and the carpus, and is the major stabilizer of the distal radioulnar joint. The complex includes:

• cartilage
• ulnar meniscus homolog
• ulnar collateral ligament
• numerous carpal ligaments
• extensor carpi ulnaris tendon sheath

The axially loaded forearm bears 82% of the load through the radius and 18% through the TFCC and ulna. Positive ulnar variance results in ↑ load-bearing through the ulnar axis and is associated with ↑ TFCC injury. There may also be an association of prior distal radial epiphysitis (e.g. in gymnasts). Compressive loads to the wrist especially with ulnar deviation may tear the central portion of the cartilage.

TFC injury and ulnar wrist pain are common in gymnasts, racquet players, hockey (from impact with the boards in slap shots, resulting in hyper-supination), golf, boxing, waterskiing (from traction injury), and pole vaulting.

Examination: Tenderness/swelling over the dorsal ulnar wrist, with pain on resisted wrist extension and ulnar deviation, clicking on wrist movement and ↓ grip strength.

Investigation: MRI is the investigation of choice although there can be a high false negative rate.

Treatment: Protective bracing, physio and surgery may be needed. Central tears warrant an initial trial of conservative treatment with splinting, rehab and/or CSI.

Central articular disc tears 2º to trauma respond to arthroscopic debridement of the centrum as the treatment of choice. Patients are splinted for 1 week and golf or tennis athletes may begin light-activity ball contact at 3 weeks and are typically able to return to restricted sports activity in 4-6 weeks.

Peripheral TFCC tears at the ulnar insertion benefit from arthroscopic repair, with post-op casting for 6 weeks followed by active ROM. Strengthening is begun at 8 weeks and return to sport occurs in 3-4 months.

In degenerative lesions, or chronic injuries, sometimes an ulnar osteotomy to correct positive ulnar variance may be needed.

ECU Tendinitis

ECU tendinitis is 2nd to de Quervain’s in frequency in the athlete. It is seen in rowing and racquet sports and is quite common in the non-dominant wrist of tennis players caused by the two-handed backhand.

Biomechanical studies have shown that the wrist in tennis is in ulnar deviation for most shots and the non-dominant wrist is in extensive ulnar deviation during the two-handed stroke. ECU tendinitis may be the result of underlying ulnar wrist pathology such as TFCC injury.

Treatment involves splinting, rest, nonsteroidals, occasional sheath steroid injection, and attention to technique modification to avoid recurrence. Failure to respond to this regimen may indicate underlying pathology, and a further workup may be needed.

Subluxation of the ECU

Subluxation of the ECU tendon should be considered in the athlete with ulnar wrist pain. It results from rupture or attenuation of the ECU sub-sheath usually due to a sudden volar flexion ulnar deviation stress such as hitting a low forehand in tennis. It has also been reported in golfers, weightlifters, and rodeo riders. There is rupture of the medial wall of the sub-sheath, which is separate from the overlying supra-tendinous retinaculum.

Diagnosis may be made by having the athlete actively ulnarly deviate the wrist in full supination observing the ECU tendon subluxing ulnarward over the styloid. It may be confirmed by injecting local into the ECU sheath, which should result in complete relief of pain. Underlying pathology such as TFCC injuries should be considered.

In acute injuries some authors recommend casting for 6 weeks with the wrist pronated and dorsiflexed. Others recommend open repair in acute injuries for a more predictable outcome. In chronic cases reconstruction of the sub-sheath may be performed. Direct repair to the fibrous rim attached to the ulnar groove can result in good/excellent results with a return to sport over an average of 3 months.

Wrist Flexor Tenosynovitis

FCR tendinitis is rare in the athlete. Prior to insertion at the base of the 2nd MC the FCR passes through a tunnel formed by the transverse carpal ligament, scaphoid tuberosity, trapezial ridge, and the radial margin of the FCR tunnel. It usually responds to rest and splinting, although injection into the tunnel may be indicated.

FCU tendinitis is more common and is seen in golf and racquet sports. Piso-triquetral compression syndrome may accompany this condition since the pisiform is a sesamoid bone within FCU’s substance. Pisotriquetral arthritis is best visualized on a lateral radiograph of the wrist in slight supination and mild extension.

Treatment of rest, splinting in 25° of volar wrist flexion, and CSI into the sheath or pisotriquetral joint results in resolution of symptoms in 35-40% of cases. In refractory cases, pisiform excision with or without Z-plasty lengthening of the FCU is usually curative with return to racquet sports in 6-8 weeks.

Distal radioulnar joint instability

Aetiology: The thick dorsal and volar aspects of the TFC act as dorsal and volar ligaments of this joint. Ligament avulsion leads to ulnar head subluxation. (Dorsal subluxation is more common).

Painful ballottement of the ulnar on pronation implies dorsal radio-ulnar ligament injury, while pain with supination implies volar radio-ulnar ligament injury. Lifting in pronation stresses the VRU ligament, and in supination stresses the DRU ligament.

Treatment: Requires repair of the TFCC.

Carpal tunnel syndrome

Aetiology: There is compression of the median nerve as it passes through the carpal tunnel with the flexor tendons. Diabetes mellitus is a risk factor.

Examination: Have paraesthesia and tingling in the median nerve distribution- especially at night. Carpal tunnel tests are positive if they recreate symptoms:

Tinel’s: tap over median nerve volarly

Phalen’s: passive wrist flexion for 60 seconds.

Carpal compression test: place thumb across base of hand just distal to distal palmar crease between thenar and hypothenar eminences, apply pressure

Treatment: Mild cases may respond to NSAIDs/splinting, otherwise surgical release.

Ulnar nerve compression

The ulnar nerve can be trapped in Guyons’s canal where it sits with the artery between the pisiform and the hamate. Seen in cyclists and karate. Have ulnar nerve paraesthesia. Treat with NSAIDs, and changes in the cyclists grip, +/- surgery.

Kienbock’s disease

This is AVN of the lunate, probably secondary to repeated trauma. It is common in athletes in their 20’s and is usually unilateral. They have tenderness over the lunate and loss of grip strength. Passive dorsiflexion of the middle finger produces pain, and there is usually limited wrist extension. X-ray may show a smaller lunate with increased radio-opacity, but bone scan and MRI of more use. The lunate progressively loses height and eventually fragments. There is an association with ulnar negative variance. Treatment in the early phases involves avoidance of compressive loading of the lunate, permitting revascularisation before collapse can occur. Operative radial shortening or ulnar lengthening unloads the lunate fossa and redistributes load to the scaphoid fossa. Scaphoid-trapezium-trapezoid fusion may also be performed. Late disease may require proximal row carpectomy or wrist arthrodesis.

Impingement syndromes

Scaphoid impaction syndrome may occur as a result of repetitive hyperextension stresses, which may also result in avascular necrosis of the capitate.

Impaction of the lunate dorsal pole on the distal radius is seen with gymnasts.

Extensor pollicis longus may impinge on Listers tubercle and may rupture.

Triquetrohamate impaction may result from forced extension & ulnar deviation.

Radial styloid impaction results from forced radial deviation, especially in golfers.

Treatment: Rest, protective bracing. May need steroid injection or exploration.

Ganglion

2 varieties: the external ganglion cyst that is evident on the dorsum of the wrist or the internal ganglion cyst that is intra-articular and in the depth of the wrist joint itself. Common on both dorsal and volar aspects of the wrist. Treat only if symptomatic with rest, avoidance of aggravating activities and NSAID’s. May improve with aspiration and/or corticosteroid infiltration, but high rate of recurrence. May need excision.

Hypothenar hammer syndrome

Repetitive trauma to the hypothenar eminence may cause spasm, aneurysm and thrombosis of the ulnar artery. Resultant ischaemia of the hand and fingers may result, and can occur in baseball, cycling, handball and stick and racquet sports.