Avery et al.

Journal of Orthopaedic Surgery and Research (2016) 11:99

DOI 10.1186/s13018-016-0432-8

REVIEW Open Access

Sports-related wrist and hand injuries: a

review
Daniel M. Avery III*, Craig M. Rodner and Cory M. Edgar

Abstract
Background: Hand and wrist injuries are common during athletics and can have a significant impact especially if
initially disregarded. Due to their high level of physical demand, athletes represent a unique subset of the
population.
Main body: The following is an overview of hand and wrist injuries commonly seen in athletics. Information
regarding evaluation, diagnosis, conservative measures, and surgical treatment are provided.
Conclusion: Knowledge of these entities and special consideration for the athlete can help the team physician
effectively treat these players and help them achieve their goals.
Keywords: Hand injuries, Wrist injuries, Sports, Return to play, Ligament, Fracture, Surgical treatment
Abbreviations: PA, Posteroanterior; CT, Computed tomography; MRI, Magnetic resonance imaging;
SL, Scapholunate; DISI, Dorsal intercalated segmental instability; ECU, Extensor carpi ulnaris; TFCC, Triangular
fibrocartilage complex; US, Ultrasound; FDP, Flexor digitorum profundus; UCL, Ulnar collateral ligament;
MCPJ, Metacarpophalnageal joint; IP, Interphalangeal; ROM, Range of motion; AP, Anteroposterior; K-wires, Kirschner
wires; PIP, Proximal interphalangeal; EDC, extensor digitorum communis; DIP, Distal interphalangeal; FDS, Flexor
digitorum superficialis

Background overview of hand and wrist injuries commonly seen in

Approximately 25 % of all sports-related injuries involve athletics. Information regarding evaluation, diagnosis, con-
the hand or wrist [1, 2], and incidence is growing not servative measures, and surgical treatment are provided.
only due to the competitive level of high school and
collegiate athletes but also due to the activity level of the
general population [3]. While the shoulder and knee are Radial-sided wrist injuries
the commonly thought of in athletic injury, hand and Scaphoid fracture
wrist injuries are common and can have a significant Scaphoid fractures are the most commonly injured car-
impact especially if initially disregarded with a resultant pal bone [4] with a high incidence in college football
delay to treatment. players [5] and an increasing incidence in female athletes
Due to the high level of physical demand for function, [6]. This hyperextension wrist injury tends to occur in a
athletes represent a unique subset of the population. Injury pronated, radially deviated hand. Presentation can range
time can have a significant impact on scholarship oppor- from disabling wrist pain to mild swelling and decreased
tunities or jeopardize professional aspirations with direct range of motion. It is not uncommon to find a scaphoid
financial impact. Knowledge of common sports-related nonunion with a remote history of a wrist sprain.
injuries and therapeutic strategies can help the physician Located at the radial side of the carpus, athletes will com-
effectively treat the athlete considering their sports, plain of radial-sided wrist pain with exquisite tenderness in
position, and timing during season. The following is an the anatomical snuff box, axial loading of the thumb, or
pincer grasp. Radiographic assessment of the wrist should
include a posteroanterior (PA), lateral, and ulnar deviated
* Correspondence: [email protected]
University of Connecticut Musculoskeletal Institute, 263 Farmington Avenue, view. Unfortunately, due to subtle fracture lines and the ir-
Farmington CT, 06030-4037, USA regular contour of the scaphoid, nondisplaced fractures can
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 2 of 15

be missed on radiographs and advanced imaging with extensor compartments suggests possible scapholunate
computed tomography (CT) scan for fracture identification (SL) interosseous ligament injury. Standard radiographic
or alignment. Additionally, magnetic resonance imaging assessment with PA and lateral views may appear normal
(MRI) or bone scintigraphy for occult fracture may be only showing increased flexion of the scaphoid (a signet
needed to confirm the diagnosis [7, 8]. ring sign on the PA view as in Fig. 2a). A PA clenched fist
Treatment decisions depend upon fracture location and view may show greater than 5 mm of widening between
displacement, with strong surgical consideration being the scaphoid and lunate (Terry Thomas sign) is diagnostic
given to scaphoid fractures which are displaced and/or of a complete SL ligament tear [13]. Chronic tears may
proximal. Whether treatment affects the athlete’s contin- demonstrate a static SL gap on the PA film and an
ued participation in his or her sports within the context of increased SL angle on the lateral consistent with dorsal
the status of the season may also play a role in determining intercalated segmental instability (DISI). Advanced
whether or not to operate. Due to retrograde blood supply, imaging is commonly needed in the form of MRI with or
distal pole scaphoid fractures can effectively be treated without contrast arthrography [14].
nonsurgically. Proximal pole fractures are prone to avascu- Suspected tears or partial tears can respond to
lar necrosis and necessitate stronger surgical consideration immobilization allowing the participant to still com-
[9, 10]. Likewise, displacement carries a relatively increased pete. Those with continued pain and dysfunction that
risk of nonunion and we would recommend surgical interferes with their level of play will require wrist
fixation. Operative management, mostly commonly in the arthroscopy. Geissler et. al. [15] developed an arthro-
form of headless compression screw fixation, often offers scopic grading system which helps guide management
the fastest return to sports [11]. Cast immobilization may that ranges from immobilization for attenuation of an
provide appropriate definitive treatment in a nondisplaced intact ligament to open reduction and repair for gross
fracture or a temporizing measure for return to play. instability.
Return to athletic participation is based upon the athlete’s
handedness, his or her specific sports’ requirements, and Radial-sided tendinopathies
negotiating the bulk or restriction of the cast with respect Radial-sided wrist pain from overuse injuries requires
to dexterity and/or strength [12] (Fig. 1). careful evaluation. Accurate diagnosis using provocative
maneuvers and identifying the precise location of max-
Scapholunate ligament tears imal tenderness are paramount. Radiographic assess-
Wrist instability commonly occurs in a spectrum of se- ment can be indicated for ruling out fracture depending
verity in hyperextension injuries. Contact sports such as on the patient’s history. Advanced imaging, such as MRI,
football or rugby commonly place the athlete in a pos- is not routinely used.
ition of impact with hyperextension, ulnar deviation, and The most common tendinopathy in the athlete is de
supination of the wrist that can lead to these injuries. Quervain’s tenosynovitis [16]. Repetitive thumb extension
Because of the proximity of structures in the wrist, and abduction can lead to a thickening of the abductor
diagnosis of these injuries can be challenging. Pain in a pollicis longus and extensor pollicis brevis tendons as they
loaded, extended wrist with tenderness in the dorsal pass under the first extensor compartment retinaculum.
wrist at the interval between the third and fourth Tenderness to palpation is approximately 2 cm proximal

Fig. 1 a PA radiograph of a nondisplaced proximal pole scaphoid fracture in a recreational hockey player. b PA radiograph of a nondisplaced
scaphoid waist fracture in a high school soccer player treated with headless compression screw fixation
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 3 of 15

A B

Fig. 2 a PA radiograph showing a flexed scaphoid (signet ring sign). b Intraoperative finding of a complete SL interosseous ligament tear with the
tip of the probe on the scaphoid (yellow arrow). c Open reduction of the SL interval (blue arrow) prior to ligament repair

to the radial styloid and exacerbated by tucking the thumb tennis players, and other racquet sports. Injury may
under the other fingers while ulnarly deviating the wrist present as acute or chronic encompassing tendinosis,
(a positive Finkelstein’s sign) [17, 18]. subluxation, dislocation, or rupture causing pain with or
Intersection syndrome, also called Oarsman’s wrist, is without mechanical symptoms on the ulnar side of the
caused by friction at the crossing of the tendons of the wrist. The pathophysiology involves repetitive micro-
first extensor compartment as they pass over the ten- trauma or a sudden traumatic episode during wrist
dons of the second extensor compartment (extensor flexion, supination, and ulnar deviation such as the non-
carpi radialis longus and brevis) or a stenosing tenosyno- dominant hand in a double-handed backhand in tennis or
vitis within the second extensor compartment itself [19]. the leading hand in the downward phase of a golf stroke.
Pain is elicited with extension and radial deviation Injury to the ECU will typically present with pain over
approximately 4–8 cm proximal to the radial styloid. the ulnar aspect of the wrist. Tenderness to palpation in
Without careful attention to the location of pain, this the ECU groove and pain with resisted extension and
can be misdiagnosed as de Quervain’s tenosynovitis. ulnar deviation are hallmarks of tendinopathy. Sublux-
Tendonitis of the flexor carpi radialis is due to repeti- ation will give the sensation of snapping with supin-
tive wrist flexion or acute overstretching of the wrist as ation and ulnar deviation of the wrist. The physician
can be seen in volleyball or water polo [20]. Pain should also evaluate the triangular fibrocartilage
develops from tendon thickening as it runs in its tunnel complex (TFCC) as a peripheral tear can lead to ECU
adjacent to the carpal tunnel. Pain typically courses from tendonitis. Radiographic assessment is not routinely
the radial palmar wrist crease towards the base of the required unless needed to rule out other causes of
second metacarpal made worse by resisted wrist flexion. ulnar-sided wrist pain. Ultrasound (US) can be useful in
Conservative treatment for these tendinopathies be- identifying inflammatory changes or using a dynamic
gins by avoiding inciting events. Immobilization, stretch- assessment to look for tendon subluxation or disloca-
ing techniques, ice, and nonsteroidal anti-inflammatory tion [21]. MRI can be helpful to assess other structures
medications can effectively diminish symptoms. Should such as the TFCC.
symptoms persist, anesthetic/corticosteroid injections Acute or chronic ECU tendinopathy can be managed
into the responsible tendon sheaths at the point of with immobilization in wrist extension and ulnar deviation
maximal tenderness can be of diagnostic and of with progression to isometric and eccentric exercises. In
therapeutic benefit. When recalcitrant to conservative cases of acute dislocation, reduction and immobilization
measures, surgical release of the respective tunnel or with the forearm in pronation and the wrist in radial
compartment may be warranted. deviation for 4 months can be successful but not conducive
to athletic participation [22]. Nonanatomic reconstruction
Ulnar-sided wrist injuries of the subsheath with extensor retinaculum [23, 24] or,
Extensor carpi ulnaris injury preferably, anatomic repair (Fig. 3) with reduction of the
Abnormalities of the extensor carpi ulnaris (ECU) covers periosteum and subsheath back in the ulnar groove [25] are
an array of pathologies seen in golf, baseball, hockey, successful options to return to sports.
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 4 of 15

A B

Fig. 3 a Intraoperative finding of a volarly subluxed ECU tendon (between yellow lines) in a recreational tennis player. b The ECU tendon back in
its reduced position (red lines) after an anatomic repair of the subsheath

Ulnar abutment ulnar shortening osteotomy (Fig. 4) and has shown

The majority of load absorbed at the wrist is through improvement in pain, motion, and function [33–35].
the radiocarpal joint. In the ulnar neutral wrist, the distal
ulna bears approximately 20 % of forces. As the wrist
becomes more ulnar positive, the ulnocarpal joint Triangular fibrocartilage complex tears
experiences increased forces leading to ulnar-sided wrist Another cause of ulnar-sided wrist pain, particularly in
pain. Ulnar positivity can be a normal anatomic variant, those athletes who grip and rotate baseball bats, rac-
the result of distal radius physeal arrest (so-called quets, or golf clubs, is injury to the TFCC. The TFCC is
gymnast’s wrist), or as a dynamic condition with grip a soft tissue complex that supports the distal radioulnar
and pronation [26, 27]. joint. It also acts as an extension of the radial articular
Rarely presenting after an acute injury, symptoms from surface serving as a load-bearing structure of the carpus
ulnar abutment typically manifest as an insidious onset on the distal ulna [3, 36]. In the acute setting, tears of
of pain with repetitive activities of pronation, gripping, the TFCC can occur with hyperextension and pronation
ulnar deviation, axial loading, or combinations thereof of the axially loaded, ulnar deviated wrist. However, mi-
which begin to affect the athlete’s level of play. Tender- cro- or repetitive trauma can cause peripheral tears to
ness to palpation at the prestyloid recess of the ulna and the TFCC with rapid supination-pronation of the ulnar
pain with wrist ulnar deviation as moved through a full deviated wrist as seen with swinging a baseball bat.
arc of pronosupination (ulnocarpal stress test) [28] is Deep aching pain, pain with gripping, and occasionally
characteristic of the exam. Standard PA radiograph may mechanical symptoms of clicking with pronation-
reveal ulnar positivity but when dynamic ulnar positivity supination can be experienced. Tenderness at the presty-
is suspected, a pronated/maximum grip PA view may be loid recess that is accentuated with extremes of rotation
helpful in making the diagnosis [27]. MRI is not always or translation of the ulna, anterior to posterior, is char-
necessary but may be helpful in evaluating the TFCC, acteristic of the exam. Standard radiographic evaluation
early chondral changes in the distal ulna and/or the ulnar typically appears normal. MRI or MRA are commonly
lunate, or lunotriquetral interosseous ligament tears. used to confirm the diagnosis (Fig. 5a) [37].
As a slowly progressive condition, acute surgical As repetitive trauma is more common in athletes,
treatment is rarely warranted. Conservative measures to conservative treatment is typically employed if symp-
decrease symptoms and avoid provocative activities can toms arise during season. Immobilization, with or with-
allow continued participation. Immobilization between out physical therapy if ECU irritation is involved, for a
practices with or without nonsteroidal anti- period of 3 months can be helpful at alleviating symp-
inflammatories can decrease pain. Corticosteroid injec- toms [38]. Recalcitrant or recurring symptoms require
tions as a diagnostic and therapeutic tool can be used in arthroscopy for definitive classification as set forth by
the more chronic setting [29]. If conservative measures Palmer [36]. Symptomatic peripheral TFCC tears should
fail to allow continued level of play or timing is optimal, be repaired either open or with arthroscopic assistance
surgical treatment can be used to halt the progression by (Fig. 5b, c) [39–43] and typically require 3 months
decreasing ulnar positivity and debriding the degenera- before return to play. Symptomatic tears of the central
tive TFCC tear. Arthroscopic debridement and ulnar articular disk which fail conservative management can
shortening are the mainstays of treatment. While be treated with arthroscopic debridement (with or
arthroscopic wafer resection enjoys the benefit of shorter without a concomitant ulnar shortening osteotomy if
recovery times [30–32], the gold standard is diaphyseal indicated), but are not amenable to repair.
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 5 of 15

A B

Fig. 4 a PA radiograph of a patient with ulnar abutment revealing both 6 mm of ulnar-positive variance and incidentally an ulnar styloid
nonunion. b Neutral to −1 mm of ulnar variance after a diaphyseal ulnar shortening osteotomy is performed

Fig. 5 a A T2-weighted coronal sequence of a wrist MRI revealing an ulnar-sided peripheral tear of the TFCC (yellow arrow). b Arthroscopy view
from the three to four portal showing the peripheral tear (red arrow). c Intraoperative arthrosopic image during an arthroscopic-assisted
outside-in repair using PDS suture (blue arrow)
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 6 of 15

Hook of the hamate fractures basketball, and football. Injury occurs from an abduction
Direct blows from a golf club with the ground or from a moment at the thumb metacarpophalangeal joint
baseball bat while “checking” a swing can result in hook (MCPJ) such as a fall onto an outstretched hand with
of the hamate fractures. Infrequently, repeated lesser the thumb abducted. An acute thumb UCL injury has
impacts from the same can result in stress fractures. been dubbed a skier’s thumb [56], in contrast to chronic
Hypothenar pain is present with palpation or with force- attritional insufficiency of the ligament which is referred
ful grip. A pull test is performed by flexing the ring and to as a gamekeeper’s thumb [57].
small finger in the ulnar deviated wrist which produces Acute injuries often present with pain, ecchymosis,
pain by the deforming force of the flexors. Because the and swelling on the ulnar aspect of the thumb MCPJ.
hook makes up one border of Guyon’s canal, dysesthesias Stress examination with the thumb in extension and 30°
in the ulnar nerve distribution or weak grip may be of flexion is the most important aspect of the physical
present. A carpal tunnel radiograph, in addition to stand- exam [58]. Laxity of 30° total, greater than 15° to the
ard PA and lateral views, is needed to make an accurate contralateral, or lack of endpoint (Fig. 7a) are all strongly
diagnosis. If radiographs are negative, a CT scan can be suggestive of ligament injury [59, 60]. The thumb UCL
most helpful in defining the bony injury (Fig. 6). has two portions, the proper (more dorsally located) and
Most fractures on presentation are subacute or chronic the accessory (more volar) ligaments. Laxity at 30° of
making definitive treatment with immobilization difficult. MCPJ flexion and at full MCPJ extension is suggestive of
Whalen et. al. [44] reported healing of all six fractures they injury to both the proper and the accessory components,
treated with immobilization, but other reports have respectively. Radiographic assessment is important for
showed less success and may risk flexor digitorum profun- excluding bony fragments but US or MRI (Fig. 7b) is
dus (FDP) tendon injury [45, 46]. Biomechanical studies often used to confirm the diagnosis. A Stener lesion re-
have suggested a possible decrease in flexion force with fers to interposition of the adductor aponeurosis in be-
hook of the hamate excision lending consideration for tween the torn off UCL and its proximal phalanx
open reduction and internal fixation [47, 48]. Nonetheless, insertion, making healing impossible.
excision of the hook of the hamate fragment is currently Immobilization with a hand-based thumb spica splint
the standard of care and has produced successful results or a cast with the interphalangeal (IP) joint free is appro-
with return to play in 6 weeks [49–53]. priate for treating UCL partial tears with a firm endpoint
to valgus stress testing at the MCPJ. For complete tears
Hand/finger injuries without an endpoint, surgery is recommended. Most
Thumb ulnar collateral ligament tears UCL injuries are amenable to direct repair using either
Ulnar collateral ligament (UCL) injuries of the thumb transosseous sutures or a suture anchor, although more
are extremely common [54, 55] and often seen in skiing, chronic tears may require reconstruction with a variety
techniques available [61–63]. Both UCL repair and
reconstruction have shown satisfactory results with
decreased pain and increased function [64].

Metacarpal/phalangeal fractures
Accounting for 10 % of all fractures presenting to the
emergency department, metacarpal and phalangeal
fractures are common injuries [65–67]. Injuries occur
from falls, direct blows, or crush during sporting activity,
although stress fractures have rarely been noted in
racquet sports [68, 69]. Incidence is highest in contact
sports such as football, lacrosse, and hockey [2, 70–72].
While swelling, ecchymosis, and deformity can be
present, not all fractures lead to obvious deformity. For
those with obvious deformity, a reduction maneuver
should not be attempted without radiographic or fluoro-
scopic examination first in order to ensure appropriate
treatment of the specific fracture, dislocation, or fracture
dislocation [73]. In less obvious injuries, careful clinical
examination of the hand with respect to digital range of
Fig. 6 Axial CT image demonstrating a hook of the hamate fracture
motion (ROM), the finger cascade, and comparison of
(red arrow) in a college hockey player
any subtle malrotation to the contralateral hand might
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 7 of 15

Fig. 7 a Preoperative photograph demonstrating a patient with no endpoint to valgus stress testing of the thumb MCP joint. b A T2-weighted
coronal sequence demonstrating a complete tear of the UCL which is detached from the proximal phalanx (yellow arrow)

point to an occult injury. Radiographic assessment with Metacarpal shaft fractures are typically stable due to the
anteroposterior (AP), oblique, and lateral views are intermetacarpal ligaments, although the net flexion
standard. Training rooms have been increasingly outfit- moment at the distal segment pulls these fractures into a
ted with mini-fluoroscopy units for rapid evaluation, classic apex dorsal position. Acceptable angulation depends
although their sensitivity in detecting fractures of the on the metacarpal involved with no greater than 10° toler-
smaller bones with possible intra-articular involvement ated in the index and up to 30° in the small finger [76].
has been questioned [74]. If further imaging for fracture Shortening of greater than 2 mm is generally not well toler-
characteristics is needed, a CT scan may be indicated. ated as it leads to an extensor lag that can eventually not be
Many fractures can be treated nonoperatively if accept- compensated for by the hyperextensible MCPJ [77]. Careful
able alignment can be maintained with immobilization. clinical exam should assess not only for the finger cascade
When conservative treatment is inadequate, operative but also for the rotational deformity. Mild rotation in the
fixation is indicated. In the athlete, operative fixation may metacarpal can lead to significant finger overlap [76].
be sought to allow faster return to play. Immobilization of isolated fractures in acceptable alignment
is usually possible but the type of sports and position can
Metacarpal fractures limit tolerability. Multiple forms of fixation are possible
Metacarpal base fractures occur from an axial load with each with its own relative advantages and disadvantages. K-
the wrist in flexion. Eponyms such as Bennett and wire fixation offers a soft tissue friendly form of fixation,
reverse-Bennett fractures are used to describe the char- adequate in maintaining alignment but protruding pins risk
acteristic fractures of the thumb and small finger meta- infection and pin migration/breakage and preclude further
carpal. Bennett fractures are sometimes associated with participation with exposed hardware in gripping athletics
significant displacement as strong muscular forces tend (i.e., tennis, basketball, golf). Lag screw fixation (Fig. 8a, b),
to pull the base of shaft in abduction and proximally. As indicated in long oblique fractures, offers minimal dissec-
an intra-articular fracture, acceptable alignment to tion and an anatomic reduction, but stability may not allow
decrease the chance of symptomatic, posttraumatic arth- an expedited return to play. Plate and screw fixation (Fig. 8c,
ritis is desirable [75]. If there is more than 25 % articular d) offers the stability of a relatively quicker return to play
involvement or more than 1 mm of articular step-off or [78], but may expose the player to an increased risk of
gapping between fracture fragments, operative fixation is infection, tendon irritation, extensor adhesions, and the
usually indicated. Closed or open reduction of the need for future hardware removal. Which treatment is
fracture stabilized with Kirschner wires (K-wires) or selected should be a collaboration between the surgeon, the
screws is frequently needed. athlete, and the training staff.
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 8 of 15

A B

Fig. 8 a Intraoperative and b fluoroscopic images of a long oblique metacarpal shaft fracture secured with three lag screws. c Intraoperative and
d fluoroscopic images of a transverse shaft fracture secured with a plate and screws

Metacarpal neck fractures are the most common Phalangeal fractures

metacarpal fracture as they occur at the metadiaphy- Shaft fractures of the proximal and middle phalanges
seal junction at the area of the weakest bone. The so- can occur in a variety of patterns, but buddy taping and/
called Boxer’s fracture is an eponym referring to or protective splint wear in acceptable alignment can
metacarpal neck fractures of the small finger which allow fast return to play. Extra-articular fractures with-
result from an impact punching with a closed fist. out rotational malalignment, less than 15°of angulation,
Immobilization is typically adequate. Various forms of and less than 6 mm of shortening are indicated for con-
immobilization with the hand in intrinsic plus pos- servative treatment [80]. Operative fixation with open
ition or buddy taping with a short arm cast do not versus closed reduction using either K-wires (Fig. 10),
show any functional difference in outcome [79]. screws, or plate and screws as fixation is sometimes re-
Acceptable alignment follows the same principles as quired, especially when there is digital malrotation [81].
for metacarpal shaft fractures with apex dorsal angu- The athlete’s demands, the status of the season, and the
lation being the most obvious deformity and increas- fracture’s characteristics combine to dictate the optimal
ing in toleration as the injury moves from the index form of treatment.
to the small finger, with approximately 40°–50° of When fractures enter the articular surface of the
apex dorsal angulation well tolerated in the small phalangeal base or condyle, operative fixation should be
finger. When acceptable alignment cannot be achieved sought unless less than 1 mm of gap or step-off is
or immobilization cannot be tolerated for the athlete, present. Fractures can range from simple articular
operative fixation is occasionally considered. Both K- fractures, fixed with K-wires or screws, to comminuted
wire and plate (Fig. 9) fixation have produced reason- pilon-type fractures which may require a distraction
ably good outcomes, each with its own inherent risk/ fixator in order to restore articular alignment through
benefit profile as previously discussed. ligamentotaxis [82–84].
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 9 of 15

Fig. 9 Plate and screw fixation of an angulated fifth metacarpal neck

fracture in a high school running back

Distal phalanx fractures, due to crush mechanisms, are

typically stable with surrounding soft tissue and the
overlying nail plate. The vast majority of these are
treated nonoperatively; however, careful attention should Fig. 10 A PA radiograph of a small finger transverse proximal
phalanx fracture with clinical malrotation which was treated with
be paid to those distal phalanx fractures with associated
closed reduction and crossed K-wires
nail bed trauma, such as displaced physeal (Seymour
type) fractures in children.
Dislocations or fracture dislocations, particularly joint surface (Fig. 11) are clearly unstable and require
those that spontaneously reduce on the field, can often surgical management.
be overlooked in athletics. These comprise a spectrum
of hyperextension jamming-type injuries from pure Sagittal band rupture
dorsal proximal interphalangeal (PIP) joint dislocations, A Boxer’s knuckle refers to an injury of the sagittal band,
to dorsal dislocations with volar plate avulsion frac- which is the structure that normally keeps the extensor
tures, to fracture dislocations involving a significant
portion of the middle phalangeal articular surface.
Radiographic assessment should be performed after
every apparent dislocation to assess the percentage of
articular surface involvement. In the setting of an acute
PIP dislocation, with or without a volar plate avulsion
fleck of bone, the PIP joint is most likely stable and
early flexion ROM rehabilitation with buddy taping is
appropriate. Fracture dislocations of the PIP joint
which involve more than 30 % of the middle phalangeal
articular surface may be unstable and should be treated
Fig. 11 Lateral radiograph of a dorsal fracture dislocation of the PIP
much more cautiously, often requiring surgery. Those
joint with 50 % articular involvement of the middle phalanx
PIP fractures which involve more than 50 % of the PIP
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 10 of 15

digitorum communis (EDC) tendon centralized over the These injuries are seen more commonly in basketball
metacarpal head at the level of the MCP joint [85]. The and volleyball players [93]. Injury leads to the lateral
sagittal bands are composed of transverse, sagittal, and bands migrating volarly with resultant PIP joint flexion
oblique fibers that can be injured by blunt trauma over and hyperextension at the distal interphalangeal (DIP)
the MCPJ with a clenched fist impact [86, 87]. Painful joint known as a boutonniere deformity. As chronicity
EDC tendon subluxation can ensue causing an inability sets in, progressive loss of motion is seen at the PIP and
to achieve active extension of the finger at the MCP DIP joints.
joint (cannot obtain, but can maintain extension). Evaluation with history and physical examination
Athletes can present with an acute or chronic injury. should elicit any history of volar PIP joint dislocation
The central rays are more often affected due to more and try to isolate pain to the central slip insertion.
prominent bony structure, thinner superficial tissue, Assessing DIP flexibility with the PIP joint resisted in
longer radial fibers, and single extensor tendons [86, 88]. extension (Elson’s test) is a helpful method for assessing
Weakness of MCPJ extension in the affected digit, the central slip [94]. An intact central slip would have a
painful tendon subluxation usually in an ulnar direction, flexible DIP while an incompetent central slip would
and tenderness over the injured sagittal band are evident have a rigid DIP. Radiographs should be obtained with
on exam. or without a history of dislocation to assess for bony
Sagittal band injury without subluxation or dislocation avulsion of the central slip and PIP joint alignment.
can be treated with MCPJ extension splinting with the Splinting of the affected digit with the PIP joint in ex-
PIP joint free. When there is frank EDC subluxation or tension and PIP free is appropriate in order to allow the
dislocation, a trial of conservative treatment can still be central slip tendon to heal in as closed to an anatomic
attempted, although results in the literature have been position as possible. Leaving the DIP joint free for
mixed [89–91] which have lead most surgeons to treat flexion assists in pulling the lateral bands into normal
these injuries operatively (Fig. 12b, c) [87, 92]. MCPJ alignment and decreases stiffness [95]. Athletes close to
immobilization after repair or reconstruction is required season completion can be allowed to continue competi-
to allow adequate healing after which aggressive ROM tion as long as their participation is not hindered by the
can be initiated. Athletes should be cautioned about splint [96]. Rarely do acute injuries require operative
returning to sports too quickly to prevent wound com- treatment unless a displaced bony fragment is identified
plications and recurrence [91, 92]. and requires screw fixation versus excision with repair
[97] after which early rehabilitation can begin [97, 98].
Central slip ruptures Chronic central slip injuries with a fixed Boutonniere
Volar dislocation or forced flexion at the PIP joint can deformity create a challenging situation for the treating
lead to acute rupture or chronic attenuation of the surgeon. Treatment begins by attempting to obtain a pas-
triangular ligament at the distal end of the central slip. sively correctable deformity by using an extension splint,

Fig. 12 a Intraoperative findings of a patient with a torn radial sagittal band and ulnarly subluxed EDC tendon before repair b and after repair
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 11 of 15

serial casting, or a dynamic external fixator [99–101] to to be most susceptible to injury due to its position in
stretch the contracted volar structures. Once a supple power grip, decreased independent motion, and failure
deformity is achieved, reconstruction can be attempted strength compared to other digits [118–122].
with a variety of techniques such as extensor tenolysis and The athlete may or may not recall the moment of
transverse retinacular ligament mobilization or release, injury to the digit. Swelling is commonly present which
terminal extensor tenotomy with lateral band lengthening, may cause the athlete to not seek attention assuming
and central slip reconstruction [102–104]. Because that the lack of DIP flexion is simply a fingertip sprain.
treatment of a chronic deformity results in much worse Commonly, they present with complaints of decreased
outcomes [97, 105, 106], athletes should be strongly motion or stiffness and lack of strength. Continuity of
encouraged to seek treatment in the acute period. the flexor system can be assessed passively by tenodesis
effect or by holding the MCPJ and PIP joints extended
Pulley ruptures and asking the athlete to flex the DIP in isolation. In
Closed annular pulley ruptures occur most commonly in cases of a bony avulsion (Fig. 13) in which the trapped
rock climbers due to the high demand placed on the fragment cannot migrate proximally through the A4 or
flexor tendon system in the hanging and crimping A5 pulley, some flexion may actually be possible but
positions [107, 108]. Pulley ruptures typically involve the decreased and painful. Radiographic assessment can be
A2 or A4 pulleys and occur most often in the middle helpful at identifying a bony avulsion with amount of
and ring fingers. Previous work has evaluated the force retraction. For pure tendon failures, MRI can provide
required to produce an A2 pulley tear and loads experi- information about continuity and retraction of the
enced during these vulnerable maneuvers finding they tendon [123, 124], but is not usually necessary.
are at particular risk for climbers [109–112].
Athletes present with the acute onset of pain over the
volar aspect of the affected digit which may exhibit
swelling and ecchymosis. They can usually isolate the
event to a particular movement or slip leading to a
forceful digital contraction and feeling a pop. Tender-
ness to palpation can usually be localized over the
affected pulley but diffuse swelling of the entire flexor
tendon sheath may cause pain with passive extension.
While rupture of the A2 and A4 pulley are generally
required to show significant bowstringing, relative
bowstringing may be appreciated or a flexion lag may be
evident on exam. Applying external pressure over the
affected area and asking the patient to flex the digit may
reduce his or her pain further supporting the diagnosis.
While pulley ruptures are not evident on plain radio-
graphs, MRI or US may be helpful in confirming the
diagnosis [113–116].
Isolated pulley ruptures can be effectively treated non-
operatively with taping or pulley rings that externally
provide support for the flexor tendon. However, in the
case of multiple pulley ruptures, or failed nonoperative
treatment, reconstruction is indicated [117]. A variety of
graft sources such as palmaris longus tendon, extensor
retinaculum, or an excised flexor digitorum superficialis
(FDS) slip are available. Early ROM to facilitate tendon
gliding is encouraged with higher loading not allowed
until 6 months postoperatively.

Jersey finger
Forceful hyperextension of the DIP joint leading to FDP Fig. 13 Lateral radiograph of a ring finger of a patient whose finger
avulsion, as seen with a jersey tearing away from a finger, got caught on a basketball net showing an FDP bony avulsion
fracture with the fragment caught up distal to the A4 pulley level
is most commonly seen in football and rugby players.
(yellow arrow)
Eccentric loading of the FDP has shown the ring finger
Avery et al. Journal of Orthopaedic Surgery and Research (2016) 11:99 Page 12 of 15

Further migration or retraction of the tendon can Conservative treatment with extension splinting of the
compromise the nutritional supply to the flexor tendon. DIP joint is appropriate for almost all mallet fingers,
Therefore, operative intervention is warranted as soon including those with bony fragments as long as there is
as possible. Various methods for repair have been no significant joint subluxation [133–135]. Full-time DIP
described, but they all involve advancement of the intact, splinting with the PIP joint free is recommended for
viable tendon to the base of the distal phalanx, often 6 weeks around the clock oftentimes with an additional
using transosseous sutures tied over a dorsal button or 6 weeks of nighttime splinting [136–141]. For athletes
suture anchors [125–129]. Chronic injuries may require experiencing splint complications such as dorsal skin
primary or staged flexor tendon reconstruction with a maceration or difficulty with the compliance of full-time
tendon graft, or in the case of an intact FDS, a DIP joint splinting, buried K-wire immobilization of the DIP joint
arthrodesis could be considered [121]. offers an alternative treatment path with possible return
to sports albeit with relatively high inherent risks [142].

Mallet finger Conclusions

Mallet finger injuries refer to the disruption of the Hand and wrist injuries in athletics are common and can
terminal extensor tendon from the distal phalanx, with have a significant impact in multiple areas. Knowledge of
or without an avulsed bony fragment. Its occurrence these entities and special consideration for the athlete can
most commonly in baseball has lead to the eponym help the team physician effectively treat these players and
“baseball finger” [130], but is also seen in football, help them achieve their goals.
basketball, and rugby [131]. Its mechanism of injury
Acknowledgements
involves forceful flexion of an extended DIP joint. No additional acknowledgements.
The hallmark of physical exam for mallet fingers is a
fingertip that is “drooped” in flexion with the inability to Funding
No funding sources were utilized in the preparation of this review.
extend at the DIP joint. Dorsal DIP swelling and
ecchymosis are commonly seen but in cases without Availability of data and materials
bony involvement are often surprisingly painless [132]. All specified information and data was retrieved from original and review
Evaluation should include assessment for swan neck articles readily available through PubMed.com.

deformity (flexed DIP with extended PIP) as this may Authors’ contributions
cause more functional deficit than a DIP flexion deform- DMA formulated the outline, searched and retrieved the articles, and drafted
ity. Radiographic assessment is necessary to assess for a the manuscript. CMR and CME assisted in the outline and drafting/revision of
the manuscript. All authors read and approved the final manuscript.
bony mallet avulsion fragment (Fig. 14) and alignment of
the DIP joint. Authors’ information
DMA is a current Orthopaedic Sports Medicine fellow that will be matriculating
into Hand and Microvascular fellowship following its completion. CMR is an
assistant professor of Orthopaedic Surgery and Hand surgeon with certificate of
added qualification in hand surgery. CME is an assistant professor of
Orthopaedic Surgery and Orthopaedic Sports Medicine physician and team
doctor with certificate of added qualification in Sports Medicine.

Competing interests
The authors declare that they have no competing interests.

Consent for publication

Gross, radiographic, and magnetic resonance imaging are nonidentifiable.

Ethics approval and consent to participate

Not applicable.

Received: 27 May 2016 Accepted: 28 August 2016

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