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CHAPTER 9:
The Wrist and Hand

The wrist is one of the most complex structures in the body. There are 10 bones involved in moving the wrist joint in various directions. These include the 2 forearm bones and 8 other, small bones. These small bones are extremely sensitive to excessive force or trauma, such as that generated in snapping the wrist in racquet and throwing sports. In addition, there are tremendous head-on forces generated in boxing, football, and wrestling as the wrist grasps and pulls against great strength. Because of all of these forces, the wrist is one of the more frequently injured parts of the body.

SPRAINED WRIST

The most common injury to the wrist is a sprain. With all of the stresses on the wrist in sports, there is a good chance that the ligaments interconnecting the wrist bones will be sprained. Many people have weak wrists because there are few muscles in the wrist to stabilize it.

All but the most minor wrist sprains should be x-rayed because a sprained ligament may pull off a little piece of bone, which changes the injury to a fracture. A sprained wrist may not need anything more than a soft splint. A fractured wrist, however, requires casting.

The treatment of a sprained wrist, as for any sprain, is immediate immobilization, rest, and ice, and then a set of range-of-motion exercises followed by strengthening exercises. Use the same exercises outlined in Chapter 8 for the elbow. These exercises help take the pressure off the wrists to prevent injuries.

The ultimate sprain is a subluxation of the wrist bones. This happens when the ligaments connecting two or more of the small bones become torn completely, and the bones slide out of place. This is a common injury among boxers and usually results from hitting the heavy bag in training. The shock transmitted to wrist bones from hitting this large, mostly immovable object or from body punching during training causes undue stress on the small bones of the wrist. When the boxer hits with the afflicted hand, he feels severe pain.

Several professional boxers have required hand surgery to correct this problem, including then-middleweight Bobby Czyz and heavyweight Scott Frank, as have several top-ranked amateurs.

Athletes in other sports also are subject to this injury. Giants linebacker Carl Banks suffered a wrist sprain in 1990 severe enough to require surgery. That same year, the Detroit Pistons All-Pro guard Isiah Thomas had a similar injury and surgery. Ageless tennis ace Jimmy Connors had to have his wrist completely rebuilt surgically after years of overuse. The long, arduous rehabilitation from surgery requires the services of a good hand therapist for the athlete to regain full motion in the wrist.

BROKEN WRIST

Any severe wrist pain following a fall or blow should be seen by a physician and x-rayed because of the possibility of a fracture. One or both of the two bones in the forearm that lead to the wrist, the radius and ulna, are the most likely to fracture. A wrist usually fractures because of a fall. However, a wrist can also fracture by being hit by a thrown or batted ball, which is what happened to New York Mets pitcher Sid Fernandez. He missed about half of the 1991 season recovering from a broken wrist.

A wrist fracture is often written off as a sprain or a bruise, and the victim may not see a physician for some time. I have seen many patients complain of a sprained wrist that wouldn't heal and that turned out to be fractured.

You may also fracture the small bone in the wrist just behind the base of the thumb, called the navicular bone. This fracture is usually caused by stretching your hand out to break a fall or by hitting your hand against an opposing player's helmet.

Even if you go to a doctor soon after this injury, the navicular fracture may not be apparent on the first x-ray because the fracture line is too fine to see. If you feel chronic pain in your wrist that doesn't respond to simple treatments, have it x-rayed once and then again 10 days to two weeks later to confirm the diagnosis. By this time, the fracture line will have widened as a result of the healing process.

Healing is more difficult for this fracture than for most other fractures in the body because there may not be adequate blood supply to the broken bone. It can take eight weeks to eight months for this bone to heal by itself. There are new techniques, however, such as implanting an electromagnet in the cast, that speed bone healing. A magnet works by making the underlying filaments of the bone matrix line up with the same polarity. The filaments tend to get jumbled at the fracture line, and if you can get them to line up, they will form a bridge that can cross the fracture line. A magnet is now commonly used when there is no evidence of healing after a reasonable amount of time, about six weeks.

Finally, if the bone does not reknit, it probably will need to be fixed surgically. You may need a bone graft, which entails taking a piece of bone from the pelvis and placing it across the two bone fragments into a groove. This acts to hold the two pieces together and forms a bridge to help the fracture heal.

If left untreated, the navicular fracture will lead to chronic pain in the wrist and the loss of ability to extend the wrist backward.

RACQUET WRIST

Tennis or racquetball players may develop pain at the base of the hand below the "pinky" finger. Every time the player hits a ball, the racquet butt bangs into and bruises one of the small bones of the wrist. This usually occurs because the racquet butt is too big for the player's hand.

If the pain is severe, you should see a doctor because the little hook of bone at this spot might be broken. If it is, it will need to be treated as a fracture.

TENDINITIS

The wrist is the passageway for tendons that begin in the forearm and extend into the fingers. The fingers are actually controlled by muscles in the forearm, not in the hand. Overuse of the wrist in sports causes inflammation of the finger tendons attached to these forearm muscles. This results in swelling, pain, and limited function in one or more of the fingers.

Two tendons in the thumb are particularly sensitive to overuse: the extensor and flexor tendons. The extensor tendon moves the thumb away from the second finger, and the flexor tendon moves it toward the second finger. Tendinitis greatly limits your ability to grasp with the thumb. I see many tennis players with pain and swelling on the thumb side of the wrist, which is often caused by gripping the racquet too tightly.

Treatment involves resting and icing the tendon in the wrist, followed by administration of anti-inflammatory agents and immobilization of the thumb and wrist to further reduce the inflammation.

I normally make a small, lightweight thumb splint from pliable plastic that can be removed so that my patient can wash the hand. If the pain is severe, I may also give a cortisone injection.

To prevent the wrist from being overstressed, you need to strengthen the appropriate muscles and tendons. Follow the forearm-strengthening exercises outlined in Chapter 8. Pay particular attention to Ball Squeezing on page 81. Squeeze to the point of fatigue as many times a day as you can to improve your grip strength.

Finger Flexion and Extension Exercises

You can also improve the extension and lateral movement of your fingers by doing exercises with a rubber band. The large rubber bands used by grocery stores on broccoli or celery provide about the right amount of resistance.

GANGLION

A ganglion is a small lump on the wrist or hand that can vary from the size of a kernel of corn to the size of a cherry. It can occur on the back or front of the wrist, depending on whether an extensor or flexor tendon is involved. Both of these tendons slide through a sheath lined with cells that produce a slippery, thick fluid. The sheath allows the fingers to make the rapid movements that pianists need and all of us depend on.

If a finger tendon and its sheath become inflamed from overuse or a blow to the wrist, the inflammation can cause part of the tendon sheath to seal off. A cyst forms at this spot because the liquid produced by the sheath is trapped. The cyst, called a ganglion, swells inside the tendon sheath as the cells produce more fluid, and it can become quite painful.

The ganglion may open at one end if there is pressure from overproduction of fluid or from a sudden blow. The increased pressure blows open one end of the cyst, and the fluid runs out. The ganglion then collapses. The problem is that the raw surfaces that have blown out may seal off again, causing the ganglion to reform, and the whole process can repeat itself.

A ganglion is a problem when it becomes painful with activity. As long as it doesn't bother you, you don't need to treat it.

When I first went into medical practice, the treatment for a persistent ganglion was to smash it by hitting it with a book. That's the reason doctors kept Gray's Anatomy around after they graduated from medical school. The trick was to hit the ganglion hard enough with the thick book to break up the ganglion without breaking the wrist.

Today doctors inject a ganglion with cortisone, which causes it to disappear. If the ganglion continues to reform after several injections, surgical removal may be necessary.

CARPAL TUNNEL SYNDROME

The finger tendons pass through the wrist in a narrow, tunnel-like enclosure. With chronic overuse or excessive twisting of the wrist, fluid builds up in the sheaths of the tendons, causing the tendons to become inflamed and swollen. Also, the carpal ligament becomes thickened from overuse. Both of these things narrow the tunnel and pinch the main nerve that passes through the tunnel to the fingers.

The result is a painful wrist condition known as carpal tunnel syndrome, named after the carpal ligament that goes across the top of this tunnel. The pain extends up into the forearm and down into the hand, and there may be numbness, tingling, and even loss of strength in the middle and ring fingers.

Carpal tunnel syndrome, also called repetitive motion injury, has been called the occupational disease of the 1980s. Office workers who type at computer terminals, meat cutters, textile workers, musicians, and many others are prone to this injury. The injury is not confined to the workplace, however. Anyone who tightly grips something while exercising may also suffer carpal tunnel syndrome.

The treatment is to rest the affected wrist and apply ice. If the symptoms do not subside, then anti-inflammatory agents may help. Many people will need a splint to minimize or prevent pressure on the nerve and perhaps a steroid injection into the ligament to help reduce the swelling. If the pain persists, surgery to cut the ligament at the bottom of the wrist may be the only way to release the pressure.

To help you avoid repetitive motion injuries, here are a few stretching exercises:

THE HAND

Because the hand is so complex and so vital to everyday activities, all hand injuries should be considered serious and seen by a doctor. You can do irreparable damage by not getting immediate treatment to identify a broken bone. Any rotation of a broken finger bone can compromise that finger's function. Dislocations need to be x-rayed, even if the finger easily pops back into place. A dislocated finger also needs to be immobilized so that the ligaments can heal, or it may dislocate again with much less pressure on the finger.

The locker room saying "It can't be broken because I can move it" is a myth. All kinds of fractures of the hand still allow you to move the hand. If your hand hurts enough that you suspect a broken bone, it's best to have it x-rayed.

BROKEN HAND

The long bones of the hand, the metacarpals, are very subject to fracture, almost always due to a head-on blow to the knuckle, as when an angry person lashes out and hits a wall with the fist. I frequently see these fractures as a result of a player smashing his hand into another player's helmet by accident. Having your hand stepped on can also break the bones in the middle of the hand.

The treatment for a broken hand is to cast it for four to six weeks. However, if the break is directly across the shaft of the bone and the ends are jammed together, an athlete may be able to return to activity in a much shorter time with a light, plastic splint to protect it. If, on the other hand, the bones have been twisted apart and there are sharp ends at the fracture, the hand will have to stay in a cast until the fracture heals.

It is up to the physician's discretion as to which treatment method is safer. The type of fracture depends mainly on the direction of the force applied to the hand, not the particular sport you are playing.

BROKEN FINGER

Finger fractures are very common in sports. They commonly occur when a deflected ball hits the end of a finger. Many finger fractures are not serious, particularly those in the tip of the finger. If the finger is properly protected, you can continue to compete. "Buddy taping," or taping an injured finger to the healthy one next to it, usually allows you to return to activity almost immediately. If the fracture is in the second or third finger bone, you will need to splint the finger for four to six weeks to allow the fracture to heal.

DISLOCATED FINGER

If a finger is struck with a great deal of force, one of its joints may dislocate. On television, you may have seen a football player come to the sidelines with a finger sticking up at a crazy angle. It's usually simple for the team doctor or trainer to pop the finger back into place. Buddy-taping the dislocated finger to a healthy one stabilizes the joint, and the player can go back into the game.

The finger is always x-rayed later on. A piece of bone at the base of the dislocated finger may break off, and this can cause a bad fracture that extends into the joint. If not taken care of, this can result in great loss of function in the finger and future disability. So if you dislocate a finger, make sure to have it x-rayed to check for a fracture.

JAMMED FINGER

If you "jam" a finger, typically by hitting something head-on at the tip of the finger, it usually becomes very swollen. One of the joints holding the finger bone may not be totally dislocated, but the bone may have snapped partway out of joint and then snapped back in. This injures the cartilage on the end of the bone, as well as the capsule around the joint, and stretches the ligaments that hold the joint together. The result is a swollen, painful finger that may appear normal on an x-ray.

A jammed finger heals very slowly. The finger should be immobilized for 7 to 10 days and then buddy-taped to the finger next to it. I warn my patients that it can take six months for the joint to return toward normal size. And, as with any severely jammed joint, it usually will not return to full function. A jammed finger will always be larger than it was or larger than the joint on the opposite hand. You will lose a few degrees of flexibility in the finger, but not enough to cause any great difficulty in dexterity.

TENDON TEARS

A sudden, violent force to the fingers can cause tendons to tear. Any tendon that is torn through must be repaired surgically to prevent loss of finger function. If you have a weakness or an inability to move one of the joints in a finger, you must consider that a tendon may be torn, and you should seek a doctor's advice immediately.

Baseball players often tear the tendon on top of a finger from a blow to the end of the finger. As a result, the tip of the finger droops down, and you can not straighten out the fingertip. Either the tendon itself is torn in half or a piece of bone where the tendon attaches to the tip has been torn off. In either case, the finger must be splinted with the fingertip in the extended position for six weeks. This condition is known as baseball finger and is also seen among basketball and volleyball players who are hit by the ball on the end of the finger.

If the tendon doesn't heal, then you will need surgery to straighten out the fingertip. The only finger that I usually don't recommend for surgery is the "pinky" since loss of function there is not that important for sports.

SKI POLE THUMB

In the early 1970s the New York Nets' reserve center, Eddie Johnson, was a notoriously bad foul shooter. He tried everything to correct his foul-shooting stroke, to no avail. On investigating his problem, we discovered that he had torn the ligaments in his right thumb and was unable to control the ball. He had surgery to repair the damaged thumb, and he markedly improved his foul-shooting percentage. I'd like to say he became one of the best foul shooters in the league. At least he became respectable.

The most common ligament tear in the hand occurs on the inner side of the thumb. This is the so-called ski pole injury suffered by snow skiers when a thumb gets trapped in the loop of the pole during a fall. When the thumb ligaments are torn, you can't press the thumb sideways against the other fingers to grasp an object. This necessary movement of the thumb is what distinguishes the human hand from an animal's paw. Occasionally, basketball players also suffer this injury, as the Nets' Eddie Johnson did.

The immediate treatment is to ice the thumb and splint it. Then get to a doctor. You will have to immobilize the thumb for approximately six weeks and see if the ligament heals. If it doesn't heal, it will have to be surgically repaired.

TRIGGER FINGER

Trigger finger is the result of repeated trauma to the palm of the hand. This may be from a tennis racquet jamming into the palm or a baseball repeatedly hitting a catcher's palm. The trauma causes injury to the flexor tendon of one of the fingers. The tendon's sheath thickens, leaving a narrowed area for the tendon, and the tendon itself also thickens. Consequently, it becomes difficult for the thickened part of the tendon to get through the narrowed part of the sheath.

The flexor muscles of the fingers, which are stronger than the extensor muscles, are able to pull on the tendon and bend the finger. But the extensors are not strong enough to pull it back. The finger ends up in a bent position, the same position as a finger that has pulled the trigger on a gun. The only way to straighten out the finger is to pull on it with the other hand.

This injury sometimes responds to cortisone injection, which reduces inflammation in the tendon sheath. If not, the sheath will need to be split surgically to allow free motion of the finger.

BLISTERS AND CALLUSES

Many athletes suffer blisters and calluses on their hands and fingers from gripping balls, clubs, and racquets. Blisters form on skin that is damaged by friction or burns. Sweat makes your skin sticky, and the friction between your hands and the object you are gripping can cause blisters.

There are two theories on treating blisters. One is to leave the blisters alone and let them heal. New skin forms under the blister, and the fluid in the blister gradually becomes absorbed. Eventually, the outer layer of skin sloughs off.

The other theory recommends opening up the blister and letting the fluid drain out. Then you snip away the dead skin, apply an antibiotic cream to the area, and cover it with a dressing.

I prefer the first method because the second one leaves the raw skin under the blister painful and open to infection. If a blister breaks or becomes damaged by further friction, then use an antibiotic ointment and dressing. If it becomes infected, see a physician.

Calluses are areas of skin that have thickened because of constant pressure. The pressure causes the tissues underneath the callus to become tender. If the callus becomes bothersome, you can soften it with a cream or ointment and rub away dead skin with a pumice stone. If this does not help, a physician can trim the callus surgically or chemically.

To prevent these uncomfortable annoyances, you need to find out what is causing them. Tennis players and golfers may not be holding the racquet or club properly, or they may need new grips. Gymnasts should wear gloves and put powder on their hands before exercising on the parallel or high bars. There's not much baseball pitchers can do. Nolan Ryan used to soak his hands in pickle brine, which apparently worked for him, though I can't recommend it for everyone.


Hand Rehab and Injury Prevention

The rehabilitation of hand injuries is so complex that you should seek out a specialist in hand therapy. Under the specialist's direction, you can usually rehabilitate your hand with exercises at home.

There's not much you can do to prevent hand injuries since most of them are caused by accidents. You can use golf or batting gloves to prevent minor problems such as blisters and calluses.

If you feel persistent pain in your hand from racquet sports, get your racquet size evaluated immediately. Don't wait until you develop a fracture.

Strong fingers are important in almost every sport. They are especially important in golf and tennis for holding the club or racquet lightly but securely. Following is one simple finger exercise.




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