Tuesday, September 20, 2016
Injuries happen in football. Whether a player can return to play quickly or perhaps needs weeks of rehab depends on the injured body part and the player’s position. Demarcus Ware, a Denver Bronco lineman might play within 4-5 weeks after a forearm fracture but the Bears’ quarterback Jay Cutler may have a season ending injury because of an injured thumb on his throwing hand. The hand is a complicated machine with tendons and pulleys manipulating multiple joints to allow precise, minute movements…or the ability roughly grasp a football and be able to throw a spiral.
The language of medicine has allowed many hand injuries to be described with colorful terms or eponyms that can be confusing when the general public tries to understand what might actually be wrong.
Gamekeeper’s or skier’s thumb described a torn ulnar collateral ligament. This is the ligament that attached the thumb to the rest of the hand and if it is damaged, the ability to grasp with power is lost. The damage occurs during a fall on an outstretched hand where the thumb splays away from the rest of the hand. The ligament needs to heal and this may be allowed to occur naturally by keeping the thumb and hand casted for weeks. Otherwise, surgery is an option to reattach the torn ends. Occasionally, a piece of bone gets torn off where the ligament attaches and potentially makes surgery more of an option.
The metacarpals are the long bones of the hand that attach the carpal bones to the digits (thumb and fingers). The first metacarpal is the long bone just proximal to the thumb. Should the thumb be flexed just as a fall occurs, the base of the first metacarpal can break (fracture, crack mean the same thing) and potentially become unstable. As well, if the bone does not heal well, the joint between it and the carpal bone can become arthritis and cause chronic pain and weakness with grasp. Surgery is often required to wire the bones into good alignment and hopefully produce a normally functioning hand.
If the tip of a finger is hit by a ball and is forcibly flexed, it can tear the extensor tendon off the distal phalanx (the tip of the finger where the nail is located). The last joint in the finger, the distal interphalangeal joint (DIP), cannot extend and the fingertip droops. While not a terrible injury, a droopy finger gets in the way when the hand tries to grasp or if one tries to put their hand in a pocket. The finger can be splinted for a few weeks and the tendon often reattaches. Surgery is an alternative to reattach the tendon or if a significant chunk of bone gets pulled of the distal phalanx when the injury occurred.
The proximal interphalangeal joint (PIP) is a construction wonder, since tendons have to attach to move it while at the same time allow other tendons to span the joint and get to the DIP joint. It’s a complicated engineering feat and includes tendons that slide on each side of the joint with a central hood that then protects the PIP. If the finger is forcibly flexed or dislocated, this central slip can be torn, the tendons displaced and the joint gets pushed through the central slip. The joint gets stuck and leads to the deformity. Hand function may or may not be affected but the finger but looks weird. Chronic pain and arthritis may develop, like in any other joint injury. Splinting or surgery may or may not work to fix the problem.
This seems simple enough. If one were to hit a wall, or some other immoveable object, bones in the hand can break. A Boxer’s fracture describes a broken fifth metacarpal head, the bone just proximal to the little finger and the metacarpophalageal joint. If the fracture does not involve the joint, then the body can tolerate significant amount of angulation and still have a normally functioning hand. Attempts to manipulate and cast this injury usually fail and the bone tends to heal but the bone remains misshapen but does not affect how the hand moves, grasps or looks.
Just a Bruise
And sometimes, the hand just doesn’t break but can look bad. Viking quarterback, Sam Bradford, had the back of his hand smack up against a defensive player and had immediate swelling. The dorsum of the hand (the side opposite of the palm) has little padding and if one of the prominent veins breaks, there can be significant bleeding. The skin is loose and there is nothing to tamponade or place pressure on the broken vein to make the blood clot quickly. It is sometimes hard to tell whether the bleeding is due to just that or a broken bone underneath. Bradford’s x-rays were negative and al that ugly swelling was no more than a bad bruise. There is no eponym for that yet.
This entry was tagged Bennett, boutonniere deformity, boxer's fracture, Demarcus Ware, finger, fracture, gamekeeper's thumb, Jay Cutler, mallet finger, Sam Bradford, skier's thumb
Monday, September 16, 2013
The mantra for a successful quarterback is pretty simple: three to five step drop, set feet, step into the throw and follow through. It is not, as Cleveland Browns’ quarterback Brandon Weeden found out, follow through into the opponent’s helmet. The accidental collision damaged Mr. Weeden’s thumb, making it difficult for him to grip the ball and his game day was over. In the quarterback’s job description, the ability to have a strong grip on the ball is a prerequisite and that ability depends upon an intact ulnar collateral ligament (UCL) of the thumb.
Some quick anatomy. So that everybody is on the same page when discussing hand injuries, doctors use specific location descriptors. The palm side of the hand is palmar but is sometimes also referred to as volar. The opposite of palmar is dorsal, the back of the hand. The two wrist bones, the radius and ulna are landmarks that are used as landmarks. The radius is located on the thumb side of the wrist and the ulna on the little finger side. Each finger then has a radial side and an ulnar side.
The genius of the thumb is its ability to oppose and touch all the other fingers. It allows the hand to grasp things and power is generated only if the thumb is stable. That stability is due to a small band of tissue or ligament that runs from the ulnar side of the first metacarpal to the ulnar side of the first phalanx, crossing the metacarpophalangeal joint at the base of the thumb. Tear or sprain the ulnar collateral ligament and grip strength fails because the thumb literally slides off the side of the hand.
When Mr. Weeden followed through and hit his hand on an opponent’s helmet, his thumb was likely stretched away from the hand, spraining the ligament, either stretching or tearing its fibers. He couldn’t continue because he couldn’t grip the ball. X-rays were normal because it was not a bony injury and he now awaits an MRI to decide his fate.
Sprains are classified as grade 1, 2 or 3. Ligament fibers are stretched but not torn in a grade 1 sprain. Grade 2 sprains describe a ligament that is partially torn and in a grade 3 sprain the ligament is completely disrupted. Physical exam can attempt to decide if the ligament is intact by feeling for a “stop” when the ligament is stressed, but this is not an exact science and sometimes the hand muscles can go into spasm and give a false sense of ligament stability. Stressing the ligament isn’t done until x-rays have been completed and are normal. The mechanism of injury may cause fragments of bone to be pulled away with the damaged UCL and stressing the joint might displace the bone fragments.
Once the bones are found to be normal, an MRI will not only give the answer but direct the treatment.
Grade 1 and 2 UCL sprains can be treated with splinting to allow the ligament to heal itself and it may take 3-4 weeks to get better.
Surgery is reserved for grade 3 UCL sprains because completely ruptured tendon is associated with an unusual complication. The torn end of the ligament can finds itself tucked under the adductor pollicis muscle, making it impossible for it to become reattached. This complication is called a Stener lesion, named after Dr. Stener who first recognized and described it. Surgery is often required for sprains associated with bony fractures.
The use of eponyms or descriptive names is common in medicine and the UCL sprain has two. An acute ulnar collateral ligament sprain is also known as a skier’s thumb, describing the mechanism of falling on outstretched hand where the ski pole grip acts as a fulcrum, splaying the thumb radially away from the rest of the hand and stretching the UCL. Chronic damage to the UCL was first described in European gamekeepers who would wring the neck of game animals like chickens and the repetitive motion would stretch and weaken the UCL.
The bad news for Mr. Weeden is that there is no quick fix to make the ulnar collateral ligament heal itself and there is no mind over matter potential to overcome pain to be able to play. Until the UCL heals, by surgery or with time, the ability to grip, handoff and throw a football is lost. And that is on the top of the quarterback’s job description.
This entry was tagged Brandon Weeden, gamekeeper's thumb, skier's thumb, sprain, ulnar collateral ligament