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WRIST AND HAND OVERUSE SYNDROMES
OVERUSE INJURIES IN THE UPPER EXTREMITY
0278-5919/01 $15.00
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WRIST AND HAND OVERUSE SYNDROMES Arthur C. Rettig, MD
Overuse injuries of the wrist and hand are common in athletic endeavors. It has been estimated that 25% to 50% of all sports injuries are attributed to overuse.32,34 Wrist syndromes are the most common upper extremity overuse injuries.30 The incidence of wrist problems in athletic activities is extremely high. For example, in gymnastics, the wrist and hand support body weight. Repetitive activities in which the wrist and hand have contact with a ball (such as handball and volleyball) or grip a racquet or an oar also result in a high number of overuse injuries.'O TENOSYNOVITIS OF WRIST AND HAND
Tendinitis can occur due to tension overload or shear stress. Pitner32 noted that overuse is defined as a level of repetitive microtrauma that exceeds the ability of the tissue to adapt. At the molecular level, tendon failure occurs due to stretching of collagen, the chief component of the structure. Up to 4% of elongation is well tolerated, and no tissue damage occurs. Between 4% and 8% of elongation, the collagen cross-links rupture, and collagen fibers slide past one a n ~ t h e rMacroscopic .~ failure of the tendon occurs when greater than 8% elongation occurs, and the fibers r ~ p t u r e . ~ Clancy' noted that tension overload can occur in the muscle, at the musculotendinous junction, in the tendon substance itself, or at its
From the Methodist Sports Medicine Center, Thomas A. Brady Clinic, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
CLINICS IN SPORTS MEDICINE VOLUME 20 * NUMBER 3 * JULY 2001
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attachment to bone. Overload can be obviated in some cases by appropriate training methods involving gradually increasing stress load. Tendons adapt to applied loads according to the Wolff law, which involves an increase in collagen content and cross-linking. This process takes time, training, and the use of proper t e c h n i q ~ e s . ~ ~ Shear stress can occur where tendons pass in close proximity to a fixed structure (e.g., de Quervain's syndrome). Tenosynovial tissue surrounds tendons at these points and lubricates and protects these structures as they pass through tunnels or around bony prominences (Fig. 1). The process involved in the pathogenesis and natural history of tendinitis, whether it is due to tension overload or shear stress, can be divided into four stages: inflammatory, proliferative, maturation, and fibrosis. Treatment modalities differ to some extent depending on the stage of the process at presentation. The inflammatory response to microtrauma is characterized clinically by pain, swelling, increased temperature, and tenderness at the site. At the cellular level, vascular ingrowth, increased capillary permeability, and accumulation of inflammatory cells occur.32Treatment of tendinitis at this stage involves rest to prevent exacerbation and prolongation of the healing process. This includes avoiding activities that cause discomfort, splinting, or in some cases, casting. Icing, elevation, compression, and nonsteroidal anti-inflammatory drugs (NSAIDs) also can be of benefit. P i t r ~ e rdescribed ~~ the stage of proliferation as lasting 1 to 2 weeks and involving the production of poorly organized collagen and growth substance. During this stage, excessive activity is to be avoided, although light stretching and controlled range of motion are permitted. This stage of maturation consists of maturation of collagen with cross-linking and occurs over 1 to 3 months. Controlled stretching and strengthening are
Tendon sheath
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Figure 1. Tension overload of the tendon itself or shear stress at the sheath-tendon interface may produce tendinitis caused by overuse. (Modified from Fulcher SM, Kiefhaber TR, Stern PJ: Upper extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med 11:39-55, 1992; with permission.)
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recommended, with the goal of treatment being to avoid disuse atrophy but also to avoid reinjury and re-entry into the inflammatory phase. Fibrosis occurs with repeated inflammatory episodes and results in scarring of the tendon retinacular sheaths or the tendon itself. Entities due to shear trauma, such as “trigger finger” or de Quervain syndrome, frequently do not respond to rest or corticosteroid injection once they have progressed to this stage, and can require surgical release. SPECIFIC TENOSYNOVITIS OF HAND AND WRIST De Quervain Syndrome
Tenosynovitis of the first dorsal compartment, or de Quervain syndrome, is the most common tendinitis of the wrist in athletes. The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons course beneath the fibrous sheath overlying a groove along the radial styloid process (Fig. 2). Shear stress resulting from repetitive wrist motion, including radial and ulnar deviation as well as flexion and extension, results in inflammation of the tenosynovium.2,9,26 Sports most commonly associated with de Quervain syndrome include golf, racquet sports (especially racquetball, badminton, and squash), and fishing.24,26 On physical examination, tenderness over the first dorsal compartment is present, and a positive Finkelstein test is pathognomic for the diagnosis. This test is performed by flexing the thumb into the palm and passively deviating the wrist ulnarly, thus causing maximum stretch to the APL and EPB tendons. In chronic cases, thickening of the fibrous sheath and occasionally a ganglion cyst can be p r e ~ e n t . ~ Treatment of de Quervain syndrome depends on the stage at presentation. Although acute cases can respond to rest and splinting, most experts recommend corticosteroid injection into the sheath. Cure rates EPB
,/‘
Suphicia1 branch radial nerve
Figure 2. Frequently the extensor pollicis brevis (EPB) tendon lies in a separate compartment from the obductor pollicis longus (APL), which usually is composed of 2 to 5 slips. (Modified from Fulcher SM, Kiefhaber TR, Stern PJ: Upper extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med 11:39-55, 1992; with permission.)
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of 80% and 62% have been reported by Osterman et a1 and Gelberman l2 Injection alone recently has been found superior et al, respe~tively.~~, to splinting and to injection and splinting together.12 Our recommended treatment program in the acute case is corticosteroid injection using dexamethasone and betamethasone and splinting, followed by stretching of the APL and EPB tendons and strengthening. If symptoms recur, a second or third injection is performed, followed by appropriate rehabilitation. If this fails, surgical decompression should be considered. In chronic cases of first dorsal compartment tenosynovitis, the above treatment is initiated; however, the success rate is decreased due to the presence of fibrosis, and frequently surgery is indicated. Surgery is performed through a longitudinal curvilinear incision (Fig. 3), and the branches of the superficial radial nerve are identified and carefully protected. The sheath of the first dorsal compartment is divided longitudinally, leaving a flap of sheath volarly to prevent volar subluxation of the tendons. Jackson et a1 noted that a separate compartment for the EPB is common in patients with de Quervain syndrome, and it is imperative to identify this tendon and divide its sheath.2o Postoperatively, the wrist is splinted for 7 to 10 days, followed by rangeof-motion and strengthening exercises. Return to sport can be expected in 6 to 9 weeks.
Superficial branch radial N. Radial A'.
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Figure 3. A longitudinal curvilinear incision (dashed line) is preferred to better protect the superficial branches of the radial nerve. The first dorsal compartment sheath is divided and EPB and APL tendons decompressed. (Modified from Cooney WP, Linscheid RL, Dobyns JA: The Wrist: Diagnosis and Operative Treatment, vol 2. Mosby, 1998, pp 1188-1190.)
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Intersection Syndrome
Intersection syndrome refers to inflammation or bursitis at the point of crossing of the outcropping muscles (APL, EPB, extensor indicis proprius) and the radial wrist extensors (extensor carpi radialis longus [ECRL], extensor carpi radialis brevis [ECRB]). This condition is also known as "cross-over tendinitis," "peritendinitis," and "squeakers." Participants in racquet sports, oarsmen, and weight-training athletes can develop this The pathophysiology of this condition is poorly understood, but theories include (1)friction between the tendons producing a (2) tenosynovitis of the ECRL and ECRBI4; and (3) hypertrophy of the APL and EPB muscle bellies, causing pressure on the radial wrist (Fig. 4). Intersection syndrome responds well to rest, splinting, injection, and NSAIDs. Return to sport should be gradual after symptoms have subsided. Because of the multifactorial etiology, if surgery is performed, Fulcher et all" recommended debridement of bursa1 tissue between the tendons, fasciotomy of the APL and EPB, and release of the second dorsal compartment. Postoperatively, the wrist is splinted for 7 to 10 days, followed by a stretching and strengthening program. Return to sport is allowed only when the patient is symptom free. Extensor Carpi Ulnaris Tendinitis
According to Wood and Dobyns,4* extensor carpi ulnaris (ECU) tendinitis is the second most common sport-related overuse syndrome. This entity is noted frequently in racquet sports requiring repetitive wrist motion (e.g., squash, badminton, racquetball, and rowing). In our experience, it is quite often seen secondary to excessive ulnar deviation
Intersection bursa
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ECRL ECRB Figure 4. Area of intersection within the muscles of EPB and APL (arrows) and tendons of extensor corpi radialus longus (ECRL) and extensor carpi radialus brevis (ECRB). (Modified from Kiefhaber TR, Stern PJ. Upper extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med 11:39-55, 1992; with permission.)
in the nondominant wrist of tennis players using a two-handed backhand stroke. ECU tendinitis should be included in the differential diagnosis of ulnar wrist pain in the athlete. Stenosing tenosynovitis of the sixth dorsal compartment should be distinguished from a subluxating ECU. The supratendinous retinaculum overrides the sixth dorsal compartment and attaches volarly to the pisiform, but the compartment housing the ECU (Fig. 5) is bounded ulnarly by a subsheath attached to the ulna medial to the ECU groove. Diagnosis of ECU tendinitis is made on physical examination with findings of tenderness over the sixth dorsal compartment. The ECU lies dorsal to the ulnar styloid in supination and volar in pronation. Subluxation of the ECU can be elicited by active ulnar deviation with the wrist in supination. Diagnosis of ECU involvement is confirmed by xylocaine injection into the tendon sheath. Underlying pathology, such as triangular fibrocartilage injuries or ulnar-carpal impingement, should be suspected in these patients, particularly when symptoms are not completely relieved by the injection. Acute ECU tendinitis is best treated by rest, splinting, and NSAIDs. In the acute phase, a corticosteroid injection can be curative. In chronic cases, surgical decompression can be indicated. An incision over the sixth dorsal compartment is made through the extensor retinaculum; the subsheath is divided radially, and the radial septum of the compartment is released (Fig. 6). Care is taken to protect the ulnar insertion of the subsheath. After decompression, the wrist is immobilized in 20" of extension for approximately 3 weeks. Subluxation of the extensor carpi ulnaris due to traumatic rupture of the ECU subsheath is seen with supination, palmar flexion, and ulnar deviation of the wrist.* This is common in tennis players hitting a low forehand and baseball players swinging a bat, and has been reported in
ECU subsheath
Extensor retinaculum
Figure 5. Sixth dorsal compartment houses the extensor carpi ulnaris (ECU) which is stabilized by a separate subsheath attached to the ulna. (Modified from Cooney WP, Linscheid RL, Dobyns JA: The Wrist: Diagnosis and Operative Treatment, vol 2. Mosby, 1998, pp 1188-1190.)
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Extensor retinaculum
ECU .A TFCC Ulna
Figure 6. Decompression of sixth dorsal compartment by radial release (A) of the subsheath and repair of the retinaculum. Care is taken to preserve medial subsheath insertion on the ulna. (Redrawn from Cooney WP, Linscheid RL, Dobyns JA: The Wrist: Diagnosis and Operative Treatment, vol 2. Mosby, 1998, pp 1188-1 190.)
bronco riders. The diagnosis is overlooked easily and always should be suspected in athletes presenting with ulnar wrist pain. Management of acute ECU subluxation can involve casting in slight radial deviation and palmar flexion, or as R ~ w l a n dhas ~ ~advocated, by repair of the ruptured subsheath. We prefer the surgical option in that earlier range of motion can be instituted with more confidence. In most cases, even in chronic subluxation, satisfactory subsheath tissue is usually present, and this is sutured to the fibrous osseous ulnar rim of the ECU groove (Fig. 7). Immobilization for 4 to 6 weeks in the Muenster
Extensor retinaculum
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Figure 7. Repair of chronic (or acute) ruptures of ECU subsheath to fibrous rim ulna (A) to groove for ECU. Proximal based flap of extensor retinaculum may be utilized to reinforce repair. (Redrawn from Cooney WP, Linscheid RL, Dobyns JA: The Wrist: Diagnosis and Operative Treatment, vol 2. Mosby, 1998, pp 1188-1 190.)
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cast is recommended after repair. Return to sports such as tennis requires a minimum of 8 to 10 weeks following surgery. Flexor Carpi Radialis Tendinitis
Flexor carpi radialis (FCR) tendinitis can occur due to repetitive wrist motion and is common in racquet players, golfers, and baseball hitters. The tendon travels in a tunnel separate from the carpal tunnel, which is bounded by the scaphoid tuberosity and the trapezia1 ridge dorsally and the transverse retinacular ligament volarly (Fig. 8). The Trapezium
Carpal tunnel TraDezium
Figure 8. Anatomy of radial tunnel, which houses the flexor carpi radialis tendon (FCR). (Redrawn from Bishop AT, Gabel G, Carmichael: Flexor Carpi Radialis Tendinitis, J Bone Joint Surg 76:1009-1014, 1994; with permission.)
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tendinitis can be due primarily to overuse or secondary to arthritis of the scaphotrapezial-trapezoid joint. The diagnosis of FCR tendinitis is made by noting tenderness over the insertion and pain with resisted wrist flexion. A test described by Listerz5involves suddenly dorsiflexing the relaxed wrist; the pain elicited is similar to the Finkelstein test for de Quervain syndrome. The diagnosis is confirmed by injection of xylocaine, which can be combined with cortisone, into the radial tunnel. Treatment of FCR tunnel syndrome includes rest, splinting, and stretching exercises. In prolonged cases, surgical release can be indicated. Gable et a1 described a surgical decompression procedure that involves a longitudinal incision centered over the FCR, beginning proximal to the flexion crease and extending to the thenar eminence. The thenar muscles are elevated, and the tendon sheath is divided to the trapezia1 crest. The tunnel is incised along the ulnar margin of the trapezoidal crest, and the tendon is pulled from the groove to confirm decompression. The wrist is splinted for 1 week, then range-of-motion exercises are begun."
Flexor Carpi Ulnar-Pisotriquetral Disorders
Flexor carpi ulnaris (FCU) tendinitis, with or without pisotriquetral compression syndrome, should be included in the differential diagnosis of ulnar wrist pain in the athlete. This entity is seen in racquet players, particularly racquetball, squash, and badminton players, and golfers. The athlete complains of ulnar wrist pain. Tenderness is present along the FCU tendon, and pain occurs with resisted wrist flexion. If pisotriquetral lesions are present, the pisotriquetral shuck or grind test is positive. Although usually negative, a lateral radiograph taken in slight wrist supination and extension can show changes in the pisotriquetral joint or calcification in the FCU tendon. Initial treatment involves rest and splinting in slight wrist flexion. Injection of corticosteroid into the pisotriquetral joints confirms the diagnosis and occasionally results in long-term improvement in symptoms. Successful conservative treatment has been reported in 40% of patients with pisotriquetral a r t h r i t i ~ . ~ ~ In recalcitrant cases, subperiosteal excision of the pisiform with repair of the defect in the FCU is recommended and usually curative. Palmieri31advocated supplementing the procedure with a 5-mm Z-plasty lengthening of the FCU. According to Helal,15 return to sports following the procedure averages 8 weeks.
Trigger Finger
Although stenosing tenosynovitis of the digital flexors is usually secondary to degenerative changes in the A-1 pulley and flexor tendons, direct pressure on the distal palm and metatarsophalangeal flexion
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crease from a racquet, golf club, or bat can cause acute inflammation and produce "trigger finger" in the athlete. The athlete complains of pain in the flexor aspect of the digit and can experience catching or even locking. Rest and NSAIDs can be tried in the acute setting, but most experts recommend corticosteroid injection into the sheath initially, with cure rates from 36% to 84% reported in the 1iteratu1-e.~~. 33 Surgical treatment involves either percutaneousZ7or, as recommended by most authors, open release of the A-1 pulley, by dividing the proximal 1.5cm of pulley. Return to racquet sports can be anticipated in 6 to 8 weeks, after the palm scar has matured. Focal Dystonia Syndrome
Focal dystonia is a poorly understood syndrome that occurs frequently in musicians and writers (i.e., writer's cramp) but also can be seen in the forearm intrinsic muscles of athletes who frequently grip a club, such as tennis players, oarsmen, or golfers. Patients complain of cramping pain in forearm or hand with activity. Although theories of etiology include central, peripheral, and functional17factors, medication is usually ineffective. In cases of peripheral etiology due to overactivity of wrist extensors, good response to local injection of botulism toxin type A (Botox, Allergan, Irvine, CA) has been reported.17 Compartment Syndrome
Exertional compartment syndrome is common in the anterior compartment of the lower leg; however, a similar entity can occur in the upper extremity.32The athlete usually complains of pain with prolonged activity that resolves shortly after activity ceases. Forearm and interosseous overuse compartment syndromes have been reported.l*,23 Physical examination is usually entirely normal. Diagnosis is made by intracompartmental pressure measured at rest and immediately after exercise. Although resting pressure can be slightly elevated (normal = 4 to 8 mm Hg), the critical diagnostic factor is prolonged return to resting pressure after exercise.32 Oarsmen and racquet sports participants who maintain a sustained grip on a tool are prone to upper extremity compartment syndromes. Treatment is surgical decompression. NEUROVASCULAR SYNDROMES
Nerve entrapment syndromes are thought to be due to mechanical compression and ensuing vascular compromise. The pathophysiology involves obstruction of venous return from the nerve by compression, which results in venous congestion involving epineural, perineural, and
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intrafascicular vessels. Anoxia of the nerve segment can result, with subsequent edema, which can enhance the effect of the regional compression. If the process continues for a long time, fibroblast proliferation will lead to intraneural scarring.38When nerve entrapment syndromes occur, compression must be relieved by rest, splinting, or surgical decompression to restore the health of the nerve.
Carpal Tunnel Syndrome: Median Neuropathy Carpal tunnel syndrome is the most common entrapment neuropathy in sports and occurs in many activities involving repetitive use of the wrist and hand. It frequently is seen in sports requiring gripping and throwing, cycling, and swimming, and even can be due to direct trauma. The median nerve travels in the carpal canal along with the four flexor profundus and four sublimis tendons, plus the flexor pollicis longus tendon. The floor of the tunnel is formed by the volar wrist capsule and the roof by the transverse retinacular ligament, which extends from the volar tubercle of the trapezium to the hook of the hamate and pisiform ulnarly (Fig. 9). The nerve becomes compressed in the tunnel due to increased pressure, usually from flexor tenosynovitis. Clinically, the athlete complains of pain in the hand or wrist, with
Ulnar N.
Palmar iutaneous branch median N. Figure 9. Median nerve and flexor tendons travel deep to transverse retinacular ligament. (Modified from Eversmann WW, Entrapment and compression neuropathies. In Green DP [ed]: Operative Hand Surgery, ed 2. New York, Churchill Livingstone, 1988, pp 1423-1478.)
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radiation proximally in some patients, and paresthesias in the median nerve distribution. Symptoms can be present only in the index and long fingers.39The pain occurs with activity and at night. This finding helps to differentiate the syndrome from pronator syndrome median nerve compression in the proximal forearm, in which symptoms are usually present only during activity. Physical examination has been well described and consists of a positive Tine1 sign, positive Phalen sign (Fig. lo), and positive direct median nerve compression test. Sensation should be tested by two-point discrimination, and grip strength can give an indication of the severity of involvement. Further diagnostic studies include electromyogram and nerve conduction studies, plain radiographs of the wrist, and magnetic resonance (MR) imaging. Plain roentgenograms are routinely obtained to rule out osseous lesions. Electromyogram and nerve conduction studies are negative in 20% of clinically proven carpal tunnel syndrome patients, and this number can be even higher in young athletes when compression is due to flexor tendon edema.*l These studies should be obtained when diagnosis is in doubt. MR imaging is reserved for special circumstances to rule out such conditions as anomalous muscle bellies, marked synovitis, or abnormalities of the nerve itself, such as a tum0r.3~ Primary treatment of carpal tunnel syndrome is splinting, which can vary from night only to full time for several days. During this time, isolated flexor digitorum profundus and flexor digitorum superficialis exercises are performed, and intermittent icing and NSAIDs are prescribed. Injection of corticosteroid has been advocated as both a diagnostic and therapeutic modality. Wood has shown a positive correlation between relief of symptoms by injection and results of surgical decom-
Figure 10. Phalen's test to reproduce symptoms of carpal tunnel syndrome. Arrows indicate compression on nerve. (Modified from Hoppenfeld S: Physical Examination of the Wrist and Hand: Physical Examination of the Spine and Extremities. New York, Appleton-CentutyCrofts, 1976, p 83; with permission.)
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pression.41 Transient relief can be anticipated with injection, although recurrence in 65% to 90% of patients has been reported.13 Injection can be particularly useful in an athlete who needs to recover quickly for an upcoming event. For best results, the wrist should be rested for 1 week after injection before returning to training. Surgical decompression is recommended only after failure of the above measures to control symptoms. Carpal tunnel release can be performed open or endoscopically. We recommend a limited-incision open technique, which minimizes postoperative palmar discomfort (pillar pain) and allows for rapid return to activities. Postoperative rehabilitation is designed to decrease edema and establish range of motion in phase I; begin strengthening in phase 11; and begin sport-specific training in phase 111. Return to sport depends on the sport and individual. Patients returning to sports using a racquet, club, or bat should use a specially padded glove to protect the hand from shock and vibratory trauma. Ulnar Neuropathy: Guyon Canal Syndrome
Ulnar neuropathy affects athletes involved in cycling, martial arts, racquet sports, and other sports requiring repetitive wrist motion, similar to carpal tunnel syndrome. The ulnar nerve travels through the Guyon canal, bordered on the ulnar aspect by the volar carpal ligament, dorsally by the transverse retinacular ligament, medially by the pisiform, and laterally by the hook of the hamate (Fig. 11).At the distal aspect of the canal, the nerve divides into a superficial sensory branch, which supplies the ulnar half of the ring and small fingers, and a deep motor branch, which travels deep and distal to the hook of the hamate between the origins of the abductor digiti minimi and flexor digiti minimi muscles. The nerve can be subjected to compression injury by both repetitive and continuous pressure or by repetitive wrist motion. The nerve is protected distal to the canal only by the palmaris brevis muscle and is subject to external trauma in this location. Shea and M ~ C l a i ndescribed ~~ three types of syndromes. Type I involved motor and sensory components due to compression in the proximal portion of the Guyon canal. Type I1 involved the distal aspect of the canal and hook of the hamate and selectively involved the motor branch. Type I11 lesions occurred in the distal part of the canal and resulted only in sensory deficits (see Fig. 11). Clinically, patients present with paresthesias in the ulnar nerve distribution and variable amounts of weakness, depending on the motor involvement. On physical examination, there is tenderness and a positive Tine1 sign over Guyon's canal, with radiation to the ring and small fingers. Ulnar-innervated muscles should be tested by checking the first dorsal interosseous muscle and by examining for the presence of the Froment sign (Fig. 12). The Wartenberg sign-abducted posture of the small finger due to interosseous and lumbrical compromise-also can
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Opponens digiti quinti Flexor digiti quinti Type 111 syndrome
Superficial branch u l n a N.
Deep branch u l n a N.
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Pisiform
Figure 11. Guyon's Canal showing three areas of compression described by Shea and McClain. (Modified from Eversmann WW: Entrapment and compression neuropathies. In Green DP [ed]: Operative Hand Surgery, ed 2. New York, Churchill Livingstone, 1988, ppl422-1478.)
be present. Grip strength testing is important because 40% of the grip strength is due to ulnar-innervated muscles. Two-point discrimination should be tested to evaluate sensory function. Radiographic studies are usually negative. Electrophysiologic testing can be helpful, but normal studies do not rule out the diagnosis. If a hook of the hamate fracture is suspected, a computed tomography (CT) scan should be performed. This can be an underlying cause of Guyon canal syndrome. The differential diagnosis consists of hypothenar hammer syndrome and other vascular abnormalities that can be confirmed by a positive
Figure 12. Frornent's sign demonstrating activation of flexor pollicis longus to substitute for adductor pollicis. (From Rettig AC: Neurovascular Injuries in the Wrists and Hands of Athletes, Clin Sports Med 9:389-417, 1990.)
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Allen test. Underlying causes of nerve compression, such as hook of the hamate fracture or ganglion cyst, should be ruled out. The possibility of a double-crush syndrome involving compression of the nerve at the elbow and wrist should also be kept in mind. Treatment of Guyon canal syndrome begins with rest and splinting. Cryotherapy and NSAIDs can be used, particularly in acute cases. Serial electromyograms can be helpful in following patients, and persistent sensory or motor compromise, or both, is an indication for surgical decompression. If symptoms are controlled with rest, return to sport with appropriate padding and technique adjustments is possible. After surgical decompression, the athlete can return to sport in 4 to 8 weeks, depending on the activity involved.
Radial Nerve Compression at the Wrist (Wartenberg Syndrome) This entity involves compression of the superficial branch of the radial nerve, also known as ”hand cuff neuropathy.” The superficial branch of the radial nerve pierces the deep fascia between the dorsal border of the brachial radialis muscle and the extensor carpi radialis to assume a subcutaneous position. The patient complains of pain and paresthesias over the dorsoradial aspect of the wrist and thumb. A positive Tinel sign over the point of compression usually is noted. Athletes participating in sports requiring repetitive ulnar flexion, pronation, and supination can experience this syndrome due to shear stress. Direct compression from wrist bands and taping also has been 38 rep~rted.~, Dellon and Mackinnon reported on 58 cases of superficial branch of radial nerve compression and recommended splinting in supination as the initial treatment.5Best results were reported in patients whose symptoms were caused by extensive physical activity or simple contusion, as seen in sports. Only rarely is surgical decompression indicated, and good to excellent results can be expected in 86%.5
Digital Neuropathy Digital nerve symptoms in the athlete are less common than those involving the wrist. The most commonly described entity is bowler’s thumb, originally reported by Dobyns et a1 in 1972.6 The pathology in bowler’s thumb stems from recurrent trauma to the ulnar digital nerve of the thumb from direct pressure of the edge of the thumb hole in the ball (Fig. 13). Proliferation of fibrous tissue around and within the nerve occurs, and the nerve becomes less mobile and cannot displace in the subcutaneous tissue when pressure is applied.6 Physical examination reveals a positive Tinel sign, and palpation of
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Figure 13. Bowler’s thumb-compression of ulnar digital nerve near thumb MP joint from thumb hole. (From Rettig AC: Neurovascular Injuries in the Wrists and Hands of Athletes. Clin Sports Med 9:389-417,1990.)
the thickened nerve in some patients. Two-point discrimination can be abnormal. Treatment involves rest (including rest from bowling) and NSAIDs. A molded orthotic to protect the ulnar base of the thumb and redrilling of the ball to relieve pressure on the affected area allow the athlete to return to the sport when pain and numbness resolve. Surgical decompression and transfer of the nerve rarely are indicated.35 OVERUSE VASCULAR SYMPTOMS
Vascular injuries occur due to repetitive trauma to the palmar aspect of the hand and wrist and are seen in athletes whose sports involve significant repetitive energy absorption in the hands. Vascular syndromes specifically include hypothenar hammer syndrome due to trauma to the ulnar artery at the wrist, trauma to the digital vessels, and vasospastic disorders of the digits in baseball players. The primary blood supply to the hand is from the terminal branches of the ulnar and radial arteries. Two vascular arches are formed, with the ulnar artery contributing primarily to the superficial palmar arch and the radial artery forming the deep palmar arch. In 80% of individuals, each arch receives contributions from both the radial and ulnar arteries and is considered ”complete” (Fig. 14). In the 20% of individuals with incomplete arches, loss of radial or ulnar artery flow can compromise digital circulation (Fig. 15). Hypothenar Hammer Syndrome
This overuse syndrome from repetitive impact trauma to the hypothenar region of the hand is seen in such sports as judo, karate, and lacrosse, or can occur from a single traumatic event.3,1 6 , The ~ pathophysiology involves trauma to the ulnar artery distal to Guyon’s canal, which
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Common volar
Figure 14. Most common pattern of complete arch (80% of hands). (Modified from Coleman SS, Anson BJ: Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 113:409421, 1961; with permission.)
leads to ischemia. This occurs due to (1) initial damage and resultant thrombosis; (2) altered flow due to either true aneurysm formation, in which all layers of the vessel wall are injured, or false aneurysm secondary to a laceration or penetration of the vessel wall with encapsulation and hematoma formation (Fig. 16); and (3) vasospasm secondary to changes in the arterial flow pattern.
Figure 15. Most common variations of 20% with incomplete arches. (Modified from Coleman SS, Anson BJ: Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 113:409421, 1961; with permission.)
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A
B
Figure 16. A, False aneurysm. Note the saccular form involving one side of the artery. B, True aneurysm. Note the fusiform shape involving the entire artery. (Modified from Green DP: True and false traumatic aneurysms in the hand: Report on two cases and review of the literature. J Bone Joint Surg 55A:120-128, 1973; with permission.)
Athletes can present with cold intolerance and pain in the palm or numbness in the ulnar-innervated digits, or both, due to ulnar nerve compression secondary to aneurysm formation. Physical examination usually will differentiate vascular etiology from isolated ulnar nerve compression. A positive Tine1 sign can be present due to ulnar nerve compression. The Allen test is specific for arterial insufficiency and is performed by compressing both radial and ulnar arteries while the patient makes a tight fist. After relaxing the fist, one artery is released and lack of blush within 5 seconds indicates insufficiency in the released vessel. This test also can be performed on digital vessels to determine patency. Supplemental tests include the Doppler scan, photo plethysmography, ultrasound, and cold testing. Initial-phase bone scan can be helpful in isolating lesions, and arthrography should be performed if surgery is a consideration. Treatment consists of rest from the offending activity and, in mild cases, participation can be permitted with increased padding of the exposed portion of the hand (Fig. 17). Vasolytic and sympatholytic agents also can be used. Surgical options include exploration and excision of the thrombosed segment of the artery with ligation in those with complete arches, or vein graft re-establishment of flow in those with incomplete arches. Digital Ischemia
Digital ischemia has been studied in handball players by Buckout and Warner and in baseball catchers by Lowrey2*(Fig. 18) and Sugawara
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Figure 17. Antivibratory glove (Smith Nephew, Germantown, WI) provides padding for the thenar area of the hand.
et al.38aAthletes in both sports demonstrated a high incidence of digital ischema. Sugawara et a138aconcluded that the development of circulatory problems was related to number of years played, frequency of practice, and position played. They recommended prophylactic use of increased padding in the gloves of baseball players. Vascular compromise in the pitching hands of baseball players has been described by Itoh et al? digital vessels were compressed in the lumbrical canals in two cases and as the vessels pass deep to the Cleland ligament in another. Vasospastic disorders of the pitcher’s index finger
Figure 18. Digital Allen’s test position (+) and impaired flow by Doppler testing (-). (Modified from Lowrey CW, Chadwick RO, Waltman EN: Digital vessel trauma from repetitive impact in baseball catchers. J Hand Surg 1:236-238, 1976; with permission.)
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have been reported, and are thought to be due to overstimulation of digital sympathetic^.^^" In the cases described by Itoh et al, surgical decompression was curative, whereas sympathetic blocks or vasodilator modalities or medications are be indicated for vasospastic disorders.
SUMMARY
Overuse syndromes in the wrist or hand can occur from repetitive use of the wrist and hand or from recurrent direct trauma to the hand area. Tendinitis syndromes due to overstretching or shear stress are seen commonly on both the extensor and flexor sides of the wrist. Overuse syndromes also can take the form of neurovascular syndromes, resulting in compression syndromes of the median, ulnar, and superficial branch of the radial nerve in the wrist area and trauma to the ulnar and digital vessels supplying the hand. Treatment in most cases involves rest with splinting, icing, and NSAIDs in acute cases, although surgical decompression is indicated in chronic or recurrent cases.
References 1. Clancy WG: Tendon trauma and overuse injuries. In Leadbetter W, Buckwalter J, Gordon S (eds): Sports-Induced Inflammation. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, pp 609-618 2. Conklin J, White W Stenosing tenosynovitis and its possible relation to the carpal tunnel syndrome. Surg Clin North Am 40:531-540,1960 3. Conn J, Bergan JJ, Bell JL: Hypothenar hammer syndrome: Posttraumatic digital ischemia. Surgery 68:1122-1128, 1970 4. Curwin S, Stanish W Tendinitis: Its Etiology and Treatment. Lexington, MA, The Collamore Press, 1984 5. Dellon AL, MacKinnon SE: Radial sensory nerve entrapment in the forearm. J Hand Surg [Am] 11:199-205, 1986 6. Dobyns JH, OBrien ET, Linscheid RL, et al: Bowler’s thumb, diagnosis and treatment Review of 17 cases. J Bone Jont Surg Am 54:751-755, 1972 7. Dorfman LJ, Jayram AR Handcuff neuropathy. JAMA 239:957, 1978 8. Eckhardt W, Palmer AK Recurrent dislocation of extensor carui ulnaris tendon. T Hand Surg [Am] 6:629-631,1981 9. Finkelstein H: Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg Am 12509-540, 1930 10. Fulcher SM, Kiefhaber TR, Stem PF: Upper-extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med 17433448,1998 11. Gabel G, Bishop AT, Wood MB: Flexor carpi radialis tendinitis: 11. Results of operative treatment. J Bone Joint Surg Am 769015-1018,1994 12. Gelberman RH, Aronson D, Weisman MH: Carpal tunnel syndrome. Results of a prospective trial of steroid injection and splint&g. J Bone Joint Surg Am 6211811184, 1980 13. Green DP: Diagnostic and the therapeutic value of carpal tunnel injection. J Hand Surg [Am] 9:850-854, 1984 14. Grundberg AB, Reagan DS Pathologic anatomy of the forearm: Intersection syndrome. J Hand Surg [Am] 10299-302,1985 15. Helal 8: Racquet player’s pisiform. Hand 10:87-90, 1978
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16. Ho PK, Dellon AL, Wilgis EFS True aneurysms of the hand resulting from athletic injury. Am J Sports Med 13:136-138, 1985 17. Hochberg FH, Harris SU, Blattert TR. Occupational hand cramps: Professional disorders or motor control. Hand Clinics 6:417428, 1990 18. Imbriglia JE, Boland DM: An exercise-induced compartment syndrome of the dorsal forearm: A case report. J Hand Surg 9:142-143, 1984 19. Itoh Y, Wakano K, Takeda T, el al: Circulatory disturbances in the throwing hand of baseball pitchers. Am J Sports Med 153264-269, 1987 20. Jackson WT, Wiegas SF, Coon T Anatomical variations in the first extensor compartment of the wrist. J Bone Joint Surg Am 68:923-926, 1986 21. Kaplan EB, Spinner M Normal and anomalous innervation patterns in the upper extremity. In Omer GE, Spinner (eds): Management of Peripheral Nerve Problems. Philadelphia, WB Saunders, 1980, pp 75-99 22. Kulund DN, Brubaker CE: Injuries in the bike centennial tour. Physicians of Sportsmedicine 6:74-78, 1978 23. Kutz JE, Singer R, Lindsay M: Chronic exertional compartment syndrome of the forearm: A case report. J Hand Surg [Am] 10:302-304, 1985 24. Lipscomp PR Stenosing tenosynovitis at the radial styloid process (deQuervain’s disease). Am J Surg 134:llO-115, 1951 25. Lister G: In The Hand, ed 2. Edinburgh, Churchill Livingstone, 1984, p 244 26. Loomis L: Variations of stenosing tenosynovitis at the radial styloid process. J Bone Joint Surg Am 33:340-346,1951 27. Lorthioir J: Surgical treatment of trigger finger by a subcutaneous method. J Bone Joint Surg Am 40:793-795,1958 28. Lowrey CW, Chadwick RO, Waltman E N Digital vessel trauma from repetitive impact in baseball catchers. J Hand Surg 1:23&238, 1976 29. Marks M, Gunther SF: Efficacy of cortison injection in treatment of trigger fingers and thumbs. J H and Surg [Am] 14:722-727, 1989 30. Osterman AL, Moskow L, Low D Soft-tissue injuries of the hand and wrist in racquet sports. Clin Sports Med 7329-348,1988 31. Palmeiri TJ: Pisiform area pain treatment by pisiform excision. J Hand Surg [Am] 7477-480, 1982 32. Pitner M. Pathophysiology of overuse injuries in the hand and wrist. Hand Clin 6~355-364,1990 33. Quinnell R: Conservative management of trigger finger. Practitioner 224:187-190,1980 34. Renstrom P, Johnson R Overuse injuries in sports: A review. Sports Med 2:316-333, 1985 35. Rettig, AC: Neurovascular injuries in the wrists and hands of athletes. Clin Sports Med 9:389417, 1990 36. Rowland S A Acute traumatic subluxation of the extensor carpi ulnaris tendon at the wrist. J Hand Surg [Am] 11A:809-811, 1986 37. Shea JD, McClain E F Unlar-nerve compression syndrome at and below the wrist. J Bone Joint Surg Am 51:10951103, 1969 38. Smith MS: Handcuff neuropathy. Ann Emerg Med 10:668, 1981 38a. Sugawara M, Oginot T, Minami A, et al: Digital ischema in baseball players. Am J Sports Med 14:329-333, 1986 39. Sunderland S The nerve lesion in the carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 39:615426, 1976 40. Williams J: Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg Br 59:408, 1977 41. Wood MR Hydrocortisone injections for carpal tunnel syndrome. Hand 12:6244,1980 42. Wood M, Dobyns J: Sports-related extraarticular wrist syndromes. Clin Orthop 202:93-102, 1986 43. Wood M, Linscheid R Abductor pollicis bursitis. Clin Orthop 93:293-296, 1973
Address reprint requests to Arthur C. Rettig, MD 201 Pennsylvania Parkway, Suite 200 Indianapolis, IN 46280
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WRIST AND HAND OVERUSE SYNDROMES Arthur C. Rettig, MD
Overuse injuries of the wrist and hand are common in athletic endeavors. It has been estimated that 25% to 50% of all sports injuries are attributed to overuse.32,34 Wrist syndromes are the most common upper extremity overuse injuries.30 The incidence of wrist problems in athletic activities is extremely high. For example, in gymnastics, the wrist and hand support body weight. Repetitive activities in which the wrist and hand have contact with a ball (such as handball and volleyball) or grip a racquet or an oar also result in a high number of overuse injuries.'O TENOSYNOVITIS OF WRIST AND HAND
Tendinitis can occur due to tension overload or shear stress. Pitner32 noted that overuse is defined as a level of repetitive microtrauma that exceeds the ability of the tissue to adapt. At the molecular level, tendon failure occurs due to stretching of collagen, the chief component of the structure. Up to 4% of elongation is well tolerated, and no tissue damage occurs. Between 4% and 8% of elongation, the collagen cross-links rupture, and collagen fibers slide past one a n ~ t h e rMacroscopic .~ failure of the tendon occurs when greater than 8% elongation occurs, and the fibers r ~ p t u r e . ~ Clancy' noted that tension overload can occur in the muscle, at the musculotendinous junction, in the tendon substance itself, or at its
From the Methodist Sports Medicine Center, Thomas A. Brady Clinic, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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attachment to bone. Overload can be obviated in some cases by appropriate training methods involving gradually increasing stress load. Tendons adapt to applied loads according to the Wolff law, which involves an increase in collagen content and cross-linking. This process takes time, training, and the use of proper t e c h n i q ~ e s . ~ ~ Shear stress can occur where tendons pass in close proximity to a fixed structure (e.g., de Quervain's syndrome). Tenosynovial tissue surrounds tendons at these points and lubricates and protects these structures as they pass through tunnels or around bony prominences (Fig. 1). The process involved in the pathogenesis and natural history of tendinitis, whether it is due to tension overload or shear stress, can be divided into four stages: inflammatory, proliferative, maturation, and fibrosis. Treatment modalities differ to some extent depending on the stage of the process at presentation. The inflammatory response to microtrauma is characterized clinically by pain, swelling, increased temperature, and tenderness at the site. At the cellular level, vascular ingrowth, increased capillary permeability, and accumulation of inflammatory cells occur.32Treatment of tendinitis at this stage involves rest to prevent exacerbation and prolongation of the healing process. This includes avoiding activities that cause discomfort, splinting, or in some cases, casting. Icing, elevation, compression, and nonsteroidal anti-inflammatory drugs (NSAIDs) also can be of benefit. P i t r ~ e rdescribed ~~ the stage of proliferation as lasting 1 to 2 weeks and involving the production of poorly organized collagen and growth substance. During this stage, excessive activity is to be avoided, although light stretching and controlled range of motion are permitted. This stage of maturation consists of maturation of collagen with cross-linking and occurs over 1 to 3 months. Controlled stretching and strengthening are
Tendon sheath
-
Figure 1. Tension overload of the tendon itself or shear stress at the sheath-tendon interface may produce tendinitis caused by overuse. (Modified from Fulcher SM, Kiefhaber TR, Stern PJ: Upper extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med 11:39-55, 1992; with permission.)
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recommended, with the goal of treatment being to avoid disuse atrophy but also to avoid reinjury and re-entry into the inflammatory phase. Fibrosis occurs with repeated inflammatory episodes and results in scarring of the tendon retinacular sheaths or the tendon itself. Entities due to shear trauma, such as “trigger finger” or de Quervain syndrome, frequently do not respond to rest or corticosteroid injection once they have progressed to this stage, and can require surgical release. SPECIFIC TENOSYNOVITIS OF HAND AND WRIST De Quervain Syndrome
Tenosynovitis of the first dorsal compartment, or de Quervain syndrome, is the most common tendinitis of the wrist in athletes. The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons course beneath the fibrous sheath overlying a groove along the radial styloid process (Fig. 2). Shear stress resulting from repetitive wrist motion, including radial and ulnar deviation as well as flexion and extension, results in inflammation of the tenosynovium.2,9,26 Sports most commonly associated with de Quervain syndrome include golf, racquet sports (especially racquetball, badminton, and squash), and fishing.24,26 On physical examination, tenderness over the first dorsal compartment is present, and a positive Finkelstein test is pathognomic for the diagnosis. This test is performed by flexing the thumb into the palm and passively deviating the wrist ulnarly, thus causing maximum stretch to the APL and EPB tendons. In chronic cases, thickening of the fibrous sheath and occasionally a ganglion cyst can be p r e ~ e n t . ~ Treatment of de Quervain syndrome depends on the stage at presentation. Although acute cases can respond to rest and splinting, most experts recommend corticosteroid injection into the sheath. Cure rates EPB
,/‘
Suphicia1 branch radial nerve
Figure 2. Frequently the extensor pollicis brevis (EPB) tendon lies in a separate compartment from the obductor pollicis longus (APL), which usually is composed of 2 to 5 slips. (Modified from Fulcher SM, Kiefhaber TR, Stern PJ: Upper extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med 11:39-55, 1992; with permission.)
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of 80% and 62% have been reported by Osterman et a1 and Gelberman l2 Injection alone recently has been found superior et al, respe~tively.~~, to splinting and to injection and splinting together.12 Our recommended treatment program in the acute case is corticosteroid injection using dexamethasone and betamethasone and splinting, followed by stretching of the APL and EPB tendons and strengthening. If symptoms recur, a second or third injection is performed, followed by appropriate rehabilitation. If this fails, surgical decompression should be considered. In chronic cases of first dorsal compartment tenosynovitis, the above treatment is initiated; however, the success rate is decreased due to the presence of fibrosis, and frequently surgery is indicated. Surgery is performed through a longitudinal curvilinear incision (Fig. 3), and the branches of the superficial radial nerve are identified and carefully protected. The sheath of the first dorsal compartment is divided longitudinally, leaving a flap of sheath volarly to prevent volar subluxation of the tendons. Jackson et a1 noted that a separate compartment for the EPB is common in patients with de Quervain syndrome, and it is imperative to identify this tendon and divide its sheath.2o Postoperatively, the wrist is splinted for 7 to 10 days, followed by rangeof-motion and strengthening exercises. Return to sport can be expected in 6 to 9 weeks.
Superficial branch radial N. Radial A'.
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Figure 3. A longitudinal curvilinear incision (dashed line) is preferred to better protect the superficial branches of the radial nerve. The first dorsal compartment sheath is divided and EPB and APL tendons decompressed. (Modified from Cooney WP, Linscheid RL, Dobyns JA: The Wrist: Diagnosis and Operative Treatment, vol 2. Mosby, 1998, pp 1188-1190.)
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Intersection Syndrome
Intersection syndrome refers to inflammation or bursitis at the point of crossing of the outcropping muscles (APL, EPB, extensor indicis proprius) and the radial wrist extensors (extensor carpi radialis longus [ECRL], extensor carpi radialis brevis [ECRB]). This condition is also known as "cross-over tendinitis," "peritendinitis," and "squeakers." Participants in racquet sports, oarsmen, and weight-training athletes can develop this The pathophysiology of this condition is poorly understood, but theories include (1)friction between the tendons producing a (2) tenosynovitis of the ECRL and ECRBI4; and (3) hypertrophy of the APL and EPB muscle bellies, causing pressure on the radial wrist (Fig. 4). Intersection syndrome responds well to rest, splinting, injection, and NSAIDs. Return to sport should be gradual after symptoms have subsided. Because of the multifactorial etiology, if surgery is performed, Fulcher et all" recommended debridement of bursa1 tissue between the tendons, fasciotomy of the APL and EPB, and release of the second dorsal compartment. Postoperatively, the wrist is splinted for 7 to 10 days, followed by a stretching and strengthening program. Return to sport is allowed only when the patient is symptom free. Extensor Carpi Ulnaris Tendinitis
According to Wood and Dobyns,4* extensor carpi ulnaris (ECU) tendinitis is the second most common sport-related overuse syndrome. This entity is noted frequently in racquet sports requiring repetitive wrist motion (e.g., squash, badminton, racquetball, and rowing). In our experience, it is quite often seen secondary to excessive ulnar deviation
Intersection bursa
...
ECRL ECRB Figure 4. Area of intersection within the muscles of EPB and APL (arrows) and tendons of extensor corpi radialus longus (ECRL) and extensor carpi radialus brevis (ECRB). (Modified from Kiefhaber TR, Stern PJ. Upper extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med 11:39-55, 1992; with permission.)
in the nondominant wrist of tennis players using a two-handed backhand stroke. ECU tendinitis should be included in the differential diagnosis of ulnar wrist pain in the athlete. Stenosing tenosynovitis of the sixth dorsal compartment should be distinguished from a subluxating ECU. The supratendinous retinaculum overrides the sixth dorsal compartment and attaches volarly to the pisiform, but the compartment housing the ECU (Fig. 5) is bounded ulnarly by a subsheath attached to the ulna medial to the ECU groove. Diagnosis of ECU tendinitis is made on physical examination with findings of tenderness over the sixth dorsal compartment. The ECU lies dorsal to the ulnar styloid in supination and volar in pronation. Subluxation of the ECU can be elicited by active ulnar deviation with the wrist in supination. Diagnosis of ECU involvement is confirmed by xylocaine injection into the tendon sheath. Underlying pathology, such as triangular fibrocartilage injuries or ulnar-carpal impingement, should be suspected in these patients, particularly when symptoms are not completely relieved by the injection. Acute ECU tendinitis is best treated by rest, splinting, and NSAIDs. In the acute phase, a corticosteroid injection can be curative. In chronic cases, surgical decompression can be indicated. An incision over the sixth dorsal compartment is made through the extensor retinaculum; the subsheath is divided radially, and the radial septum of the compartment is released (Fig. 6). Care is taken to protect the ulnar insertion of the subsheath. After decompression, the wrist is immobilized in 20" of extension for approximately 3 weeks. Subluxation of the extensor carpi ulnaris due to traumatic rupture of the ECU subsheath is seen with supination, palmar flexion, and ulnar deviation of the wrist.* This is common in tennis players hitting a low forehand and baseball players swinging a bat, and has been reported in
ECU subsheath
Extensor retinaculum
Figure 5. Sixth dorsal compartment houses the extensor carpi ulnaris (ECU) which is stabilized by a separate subsheath attached to the ulna. (Modified from Cooney WP, Linscheid RL, Dobyns JA: The Wrist: Diagnosis and Operative Treatment, vol 2. Mosby, 1998, pp 1188-1190.)
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Extensor retinaculum
ECU .A TFCC Ulna
Figure 6. Decompression of sixth dorsal compartment by radial release (A) of the subsheath and repair of the retinaculum. Care is taken to preserve medial subsheath insertion on the ulna. (Redrawn from Cooney WP, Linscheid RL, Dobyns JA: The Wrist: Diagnosis and Operative Treatment, vol 2. Mosby, 1998, pp 1188-1 190.)
bronco riders. The diagnosis is overlooked easily and always should be suspected in athletes presenting with ulnar wrist pain. Management of acute ECU subluxation can involve casting in slight radial deviation and palmar flexion, or as R ~ w l a n dhas ~ ~advocated, by repair of the ruptured subsheath. We prefer the surgical option in that earlier range of motion can be instituted with more confidence. In most cases, even in chronic subluxation, satisfactory subsheath tissue is usually present, and this is sutured to the fibrous osseous ulnar rim of the ECU groove (Fig. 7). Immobilization for 4 to 6 weeks in the Muenster
Extensor retinaculum
,
I
Figure 7. Repair of chronic (or acute) ruptures of ECU subsheath to fibrous rim ulna (A) to groove for ECU. Proximal based flap of extensor retinaculum may be utilized to reinforce repair. (Redrawn from Cooney WP, Linscheid RL, Dobyns JA: The Wrist: Diagnosis and Operative Treatment, vol 2. Mosby, 1998, pp 1188-1 190.)
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cast is recommended after repair. Return to sports such as tennis requires a minimum of 8 to 10 weeks following surgery. Flexor Carpi Radialis Tendinitis
Flexor carpi radialis (FCR) tendinitis can occur due to repetitive wrist motion and is common in racquet players, golfers, and baseball hitters. The tendon travels in a tunnel separate from the carpal tunnel, which is bounded by the scaphoid tuberosity and the trapezia1 ridge dorsally and the transverse retinacular ligament volarly (Fig. 8). The Trapezium
Carpal tunnel TraDezium
Figure 8. Anatomy of radial tunnel, which houses the flexor carpi radialis tendon (FCR). (Redrawn from Bishop AT, Gabel G, Carmichael: Flexor Carpi Radialis Tendinitis, J Bone Joint Surg 76:1009-1014, 1994; with permission.)
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tendinitis can be due primarily to overuse or secondary to arthritis of the scaphotrapezial-trapezoid joint. The diagnosis of FCR tendinitis is made by noting tenderness over the insertion and pain with resisted wrist flexion. A test described by Listerz5involves suddenly dorsiflexing the relaxed wrist; the pain elicited is similar to the Finkelstein test for de Quervain syndrome. The diagnosis is confirmed by injection of xylocaine, which can be combined with cortisone, into the radial tunnel. Treatment of FCR tunnel syndrome includes rest, splinting, and stretching exercises. In prolonged cases, surgical release can be indicated. Gable et a1 described a surgical decompression procedure that involves a longitudinal incision centered over the FCR, beginning proximal to the flexion crease and extending to the thenar eminence. The thenar muscles are elevated, and the tendon sheath is divided to the trapezia1 crest. The tunnel is incised along the ulnar margin of the trapezoidal crest, and the tendon is pulled from the groove to confirm decompression. The wrist is splinted for 1 week, then range-of-motion exercises are begun."
Flexor Carpi Ulnar-Pisotriquetral Disorders
Flexor carpi ulnaris (FCU) tendinitis, with or without pisotriquetral compression syndrome, should be included in the differential diagnosis of ulnar wrist pain in the athlete. This entity is seen in racquet players, particularly racquetball, squash, and badminton players, and golfers. The athlete complains of ulnar wrist pain. Tenderness is present along the FCU tendon, and pain occurs with resisted wrist flexion. If pisotriquetral lesions are present, the pisotriquetral shuck or grind test is positive. Although usually negative, a lateral radiograph taken in slight wrist supination and extension can show changes in the pisotriquetral joint or calcification in the FCU tendon. Initial treatment involves rest and splinting in slight wrist flexion. Injection of corticosteroid into the pisotriquetral joints confirms the diagnosis and occasionally results in long-term improvement in symptoms. Successful conservative treatment has been reported in 40% of patients with pisotriquetral a r t h r i t i ~ . ~ ~ In recalcitrant cases, subperiosteal excision of the pisiform with repair of the defect in the FCU is recommended and usually curative. Palmieri31advocated supplementing the procedure with a 5-mm Z-plasty lengthening of the FCU. According to Helal,15 return to sports following the procedure averages 8 weeks.
Trigger Finger
Although stenosing tenosynovitis of the digital flexors is usually secondary to degenerative changes in the A-1 pulley and flexor tendons, direct pressure on the distal palm and metatarsophalangeal flexion
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crease from a racquet, golf club, or bat can cause acute inflammation and produce "trigger finger" in the athlete. The athlete complains of pain in the flexor aspect of the digit and can experience catching or even locking. Rest and NSAIDs can be tried in the acute setting, but most experts recommend corticosteroid injection into the sheath initially, with cure rates from 36% to 84% reported in the 1iteratu1-e.~~. 33 Surgical treatment involves either percutaneousZ7or, as recommended by most authors, open release of the A-1 pulley, by dividing the proximal 1.5cm of pulley. Return to racquet sports can be anticipated in 6 to 8 weeks, after the palm scar has matured. Focal Dystonia Syndrome
Focal dystonia is a poorly understood syndrome that occurs frequently in musicians and writers (i.e., writer's cramp) but also can be seen in the forearm intrinsic muscles of athletes who frequently grip a club, such as tennis players, oarsmen, or golfers. Patients complain of cramping pain in forearm or hand with activity. Although theories of etiology include central, peripheral, and functional17factors, medication is usually ineffective. In cases of peripheral etiology due to overactivity of wrist extensors, good response to local injection of botulism toxin type A (Botox, Allergan, Irvine, CA) has been reported.17 Compartment Syndrome
Exertional compartment syndrome is common in the anterior compartment of the lower leg; however, a similar entity can occur in the upper extremity.32The athlete usually complains of pain with prolonged activity that resolves shortly after activity ceases. Forearm and interosseous overuse compartment syndromes have been reported.l*,23 Physical examination is usually entirely normal. Diagnosis is made by intracompartmental pressure measured at rest and immediately after exercise. Although resting pressure can be slightly elevated (normal = 4 to 8 mm Hg), the critical diagnostic factor is prolonged return to resting pressure after exercise.32 Oarsmen and racquet sports participants who maintain a sustained grip on a tool are prone to upper extremity compartment syndromes. Treatment is surgical decompression. NEUROVASCULAR SYNDROMES
Nerve entrapment syndromes are thought to be due to mechanical compression and ensuing vascular compromise. The pathophysiology involves obstruction of venous return from the nerve by compression, which results in venous congestion involving epineural, perineural, and
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intrafascicular vessels. Anoxia of the nerve segment can result, with subsequent edema, which can enhance the effect of the regional compression. If the process continues for a long time, fibroblast proliferation will lead to intraneural scarring.38When nerve entrapment syndromes occur, compression must be relieved by rest, splinting, or surgical decompression to restore the health of the nerve.
Carpal Tunnel Syndrome: Median Neuropathy Carpal tunnel syndrome is the most common entrapment neuropathy in sports and occurs in many activities involving repetitive use of the wrist and hand. It frequently is seen in sports requiring gripping and throwing, cycling, and swimming, and even can be due to direct trauma. The median nerve travels in the carpal canal along with the four flexor profundus and four sublimis tendons, plus the flexor pollicis longus tendon. The floor of the tunnel is formed by the volar wrist capsule and the roof by the transverse retinacular ligament, which extends from the volar tubercle of the trapezium to the hook of the hamate and pisiform ulnarly (Fig. 9). The nerve becomes compressed in the tunnel due to increased pressure, usually from flexor tenosynovitis. Clinically, the athlete complains of pain in the hand or wrist, with
Ulnar N.
Palmar iutaneous branch median N. Figure 9. Median nerve and flexor tendons travel deep to transverse retinacular ligament. (Modified from Eversmann WW, Entrapment and compression neuropathies. In Green DP [ed]: Operative Hand Surgery, ed 2. New York, Churchill Livingstone, 1988, pp 1423-1478.)
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radiation proximally in some patients, and paresthesias in the median nerve distribution. Symptoms can be present only in the index and long fingers.39The pain occurs with activity and at night. This finding helps to differentiate the syndrome from pronator syndrome median nerve compression in the proximal forearm, in which symptoms are usually present only during activity. Physical examination has been well described and consists of a positive Tine1 sign, positive Phalen sign (Fig. lo), and positive direct median nerve compression test. Sensation should be tested by two-point discrimination, and grip strength can give an indication of the severity of involvement. Further diagnostic studies include electromyogram and nerve conduction studies, plain radiographs of the wrist, and magnetic resonance (MR) imaging. Plain roentgenograms are routinely obtained to rule out osseous lesions. Electromyogram and nerve conduction studies are negative in 20% of clinically proven carpal tunnel syndrome patients, and this number can be even higher in young athletes when compression is due to flexor tendon edema.*l These studies should be obtained when diagnosis is in doubt. MR imaging is reserved for special circumstances to rule out such conditions as anomalous muscle bellies, marked synovitis, or abnormalities of the nerve itself, such as a tum0r.3~ Primary treatment of carpal tunnel syndrome is splinting, which can vary from night only to full time for several days. During this time, isolated flexor digitorum profundus and flexor digitorum superficialis exercises are performed, and intermittent icing and NSAIDs are prescribed. Injection of corticosteroid has been advocated as both a diagnostic and therapeutic modality. Wood has shown a positive correlation between relief of symptoms by injection and results of surgical decom-
Figure 10. Phalen's test to reproduce symptoms of carpal tunnel syndrome. Arrows indicate compression on nerve. (Modified from Hoppenfeld S: Physical Examination of the Wrist and Hand: Physical Examination of the Spine and Extremities. New York, Appleton-CentutyCrofts, 1976, p 83; with permission.)
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pression.41 Transient relief can be anticipated with injection, although recurrence in 65% to 90% of patients has been reported.13 Injection can be particularly useful in an athlete who needs to recover quickly for an upcoming event. For best results, the wrist should be rested for 1 week after injection before returning to training. Surgical decompression is recommended only after failure of the above measures to control symptoms. Carpal tunnel release can be performed open or endoscopically. We recommend a limited-incision open technique, which minimizes postoperative palmar discomfort (pillar pain) and allows for rapid return to activities. Postoperative rehabilitation is designed to decrease edema and establish range of motion in phase I; begin strengthening in phase 11; and begin sport-specific training in phase 111. Return to sport depends on the sport and individual. Patients returning to sports using a racquet, club, or bat should use a specially padded glove to protect the hand from shock and vibratory trauma. Ulnar Neuropathy: Guyon Canal Syndrome
Ulnar neuropathy affects athletes involved in cycling, martial arts, racquet sports, and other sports requiring repetitive wrist motion, similar to carpal tunnel syndrome. The ulnar nerve travels through the Guyon canal, bordered on the ulnar aspect by the volar carpal ligament, dorsally by the transverse retinacular ligament, medially by the pisiform, and laterally by the hook of the hamate (Fig. 11).At the distal aspect of the canal, the nerve divides into a superficial sensory branch, which supplies the ulnar half of the ring and small fingers, and a deep motor branch, which travels deep and distal to the hook of the hamate between the origins of the abductor digiti minimi and flexor digiti minimi muscles. The nerve can be subjected to compression injury by both repetitive and continuous pressure or by repetitive wrist motion. The nerve is protected distal to the canal only by the palmaris brevis muscle and is subject to external trauma in this location. Shea and M ~ C l a i ndescribed ~~ three types of syndromes. Type I involved motor and sensory components due to compression in the proximal portion of the Guyon canal. Type I1 involved the distal aspect of the canal and hook of the hamate and selectively involved the motor branch. Type I11 lesions occurred in the distal part of the canal and resulted only in sensory deficits (see Fig. 11). Clinically, patients present with paresthesias in the ulnar nerve distribution and variable amounts of weakness, depending on the motor involvement. On physical examination, there is tenderness and a positive Tine1 sign over Guyon's canal, with radiation to the ring and small fingers. Ulnar-innervated muscles should be tested by checking the first dorsal interosseous muscle and by examining for the presence of the Froment sign (Fig. 12). The Wartenberg sign-abducted posture of the small finger due to interosseous and lumbrical compromise-also can
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Opponens digiti quinti Flexor digiti quinti Type 111 syndrome
Superficial branch u l n a N.
Deep branch u l n a N.
\
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Pisiform
Figure 11. Guyon's Canal showing three areas of compression described by Shea and McClain. (Modified from Eversmann WW: Entrapment and compression neuropathies. In Green DP [ed]: Operative Hand Surgery, ed 2. New York, Churchill Livingstone, 1988, ppl422-1478.)
be present. Grip strength testing is important because 40% of the grip strength is due to ulnar-innervated muscles. Two-point discrimination should be tested to evaluate sensory function. Radiographic studies are usually negative. Electrophysiologic testing can be helpful, but normal studies do not rule out the diagnosis. If a hook of the hamate fracture is suspected, a computed tomography (CT) scan should be performed. This can be an underlying cause of Guyon canal syndrome. The differential diagnosis consists of hypothenar hammer syndrome and other vascular abnormalities that can be confirmed by a positive
Figure 12. Frornent's sign demonstrating activation of flexor pollicis longus to substitute for adductor pollicis. (From Rettig AC: Neurovascular Injuries in the Wrists and Hands of Athletes, Clin Sports Med 9:389-417, 1990.)
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Allen test. Underlying causes of nerve compression, such as hook of the hamate fracture or ganglion cyst, should be ruled out. The possibility of a double-crush syndrome involving compression of the nerve at the elbow and wrist should also be kept in mind. Treatment of Guyon canal syndrome begins with rest and splinting. Cryotherapy and NSAIDs can be used, particularly in acute cases. Serial electromyograms can be helpful in following patients, and persistent sensory or motor compromise, or both, is an indication for surgical decompression. If symptoms are controlled with rest, return to sport with appropriate padding and technique adjustments is possible. After surgical decompression, the athlete can return to sport in 4 to 8 weeks, depending on the activity involved.
Radial Nerve Compression at the Wrist (Wartenberg Syndrome) This entity involves compression of the superficial branch of the radial nerve, also known as ”hand cuff neuropathy.” The superficial branch of the radial nerve pierces the deep fascia between the dorsal border of the brachial radialis muscle and the extensor carpi radialis to assume a subcutaneous position. The patient complains of pain and paresthesias over the dorsoradial aspect of the wrist and thumb. A positive Tinel sign over the point of compression usually is noted. Athletes participating in sports requiring repetitive ulnar flexion, pronation, and supination can experience this syndrome due to shear stress. Direct compression from wrist bands and taping also has been 38 rep~rted.~, Dellon and Mackinnon reported on 58 cases of superficial branch of radial nerve compression and recommended splinting in supination as the initial treatment.5Best results were reported in patients whose symptoms were caused by extensive physical activity or simple contusion, as seen in sports. Only rarely is surgical decompression indicated, and good to excellent results can be expected in 86%.5
Digital Neuropathy Digital nerve symptoms in the athlete are less common than those involving the wrist. The most commonly described entity is bowler’s thumb, originally reported by Dobyns et a1 in 1972.6 The pathology in bowler’s thumb stems from recurrent trauma to the ulnar digital nerve of the thumb from direct pressure of the edge of the thumb hole in the ball (Fig. 13). Proliferation of fibrous tissue around and within the nerve occurs, and the nerve becomes less mobile and cannot displace in the subcutaneous tissue when pressure is applied.6 Physical examination reveals a positive Tinel sign, and palpation of
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Figure 13. Bowler’s thumb-compression of ulnar digital nerve near thumb MP joint from thumb hole. (From Rettig AC: Neurovascular Injuries in the Wrists and Hands of Athletes. Clin Sports Med 9:389-417,1990.)
the thickened nerve in some patients. Two-point discrimination can be abnormal. Treatment involves rest (including rest from bowling) and NSAIDs. A molded orthotic to protect the ulnar base of the thumb and redrilling of the ball to relieve pressure on the affected area allow the athlete to return to the sport when pain and numbness resolve. Surgical decompression and transfer of the nerve rarely are indicated.35 OVERUSE VASCULAR SYMPTOMS
Vascular injuries occur due to repetitive trauma to the palmar aspect of the hand and wrist and are seen in athletes whose sports involve significant repetitive energy absorption in the hands. Vascular syndromes specifically include hypothenar hammer syndrome due to trauma to the ulnar artery at the wrist, trauma to the digital vessels, and vasospastic disorders of the digits in baseball players. The primary blood supply to the hand is from the terminal branches of the ulnar and radial arteries. Two vascular arches are formed, with the ulnar artery contributing primarily to the superficial palmar arch and the radial artery forming the deep palmar arch. In 80% of individuals, each arch receives contributions from both the radial and ulnar arteries and is considered ”complete” (Fig. 14). In the 20% of individuals with incomplete arches, loss of radial or ulnar artery flow can compromise digital circulation (Fig. 15). Hypothenar Hammer Syndrome
This overuse syndrome from repetitive impact trauma to the hypothenar region of the hand is seen in such sports as judo, karate, and lacrosse, or can occur from a single traumatic event.3,1 6 , The ~ pathophysiology involves trauma to the ulnar artery distal to Guyon’s canal, which
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Common volar
Figure 14. Most common pattern of complete arch (80% of hands). (Modified from Coleman SS, Anson BJ: Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 113:409421, 1961; with permission.)
leads to ischemia. This occurs due to (1) initial damage and resultant thrombosis; (2) altered flow due to either true aneurysm formation, in which all layers of the vessel wall are injured, or false aneurysm secondary to a laceration or penetration of the vessel wall with encapsulation and hematoma formation (Fig. 16); and (3) vasospasm secondary to changes in the arterial flow pattern.
Figure 15. Most common variations of 20% with incomplete arches. (Modified from Coleman SS, Anson BJ: Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 113:409421, 1961; with permission.)
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A
B
Figure 16. A, False aneurysm. Note the saccular form involving one side of the artery. B, True aneurysm. Note the fusiform shape involving the entire artery. (Modified from Green DP: True and false traumatic aneurysms in the hand: Report on two cases and review of the literature. J Bone Joint Surg 55A:120-128, 1973; with permission.)
Athletes can present with cold intolerance and pain in the palm or numbness in the ulnar-innervated digits, or both, due to ulnar nerve compression secondary to aneurysm formation. Physical examination usually will differentiate vascular etiology from isolated ulnar nerve compression. A positive Tine1 sign can be present due to ulnar nerve compression. The Allen test is specific for arterial insufficiency and is performed by compressing both radial and ulnar arteries while the patient makes a tight fist. After relaxing the fist, one artery is released and lack of blush within 5 seconds indicates insufficiency in the released vessel. This test also can be performed on digital vessels to determine patency. Supplemental tests include the Doppler scan, photo plethysmography, ultrasound, and cold testing. Initial-phase bone scan can be helpful in isolating lesions, and arthrography should be performed if surgery is a consideration. Treatment consists of rest from the offending activity and, in mild cases, participation can be permitted with increased padding of the exposed portion of the hand (Fig. 17). Vasolytic and sympatholytic agents also can be used. Surgical options include exploration and excision of the thrombosed segment of the artery with ligation in those with complete arches, or vein graft re-establishment of flow in those with incomplete arches. Digital Ischemia
Digital ischemia has been studied in handball players by Buckout and Warner and in baseball catchers by Lowrey2*(Fig. 18) and Sugawara
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Figure 17. Antivibratory glove (Smith Nephew, Germantown, WI) provides padding for the thenar area of the hand.
et al.38aAthletes in both sports demonstrated a high incidence of digital ischema. Sugawara et a138aconcluded that the development of circulatory problems was related to number of years played, frequency of practice, and position played. They recommended prophylactic use of increased padding in the gloves of baseball players. Vascular compromise in the pitching hands of baseball players has been described by Itoh et al? digital vessels were compressed in the lumbrical canals in two cases and as the vessels pass deep to the Cleland ligament in another. Vasospastic disorders of the pitcher’s index finger
Figure 18. Digital Allen’s test position (+) and impaired flow by Doppler testing (-). (Modified from Lowrey CW, Chadwick RO, Waltman EN: Digital vessel trauma from repetitive impact in baseball catchers. J Hand Surg 1:236-238, 1976; with permission.)
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have been reported, and are thought to be due to overstimulation of digital sympathetic^.^^" In the cases described by Itoh et al, surgical decompression was curative, whereas sympathetic blocks or vasodilator modalities or medications are be indicated for vasospastic disorders.
SUMMARY
Overuse syndromes in the wrist or hand can occur from repetitive use of the wrist and hand or from recurrent direct trauma to the hand area. Tendinitis syndromes due to overstretching or shear stress are seen commonly on both the extensor and flexor sides of the wrist. Overuse syndromes also can take the form of neurovascular syndromes, resulting in compression syndromes of the median, ulnar, and superficial branch of the radial nerve in the wrist area and trauma to the ulnar and digital vessels supplying the hand. Treatment in most cases involves rest with splinting, icing, and NSAIDs in acute cases, although surgical decompression is indicated in chronic or recurrent cases.
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