- Email: [email protected]
Baseball and Softball Injuries: Elbow, Wrist, and Hand
IN BRIEF
Baseball and Softball Injuries: Elbow, Wrist, and Hand Samir K. Trehan, MD, Andrew J. Weiland, MD CME INFORMATION AND DISCLOSURES The Review Section of JHS will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $15.00 includes the exam questions/answers only and does not include access to the JHS articles referenced.
Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. Technical Requirements for the Online Examination can be found at http://jhandsurg. org/cme/home. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx. ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. Disclosures for this Article
Statement of Need: This CME activity was developed by the JHS review section editors and review article authors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 1.00 “AMA PRA Category 1 Credits”. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
In Brief
ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.
U
baseball and softball players span a wide spectrum from those commonly encountered in hand surgical practice (eg, mallet finger) to more rare pathology (eg, digital ischemia). These can be acute or chronic and can affect players of all skill levels. In an PPER EXTREMITY INJURIES AFFECTING
From the Hospital for Special Surgery, New York, NY. Received for publication November 18, 2014; accepted in revised form November 24, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Andrew J. Weiland, MD, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021; e-mail: [email protected]. 0363-5023/15/4004-0033$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.11.024
826
r
2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
Editors Dawn LaPorte, MD, has no relevant conflicts of interest to disclose. Authors All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page. Planners Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose. Learning Objectives
Assess the epidemiology of baseball injuries. Discuss the evaluation of patients with baseball injuries. List specific injuries affecting baseball athletes. Summarize treatment options of upper extremity baseball injuries. Evaluate preventive methods for baseball injuries.
Deadline: Each examination purchased in 2015 must be completed by January 31, 2016, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to 1 hour. Copyright ª 2015 by the American Society for Surgery of the Hand. All rights reserved.
analysis of over 2 million softball injuryerelated emergency department visits, the most frequently affected body part (22.2%) was the hand/wrist.1 It is, therefore, essential for hand surgeons to be familiar with the diagnosis and management of these injuries. Table 1 provides a comprehensive list of injuries reported in ballplayers.2 CLINICAL EVALUATION AND TREATMENT History and physical examination are important components of the initial assessment. Pertinent history includes age, skill level (correlating with the intensity of play), position, and specific painful activities during play. Pertinent examination includes grip strength, range of motion, and neurovascular assessment. A study evaluating risk factors for elbow injury as
BASEBALL AND SOFTBALL UPPER EXTREMITY INJURIES
827
TABLE 1. Elbow, Wrist, and Hand Conditions Reported in Baseball and Softball Players MCL insufficiency* Cubital tunnel syndrome
Forearm
Exertional compartment syndrome
Wrist
Carpal fracture (scaphoid, hook of hamate*, pisiform) Scapholunate ligament tear Pisotriquetral arthritis Ulnar impaction syndrome Triangular fibrocartilage complex tear Ulnar head subluxation Extensor carpi ulnaris instability
Hand
Flexor tendon injury Flexor pulley rupture* Bouttonniere deformity Thumb ulnar collateral ligament injury Adductor pollicis longus injury Mallet finger* Hand fracture (metacarpal, proximal interphalangeal joint, phalanx)
Vascular
Thoracic outlet syndrome Quadrilateral space syndrome Axillary artery aneurysm* Digital ischemia/microvascular trauma*
FIGURE 1: A 21-year-old right-handed professional baseball player with point tenderness over the hook of the hamate in his lead (ie, left) hand sustained while batting. Fracture of the hook of the hamate was diagnosed on computed tomography scan. Under regional anesthetic, the fracture fragment was excised. The patient wore an orthosis for 2 weeks and returned to play without complication.
resonance imaging in all throwing patients with clinical concern for elbow MCL injury. Although relatively rare, there has been a recent increase in elbow MCL injury treatment.4 This trend is likely due to increasing overuse among amateur athletes, growing awareness by patients and physicians, and promising surgical outcomes. Nonsurgical treatment remains the treatment of choice for recreational athletes. In highly competitive athletes, surgical reconstruction may be considered, although patients must be counseled that return to competitive play takes up to 1 year. We prefer reconstruction with the docking technique, as previously described.6 Ulnar nerve transposition is performed if nerve symptoms and/or instability is present. Greater than 90% of patients return to the same, or higher, level of play after surgery.6
*Injuries and conditions specifically discussed in this review.
detected by ultrasound in 294 pediatric ballplayers demonstrated associations with age, height, pitching position, days of training, grip strength, shoulder external rotation motion, and strength.3 Pitchers may also demonstrate glenohumeral internal rotation deficit and elbow flexion contracture.4 In this review, we describe several common and/or unique hand conditions affecting ballplayers. Of note, we have previously outlined our approach to extensor carpi ulnaris instability, triangular fibrocartilage complex tear, ulnar styloid impingement, and triquetrohamate impingement in the athlete.5
HOOK OF HAMATE FRACTURE Hook of hamate fractures occur from the impact of the bat in the lead (ie, nondominant) hand or a direct blow from a ball. Baseball is the most common athletic etiology.7 Patients present with localized pain and reduced/ painful grip. On examination, potential associated neurovascular findings are assessed including ulnar artery thrombosis, impingement of the motor branch of the ulnar nerve, and entrapment of the flexor tendons to the ulnar 2 digits.5 Although historically diagnosed by carpal tunnel view radiograph, we routinely obtain a computed tomography scan when suspected (Fig. 1). Owing to the risk of nonunion, neurovascular impingement, and flexor tendon attenuation, our preferred treatment is early surgical excision. Stark et al7 reported that 57 of 59 patients were able to return to their
ELBOW MEDIAL COLLATERAL LIGAMENT INJURY During overhead throwing, a valgus moment across the elbow occurs during late cocking and increases during acceleration. Repetitive, high-velocity throwing can lead to a chronic overuse injury characterized by attenuation of the elbow medial collateral ligament (MCL). This injury presents with medial elbow pain, decreased throwing velocity, and decreased control. Specific examination maneuvers include the valgus stress test, milking maneuver, and moving valgus stress test.4 Given potential concomitant symptoms, ulnar nerve examination is also essential. We routinely obtain radiographs and magnetic J Hand Surg Am.
r
Vol. 40, April 2015
In Brief
Elbow
828
BASEBALL AND SOFTBALL UPPER EXTREMITY INJURIES
In Brief
FIGURE 2: A right-handed professional baseball catcher with ischemic symptoms affecting his left index finger. A Photoplethysmography demonstrated decreased waveforms in the index finger. B, C Angiography demonstrated impaired perfusion to the index finger. The patient stopped chewing tobacco, was started on aspirin, and had complete symptom resolution.
of these microvascular changes include index finger hypertrophy, digital hypersensitivity, cold intolerance, and ulcers; however, the long-term effects, if any, are unknown.8,9 Of note, microvascular abnormalities have been reported during screening of asymptomatic professional ballplayers, suggesting a potential unmet need in protective hand equipment.9 Treatment is warranted in the presence of symptoms and consists of cold avoidance, increased protective equipment, short-term vasodilator therapy, and cessation of all nicotine-containing products.
preoperative functional level without any complications (and the 2 remaining patients had sustained more severe crush injuries). After surgery, patients are immobilized for 2 weeks, allowed to throw at 2 weeks, and allowed to hit at 6 weeks. MICROVASCULAR TRAUMA AND DIGITAL ISCHEMIA Repetitive hand trauma in ballplayers (especially the gloved hand in catchers, hypothenar region in hitters, and fingertips of pitchers) can result in microvascular trauma (Fig. 2). Widespread tobacco use in baseball is another potential contributing factor. For these reasons, a thorough vascular examination (ie, Allen test and assessment of digital perfusion) is warranted in all competitive ballplayers presenting for evaluation by a hand surgeon. Clinical consequences J Hand Surg Am.
AXILLARY ARTERY ANEURYSM Although rare, a spectrum of axillary artery pathology has been reported in baseball pitchers, ranging from intermittent compression to thrombosis to aneurysm.10 These anomalies are caused by repetitive impingement r
Vol. 40, April 2015
BASEBALL AND SOFTBALL UPPER EXTREMITY INJURIES
829
ring finger A2 pulley, and pitchers injure the middle finger A4 pulley. We routinely obtain magnetic resonance imaging to rule out vincular tears that may be associated with local bleeding. Conservative treatment consisting of wearing an orthosis and symptomatic relief is indicated. There is no role for corticosteroid injection owing to adverse effects on healing and potential rerupture. Patients can return to throwing in 4 to 6 weeks with gradual return to competitive play. In Lourie et al’s series,12 all 4 patients made a full recovery using a similar, nonoperative regimen.
of the axillary and/or humeral circumflex (usually posterior) arteries by the pectoralis minor or humeral head with the arm in an abducted, externally rotated and extended position during throwing. Patients may present with early fatigue in the affected arm, cold intolerance, numbness, ischemic pain, and/or embolic phenomena. We prefer to obtain cross-sectional imaging (ie, computed tomography or magnetic resonance angiography) to confirm the diagnosis. Vascular surgery consultation is recommended and treatment consists of anticoagulation and angioplasty/stenting versus surgical resection (Fig. 3).10
MALLET FINGER Also known as “baseball finger,” mallet finger is most commonly caused by a flexion force (eg, direct impact of a baseball) at the distal interphalangeal joint on an actively extended finger. Our recommended treatment in an athlete is identical to that in a nonathlete—that is, full-time wear of an extension orthosis for 6 weeks followed by night wearing of an orthosis for 6 weeks.
FLEXOR PULLEY RUPTURE Previously described in rock climbers and pitchers, flexor pulley rupture is caused by a hyperextension force at the distal interphalangeal joint with the proximal interphalangeal joint flexed.11 Lourie et al12 noted that rock climbers most commonly injure the J Hand Surg Am.
r
Vol. 40, April 2015
In Brief
FIGURE 3: A 25-year-old right-handed professional baseball pitcher with a 2.5-year history of progressive early fatigue and cold intolerance in the index and middle fingers of his throwing arm. On examination, a callus was identified on the distal aspect of his index finger suspicious for an ischemic ulcer. Other details from this case have been previously reported.10 A Angiography revealed an aneurysm in the axillary artery where the posterior humeral circumflex artery branches. The anterior humeral circumflex artery had thrombosed. B In collaboration with a vascular surgeon, an axillary approach was undertaken. C, D The aneurysm was identified at its expected location and excised. It measured approximately 2 cm in all 3 dimensions. E Given the length of the defect, primary repair was not possible. Reconstruction with saphenous vein autograft was performed. The patient returned to play after an uneventful recovery.
830
BASEBALL AND SOFTBALL UPPER EXTREMITY INJURIES
As has been previously described, this recommendation may be problematic for the professional athlete desiring immediate return to play.13 In this scenario, patient education is essential regarding the consequences of neglect including extensor lag and delayed onset swan neck deformity. In the absence of wearing an orthosis, however, the patient can immediately return to play without restriction. Baseball and softball players frequently present with elbow, wrist, and hand complaints. Level of play, position, and tobacco use are important components of the history. Even in the asymptomatic patient, abnormal findings may be uncovered during range of motion and neurovascular examinations. In this article, we review several unique pathologies affecting ballplayers as well as more common injuries with player-specific treatment algorithms. Familiarity with these conditions, in addition to those listed in Table 1, is essential for managing these patients and preventing future injury.
3. Harada M, Takahara M, Mura N, Sasaki J, Ito T, Ogino T. Risk factors for elbow injuries among young baseball players. J Shoulder Elbow Surg. 2010;19(4):502e507. 4. Lynch JR, Waitayawinyu T, Hanel DP, Trumble TE. Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg Am. 2008;33(3):430e437. 5. Ek ET, Suh N, Weiland AJ. Hand and wrist injuries in golf. J Hand Surg Am. 2013;38(10):2029e2033. 6. Dodson CC, Thomas A, Dines JS, Nho SJ, Williams RJ III, Altchek DW. Medial ulnar collateral ligament reconstruction of the elbow in throwing athletes. Am J Sports Med. 2006;34(12): 1926e1932. 7. Stark HH, Chao EK, Zemel NP, Rickard TA, Ashworth CR. Fracture of the hook of the hamate. J Bone Joint Surg Am. 1989;71(8): 1202e1207. 8. Itoh Y, Wakano K, Takeda T, Murakami T. Circulatory disturbances in the throwing hand of baseball pitchers. Am J Sports Med. 1987;15(3): 264e269. 9. Ginn TA, Smith AM, Snyder JR, Koman LA, Smith BP, Rushing J. Vascular changes of the hand in professional baseball players with emphasis on digital ischemia in catchers. J Bone Joint Surg Am. 2005;87(7):1464e1469. 10. Schneider K, Kasparyan NG, Altchek DW, Fantini GA, Weiland AJ. An aneurysm involving the axillary artery and its branch vessels in a major league baseball pitcher. A case report and review of the literature. Am J Sports Med. 1999;27(3):370e375. 11. Weiland AJ. Boutonniere and pulley rupture in elite baseball players. Hand Clin. 2012;28(3):447. 12. Lourie GM, Hamby Z, Raasch WG, Chandler JB, Porter JL. Annular flexor pulley injuries in professional baseball pitchers: a case series. Am J Sports Med. 2011;39(2):421e424. 13. Shin SS. Baseball commentary—tendon ruptures: mallet, FDP. Hand Clin. 2012;28(3):431e432.
REFERENCES 1. Birchak JC, Rochette LM, Smith GA. Softball injuries treated in US EDs, 1994 to 2010. Am J Emerg Med. 2013;31(6):900e905. 2. Linscheid RL, Dobyns JH. Athletic injuries of the wrist. Clin Orthop Relat Res. 1985;(198):141e151.
JOURNAL CME QUESTIONS
In Brief
Baseball and Softball Injuries: Elbow, Wrist, and Hand
Which is the most appropriate treatment for a baseball player who presents with a weak painful grip, paresthesias in the ulnar digits, ischemic hand symptoms with a normal Allen test, and symptoms of flexor tendon attenuation? a. Ulnar nerve decompression at the elbow b. Elbow medial collateral ligament reconstruction c. Excision of the hook of hamate d. Vascular reconstruction of the ulnar artery e. Pulley reconstruction at the proximal interphalangeal joint
Which of the following part(s) of the upper extremity is most affected by baseball injuries? a. Shoulder b. Elbow c. Forearm d. Wrist and hand e. Thumb
To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.
J Hand Surg Am.
r
Vol. 40, April 2015
Baseball and Softball Injuries: Elbow, Wrist, and Hand Samir K. Trehan, MD, Andrew J. Weiland, MD CME INFORMATION AND DISCLOSURES The Review Section of JHS will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $15.00 includes the exam questions/answers only and does not include access to the JHS articles referenced.
Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. Technical Requirements for the Online Examination can be found at http://jhandsurg. org/cme/home. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx. ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. Disclosures for this Article
Statement of Need: This CME activity was developed by the JHS review section editors and review article authors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 1.00 “AMA PRA Category 1 Credits”. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
In Brief
ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.
U
baseball and softball players span a wide spectrum from those commonly encountered in hand surgical practice (eg, mallet finger) to more rare pathology (eg, digital ischemia). These can be acute or chronic and can affect players of all skill levels. In an PPER EXTREMITY INJURIES AFFECTING
From the Hospital for Special Surgery, New York, NY. Received for publication November 18, 2014; accepted in revised form November 24, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Andrew J. Weiland, MD, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021; e-mail: [email protected]. 0363-5023/15/4004-0033$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.11.024
826
r
2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
Editors Dawn LaPorte, MD, has no relevant conflicts of interest to disclose. Authors All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page. Planners Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose. Learning Objectives
Assess the epidemiology of baseball injuries. Discuss the evaluation of patients with baseball injuries. List specific injuries affecting baseball athletes. Summarize treatment options of upper extremity baseball injuries. Evaluate preventive methods for baseball injuries.
Deadline: Each examination purchased in 2015 must be completed by January 31, 2016, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to 1 hour. Copyright ª 2015 by the American Society for Surgery of the Hand. All rights reserved.
analysis of over 2 million softball injuryerelated emergency department visits, the most frequently affected body part (22.2%) was the hand/wrist.1 It is, therefore, essential for hand surgeons to be familiar with the diagnosis and management of these injuries. Table 1 provides a comprehensive list of injuries reported in ballplayers.2 CLINICAL EVALUATION AND TREATMENT History and physical examination are important components of the initial assessment. Pertinent history includes age, skill level (correlating with the intensity of play), position, and specific painful activities during play. Pertinent examination includes grip strength, range of motion, and neurovascular assessment. A study evaluating risk factors for elbow injury as
BASEBALL AND SOFTBALL UPPER EXTREMITY INJURIES
827
TABLE 1. Elbow, Wrist, and Hand Conditions Reported in Baseball and Softball Players MCL insufficiency* Cubital tunnel syndrome
Forearm
Exertional compartment syndrome
Wrist
Carpal fracture (scaphoid, hook of hamate*, pisiform) Scapholunate ligament tear Pisotriquetral arthritis Ulnar impaction syndrome Triangular fibrocartilage complex tear Ulnar head subluxation Extensor carpi ulnaris instability
Hand
Flexor tendon injury Flexor pulley rupture* Bouttonniere deformity Thumb ulnar collateral ligament injury Adductor pollicis longus injury Mallet finger* Hand fracture (metacarpal, proximal interphalangeal joint, phalanx)
Vascular
Thoracic outlet syndrome Quadrilateral space syndrome Axillary artery aneurysm* Digital ischemia/microvascular trauma*
FIGURE 1: A 21-year-old right-handed professional baseball player with point tenderness over the hook of the hamate in his lead (ie, left) hand sustained while batting. Fracture of the hook of the hamate was diagnosed on computed tomography scan. Under regional anesthetic, the fracture fragment was excised. The patient wore an orthosis for 2 weeks and returned to play without complication.
resonance imaging in all throwing patients with clinical concern for elbow MCL injury. Although relatively rare, there has been a recent increase in elbow MCL injury treatment.4 This trend is likely due to increasing overuse among amateur athletes, growing awareness by patients and physicians, and promising surgical outcomes. Nonsurgical treatment remains the treatment of choice for recreational athletes. In highly competitive athletes, surgical reconstruction may be considered, although patients must be counseled that return to competitive play takes up to 1 year. We prefer reconstruction with the docking technique, as previously described.6 Ulnar nerve transposition is performed if nerve symptoms and/or instability is present. Greater than 90% of patients return to the same, or higher, level of play after surgery.6
*Injuries and conditions specifically discussed in this review.
detected by ultrasound in 294 pediatric ballplayers demonstrated associations with age, height, pitching position, days of training, grip strength, shoulder external rotation motion, and strength.3 Pitchers may also demonstrate glenohumeral internal rotation deficit and elbow flexion contracture.4 In this review, we describe several common and/or unique hand conditions affecting ballplayers. Of note, we have previously outlined our approach to extensor carpi ulnaris instability, triangular fibrocartilage complex tear, ulnar styloid impingement, and triquetrohamate impingement in the athlete.5
HOOK OF HAMATE FRACTURE Hook of hamate fractures occur from the impact of the bat in the lead (ie, nondominant) hand or a direct blow from a ball. Baseball is the most common athletic etiology.7 Patients present with localized pain and reduced/ painful grip. On examination, potential associated neurovascular findings are assessed including ulnar artery thrombosis, impingement of the motor branch of the ulnar nerve, and entrapment of the flexor tendons to the ulnar 2 digits.5 Although historically diagnosed by carpal tunnel view radiograph, we routinely obtain a computed tomography scan when suspected (Fig. 1). Owing to the risk of nonunion, neurovascular impingement, and flexor tendon attenuation, our preferred treatment is early surgical excision. Stark et al7 reported that 57 of 59 patients were able to return to their
ELBOW MEDIAL COLLATERAL LIGAMENT INJURY During overhead throwing, a valgus moment across the elbow occurs during late cocking and increases during acceleration. Repetitive, high-velocity throwing can lead to a chronic overuse injury characterized by attenuation of the elbow medial collateral ligament (MCL). This injury presents with medial elbow pain, decreased throwing velocity, and decreased control. Specific examination maneuvers include the valgus stress test, milking maneuver, and moving valgus stress test.4 Given potential concomitant symptoms, ulnar nerve examination is also essential. We routinely obtain radiographs and magnetic J Hand Surg Am.
r
Vol. 40, April 2015
In Brief
Elbow
828
BASEBALL AND SOFTBALL UPPER EXTREMITY INJURIES
In Brief
FIGURE 2: A right-handed professional baseball catcher with ischemic symptoms affecting his left index finger. A Photoplethysmography demonstrated decreased waveforms in the index finger. B, C Angiography demonstrated impaired perfusion to the index finger. The patient stopped chewing tobacco, was started on aspirin, and had complete symptom resolution.
of these microvascular changes include index finger hypertrophy, digital hypersensitivity, cold intolerance, and ulcers; however, the long-term effects, if any, are unknown.8,9 Of note, microvascular abnormalities have been reported during screening of asymptomatic professional ballplayers, suggesting a potential unmet need in protective hand equipment.9 Treatment is warranted in the presence of symptoms and consists of cold avoidance, increased protective equipment, short-term vasodilator therapy, and cessation of all nicotine-containing products.
preoperative functional level without any complications (and the 2 remaining patients had sustained more severe crush injuries). After surgery, patients are immobilized for 2 weeks, allowed to throw at 2 weeks, and allowed to hit at 6 weeks. MICROVASCULAR TRAUMA AND DIGITAL ISCHEMIA Repetitive hand trauma in ballplayers (especially the gloved hand in catchers, hypothenar region in hitters, and fingertips of pitchers) can result in microvascular trauma (Fig. 2). Widespread tobacco use in baseball is another potential contributing factor. For these reasons, a thorough vascular examination (ie, Allen test and assessment of digital perfusion) is warranted in all competitive ballplayers presenting for evaluation by a hand surgeon. Clinical consequences J Hand Surg Am.
AXILLARY ARTERY ANEURYSM Although rare, a spectrum of axillary artery pathology has been reported in baseball pitchers, ranging from intermittent compression to thrombosis to aneurysm.10 These anomalies are caused by repetitive impingement r
Vol. 40, April 2015
BASEBALL AND SOFTBALL UPPER EXTREMITY INJURIES
829
ring finger A2 pulley, and pitchers injure the middle finger A4 pulley. We routinely obtain magnetic resonance imaging to rule out vincular tears that may be associated with local bleeding. Conservative treatment consisting of wearing an orthosis and symptomatic relief is indicated. There is no role for corticosteroid injection owing to adverse effects on healing and potential rerupture. Patients can return to throwing in 4 to 6 weeks with gradual return to competitive play. In Lourie et al’s series,12 all 4 patients made a full recovery using a similar, nonoperative regimen.
of the axillary and/or humeral circumflex (usually posterior) arteries by the pectoralis minor or humeral head with the arm in an abducted, externally rotated and extended position during throwing. Patients may present with early fatigue in the affected arm, cold intolerance, numbness, ischemic pain, and/or embolic phenomena. We prefer to obtain cross-sectional imaging (ie, computed tomography or magnetic resonance angiography) to confirm the diagnosis. Vascular surgery consultation is recommended and treatment consists of anticoagulation and angioplasty/stenting versus surgical resection (Fig. 3).10
MALLET FINGER Also known as “baseball finger,” mallet finger is most commonly caused by a flexion force (eg, direct impact of a baseball) at the distal interphalangeal joint on an actively extended finger. Our recommended treatment in an athlete is identical to that in a nonathlete—that is, full-time wear of an extension orthosis for 6 weeks followed by night wearing of an orthosis for 6 weeks.
FLEXOR PULLEY RUPTURE Previously described in rock climbers and pitchers, flexor pulley rupture is caused by a hyperextension force at the distal interphalangeal joint with the proximal interphalangeal joint flexed.11 Lourie et al12 noted that rock climbers most commonly injure the J Hand Surg Am.
r
Vol. 40, April 2015
In Brief
FIGURE 3: A 25-year-old right-handed professional baseball pitcher with a 2.5-year history of progressive early fatigue and cold intolerance in the index and middle fingers of his throwing arm. On examination, a callus was identified on the distal aspect of his index finger suspicious for an ischemic ulcer. Other details from this case have been previously reported.10 A Angiography revealed an aneurysm in the axillary artery where the posterior humeral circumflex artery branches. The anterior humeral circumflex artery had thrombosed. B In collaboration with a vascular surgeon, an axillary approach was undertaken. C, D The aneurysm was identified at its expected location and excised. It measured approximately 2 cm in all 3 dimensions. E Given the length of the defect, primary repair was not possible. Reconstruction with saphenous vein autograft was performed. The patient returned to play after an uneventful recovery.
830
BASEBALL AND SOFTBALL UPPER EXTREMITY INJURIES
As has been previously described, this recommendation may be problematic for the professional athlete desiring immediate return to play.13 In this scenario, patient education is essential regarding the consequences of neglect including extensor lag and delayed onset swan neck deformity. In the absence of wearing an orthosis, however, the patient can immediately return to play without restriction. Baseball and softball players frequently present with elbow, wrist, and hand complaints. Level of play, position, and tobacco use are important components of the history. Even in the asymptomatic patient, abnormal findings may be uncovered during range of motion and neurovascular examinations. In this article, we review several unique pathologies affecting ballplayers as well as more common injuries with player-specific treatment algorithms. Familiarity with these conditions, in addition to those listed in Table 1, is essential for managing these patients and preventing future injury.
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JOURNAL CME QUESTIONS
In Brief
Baseball and Softball Injuries: Elbow, Wrist, and Hand
Which is the most appropriate treatment for a baseball player who presents with a weak painful grip, paresthesias in the ulnar digits, ischemic hand symptoms with a normal Allen test, and symptoms of flexor tendon attenuation? a. Ulnar nerve decompression at the elbow b. Elbow medial collateral ligament reconstruction c. Excision of the hook of hamate d. Vascular reconstruction of the ulnar artery e. Pulley reconstruction at the proximal interphalangeal joint
Which of the following part(s) of the upper extremity is most affected by baseball injuries? a. Shoulder b. Elbow c. Forearm d. Wrist and hand e. Thumb
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J Hand Surg Am.
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Vol. 40, April 2015