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Proximal Interphalangeal Joint Fracture Dislocations in Professional Baseball Players
P ro x i m a l I n t e r p h a l a n g e a l J o i n t Fr a c t u re D i s l o c a t i o n s i n P ro f e s s i o n a l B a s e b a l l Pl a y e r s
Melvin P. Rossenwasser, MD
Proximal interphalangeal (PIP) joint injuries, including dislocations with or without fractures, are common injuries in sports.1–6 In baseball, common mechanisms leading to injury at the PIP joint include sliding into base, diving for a ball, or direct impact from a ball. Injury patterns may range from an acute boutonniere deformity characterized by rupture of the central slip to simple dislocation to more complex fracture dislocation. PIP dislocations are first differentiated on the basis of the absence or presence of a fracture and then classified on the basis of the direction of middle phalanx dislocation: dorsal, volar, or lateral. Following recognition of an injury pattern, the physical examination is key to assessment of the stability, which then guides treatment. Most baseball players injure their fingers during play but assume that all such injuries are nothing more than jammed fingers and continue playing using various wraps or tapes. As a result, it is not uncommon for these injuries to present in a subacute or chronic manner, including as an unrecognized fracture dislocation of the PIP joint.6 Therefore, especially in a professional athlete, it is vital to obtain imaging to evaluate for fracture. High-quality radiographs must include a true lateral image of the PIP joint, particularly following a reduction of the joint to assess concentricity of reduction. Radiographs allow recognition of marginal dorsal and volar fractures as well as pilon impaction fractures. The size of the fragment may imply stability of reduction. Greater than 40% of articular surface displacement
may preclude closed treatment. Complex comminuted intra-articular fractures are better assessed with a computed tomographic scan.
SPORT-SPECIFIC TREATMENT In the professional athlete, immediate evaluation and imaging are important for recommendation of return to play versus a stint on the 15-day disabled list. Prompt reduction minimizes soft tissue injury and swelling; however, multiple closed reduction attempts should be avoided if the joint is grossly unstable or difficult to reduce. Experienced professional athletic trainers and orthopedic surgeon consultants are aware when an open or complex dislocation needs urgent care. The simple PIP dislocation involves a volar plate injury usually at the middle phalanx insertion and is often accompanied by one proper collateral ligament sprain, usually radial. If stable, the digit is buddy taped to an adjacent finger for 2 to 3 weeks while allowing immediate range of motion. Depending on the baseball player’s position, return to practice and play is safe within days when comfortable. PIP fracture dislocations that demonstrate dorsal subluxation on immediate postreduction radiographs often have a major volar articular fragment (>40%), which may preclude unprotected extension. These are treated with dorsal blocking splints at 30 if concentric reduction is obtained and maintained on serial radiographs. The PIP joint may then be extended over a period of approximately 4 weeks with interval radiographs to ensure maintained concentric reduction. For
Hand Clin 28 (2012) 417–420 doi:10.1016/j.hcl.2012.05.037 0749-0712/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
hand.theclinics.com
INTRODUCTION
418
PIP Joint Fracture Dislocations in Baseball
Fig. 1. Anteroposterior (A) and lateral (B) radiographs of injury.
continued instability, a variety of surgical options are available based on surgeon preference and the injury pattern. The fracture may be stabilized with percutaneous pinning (either in the fragment or as a blocking pin), open reduction and internal fixation, or dynamic traction.6 Figs. 1–3 demonstrate the case of a 27-year-old man who sustained a hyperextension and axial load injury to the left ring finger with a previous malunion of the distal phalanx. The highly unstable pilon fracture of the base of the middle phalanx is treated with a jointspanning external fixator, leading to a congruent and stable joint following union and remodeling. When a volar fracture fragment is too small for repair or the injury is chronic, a volar plate arthroplasty is a good option.7,8 Certain unreconstructable fractures of the middle phalanx base may be best managed with a hemihamate autograft.9,10 Good outcomes can be achieved by prompt recognition and treatment of these injuries. However, even a simple dislocation can result in
a flexion contracture, although this is usually well tolerated and does not affect performance, save for the pitching hand for certain pitches and grips.6 Appropriate treatment can facilitate return to play at a professional or competitive amateur level, but long-term outcome studies of many of these treatments report the occurrence of PIP joint stiffness and osteoarthritis, particularly when treatment is delayed.6,7,9,11
SPORT-SPECIFIC RETURN-TO-PLAY GUIDELINES The severity of injury, stability of the joint, and player position and handedness determine return to play. A baseball player may be able to return within 2 to 7 days if an injury is stable following closed reduction but may require 4 to 8 weeks after open treatment. Standard occupational therapy regimens are followed for rehabilitation, but baseball-specific conditioning to ramp up to
Fig. 2. Anteroposterior (A) and lateral (B) radiographs following reduction and application of external fixator.
PIP Joint Fracture Dislocations in Baseball
Fig. 3. Anteroposterior (A) and lateral (B) radiographs following union and remodeling.
game play is often the slowest part of this recovery. For batting, the lead hand must be strong and must finish the swing, so it must allow for strong grip without pain or apprehension on contact with the ball. For the baseball pitcher, an injury to the pitching digits may prevent return until complete healing, but injury to the nondominant hand may allow return without missing a start if the player does not have to bat. All injuries to the PIP joint in nonprofessional and professional baseball players are treated with similar guidelines, but skeletally immature players are protected until healing is certain without regard to schedules or pennant races.
SUMMARY Treatment of professional baseball players with PIP injuries requires careful evaluation and prompt treatment. Stability of the injury dictates treatment and return to play. The majority of injuries can be managed with minimal splinting or buddy taping, but the most complex injuries require operative intervention to ensure stable reduction. Consideration of players’ position and handedness is important in determining return to practice and play.
Michael V. Birman, MD Melvin P. Rossenwasser, MD
REFERENCES 1. Morgan WJ, Slowman LS. Acute hand and wrist injuries in athletes: evaluation and management. J Am Acad Orthop Surg 2001;9:389–400. 2. Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med 2000; 30:117–35. 3. Le TB, Hentz VR. Hand and wrist injuries in young athletes. Hand Clin 2000;16:597–607. 4. Mall NA, Carlisle JC, Matava MJ, et al. Upper extremity injuries in the National Football League: part I: hand and digital injuries. Am J Sports Med 2008;36:1938–44. 5. Rettig AC. Athletic injuries of the wrist and hand: part II: overuse injuries of the wrist and traumatic injuries to the hand. Am J Sports Med 2004;32:262–73. 6. Bindra RR, Foster BJ. Management of proximal interphalangeal joint dislocations in athletes. Hand Clin 2009;25:423–35. 7. Dionysian E, Eaton RG. The long-term outcome of volar plate arthroplasty of the proximal interphalangeal joint. J Hand Surg Am 2000;25:429–37.
419
420
PIP Joint Fracture Dislocations in Baseball 8. Durham-Smith G, McCarten GM. Volar plate arthroplasty for closed proximal interphalangeal joint injuries. J Hand Surg Br 1992;17:422–8. 9. Calfee RP, Kiefhaber TR, Sommerkamp TG, et al. Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am 2009;34:1232–41.
10. Williams RM, Kiefhaber TR, Sommerkamp TG, et al. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 2003;28:856–65. 11. Deitch MA, Kiefhaber TR, Comisar BR, et al. Dorsal fracture dislocations of the proximal interphalangeal joint: surgical complications and long-term results. J Hand Surg Am 1999;24:914–23.
Melvin P. Rossenwasser, MD
Proximal interphalangeal (PIP) joint injuries, including dislocations with or without fractures, are common injuries in sports.1–6 In baseball, common mechanisms leading to injury at the PIP joint include sliding into base, diving for a ball, or direct impact from a ball. Injury patterns may range from an acute boutonniere deformity characterized by rupture of the central slip to simple dislocation to more complex fracture dislocation. PIP dislocations are first differentiated on the basis of the absence or presence of a fracture and then classified on the basis of the direction of middle phalanx dislocation: dorsal, volar, or lateral. Following recognition of an injury pattern, the physical examination is key to assessment of the stability, which then guides treatment. Most baseball players injure their fingers during play but assume that all such injuries are nothing more than jammed fingers and continue playing using various wraps or tapes. As a result, it is not uncommon for these injuries to present in a subacute or chronic manner, including as an unrecognized fracture dislocation of the PIP joint.6 Therefore, especially in a professional athlete, it is vital to obtain imaging to evaluate for fracture. High-quality radiographs must include a true lateral image of the PIP joint, particularly following a reduction of the joint to assess concentricity of reduction. Radiographs allow recognition of marginal dorsal and volar fractures as well as pilon impaction fractures. The size of the fragment may imply stability of reduction. Greater than 40% of articular surface displacement
may preclude closed treatment. Complex comminuted intra-articular fractures are better assessed with a computed tomographic scan.
SPORT-SPECIFIC TREATMENT In the professional athlete, immediate evaluation and imaging are important for recommendation of return to play versus a stint on the 15-day disabled list. Prompt reduction minimizes soft tissue injury and swelling; however, multiple closed reduction attempts should be avoided if the joint is grossly unstable or difficult to reduce. Experienced professional athletic trainers and orthopedic surgeon consultants are aware when an open or complex dislocation needs urgent care. The simple PIP dislocation involves a volar plate injury usually at the middle phalanx insertion and is often accompanied by one proper collateral ligament sprain, usually radial. If stable, the digit is buddy taped to an adjacent finger for 2 to 3 weeks while allowing immediate range of motion. Depending on the baseball player’s position, return to practice and play is safe within days when comfortable. PIP fracture dislocations that demonstrate dorsal subluxation on immediate postreduction radiographs often have a major volar articular fragment (>40%), which may preclude unprotected extension. These are treated with dorsal blocking splints at 30 if concentric reduction is obtained and maintained on serial radiographs. The PIP joint may then be extended over a period of approximately 4 weeks with interval radiographs to ensure maintained concentric reduction. For
Hand Clin 28 (2012) 417–420 doi:10.1016/j.hcl.2012.05.037 0749-0712/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
hand.theclinics.com
INTRODUCTION
418
PIP Joint Fracture Dislocations in Baseball
Fig. 1. Anteroposterior (A) and lateral (B) radiographs of injury.
continued instability, a variety of surgical options are available based on surgeon preference and the injury pattern. The fracture may be stabilized with percutaneous pinning (either in the fragment or as a blocking pin), open reduction and internal fixation, or dynamic traction.6 Figs. 1–3 demonstrate the case of a 27-year-old man who sustained a hyperextension and axial load injury to the left ring finger with a previous malunion of the distal phalanx. The highly unstable pilon fracture of the base of the middle phalanx is treated with a jointspanning external fixator, leading to a congruent and stable joint following union and remodeling. When a volar fracture fragment is too small for repair or the injury is chronic, a volar plate arthroplasty is a good option.7,8 Certain unreconstructable fractures of the middle phalanx base may be best managed with a hemihamate autograft.9,10 Good outcomes can be achieved by prompt recognition and treatment of these injuries. However, even a simple dislocation can result in
a flexion contracture, although this is usually well tolerated and does not affect performance, save for the pitching hand for certain pitches and grips.6 Appropriate treatment can facilitate return to play at a professional or competitive amateur level, but long-term outcome studies of many of these treatments report the occurrence of PIP joint stiffness and osteoarthritis, particularly when treatment is delayed.6,7,9,11
SPORT-SPECIFIC RETURN-TO-PLAY GUIDELINES The severity of injury, stability of the joint, and player position and handedness determine return to play. A baseball player may be able to return within 2 to 7 days if an injury is stable following closed reduction but may require 4 to 8 weeks after open treatment. Standard occupational therapy regimens are followed for rehabilitation, but baseball-specific conditioning to ramp up to
Fig. 2. Anteroposterior (A) and lateral (B) radiographs following reduction and application of external fixator.
PIP Joint Fracture Dislocations in Baseball
Fig. 3. Anteroposterior (A) and lateral (B) radiographs following union and remodeling.
game play is often the slowest part of this recovery. For batting, the lead hand must be strong and must finish the swing, so it must allow for strong grip without pain or apprehension on contact with the ball. For the baseball pitcher, an injury to the pitching digits may prevent return until complete healing, but injury to the nondominant hand may allow return without missing a start if the player does not have to bat. All injuries to the PIP joint in nonprofessional and professional baseball players are treated with similar guidelines, but skeletally immature players are protected until healing is certain without regard to schedules or pennant races.
SUMMARY Treatment of professional baseball players with PIP injuries requires careful evaluation and prompt treatment. Stability of the injury dictates treatment and return to play. The majority of injuries can be managed with minimal splinting or buddy taping, but the most complex injuries require operative intervention to ensure stable reduction. Consideration of players’ position and handedness is important in determining return to practice and play.
Michael V. Birman, MD Melvin P. Rossenwasser, MD
REFERENCES 1. Morgan WJ, Slowman LS. Acute hand and wrist injuries in athletes: evaluation and management. J Am Acad Orthop Surg 2001;9:389–400. 2. Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med 2000; 30:117–35. 3. Le TB, Hentz VR. Hand and wrist injuries in young athletes. Hand Clin 2000;16:597–607. 4. Mall NA, Carlisle JC, Matava MJ, et al. Upper extremity injuries in the National Football League: part I: hand and digital injuries. Am J Sports Med 2008;36:1938–44. 5. Rettig AC. Athletic injuries of the wrist and hand: part II: overuse injuries of the wrist and traumatic injuries to the hand. Am J Sports Med 2004;32:262–73. 6. Bindra RR, Foster BJ. Management of proximal interphalangeal joint dislocations in athletes. Hand Clin 2009;25:423–35. 7. Dionysian E, Eaton RG. The long-term outcome of volar plate arthroplasty of the proximal interphalangeal joint. J Hand Surg Am 2000;25:429–37.
419
420
PIP Joint Fracture Dislocations in Baseball 8. Durham-Smith G, McCarten GM. Volar plate arthroplasty for closed proximal interphalangeal joint injuries. J Hand Surg Br 1992;17:422–8. 9. Calfee RP, Kiefhaber TR, Sommerkamp TG, et al. Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am 2009;34:1232–41.
10. Williams RM, Kiefhaber TR, Sommerkamp TG, et al. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 2003;28:856–65. 11. Deitch MA, Kiefhaber TR, Comisar BR, et al. Dorsal fracture dislocations of the proximal interphalangeal joint: surgical complications and long-term results. J Hand Surg Am 1999;24:914–23.