Abstract
Concussion is a disruption to the normal function of the brain secondary to a force to the head or body. The symptoms may be apparent immediately but often may be delayed 5–10 minutes; presentations up to 24 hours after impact have been reported. The symptoms can be varied and a full neurologic examination is important to look for “Red Flag” symptoms of other neurologic injury such as subdural bleed. Early brief mental and longer physical rest is important for the recovery as the brain heals. Return to learn in a graded manner is important as well as return to play once concussion symptoms have resolved.
Keywords
brain injury, concussion, post-concussion syndrome, return to learn, return to play
Some of the most common acute hand and wrist injuries include scaphoid fracture, distal radius fracture, boxer’s fracture (fifth metacarpal neck fracture), mallet finger, jersey finger, skier’s thumb, and proximal interphalangeal (PIP) joint dislocations. This chapter reviews these injuries with emphasis on initial management and treatment.
Case: A 26-year-old male was trying to impress his girlfriend while ice skating and attempted to skate backward. In doing so, he slipped and fell, trying to catch himself with an outstretched hand with the wrist in extension. (Needless to say, he did not impress her at all!) He presents with pain, swelling, and tenderness in his right wrist. This type of injury is called a FOOSH (fall on outstretched hand) and can lead to hand or wrist injuries.
1
How does a scaphoid fracture occur?
The scaphoid is the most commonly fractured carpal bone, accounting for 15% of acute wrist injuries. This often results from a force on an extended wrist, which places a tensile force at the volar scaphoid and a compression force at the dorsal scaphoid. The other mechanism in which scaphoid fractures occur is with a longitudinally directed axial force across the wrist.
2
What are the physical examination findings for a patient with a scaphoid fracture?
Wrist range of motion is usually only slightly reduced, but pain is reproduced with extremes of flexion and extension. Patients will generally have pain in the anatomic snuffbox in neutral or with the wrist in ulnar deviation. Associated injuries may cause symptoms of median nerve compression (paresthesias).
3
When should radiographs be used to evaluate the injury?
Radiographs are always indicated in evaluation of suspected scaphoid fracture! Posteroanterior (PA), lateral, scaphoid, and 45-degree pronated views are helpful in assessing for possible fracture. Magnetic resonance imaging (MRI) is most sensitive in determining fractures and ligament injuries.
4
What if x-ray findings are negative but the patient has snuffbox tenderness?
Snuffbox tenderness should be treated as a scaphoid fracture regardless of negative radiographs on the initial evaluation ( Fig. 33.1 ).
5
What if radiograph findings at 2 weeks are negative?
Radiographs may continue to be negative at 2 weeks. If tenderness persists over the scaphoid, further imaging is indicated (see Fig. 33.1 ).
6
When are referrals for surgical evaluation needed?
Surgical referral is needed for unstable fractures. Proximal pole fractures are particularly at risk for nonunion given their avascular nature, so these fractures should be referred for internal fixation. Additionally, displacement >1 mm, comminuted fractures, and radiolunate angle >15 degrees should be referred for surgical evaluation. Nondisplaced fractures may be referred for internal fixation if quicker return to sport is required. Surgical fixation leads to 90%–95% union rates. Given the risk of these fractures to progress to nonunion and subsequent pain and disability, these fractures should be managed by physicians trained in the management of scaphoid fractures.
7
Length and type of immobilization. ( Table 33.1 )
| Initial Treatment | ||||
|---|---|---|---|---|
| Suspected | Fracture Location | |||
| Distal | Middle | Proximal | ||
| Splint type and position | Short-arm thumb spica cast or splint | Short arm-thumb spica cast with slight wrist extension | Long arm-thumb spica cast/splint with slight wrist extension | |
| Follow-up | 2 weeks | 1–2 weeks | ||
| Patient education | Ice and elevate for 24–48 hours Maintain finger and shoulder range of motion | |||
| Follow-Up Care | ||||
| Splint type and position | Short-arm thumb spica cast or splint | Short arm-thumb spica cast with slight wrist extension | Long arm-thumb spica cast/splint with slight wrist extension for weeks 1–6; then short arm-thumb spica cast/splint | |
| Immobilization time | Until diagnosis confirmed | 4–6 weeks | 10–12 weeks | 12–20 weeks |
| Healing time | 6–8 weeks | 12–14 weeks | 18–24 weeks | |
| Follow-up interval | Every 2 weeks until diagnosis confirmed | Every 2–3 weeks until union confirmed | ||
| Repeat radiographic interval | Every 2 weeks until diagnosis confirmed | Every 2–3 weeks until union confirmed | ||
| Patient education | Maintain finger and shoulder range of motion | |||
| Indications for orthopedics referral | Proximal pole fractures due to high risk of avascular necrosis Displaced fractures Nonunion Concern for early signs of avascular necrosis | |||
8. What is the typical length of injury/healing time? ( Table 33.1 )
9
What is a boxer’s fracture?
A boxer’s fracture is a fracture of the fifth metacarpal neck. This results from an impaction injury with an axial load to the fifth metacarpal. Ironically this injury is less common in boxers but more common in individuals not trained in throwing punches. Metacarpal fractures account for 40% of all hand injuries, and the fifth metacarpal is the most commonly fractured.
10
What symptoms will a patient with a boxer’s fracture have?
Individuals often present with pain, swelling, and ecchymosis at the area over the fifth metacarpal dorsally. Despite this, most individuals are able to maintain a full functional status of the hand and fingers, unless there is an open wound along with the fracture.
11
What findings should I look for on physical examination for a boxer’s fracture?
Attention should be given to any obvious bony step-off or deformity. More importantly, rotational angulation of the fracture can be assessed with closed fist assessment of the distal phalanx of the fifth digit. Normal orientation of the fifth digit should have it pointing toward the scaphoid bone. Ulnar deviation may indicate further angulation of the fracture. Loss of the bony knuckle at the metacarpophalangeal (MCP) joint is frequently seen with these fractures.
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