Longitudinal disruptions, or axial dislocations, of the hand are rare injuries, comprising only 1.4% of all carpal injuries.1 Longitudinal disruptions frequently result from a powerful crush injury.1–3 In severe cases, the result can be a complete carpometacarpal dislocation with various fractures to the carpal bones. Less severe injuries may result from athletic events, especially for high-level athletes. We describe three cases of longitudinal disruptions in professional athletes that represent a similar but less severe form of longitudinal disruption. Our case series reviews the literature regarding longitudinal disruptions, describes clinical and radiographic evaluations, and introduces a novel taping technique that may assist current management.
A 30-year-old male major league baseball player sustained an injury to his left hand while swinging the bat with a checked swing. He finished the game but noted continuous pain while hitting. He was a right-handed hitter and the injury occurred to the left hand. In a right-handed hitter, the left hand represents the low and lead hand, making swinging painful if injured. The injury and subsequent pain caused hitting to be difficult. The initial complaints were at the fourth carpometacarpal region and dorsum of the hand. After attempting to play in four consecutive games, he was unable to swing the bat effectively and was placed on the disabled list. Diagnostics were completed to further evaluate the injury.
The examination revealed persistent pain from the area between the third and fourth metacarpal heads and extending proximally to the base of the two metacarpals. His range of motion was normal and swelling subsided by the examination. Pain was noted with gripping of the bat, which flattened the palm, and the provocative maneuver of separating the third and fourth rays caused exquisite pain. Volar and dorsal translation between the triquetrum and lunate and between the capitate and hamate did not produce pain. However, volar and dorsal translation between the third and fourth rays resulted in considerable discomfort.
Plain x-ray results were unremarkable, but magnetic resonance imaging (MRI) demonstrated a variable injury to the interossei musculature and disruption of the dorsal intermetacarpal ligament between the long and ring metacarpal bases (Figure 1).
Magnetic resonance imaging (MRI) of the soft tissue injury in case 1 showing (A) a coronal dress MRI (cutlines are represented in B axial cuts), (B) the disruption of the dorsal intermetacarpal ligament (arrow) with intact adjacent rays intermetacarpal ligament (arrowhead), and (C) the disruption and high-grade strain of the interossei musculature.
The patient was treated with a variety of modalities to decrease the inflammation. Rather than immobilizing the rays, we performed a unique taping technique (Figure 2). This technique prevents the divergence of the rays, while recreating the natural transverse arc of the hand and resists flattening the palm. The patient progressed slowly, but he was not able to return to play for 4 weeks due to discomfort. He was not permitted to bat for 8 weeks, but his symptoms resolved completely.
The novel taping technique to control each patient's symptoms focused on recreating the distal transverse arch of the hand. (A) Initial taping was done with 2-in Stretch MTape Premium (Mueller Sports Medicine, Inc., Prairie du Sac, WI) followed by 2-in McConnell Tape (2-in Kinesiology Tape; Mueller Sports Medicine, Inc.). Taping began at the third to fourth intermetacarpal space and wrapped taut in ulnar and palmar directed force to the first web space. This maneuver flexes the mobile fourth to fifth rays. (B) The flexion taping is reinforced with a 2-in prewrap and a 2-in cover roll. The second layer reinforces the initial arch taping and compresses the rays together, resisting a forceful flattening of the arch. (C) The comparison axial view shows the taping assisting the maintenance of progressive metacarpal head flexion during force grip. Images show the patient gripping a cylinder in each hand.
A 33-year-old male professional football player (line-backer) sustained an injury during a game. He did not recall the specific injury, but he noted severe hand pain at the end of the game. He developed marked swelling and bruising in the palm of his hand and localized exquisite pain over the base of his fourth metacarpal (Figure 3). The patient reported discomfort when holding his forearm in a neutral (supination or pronation) position, which separated the fourth and fifth rays by gravity. Palpation elicited pain between the fourth and fifth rays and ulnarly near the pisiform. He experienced tenderness when separating the fourth and fifth rays. He was unable to participate in practice for 3 days.
Clinical photograph of case 2 identifying (A) the point of maximal tenderness and (B) palmar ecchymosis.
The x-rays were normal. The MRI revealed an interossei injury over the fourth metacarpal and disruption of the ring and small finger dorsal intermetacarpal ligaments, nearly identical to the imaging in case 1.
He was also treated with the novel taping technique. He declined a rigid orthosis or cast. The fourth and fifth fingers were buddy taped along with the previously described hand taping technique. He was able to return to play 1 week following the injury.
A 24-year-old male minor league baseball player suffered a left hand injury during a swing, fouling off a pitch. Initially, he continued play and did not seek treatment. He experienced symptoms for 4 weeks, which prompted his initial evaluation. He noted significant pain while batting, but he had minimal symptoms throughout the day. As a right-handed batter, he noted pain in his lower and leading left hand.
On examination, he had full range of motion and strength. There was only mild swelling of the third and fourth carpometacarpal joints with focal tenderness over the same area, similar to the patient in case 1. Volar and dorsal translation between the third and fourth rays produced discomfort. Plain x-rays were unremarkable. The MRI revealed an injury to the dorsal intermetacarpal ligament between the third and fourth metacarpal bases, similar to the imaging in case 1.
The season ended by the time of the examination and the patient was not permitted to bat for 4 weeks. Following the rest period, he began a hitting program, along with the taping technique as needed for symptom control. He healed without residual symptoms.
Each athlete completed a variable period of rest based on his symptoms. For each athlete, the novel taping technique resulted in symptom control and return to play or practice. Each athlete returned to full participation in his respective sport. The second baseball player (case 3) required a longer period of active rest, but his presentation was delayed in comparison to cases 1 and 2. He had attempted to continue a high level of play without an adequate diagnosis, immobilization, or rest.
The hand is composed of a system of three arches. There are two transverse arches. One arch is formed by the distal carpal row, and the second arch is formed by the metacarpal heads. The third is the longitudinal arch, which is composed of the radial rays. The interaction of these arches enables the hand to perform prehensile grasp.4 The index and long rays are relatively immobile and more stable than the ulnar-sided ring and small finger rays. There are approximately 1 and 3 degrees of motion at the index and long finger carpometacarpal joints, respectively. In comparison, there are 8 and 15 degrees of motion at the ring and small finger carpometacarpal joints.1,5,6 This stark contrast is due to the saddle configuration of the hamatemetacarpal articulations and the looser ligamentous attachments. This anatomy portends a higher risk for disruption than the immobile radial rays, leading to the injuries described in this report.
Longitudinal disruptions, or axial dislocations, have been described as injuries that separate the rays of the hand.2,7 It is most frequently described as a diastasis between the 3rd and 4th rays extending into the carpus and separating the capitate and hamate. These injuries have a variable spectrum of presentation. Less severe forms of injury can be treated conservatively, whereas the higher energy forms require open management.8,9 In its worst form, the injuries between the stable third ray and mobile fourth and fifth rays result in axial dislocations, which are described by Garcia-Elias et al.1 and Cooney et al.10 Axial dislocations occur rarely and result in a dislocation with and without associated carpal fractures. Axial dislocations are often secondary to a high-energy crush mechanism that disrupts the two transverse arches and diverges the finger rays. This pattern accounts for 1.4% of hand injuries, with axial ulnar disruption (between third and fourth rays) occurring most often.7,8
The athletes presented in this case review had less severe injuries on the spectrum of longitudinal disruptions. Less severe disruptions have been described previously and involved the capitohamate articulation.9 In the cases that we presented, the athletes sustained a flattening of the hand through a direct blow (case 2) or gripping the rigid bat (cases 1 and 3). Cross-sectional imaging was used to diagnose the disruption of the dorsal intermetacarpal and interosseous ligament and variable injury to the interossei musculature.
The dorsal intermetacarpal ligaments run transversely between the metacarpal bases.11,12 Dzwierzynski et al.13 published a cadaveric study that characterized the ligamentous anatomy between the metacarpals. The study described the relationship of distally directed fibers of the palmar and dorsal intermetacarpal ligament and a V-shaped intermetacarpal ligament. These structures are readily visible with MRI and the configuration was corroborated in a cadaveric MRI study.14 The pathoanatomy and anatomical description of these injuries are consistent with our patients' history and imaging findings. As in our athletes, the ulnar rays flex during power grip. The injury results from the forceful flattening of the flexed rays while batting and tackling in the baseball and football athletes, respectively. The mechanism is the result of the knob of the bat striking against the volar side of the rays or a helmet strike on the hand dorsum while grasping during a tackle. Because the transverse arch is forcibly flattened, the result is a variable injury to these intermetacarpal ligaments.
Implications for Clinical Practice
Severe forms of longitudinal disruptions or axial dislocations require some type of operative fixation,1,8,15 but less severe injuries present a unique clinical challenge. Due to the lack of fractures or static bony subluxation, the diagnosis can be challenging and the injuries may result in potential problems for high-level athletes. The symptoms and injuries can easily be missed by a rudimentary examination or radiographic evaluation. The purpose of our case series was three-fold. First, we discussed three professional athletes with a previously undescribed injury pattern. Each athlete presented with a similar mechanism, a crush or flattening type of injury, and had nearly identical examination and imaging findings. Second, we described an examination maneuver that can raise the clinical suspicion for a longitudinal disruption. The provocative maneuver separating the involved rays was diagnostic for each patient. The test is performed by the examiner, grasping each finger and applying a divergent force to the fingers, resulting in a separation of the metacarpal heads. Finally, we presented a novel taping technique that, in our three patients, allowed a prompt return to play or practice. The taping technique was used acutely in cases 1 and 2, and both athletes noted symptom control and were able to return to a professional level of play. The athlete in case 3 also achieved symptom control with the taping technique, even though he presented in a subacute manner.
When managing these injuries, special attention must be paid to avoid forceful flattening, (ie, an ill-molded cast) because it will prevent apposition of the injured tissues, which could delay healing. Athletes requiring a powerful grip may require prolonged protection before returning to play to allow the soft tissue injury associated with this injury to heal.
We believe that less severe longitudinal disruption injuries can be treated with non-rigid immobilization and taping. The taping technique described in this case review provided symptom control and return to play for each athlete. In our series, the technique demonstrated utility in both baseball and football arenas. We used this technique for each athlete. The athletes' symptoms resolved and they were able to return to play or practice. We recommend an adequate physical examination and a heightened level of suspicion for this injury type. A quick diagnosis and focused treatment resulted in a complete and fast recovery for our athletes. These diagnostic and treatment techniques may be applicable across any sporting event that can produce a crush or flattening type injury to an athlete's hand.
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