It’s No Fish Tale – These Uncommon Hand & Upper Extremity Fishing Injuries Can Really Happen!

Located on the Gulf of Mexico and home to hundreds of lakes, it’s no wonder that the Texas coast is the playground to fishing enthusiasts far and wide.

Barracuda

unhook stingray2But even the seasoned sportsman can fall victim to some unlikely fishing injuries affecting the hand and upper extremity. In fact, fishermen (and women) put themselves in danger every time they come into contact with marine life – unpredictable behavior/aggressive and often forceful nature of a catch, prevalence of less commonly treated bacteria, unsanitary tools/equipment, poor wound care – all contributing to some common and not so common injuries that hand specialists see in a region like the Texas Gulf Coast.

Some common fishing injuries and conditions with which a Texas hand surgeon is all too familiar include:

fillet_2Many of these common injuries and conditions are treated non surgically and follow the same treatment protocol as any other patient with the same diagnosis – regardless of the cause.

Uncommon Hand & Upper Extremity Fishing Injuries and Conditions

Though there is very little that surprises a hand specialist practicing in “sportsman’s paradise,” an unusual injury associated with fishing will occasionally make its way to a Texas medical clinic.

Some of these uncommon injuries and conditions include:

  • Sting Ray Laceration
  • Fish Bite / Impalement
  • Fish Handler’s Disease / Bacterial Infection
  • Lodged Fish Bones, Fin Spine 

Unlike other injuries that break the skin, these types of fishing injuries are particularly concerning.  Fish and other marine life carry bacterial infections within their bodies, as well as on their skin, which can affect humans if certain precautions are not taken immediately. Some types of bacteria found in marine life are not commonly seen and do not respond to conventional antibiotics frequently used for infections.

Additionally, some marine life such as the Sting Ray utilize defense mechanisms that require special attention when used against a fisherman.

Sting Ray Laceration
While many sting ray injuries involve an inadvertent encounter between a foot or other lower extremity and a sting ray’s barb, some have occurred to the hand or wrist while trying to remove a sting ray from a fishing net or line.

These types of lacerations require more than bandaging.  Not only do sting ray barbs pierce like a weapon, all sting rays are armed with at least one serrated venomous spine at the base of their whip-like tail.  Short-tail sting rays have two tail spines: a slender spike in front of a large, jagged bayonet (1).

In addition to possible damage to muscle, tendons and nerves that can occur from the physical impalement of a sting ray barb, its venom is comprised of many different substances that can cause tissue to break down and die.
Some of the symptoms that Sting Ray venom can cause include:

 

  • Immediate and severe pain radiating up the affected limb
  • Bleeding and swelling in the affected area
  • Sweating
  • Faintness, dizziness and weakness
  • Low blood pressure
  • Salivation, nausea, vomiting, diarrhea
  • Headache
  • Shortness of breath (2)

 

Medical attention is recommended for all sting ray injuries.  Minimally, the wound will be cleaned with warm water to remove the venom and a tetanus booster given if it has been more than five years since the last tetanus booster. Tetanus prevention is required if the patient has never had a tetanus vaccination.  Antibiotics may also be required, and depending on the severity of the injury and amount of damage sustained (often the result of the delay in seeking treatment), surgical intervention to repair soft tissue damage and/or a period of rehabilitation may be required to restore strength to the injured limb (2).

Fish Bite and Impalement
While not every fish injury comes with a venomous double blow, the high risk of bacterial infection and soft tissue damage can be just as serious.  Many fish have sharp teeth, tails and pointed features that can easily break the skin.  Wrestling the unwilling catch onto the boat or beach can leave some sportsmen a bit worse for the wear.

 

Aside from the bacterial concerns that come with marine life, the forceful impact from a sharp feature of the fish can result in soft tissue damage that may require surgical repair and/or months of rehabilitation to restore hand and upper extremity function – as the hand alone is comprised of approximately 34 muscles, 120 known ligaments, and 50 nerves!

 

These types of deep puncture wounds or lacerations in the hand are also at high risk of infection and should be monitored closely.  A delay in the appropriate treatment can lead to complicated tenosynovitis and horseshoe abscess.  Additionally, marine life bacterial infections resulting from Mycobacterium marinum (M. marinum) do not respond to some conventional antibiotic treatment such as amoxicillin (3).

Fish Handler’s Disease
Not every fishing-related Mycobacterium marinum infection is the result of an obvious injury/wound.  A condition known as Fish Handler’s Disease can impact those frequently handling fish and generally affects the hands.  Any inconspicuous cut or small opening on the skin can allow the bacteria to enter the body.  The bacteria’s inability to proliferate in the warm body confines it to the affected area.

 

Common symptoms include swelling, tenderness, and bluish-purple spots. Fish Handler’s Disease is treated with special antibiotics used specifically for this type of bacterial infection.  Recovery can take months.

Lodged Fish Bones, Fin Spine
Occasionally in the handling of fish a fish bone or fin spine can lodge in the hand. Though this may not be painful or immediately worrisome to the injured party, these types of injuries are concerning.  Such injuries often leave residual fragments of foreign organic matter in the soft tissue, which can cause secondary infections such as Staphylococci and Streptococci (4).

 

Typically, x-rays are used first to try and identify a foreign body in the tissue, though are not always successful in doing so.  An MRI may be indicated to identify fine fin spines and tiny bones lodged in the body’s tissue. The surgical removal of the foreign body is important.  Failure to seek and remove the foreign body may lead to persistence of infection (4). Multiple surgical procedures may be required, and the patient is put on antibiotics to prevent infection. Physical therapy may be required after surgery to regain mobility of the hand.

 

If this type of injury goes untreated it can result in permanent disability and hospitalization for infection. Though the area may look as if it has healed, but is still tender, swollen, discolored, or abnormal in any way, individuals are urged to see a hand specialist.

 

Prevention and Precaution
Understanding the unique aspects of the marine life occupying the waters you’re sporting and utilizing protective gloves and garments while fishing can go a long way in injury prevention.  As the largest organ of the human body, our skin serves as a protective barrier.  When any area is compromised, our entire body is compromised. Individuals with other health conditions, such as diabetes or immune deficiency disorders should be particularly cautious and consult a hand specialist for proper wound care.

If not addressed properly, even seemingly minor fishing injuries can result in serious infection, lingering weakness or permanent disability – inhibiting participation in the sport you love.

 

References

 

STRIKE!

Looking behind the baseball at UCL injuries … and the role former Los Angeles Dodgers pitcher Tommy John plays

 

The goal of every great baseball pitcher is to strike out the batter.  To do this requires not only talent but extreme power every…single…pitch.

Few other athletes are required to throw with this kind of power as frequently as a pitcher.

Over the course of a baseball career, particularly if begun at a young age and played competitively, this high speed force repeatedly placed on the elbow can take a toll.

Often beginning with Little Leaguer’s Elbow, a condition affecting young pitchers who do not allow adequate rest between pitches, a baseball player’s elbow joint absorbs a tremendous amount of repetitive stress over the seasons.  The impact of this type of overhead throwing irritates the tendons and ligaments supporting the elbow joint, predisposing pitchers to more serious problems.  One such injury is an Ulnar Collateral Ligament (UCL) injury.

Once seen primarily in adult athletes, the dramatic increase in more serious overuse injuries like UCL damage, Flexor Tendinitis and Valgus Extension Overload (VEO) in young players prompted the American Sports Medicine Institute (ASMI) and the USA Baseball, Little League Baseball and Major League Baseball organizations to establish Pitch Count Guidelines.

While these changes and educational efforts are expected to reduce the number of overuse injuries seen in young players, competitive league players remain at risk.

Ulnar Collateral Ligament (UCL) Injury

Elbow Anatomy and UCL Injury

The Elbow Joint and location of the Ulnar Collateral Ligament

The ulnar collateral ligament (UCL) is among the most commonly injured ligament in throwing athletes.  To accommodate the high speed throwing motions, the ligament stretches and lengthens until it can no longer hold the elbow bones tightly enough. Severity of the injury can range from a sprain with minor damage and inflammation to a complete tear.

Symptoms Include:

baseball bullet

Pain on the inside of the elbow

baseball bulletA feeling of instability in the elbow

baseball bulletLoss of strength in throwing

baseball bulletIrritation of the ulnar nerve (funny bone) causing numbness in the small and ring fingers

Diagnosis and Treatment

A UCL injury is diagnosed based on the results of a physical examination, X-ray and MRI.  Depending on the severity of the damage, rest and refrain from play along with rehabilitative exercises and anti inflammatory medication may be indicated. Work with an athletic trainer may also be helpful, to assess throwing mechanics and improve body positioning which can reduce excessive stress on the elbow.

If there is a complete tear of the ligament and patients fail to improve with conservative treatment, surgery may be indicated.

The UCL reconstruction procedure, which was performed on former Los Angeles Dodgers pitcher Tommy John and is more commonly known as Tommy John surgery today, has dramatically changed the outcome for athletes.  In fact, his results were so impressive, it is reported that young players not actually suffering from a UCL injury have sought Tommy John surgery in hope that it would improve their performance [1]!  The procedure, though, is performed only when necessary to repair a severely torn UCL.

Tommy John surgery is a surgical graft procedure in which the injured UCL is replaced with a tendon graft taken from the forearm or the hamstring tendons.  This procedure is followed by an intense rehabilitation program that lasts from six months to a year, depending on the position an athlete plays.  Throwing exercises can begin in about 16 weeks.

The Role Tommy John Continues to Play

In the medical community, Tommy John remains credited with the shift in how athletes view UCL injuries. Once career ending, today UCL reconstruction has become a common procedure – returning most athletes to their sport at a pre injury level of play.

In the sports world, Tommy John is still revered for the excellent athlete he was, choosing baseball as his sport of choice and playing in all three of the Yankees vs Dodgers World Series in his era (1977, 1978 and 1981).

Undergoing the procedure in 1974 and spending his entire 1975 season in recovery, he learned to pitch in a way that relieved the stress he was placing on his arm and leg.  He returned to the Dodgers in 1976. His 10-10 record that year was considered “miraculous.”  But, he went on to pitch until 1989 winning 164 games after his surgery – just one game shy of baseball great Sandy Koufax.

The recognition he received for his unexpected success following the procedure now donning his name became the launching pad for other endeavors benefiting young baseball players.

His “Let’s Do It” foundation, which umbrellas the Tommy John Pitching Academy, is today dedicated to research in preventing such injuries and teaching pitching techniques that minimize the physical impact. The foundation also supports the efforts of the American Orthopedic Society for Sports Medicine (AOSSM) and its collaborators’ STOP Sports Injuries Campaign as well as the American Foundation of Suicide Prevention (AFSP).  AFSP and its outreach effort is an important component in the foundation’s efforts in memory of his son.

 References

  1. Longman, Jere. Fit young pitchers see elbow repair as cure-all. 2007 Jul.

 

 

Protecting Fingers in Fall Sports

Behind the catches, interceptions, tips, tackles and returns are some of the most commonly reported sports injuries in football, as well as other fall and winter sports – finger injuries.Football Finger Injuries

Finger injuries actually represent one of the most common body injuries in sports in general and include sprains, dislocations, tendon damage and fractures. They are very common in football, basketball and volleyball.

Rarely does a finger injury go unnoticed.  They can be very painful and more challenging to heal, as our hands are constantly in use in everyday activity.Basketball Finger Injuries

Some of the most common causes of a finger sports injury include:

  • Struggle to maintain (as well as strip) a football
  • Clashes with teammates and opponents
  • Awkward and sudden impact with a ball
  • Catching or pulling on a jersey
  • Falls onto a hard surface

Sprains and DislocationsVolley Ball Finger Injuries

Finger sprains generally represent damage to the collateral ligaments, which are band-like structures that stabilize the finger and prevent side to side movement. It most frequently occurs in the mid finger. The little finger, middle finger and thumb are the fingers most affected in such injuries.

A finger sprain can vary in severity and is graded on a scale of 1-3. Grade 1 represents the mildest type of sprain, a stretched ligament.  Grade 2 is a partially torn ligament, and Grade 3 represents one that is completely torn.  When a Grade 3 finger sprain is sustained and bones are also out of place, altering joint surface contact, it is diagnosed as a finger dislocation.

A finger dislocation may be identified as an MCP (metacarpophalangeal), DIP (distal interphalangeal) or PIP (proximal interphalangeal) dislocation depending on the finger joint and bone it affects.

Finger sprains are also often referred to as a “jammed finger.”

Depending on the severity of a “jammed finger,” symptoms may include:

Finger Anatomy

 

  • Pain and immediate swelling
  • Bruising and pain during activity
  • Impaired function
  • Deformity
  • Stiffness and difficulty during gripping activity

Tendon Injuries

Tendons in the hand are tissues connecting muscle to bone, which when contracted pull on bones causing fingers to move. These muscles moving the fingers and thumb are located in the forearm – long tendons extending through the wrist and attaching to the small bones of the fingers and thumb.

The tendons on the top of the hand straighten the fingers and are known as extensor tendons. Those on the palm side bend the fingers and are known as the flexor tendons.

When fingers are bent or straightened, the flexor tendons slide through snug tunnels, called tendon sheaths, keeping the tendons in place next to the bones.  A tendon rupture disrupts this natural flow.

A relatively common tendon injury of the hand diagnosed in fall sports is a tendon rupture, also called a “Jersey Finger.”  This occurs in a “tear-away” type of activity, such as grasping a jersey with finger(s) in a flexed position – and then forced straight as the player quickly moves in another direction.  The result is loss of flexion at the DIP joint because of damage to the flexor tendon.

An injury to the tip of the finger may result in extensor tendon damage, which is also known as a “Mallet Finger.”

Symptoms of a flexor or extensor tendon rupture may include:

Flexor

  • An inability to bend one or more joints of your finger
  • Pain when your finger is bent
  • Tenderness along your finger on the palm side of your hand
  • Swelling of the finger

Extensor

  • Inability to open or extend the hand or fingers
  • Pain
  • Swelling or weakness of the finger
  • Cut to the back of the hand or fingers

Finger Fractures

Among the more severe finger injuries occurring in sports are finger fractures.  This is a break in one of the small bones of the finger.  Finger fractures may be stable or unstable.  Among the most common finger fractures include; distal phalanx (also known as a Tuft Fracture and associated with “crush” injuries), mallet, flexor digitorum profundus avulsion, and middle and proximal phalanx fractures (non-displaced, unstable, or displaced – which are usually more complex fractures to treat).

The correct diagnoses and treatment of a finger fracture, which can often mimic a finger sprain or dislocation in pain and symptoms, is imperative in ensuring optimal long-term function.

DIAGNOSIS

While many finger injuries can be diagnosed with a physical examination, an x-ray is indicated to more thoroughly assess the injured area or possible fracture – and severity of the injury. A CT scan may also be used to evaluate complex fractures. An MRI is often used when the soft tissues are involved (such as with tendon ruptures).

TREATMENT

Treatment for most finger injuries is nonsurgical, conservative approach that may involve RICE (rest, ice, compression, elevation), splinting, anti inflammatory medications for swelling/pain, and rehabilitation exercises.  Reduction may be performed on some simple fractures and supported with splinting or “buddy taping” (practice of taping the injured finger to a nearby uninjured finger to limit mobility and provide splint-like support).

More serious injuries and those unresponsive to conservative treatment may require surgical repair and an aggressive post-surgical hand and upper extremity therapy program.

PREVENTING INJURY

Injury prevention is always preferable for athletes wanting to give it their all during the sports season.  There are some things you can do to reduce risk of injury during sports this fall and the seasons to come:

  • Avoid wearing rings or other jewelry when playing.
  • Opt for closed fist rather than open hand approaches in volleyball and blocking in football.
  • Buddy taping (as mentioned above) can also be effective in preventing finger injury in a number of different sports.
  • Finger bracing should be worn in both practice and games until symptoms of a mildly injured/painful finger resolves, to avoid more serious injury/damage.
  • Finger and hand strengthening exercises can be beneficial.

Platelet Rich Plasma Procedure, Among the Latest in Less Invasive Hand & Upper Extremity Treatment Options

While research efforts continue to assess the benefits of platelet-rich plasma (PRP) in the treatment of some orthopedic injuries and conditions, the clinical results for many, including some high-profile athletes such as Tiger Woods and Pittsburgh Steelers, Troy Polamalu and Hines Ward, are proving favorable.

PRP therapy is thought to accelerate healing by using the patient’s own “platelet rich plasma” and growth factors.  A small amount of a patient’s blood is taken and rotated in a centrifuge to separate red blood cells from platelets.  The concentrated platelets are then re-injected into the affected area – releasing growth factors that are believed to help the tissue recover more quickly.  The procedure is performed on elbows, shoulders, knees, hips and feet.

Initially PRP therapy was used to help athletes recover more quickly from an injury, accelerating recovery of arthroscopic cartilage and ligament repair.  Today, PRP injection therapy is used for some chronic tennis elbow and golfer’s elbow cases, as well as other cases of tendinitis.  The growth factors and stem cells that concentrated levels of the patient’s platelets activate not only promote more rapid healing but are also found to reduce pain and osteoarthritic symptoms and inflammation.

Tennis Elbow and Golfer’s Elbow

“Overuse conditions” affecting the muscles and tendons of the forearm where they attach at the outside of the elbow, tennis elbow (also known as lateral epicondylitis), or inside of the elbow and forearm as in golfer’s elbow (medial epicondylitis), are generally first addressed with conservative treatment – rest/activity modification, bracing, non steroidal anti inflammatory medication (NSAIDs).  Traditionally, patients continuing to suffer from chronic tennis elbow despite conservative treatment are recommended for surgery to address the affected tendons.  While arthroscopy has made surgical intervention less invasive, PRP therapy offers a non surgical option for chronic tennis elbow sufferers – providing relief for the pain and tenderness associated with the condition.

The Procedure

PRP therapy is a simple in office procedure and does not require a separate visit.  Patients opting for the therapy simply request it during their examination.  Results are usually evident within just a few days.

 

 

Forearm Fractures

Understanding Pediatric and Adult Forearm Fractures

Forearm fractures are common upper extremity fractures in kids and adults alike, as they compose the part of the arm which is integral in everyday activities, sports and hobbies – and frequently utilized to slow the force of an impact or fall.

Fracture of one of the forearm bones

Forearm bones and illustration of a forearm fracture.

The forearm bones are known as the ulna and the radius.  They run parallel to one another and connect the wrist joint (distal end) to the elbow joint (proximal end).

A forearm fracture can affect one or both forearm bones.  In fact, the impact one forearm bone sustains often forces it into the other causing both to break.

When a forearm fracture occurs, the type of break is carefully assessed using both a physical examination and x-rays.  It is then identified as a fracture involving either the proximal, middle or distal “shaft.”

Some of the common types of forearm fractures include:

  • Radial Head Fractures
  • Olecranon Fractures
  • Distal Radius Fractures (wrist fracture)
  • Radial Shaft Fractures,
  • Ulnar Shaft Fractures
Both bone forearm fracture in a young football player

An x-ray of a both bone forearm fracture in an adolescent football player.

The fracture is identified based on a set of criteria and the location on the bone.  If both the radius and the ulna are affected, it is known as a “both bone forearm fracture.”

If the fracture does not pierce through the skin it is considered a simple or closed fracture.  One that pierces through the skin is considered a complex or open fracture.

Forearm Fractures in Children

Forearm fractures represent nearly half of all childhood fractures – most of those occurring at the distal, or wrist end of the radius. These fractures are classified by the area of the bone affected, whether it is stable or displaced, how clean the break and whether it is partial or complete across the bone.

The classifications include:

  • Torus fracture, also known as a “buckle” fracture.  It results when the top layer of bone on one side compresses upon a harsh impact.  It is considered a stable fracture.
  • Metaphyseal fracture.  This type of fracture affects the upper or lower shaft of the bone without affecting the growth plate.
  • Greenstick fracture.  This type of fracture extends through part of the bone, causing it to bend on the other side.
  • Galeazzi fracture.  This impact is often a displaced fracture disrupting the radius and also the wrist joint where the radius and ulna come together at the wrist.
  • Monteggia fracture.  This fracture usually involves the ulna shaft and disrupts the elbow joint where the radius dislocates requiring urgent care.
  • Growth plate fracture. This type of fracture occurs across the growth plate.

(Fracture classifications source:  American Academy of Orthopaedic Surgeons)

Fractures in children are different from those in adults, because their bones are still growing.  As a result, they have more cartilage and collagen resulting in a more “pliable” bone less subject to a break – or one less severe as an adult might sustain with the same impact.  In fact, many fractures in children may be so subtle they are difficult to detect on an x-ray and require an orthopedic specialist to assess.  A fracture in a child heals rapidly.  So, it is important that it is addressed quickly and properly set before it heals in improper alignment – causing other long term problems.

Also unique in children is the impact a fracture could have on their growth plates.  Depending on the extent of a fracture, the growth and function of the child’s limb could be negatively impacted as a result.

Adult Forearm Fractures

The same fracture classifications applied to those in children, with the exception of growth plate and greenstick fractures, apply to those in adults.  The adult bone is less “pliable” than that of a child’s and has a higher tensile strength, which can result in a more serious break.

Adults suffering from osteoporosis are particularly subject to breaks from an impact or activity seemingly unlikely to inflict such damage.

Treatment

Fracture treatment depends on the severity of the break and any other soft tissue damage that may have occurred as a result.  The right treatment will depend on the fracture, age and lifestyle of the patient – and may be nonsurgical or surgical with internal fixation.

All treatment includes hand therapy for the best results and most rapid return to activity.

Playing with an Injury

When is it Okay to Return to Play?

As fall sports heat up, we begin to see a lot of injuries.  The first question players ask after we confirm their injury is, “how soon before I can play again?

Whether it’s a junior high schooler, college athlete or professional player, this question is asked with the same passion and underlying conviction to do whatever it takes to get back in as soon as possible.  This is their sport and their heart is all in – despite the injured limb and challenge it now presents.

Kinkaid Team Captain and outside linebacker, Harris Green, not slowed by forearm fracture

As an orthopedic physician who wants to ensure the best outcome in their recovery and a team doctor who understands this drive distinct in athletes, it’s important to develop the right treatment plan – some of which might entail permission for immediate return to play.

Green back in the game as fracture heals

While this may seem counterintuitive, certain hand and upper extremity fractures once stabilized and placed in a cast are fine for an immediate resumption of play.  This is particularly true of the younger athlete.  Some of the types of fractures allowing athletes to return quickly back to the game despite their cast or splint include certain finger and distal radius fractures and ligament sprains.

While the position on a team will impact the enthusiasm in our recommendation to allow such return to play – linemen with the capability to restrict their hands in a cast verses a receiver or running back more fully engaging their injured limb – many are as capable to play their position with their injury as they were before.

The type of injury is also a determination – stabilized fractures are more likely to be considered for immediate return to play than ligament or tendon tears.

Now, there are some risks for further damage if the injured limb is hit in such a way and the inflexibility of the cast places other vulnerabilities on the uncasted portion of the limb.  Other risks include refracture, retear of a tendon or displacement of a fracture.

But, the only way to truly avoid further injury is to sit out of the game until the injury is completely healed. And this is rarely an option for an athlete.

So, we ensure that our patients know everything upfront.  And we give them the tools to keep their injured limb as strong as possible – regardless of the decision they make.   Continuing to keep the injured limb strong by exercising the muscles and joints around the injury, in conjunction with cardiovascular exercise for overall physical well-being….is key.  We remain very involved and ready to make any readjustments we need to the treatment.