For decades the understanding of how important is extended knowledge of the hand pathologies in sports was quite limited amongst sports surgeons. On the other hand, the development of modern techniques in diagnostics and methods of treatment in hand surgery, introduction of new technologies allowed us to treat much more effectively. The old expression “one doesn’t walk on hands” is no longer valid. The younger the sport population is, the more hand injuries one can expect, the more precise treatment should be offered.
Better understanding of basic pathology is needed and for instance such a common condition as ganglia, might be early signal of joint laxity or instability and precise diagnosis should be performed.
The prophetic work of Prof. Mumenthaler in late 40th, pointing the importance of the hand in the kinematic chain of upper limb (the hand-shoulder syndrome), has shown that insufficient function of the wrist and hand might change so much the mobility patterns of the whole limb, that might be clinically presented for instance as a shoulder or elbow dysfunction.
The problem is a relative lack of dynamic tests. The hand function is so complex that classical magnetic resonance or computer tomography are nowadays not sufficient to visualize the early steps of the chondromalatia or instability and arthroscopy should become a golden standard.
The great step of the last 20 years is the introduction of wrist and small joint arthroscopy, and one cannot underestimate the role of EWAS (European Wrist Arthroscopy Society) guided at the beginning by Ch. Mathoulin and R. Lucchetti, which created a friendly environment to co-ordinate efforts of surgeons from different countries, to promote the understanding of the importance of early phases of joint pathology. New classifications of joint instability, TFCC tears and chondromalatia were created, based on extended use of arthroscope.
Some technical tips, like dry arthroscopy popularized by F. Del Pinal, facilitated the use of this technique in the treatment of distal radius fractures and DRUJ instabilities. The classical works of Ilyas and Jupiter stressed upon the importance of precise restoration of the step-off of the articular surface and among young, sport population diastases bigger than one mm should be treated. In younger population the early degeneration of the joint might be expected and painful condition will develop in a few years.
The other dynamic field is the understanding of the importance of proprioception and innervations of the wrist and finger. The precise anatomic works upon the localization of nerves lead to the development of “nerve sparing” approaches to hand, wrist and fingers, that allow preserving as much of the protective function of the upper limb, as it is possible. The great popularizing role had works of M. Garcia-Elyas.
In general, the meaning of restoration anatomy is in particular important in hand traumatology. Probably, the future is the treatment “before the instability”; probably we’ve been waiting too long with the decision of restoration of dynamic positioning of carpal bones. The total wrist prosthesis unfortunately is not yet fulfilling expectation even in amateur sport.
The other promising factor is the physiotherapy and occupational therapy of the hand and certainly better cooperation with societies devoted to functional treatment should by established
The meticulous operative technique is particularly important in hand surgery and everybody dealing with that topic has to be familiar both with classical techniques, magnification devices, and scope. Probably in ninetieth, we were too aggressive in attempts of early mobilization and a good, proper technique of 3-6 weeks functional immobilization or bracing is still a key for a good final result.
Due to fantastic healing potential of the hand, the introduction of biological agents promoting bone union or healing, e.g. growth factors, is not that developed. The possibility of promoting the scar in such a narrow and complex space as a wrist is such, that the society of hand surgeons is very prudent in introducing this methodology yet.
We kindly invite you to participate in upper limb sessions – the WSTC Team prepared a good and complex overview of crucial topics in the treatment of sports pathology.
Dr. Grzegorz Adamczyk