A Pictorial Review Of Wrist Injuries In The Elite Golfer (P2)
Ulnar Sided Injuries ECU pathology
Up to 67 % of wrist injuries occur in the ulnar aspect of the lead wrist, (the left wrist in a right-hand dominant golfer). The extensor carpi ulnaris (ECU) tendon is involved in the majority of ulnar sided injuries. Typical ECU tendon pathology includes subluxation, dislocation, tendonopathy and tenosynovitis.
Dynamic ultrasound during pronation and supination easily evaluates the position of the ECU tendon within the ulnar groove. There is normal variation in tendon position throughout the range of wrist movements, with displacement toward the ulnar border of the groove being greatest in a flexed and supinated wrist. The sensitivity and specificity of ECU displacement in diagnosing true ECU instability has yet to be determined.
Hook of Hamate fractures
Although the true incidence of stress related fractures in golfers is unknown. The hook of the hamate fracture is a common ulnar sided wrist injury observed in golfers and is reported to be the most common stress fracture seen in golfers after rib fracture. Hook of hamate fractures can arise acutely from a direct blow by the counterforce of the proximal end of the grasped golf club, as it lies immediately adjacent to the hook of the hamate. If there is a slight relaxation of grasp at the conclusion of a swing or at the time of meeting a sudden resistance such as hitting the ground, the centrifugal force of the swing results in direct trauma upon the hook. Stress fractures of the hook of hamate may also present insidiously after repetitive microtrauma. The non-dominant/leading hand is usually affected in golfers in contrast to racquets players in whom the dominant hand is more likely to be involved.
CT is far better at evaluating occult hamate fractures with a reported sensitivity of 100% and a specificity of 94% compared with 72% and 88% in plain radiographs. Associated injuries of hook of hamate fractures include injury to the ulnar nerve and artery and damage to the flexor carpi ulnaris tendon.
Hypothenar Hammer Syndrome (HHS)
HHS is a rare arteriopathy of the distal ulnar artery. Patients may present with pain in the palm, paresthesia, numbness, and signs of vascular insuf#ciency such as coldness, pallor, discoloration, and blanching of the affected ulnar sided #ngers. Frequent blunt trauma to the superficial segment of the ulnar artery at the hypothenar eminence compresses the artery against the hook of hamate triggering vasospasm of the artery. Vasospasm and repetitive trauma cause intimal damage resulting in platelet aggregation and thrombus formation. In addition to thrombosis, continued trauma can lead to damage of the tunica media and aneurysm formation. HSS syndrome has been reported in the past as an occupational disease occurring in workers using hammers and screwdrivers, and in subjects who use the hypothenar part of the hand as a ‘hammer’. It may be seen in any case of repetitive compression or blunt trauma to the hypothenar eminence. Furthermore, it has also been reported in sportsmen, particularly in mountain bikers, racquets players and there have also been case reports in golfers.
The ulnar artery in the hand can by imaged via conventional digital subtraction angiography, CTA or MRA, the diagnosis of HSS can be also confirmed easily with US. The angiographic findings characteristically show a ‘corkscrew’ elongation of the artery with segments of stenosis and ectasia. There maybe further upstream multiple digital artery occlusions which have been caused by occlusive microemboli. Conventional MR findings include isointense to hyperintense T1WI signal in the arterial lumen which is indictive of thrombus within a partially patent or occluded ulnar artery aneurysm.