Delayed Diagnosis Of Traumatic Wrist Pain In A Baseball Player

Abstract

HISTORY A 27 year old right handed baseball player complained of persistent left ulnar wrist pain of 4 months duration. He referred acute onset of sharp pain after contact of baseball bat with ball at the time of injury. He was able to continue play but reported limitation in grasping bat. Other MD evaluation suggested a “wrist sprain” due to lack of evident pathology suggested on wrist MRI. Despite history of several physical therapy sets and NSAID's, pain and swelling continued. Numbness, paresthesias or weakness was denied. He was unable to continue performing his sport. PHYSICAL EXAMINATION Physical exam revealed swelling over volar and dorsal aspect of left hand, pain on light and deep palpation of hypothenar region, more pronounced at 1–2 cm radial and distal to the pisiform prominence. Tinnel sign positive at median volar wrist; Phalen unable to perform due to pain. Wrist active range of motion was full; strength was 5/5, but painful over ulnar aspect with resisted fifth digit flexion. DIFFERENTIAL DIAGNOSIS Ulnar-sided digital flexor tendon rupture Ulnar neuritis Piso-triquetral and hamate-triquetal arthritis Ulnar artery thrombosis Small and ring finger flexors tendonitis Undiagnosed Carpal fracture TESTS AND RESULTS Wrist X-ray AnteroPosterior/Lateral Normal Three phase bone scan Prominent osteogenic and vascular bone lesion on the hook of the left side hamate bone as may be seen with a bone fracture. Magnetic Resonance Imaging of wrist Abnormal signal at the hamate bone felt to be on basis of an underlying fracture of the hook of the hamate, likely at its base. Computed Tomography of wrist Nonunion fracture of hook of the hamate. FINAL DIAGNOSIS Nonunion fracture of the hook of the hamate. TREATMENT AND OUTCOMES NSAID's and refrain from sport Hand Surgery consult when diagnosis of fracture was confirmed. Surgical excision of hook was performed. Rehabilitation: Physical modalities Grip strengthening Functional training (sport specific) with padded glove Follow-up during 6 months until full recovery achieved, practicing sport at same frequency and intensity, without complaints.