Case Study: The Athlete That Climbed Through Fracture.
This article is about avulsion fractures of the extensor tendons of the fingers. We cover imaging options, self-care and surgical interventions. As well as the long term consequences of each choice.
History of Injury:
Ashley, a medical provider herself, was a pretty hard core climber. She had been at it for a few decades, appeared to be in her middle 30's (maybe early 40's) and came in to my office two months after her accident with an "A2 pulley injury". Now when I say "accident" I mean the onset, or very beginning of her injury. For her, it qualified as an accident. When asked about how she was injured, she said she had been climbing, did a layback move on a nice crack feature, and at the time of the injury, she was in the position that her arms were at shoulder height, she had straight elbows and wrists, and was leaning back with her weight into her fingers on slippery small footholds. From this position, during a crucial weight transfer from one foot to another, she lost her core strength and her foot popped off its hold. In doing so, she heard a "pop" out of her left 3rd finger followed by immediate pain and swelling. Her climbing was done for the day.
Site of injury:
The immediate visible swelling was present in the region where you would wear a ring and the joint just distal to it, the PIPJ (Proximal interphalangeal joint). The swelling was MOSTLY on the palm side of the bone but on the back of the joint it was puffy and hot. At the time of her visit (many months later) there was still slight swelling at the joint just past the ring region (PIPJ), and she still exhibited a decreased range of motion with end range flexion of the joint into a fist. The joint itself appeared swollen and hard with soft squishy tenderness along the backside of the joint (opposite the palm). She felt ever so slight pain with use, even 2-3 months after the accident and thought it had been an A2 pulley injury but was confused about the swelling and the joint shape and inflexibility.
After the injury the client had proceeded home and had taken 2 weeks off with excellent first aid (she was in medicine). She then returned to climbing at 14 days post injury with "slight pain" but the swelling would not go down. Her finger felt strange under load at end range flexion (crimp, undercling, side-pulls) and she was wondering why a pulley would cause these symptoms.
When she presented to my office it had been 2-3 months since her accident and she was back climbing outdoors on the weekends up in Eldorado Springs State Park. She was worried about her finger as it was misshapen. She could not bend it or extend it as she could prior to the injury, and she had pain that did not correspond to the A2 pulley injury she thought she had sustained. She was taping A2 and taking Ibuprofen. Her visit with me was to confirm she was healed and that the finger was a pulley injury. She was in pain. But of course not enough to keep from climbing on it.
I ordered a diagnostic ultrasound of the finger and low and behold, there was NO injury to the A2 pulley but an evulsion fracture of the posterior joint line (back of the finger) where the extensor tendon attaches onto the bone. Usually the bone is stronger than the tendon, but in climbers often the tendons are built up so nicely that the bone fails first. Ashley at this point was 3 months into her injury which showed a fail-to-heal in regards to the boy floater and the tendon attachment. This is the crux of being a medical provider. I have to inform YOU of your choices, and in her case, they were all crummy.
First off, I order diagnostic ultrasound first usually for two reasons. One, the cost. They are WAY cheaper than an MRI ($1900 on average in a small town vs $250). Second, musculoskeletal ultrasound or MSK Ultrasound shows WAY more than just an X-Ray in regards to climbing specific structures. In addition to joint surfaces, bone surfaces and tendon surfaces, ultrasounds also show pulley tendon injuries nicely.
Most doctors want to order an X-ray first. This is just fine. X-rays are an excellent starting point if you hear a finger pop (or are a youth athlete nearing adolescence) to look for a fracture, but they cannot show soft tissue (unless there is a TON of swelling, but they only show the swelling and not the gliding surfaces). As an aside, insurance usually covers ultrasounds and you do not need an insurance OK to get one if the doctor orders it.
(Conversely, MRI is excellent, but very expensive. It can show deep within the bone to see if fractures are just superficial or if they cover a larger region thank the x-ray was merely to rule out fracture (which they saw). MRIs take some time to order and you usually have to fail PT or have a really good reason why you need one to base your decision off of. Deciding the amount of time off you need is usually not covered unless there is a nasty injury in there.)
Time OFF for this client:
In this climbers case, she will need to absolutely STOP climbing until her finger has healed. This will be MONTHS of time not using the finger until we have an Xray that shows the bony chunk looking re-attached.
When we looked at her finger with diagnostic ultrasound, we saw a fracture through the bone itself, at the site of the little extensor tendons on the backside of her finger, just over the joint line. Diagnostic ultrasound is amazing because we can load the injury and see if it is stable. You cannot do this with an MRI or X-Ray.
In this clients case, flexing under no weight, it was extremely evident that the anchor point of the tendon had pulled off a little bit of the bone, and that bony bit was now floating around. Left to heal, it is hard to tell if it will re-adhere all by itself, it is likely it would, but with her history of not following medical advice, it was unlikely that she would give it the time it needs to heal.
Often fractures, left alone, heal quite well if the bony areas are in contact (such as a stress fracture) but when an avulsion happens, we need to re-approximate the fracture edges to allow it to heal. In many cases, this happens automatically with muscle tension (such as in ribs) but in the finger, we can splint it and use compressive tape to approximate the floating chunk back to the bone but the tone of the extensor musculature needs to be soft and supple (so it isn't tractioning the fractured bit away from the healing site). If we want to take a conservative approach, this is usually my course of action. In this clients case, repetitive use never allowed it to heal in the first place, so healing it was going to be tough. All the work her body was doing to heal was being undone by her with each use. Her best bet would have been to immobilize the finger until the bone itself healed.
Research shows that these fractures are a problem in two ways.
POINT 1- Near Impossible Healing. Evulsion fractures of the posterior joint line (extensor tendon attachment) are hard to heal. They likely will NOT heal without surgery in almost all cases. I have seen a few youth heal nicely with a finger splint and compression taping and they took TIME and repeated MRIs to confirm healing prior to return to sport. Ashley did not return for follow-up imaging so I have no way to know how she healed. I had referred her out of my office to an orthopedic surgeon. I can only wonder how she healed up through the years. This was an OLD injury, but her continuing to climb on it kept it from healing and might have been the trigger for it to NOT ever heal in the long run.
POINT 2: The lesser of two evils: Surgery stabilizes but then creates arthritis.
Surgery looks like this: They surgically lock the joint so it cannot move and using pins and wire, anchor the piece of bone back onto its original position. The wire is short term and is used to hold the bony avulsion back in place while it heals for 14 days. This is not permanent and is taken out quite quickly afterwards but DOES have long term consequences. As the joint is held without motion for this period of time, allowing this extensor tendon attachment (and the bone) to finally re-attach and heal, it is highly likely to sustain excessive wear and tear in future years (even without use) and has a HIGH likelihood of degenerative joint disease. As climbers, we have no way of knowing how much more this would be in comparison to a non climber, but it is safe to say that this joint will have (says research) 70+ % more likelihood of arthritis. For an old, gentle climber who does not plan on climbing aggressively at their max, it is possible that it will now NOT heal, even with being pinned. Surgery for this is aggressive, but in my opinion is the best choice for most who wish to climb at a VERY HIGH LEVEL for years to come. If you plan on pushing your body to the max, this is a setup for disaster with an unstable extensor tendon attachment (in my opinion).