Uncommon hand injury to the batsman in ‘gully cricket’: report of two cases

Abstract

Volar plate injuries are typically caused by hyperextension of the proximal interphalangeal joint. These injuries are usually seen in sports where the ball comes in direct contact with the hands. Forceful dorsiflexion of the finger caused by the speeding ball leads to volar plate avulsion. In cricket, such finger injuries predominantly occur in fielders trying to catch or stop the speeding ball with bare hands. We report two unusual cases of volar plate avulsion injury occurring in batsmen that occurred during ‘gully cricket’ (street-cricket). We propose the possibility of a novel contrecoup-type mechanism causing this type of injury in the two cases. Both were successfully managed with splinting and had excellent recovery without any residual deformity or instability.

Background

’Gully cricket’ is a popular leisure game among the youth in the entire Indian subcontinent. It is so popular that almost every individual in India would have played or witnessed gully cricket. It is usually played with a hard-tennis ball or a rubber ball. The batsman is almost always without any protective gloves and vulnerable to injuries from the speeding ball. Although the injuries in these games are prevalent, they remain mostly under-reported.

Volar plate injuries occurring to the batsmen in a game of ‘gully cricket’ has not been reported. Further, we propose a ‘contrecoup’ type mechanism of volar plate injury, distinct from what has been previously described in the literature.

Case presentation

Case 1

A 30-year-old, right-hand dominant man, presented to the Hand clinic with pain and swelling of the middle finger of the right hand. He was hit by a hard tennis ball during a game of ‘gully cricket’. While he was batting, the ball had hit him on the dorsum of the middle finger at the proximal interphalangeal joint (PIPJ) such that the finger was stuck between the ball and the handle of the bat (figure 1). He was not wearing any protective gloves. On examination, he had diffuse swelling of the finger, ecchymosis on the volar aspect, tenderness and painful restriction of movements at the PIPJ. The distal neurovascular examination was normal. Standard anteroposterior and oblique views of the finger failed to detect any bony injury (figure 2A, B). A true lateral view of the middle finger showed a minimally displaced fracture of the base of the middle phalanx on the volar aspect indicating avulsion of the volar plate at its distal attachment (figure 2C). The finger was immobilised in extension in a stack finger splint for 2 weeks and then allowed to mobilise the joint actively. At 5-year follow-up, the radiograph showed a complete union of the fracture (figure 2D), and he had full range of movements at the PIPJ without any deformity or instability (figure 3A, B).

Figure 1.

Illustration of the mechanism of injury (credit: author Sandesh Madi).

Figure 2.

(A) Essentially normal oblique radiograph of case 1. (B) Essentially normal anteroposterior radiograph of case 1. (C) True lateral radiograph showing a fracture of the base of the middle phalanx at the attachment of the volar plate, indicating a volar plate avulsion injury in case 1. (D) Lateral radiograph of case 1 at 5 years follow-up showing the union of the fracture.

Figure 3.

(A, B) Clinical photo of case 1 demonstrating the full range of movements at 5-year follow-up.

Case 2

A 29-year-old, right-hand dominant man, presented to the Hand clinic with pain and swelling of the ring finger of the right hand with a similar mechanism of injury during a game of ‘gully cricket’ (figure 1). There was tenderness on the volar aspect of the PIPJ, and the movements were painful. True lateral X-rays revealed a fracture of the base of the middle phalanx on the volar aspect indicating avulsion of the distal attachment of the volar plate (figure 4). He too was managed non-operatively with splinting and early mobilisation (figure 5A, B).

Figure 4.

True lateral radiograph showing a volar plate avulsion injury of the ring finger in case 2.

Figure 5.

(A, B) Clinical photo demonstrating splinting of the finger with a 3D printed splint in case 2.

Investigations

Plain radiography is the initial investigation to be performed for the diagnosis of such injuries. In minimally displaced fractures, the standard anteroposterior and oblique views are often normal, and the avulsion injuries can be missed entirely. A true lateral radiograph of the injured finger is extremely valuable in identifying the injury. Radiographs can also define the extent of fracture displacement and size of the fractured fragment that will help to plan the subsequent management.

Additionally, radiographs can rule out the possibility of other bony injuries such as phalanx fractures (extra-articular or intra-articular) and indicate joint subluxation or dislocation. These avulsion injuries can also be diagnosed on the ultrasound scan. Moreover, the ultrasound scan may prove useful to assess an associated collateral ligament injury or rule out a flexor tendon injury (zone 2).¹ MRI is rarely required to diagnose the injury but, maybe valuable if any associated collateral ligament injuries are also suspected (a pure ligamentous type of injury). In both the index cases, the fractures were minimally displaced and were easily identified on the lateral radiographs, thus underlining the importance of lateral radiographs.

Differential diagnosis

A direct impact on the dorsum of a flexed PIPJ may lead to intra-articular or extra-articular fractures of proximal and middle phalanges, fracture-dislocations of PIPJ, injury to the collateral ligaments or flexor tendon (zone 2) or a rupture of the central slip of the extensor tendon. However, on examination, both the patients had active, although painful, movements at the PIPJ and had no varus or valgus instability, thereby clinically ruling out a central slip rupture and collateral ligament injury. Radiographs, however, revealed a minimally displaced fracture of the volar base of the middle phalanx in both cases, indicating a volar plate avulsion injury.

Discussion

The volar plate is a fibrocartilaginous structure that is sandwiched between the flexor tendons and the volar joint capsule of the PIPJ.² The volar plate, along with the collateral ligaments, the accessory collateral ligaments, and the central slip of the extensor tendon together form the primary stabilisers of the PIPJ. The volar plate is inserted to the base of the middle phalanx distally and has two extensions known as the checkrein ligaments proximally. This insertion distally is thin at the centre where it is confluent with the periosteum of the middle phalanx and thicker at the peripheries where it is confluent with the collateral ligaments.³ The volar plate, along with the checkrein ligaments resist hyperextension of the joint.⁴

Injuries to the PIPJ commonly occur with ball sports and have a broad spectrum from closed, stable soft tissue injuries to open fracture-dislocations.⁵ Aitken and Court-Brown in their study on the epidemiology of sports-related hand injuries observed that cricket accounted for only 3.4% of all sports-related phalangeal fractures. In contrast, football and rugby topped the chart with 35.8% and 15.6%, respectively.⁶ In cricket, Belliappa and Barton⁷ reported on 64 hand injuries, of which PIPJ was involved in 11 cases. Among the fielding injuries, eight players had a fracture of the base of the middle phalanx with PIPJ dislocation. Injuries that happened while batting involved the carpal region, and no volar plate avulsion injuries of PIPJ were reported. Recently, Ahearn et al⁸ reported 55 hand injuries that occurred during professional county cricket. In their series, nine phalangeal fractures were noted. Most of the injuries sustained by professional cricketers were during fielding. Twelve injuries had occurred to the batsman; however, no volar plate avulsion injuries were recorded.

‘Gully cricket’ is a widely popular version of recreational domestic cricket played in the alleys and fields throughout the Indian subcontinent with its own unique rules and formats. It is usually played with a hard rubber ball or a hard tennis ball, and the batsmen seldom wear any protective gloves. Therefore, injuries to the hand during these games are not uncommon. However, these injuries are frequently underreported because most of them are minor and usually heal within a few weeks. Furthermore, these injuries do not undergo any detailed radiological assessment, and a vast majority of them are treated as ‘sprain/contusion’.

Volar plate injuries have been classically described as pure hyperextension injuries of the PIPJ.^{4 9} Bowers demonstrated that a rapid application of a hyperextension force leads to rupture of the volar plate from its distal attachment, whereas, a slow but gradual application leads to rupture of the checkrein ligaments.⁴

The cases described here are unique for their mechanism of injury. Such an injury happening to a batsman while playing recreational cricket has not been previously described in the literature. We propose the possibility of a contrecoup-type of mechanism of injury to the volar plate. ‘Contrecoup’ means counterblow in French, and the injury was first described by Hippocrates to describe a fracture opposite to the point of impact.¹⁰ It occurs at a site remote from and opposite to the actual site of impact, and it is usually described for brain injuries.¹¹ A force applied on the dorsum of a flexed PIPJ while gripping an object (handle of the cricket bat) has resulted in the injury in both the cases. In flexion, the volar plate, which forms the floor of the flexor sheath, is relaxed. A directly blow on the dorsum results in a force being transmitted across the joint and result in contrecoup type injury causing rupture of the volar plate at its weakest point—its insertion on the middle phalanx. The other structures which come in the direction of the force are the central slip of the extensor tendon, the PIPJ, the collateral and the accessory collateral ligaments. All these are considerably stronger than the volar plate at its insertion on the base of the middle phalanx.^{3 12} This mechanism is different from the ‘crush injuries’ of the PIPJ previously described by Pattni et al that results in both volar plate and collateral ligament rupture.²

A true lateral radiograph is essential to identify the injury, as well as to rule out dislocation.⁹ In both cases, the fracture at the base of the middle phalanx was minimally displaced, being seen only on the lateral view. These injuries can be easily missed unless there is a high index of suspicion. Flexion contracture is a potential complication associated with these injuries. Thus, minimally displaced fractures of the PIPJ are managed with an extension-block splinting and early mobilisation.⁹ Prolonged immobilisation leads to PIPJ stiffness, and there is no consensus regarding optimal duration and type of immobilisation. Thus, alternately, when the joint is stable, immediate motion with protection using buddy taping has also been proposed.¹² In both index cases, the PIPJ was immobilised in an extension splint for 2 weeks followed by gentle active mobilisation of the PIPJ. Full range of movements returned at the end of 3 months. Other complications associated with these injuries include recurrent subluxations, swan-neck deformity and traumatic arthritis.¹³ Size of the avulsed fragment, rotation and joint stability determine the type of intervention needed. For a fragment size less than 30% of the joint surface and a stable joint (Eaton type 1-3a, or Keifhaber-Stern stable or tenuous), excellent outcomes can be expected from non-operative management with splinting and hand therapy.¹⁴

Learning points.

• This is perhaps the first report on two volar plate injuries in batsmen that occurred during ‘gully cricket’.

• A new mechanism of injury to the volar plate has been proposed: the possibility of a contrecoup-type of mechanism of injury to the volar plate.

• Lateral radiographs are essential in identifying the injury. Anteroposterior and oblique radiographs may be normal.

• Simple splinting in extension and early mobilisation for minimally displaced injuries are sufficient to achieve excellent outcomes.

• We recommend routine use of well-padded protective gloves to be worn by the Batsmen, even for domestic or recreational (gully) cricket, that could potentially prevent such injuries.