![Page 1: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/1.jpg)
Common Hand Injuries and how to “hand”le them
Daniel Grushka, BSc., MSc., MD, CCFP(EM) Assistant Professor & Enhanced Skills Program Director
Department of Family Medicine
Shrikant Chinchalkar, M.Th.O, B.Sc.OT, OTR, CHT Hand Therapist, HULC
St. Joseph’s Healthcare of London
Robert Richards, MD, FRCSC Associate Professor
Division of Plastic Surgery
![Page 2: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/2.jpg)
Disclosure
• We have no financial or commercial relationships regarding this presentation
• The topics are presented in an unbiased manner free of industry support
• The presenters have no potential for conflict of interest with this presentation
![Page 3: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/3.jpg)
Objectives
1. Review the initial assessment of common hand injuries presenting to the clinic or ER
2. Review the disposition of these injuries with regards to management and referral
3. Discuss common injuries, their presentation and management
4. Discuss local resources in the community for patients
![Page 4: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/4.jpg)
Principles of Evaluation & Management
![Page 5: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/5.jpg)
Brief Review of Anatomy
![Page 6: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/6.jpg)
The Bony Hand
• Hand injuries are a common presentation to the clinic and ER
• The best outcome depends on accurate initial evaluation and treatment
![Page 7: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/7.jpg)
Principles of Evaluation
• History
• General Hand Examination
• Testing of nerves & tendons
• Anesthesia & direct wound inspection
• Radiographs, consultation & disposition
![Page 8: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/8.jpg)
Hand History
1. Time and cause of injury
2. Position of hand at time of injury
3. Associated crush, burn, injection, chemical exposure
4. Patient’s occupation & hobbies
5. Handedness
6. AMPLE, PMH, PSx, SHx, etc.
![Page 9: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/9.jpg)
Hand History
• Details about the injury – Mechanism?
– How did the injury occur?
– Where did the injury occur?
– How much time has elapsed since the injury?
– Has any treatment been given and by whom?
![Page 10: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/10.jpg)
General Hand Examination
• Extent of injury
– Local swelling
– Deformity
– Dislocation
– Angulation
– Displacement
– Rotational malalignment
![Page 11: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/11.jpg)
General Hand Examination
• Observation
– Open wound
– Location
– Soft tissue injuries
– Skin violation
– Contamination
– Damage to neurovascular supply, tendons, bones
– Foreign bodies
![Page 12: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/12.jpg)
General Hand Examination
• Check:
– grip strength
– ROM
– evidence of scissoring
– pincer function
– vascular supply
– motor/sensory/tendon function
![Page 13: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/13.jpg)
Nerve Testing
Motor Function Sensory Funtion
Median nerve Thumb abduction away from palm Thumb IP joint flexion
Volar tip of index finger
Ulnar nerve Abduction/Adduction of digits
Volar tip of little finger
Radial nerve Dorsiflexion of wrist
First dorsal web space
![Page 14: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/14.jpg)
Vascular Testing
• Hand has a dual blood supply
– Radial & Ulnar arteries
• Fingers
– Digital arteries
![Page 15: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/15.jpg)
Testing of Tendons
• ROM against resistance
• Pain against resistance despite good strength indicates a partial laceration
• FDP, FDS, Extensor tendons should be examined
![Page 16: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/16.jpg)
Anesthesia & Direct Wound Examination
• Necessary because partial tendon or intraarticular injuries are not readily apparent
• Assess neurovascular status pre and post examination under anesthesia/tourniquet
• Tourniquet should not be in place for more than 20 minutes
![Page 17: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/17.jpg)
Diagnostic Imaging
• Primary Care
– Xray
• PA, lateral, oblique views
– CT
• Hand Specialists
– MRI
– Ultrasound
![Page 18: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/18.jpg)
Immediate Hand Surgery Consultation Guidelines
1. Vascular injury with signs of tissue ischemia
2. Poorly controlled hemorrhage
3. Grossly contaminated wounds
4. Severe crush injury
5. Compartment syndrome
6. High pressure injection injury
7. Hand/finger amputation
![Page 19: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/19.jpg)
Delayed Hand Surgery Consultation Guidelines
1. Extensor/flexor tendon laceration (if not repaired in ER)
2. Closed FDP rupture
3. Nerve injury proximal to mid middle phalanx
4. Reduced and immobilized closed fractures & dislocations
5. Ligamentous injuries without instability
![Page 20: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/20.jpg)
Acute Injuries
Ligamentous Tendinous Fracture
![Page 21: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/21.jpg)
Ligamentous Injuries
![Page 22: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/22.jpg)
Injuries to the Ligaments
• Object causing an impact or load
• Direction of impact in relation to the position of the digit
• Angle of impact in relation to the tendinous load
• Soft tissue
• Skeletal
• Complex
• Subluxation
• Dislocations
![Page 23: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/23.jpg)
PIP Joint Dislocations
• Dorsal dislocation – volar plate
• Volar dislocation – central slip
• Lateral dislocation – collateral ligaments
Ligamentous Injuries
![Page 24: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/24.jpg)
PIP Joint Injuries
• Dorsal lip fractures
• Volar lip fractures
• Condylar fractures
• Pilon fractures
Skeletal Injuries
![Page 25: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/25.jpg)
Dorsally Directed Force Volar Plate Injuries
• Mechanism of Injury:
– Sudden Impact
– Force – Volar To Dorsal
– Tearing – Directory of force
– May involve collateral ligament
![Page 26: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/26.jpg)
Classification Of
Volar Plate Injuries
• Grade 1 – SPRAIN – Partial disruption of major
retaining ligament (MRL)
– Joint stable to Active or Passive stress
![Page 27: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/27.jpg)
Treatment Of Grade I Injuries
• Dorsal blocking splint – 30 degrees of PIP flexion
• Active PIP/DIP ROM – 3 to 4 weeks
• Buddy tape & active motion
• DIP blocking exercises
![Page 28: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/28.jpg)
Treatment Of Grade I Injuries
![Page 29: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/29.jpg)
Grade II Volar Plate Injuries
• Complete disruption of single MRL
• Joint functionally stable
• Passively stressed beyond usual limits
• Joint may not sublux or dislocate
![Page 30: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/30.jpg)
Treatment Of Grade II Injuries
• Splint PIP in 30-45 degrees of flexion
• Active PIP/DIP ROM
• Adjust splint – 10 degrees increments/week
• Buddy tape & Active Motion – 1 month
![Page 31: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/31.jpg)
Grade III Volar Plate Injuries • Complete disruption of MRL
• Joint displaced –
reducible/irreducible
• Non displaced – may displace on motion
• Associated collateral rupture
• Associated central slip rupture
![Page 32: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/32.jpg)
Hand Therapy Displaced Reducible & Undisplaced Joints
• Splint PIP – 60 degrees of flexion
• PIP dorsal blocking splint
• PIP AROM with buddy tape
•
• FDP gliding exercises
![Page 33: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/33.jpg)
Hand Therapy Displaced Reducible & Undisplaced Joints
• Adjust splint – 10-15 degree increments/week
• Upon volar stability – PIP extension splinting
• Figure 8 splint – 4 additional week
• Strengthening – 8 weeks
![Page 34: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/34.jpg)
Hand Therapy
![Page 35: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/35.jpg)
Volarly Directed Force Volar Dislocation
• Less frequent than dorsal dislocation
• Frequently involves central slip
• May involve dorsal chip fracture
• Depending on the degree of dislocation collateral & accessory collateral ligament may be torn
![Page 36: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/36.jpg)
Management of Volar Dislocation
• Similar to closed Boutonniere Injury
• Splint PIP in extension upon reduction – 6+ weeks
• DIP free to move
![Page 37: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/37.jpg)
Hand Therapy
![Page 38: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/38.jpg)
Results
![Page 39: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/39.jpg)
Laterally Directed Force Lateral Dislocation
• Trauma to the collateral ligament
• Accessory collateral
• Volar plate
• Lateral bands
![Page 40: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/40.jpg)
Management of lateral dislocation • Buddy taping with wedge in the web
space
• May need dorsal PIP blocking splint with 30 degrees of flexion
• Early active PIP and DIP joint flexion
• SORL stretching exercises
• Prolonged edema control
![Page 41: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/41.jpg)
PIP Joint Dislocation
![Page 42: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/42.jpg)
Results
![Page 43: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/43.jpg)
Tendon Injuries
![Page 44: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/44.jpg)
Extensor Tendon Ruptures
![Page 45: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/45.jpg)
Mallet Finger Deformity
• Avulsion or rupture of the terminal tendon
• Laceration of the terminal tendon
• Laceration of single or both lateral bands
• Most common- Rupture & Avulsion
![Page 46: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/46.jpg)
Traditional Management
STACK -SPLINT
• Splinting –4-6weeks
• Gradual weaning over next 4-6 weeks
• Depending on the symptoms
![Page 47: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/47.jpg)
Complication of Mallet Finger Deformity
Swan Neck Deformity
![Page 48: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/48.jpg)
Patho-mechanics of Swan Neck in Mallet
![Page 49: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/49.jpg)
Mallet Finger Management
![Page 50: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/50.jpg)
Boutonniere Deformity
• Avulsion or rupture of the central tendon
• Laceration of the central tendon
• Laceration of EDC distal to the MCP joint
![Page 51: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/51.jpg)
Boutonniere Deformity • Upon Central Slip
Avulsion/laceration
• Lateral Bands Fall Volar to Joint Axis
• Increased Intrinsic Load at DIP
![Page 52: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/52.jpg)
Treatment of Boutonniere Deformity
Splinting
• PIP joint in full extension leaving DIP free for 6-8 weeks
• DIP joint active flexion with splint
![Page 53: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/53.jpg)
Results
![Page 54: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/54.jpg)
Flexor Tendon Ruptures
![Page 55: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/55.jpg)
Jersey Finger Classification Leddy & Packer
• Grade I
• Grade II
• Grade III
![Page 56: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/56.jpg)
Management of Zone I Injuries Jersey Finger
![Page 57: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/57.jpg)
Management of Zone I Injuries Jersey Finger
![Page 58: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/58.jpg)
Fractures of the Hand
![Page 59: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/59.jpg)
Typical Displacement Patterns • Metacarpal Neck & Shaft –
Volar angulation
• Proximal Phalanx – Dorsal angulation
• Spiral & Oblique – Proximal displacement & rotation
• Comminuted - Compression
![Page 60: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/60.jpg)
Metacarpal Fractures
• Represent 30 – 35% of hand fractures
• More stable than phalangeal fractures
• Usually involves neck
• Usually caused by fight or fall
• 4th and 5th involved most often
![Page 61: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/61.jpg)
Malrotation
• Common with spiral and oblique fractures
• Over 10 degrees of malrotation not acceptable due to scissoring of the digit
![Page 62: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/62.jpg)
Malrotation
![Page 63: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/63.jpg)
Management of Metacarpal Fractures
![Page 64: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/64.jpg)
Intrinsic Plus Splint
Bivalve Splint reduces motion at the hameto-metacarpal joint
3 – 4 Weeks
Buddy Taping reduces rotational deformity
![Page 65: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/65.jpg)
Tendon Gliding
Upon Discontinuing the splint
![Page 66: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/66.jpg)
Displaced Metacarpal Fractures
![Page 67: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/67.jpg)
Proximal Phalangeal Fracture
• Represents 15-20% hand fractures
• Usually proximal or mid-shaft level
• Fall or direct blunt injury
• Most common radial side
• Volar angulation
![Page 68: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/68.jpg)
Proximal Phalangeal Fracture • More difficult than
metacarpal or distal phalangeal fractures
• Frequent association of serious tendon and skin injuries
• Close relationship between fractured bone and its tendon system
![Page 69: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/69.jpg)
Treatment Consideration
• Intrinsic plus splinting
• Buddy taping
• Early active tendon gliding exercises
• Early contracture control
![Page 70: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/70.jpg)
Treatment Results
![Page 71: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/71.jpg)
Middle Phalangeal Shaft Fractures
![Page 72: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/72.jpg)
Middle Phalangeal Fractures
• Occur with less frequency (8 – 12%)
• Main cause – crush injury
• Distal portion most common
![Page 73: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/73.jpg)
Management Post Fracture Reduction
![Page 74: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/74.jpg)
Management
• Volar gutter splint – worn at all times
• Gutter splint – stabilizing middle and distal phalanx to allow active PIP ROM
![Page 75: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/75.jpg)
Management
• Gutter splint – stabilizing proximal and middle phalanx to allow active DIP ROM
• Facilitating excursion of FDS and FDP while fracture is healing
![Page 76: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/76.jpg)
Results
![Page 77: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/77.jpg)
Intra-articular Fractures
![Page 78: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/78.jpg)
Types of Intra-articular Fractures
![Page 79: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/79.jpg)
Xi-Scan Method of Fracture Evaluation
• Distraction force
• Specific positioning
• Safe permissible motion in the splint
![Page 80: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/80.jpg)
Fracture Reduction With Traction
![Page 81: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/81.jpg)
Motion Within Traction Splint
![Page 82: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/82.jpg)
Results of Traction Splinting
![Page 83: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/83.jpg)
Complications
• Swan neck or boutonniere
• Severe extension/flexion contracture
• Pain & stiffness
• Joint instability
![Page 84: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/84.jpg)
Complications
![Page 85: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/85.jpg)
Goal of Hand Therapy
• Minimize PIP Flexion/Extension contracture
• Minimize tendon adhesions
• Minimize secondary deformities
• Maximize Range of motion
• Maximize function
![Page 86: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/86.jpg)
Choice of Treatment
Understanding of tissue compliance
![Page 87: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/87.jpg)
Common Hand Disorders
![Page 88: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/88.jpg)
• Nerve compression syndromes
• Tendinitis/tennosynovitis
• Hand arthritis and other syndromes
![Page 89: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/89.jpg)
Nerve compression syndromes
• Median
– Carpal tunnel
– Pronator teres
• Ulnar
– Cubital tunnel
– Guyon’s canal
• Radial nerve
– Radial tunnel
– Wartenburg’s
![Page 90: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/90.jpg)
Tendinitis/Tenosynovitis
• Trigger finger
• DeQuervain’s
• Tennis Elbow
– Wrist extensors
– Finger extensors
![Page 91: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/91.jpg)
Other disorders
• Vibration Syndrome (White finger)
• Vascular Spasms (Raynaud’s)
• Arthritis
• Reflex sympathetic dystrophy/CRPS
![Page 92: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/92.jpg)
Carpal Tunnel Syndrome
• CTS must be considered in every patient presenting with pain, numbness, weakness, or loss of dexterity in the hand
• In many cases the findings are atypical
History Paget – 1854
Phalen – 1949 “CTS”
First Surgery 1952
![Page 93: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/93.jpg)
Carpal Tunnel Syndrome
• Most common – studies vary in incidence
• Diagnosis – best established on physical exam EMG and NCV secondary
![Page 94: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/94.jpg)
Anatomy of Carpal Tunnel
• Dorsally & laterally-Carpal row
• Volarly-thick transverse carpal ligament
• Contents-Nine flexor tendons, Median nerve most superficially placed beneath transverse carpal ligament
![Page 95: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/95.jpg)
Physical Findings
Phalen’s test
Wrist in unforced complete flexion – 30 to 60 seconds
Symptoms produced
Gradual onset of numbness and pain in median nerve distribution (test +)
![Page 96: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/96.jpg)
Physical Findings
Tinel’s sign
Tapping over volar wrist skin crease
Symptoms produced Tingling or electric shock sensation (test +)
![Page 97: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/97.jpg)
Sensory Exam
![Page 98: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/98.jpg)
Treatment
• Initially non operative
• B6? B12?
• Treat any associated conditions
![Page 99: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/99.jpg)
Treatment Conservative
• Patient education
• Splinting
• AROM digits
• Tendon & nerve gliding exercises
• Sensory re-education
• Avoiding provocative tasks
![Page 100: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/100.jpg)
Treatment Surgical
• ETCR significantly better pain and grip strength up to 6 weeks
• Long term-no difference between groups
• In absence of motor wasting no apparent problem with delay
• 90% better
• 2-5% reoperation
• 4-5% complication
Open vs. Endoscopic CT Tunnel Release
![Page 101: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/101.jpg)
Surgical Complications
• Hypersensitivity
• Hypertrophic Scarring
• Pillar pain
• Tightness along the mid point between thenar & hypothenar eminence
• Recurrance of CT symptoms
![Page 102: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/102.jpg)
DeQuervain’s Tenosynovitis
![Page 103: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/103.jpg)
Profile
• Age 30-50
• Women > Men (CMC mobility)
• Severe pain with thumb use & motion
• Etiology: Repetitive motion
Direct trauma
Multiple APL tendons
? Prominent radial styloid
Stenosing Tenosynovitis of first dorsal extensor compartment
![Page 104: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/104.jpg)
Abnormal Anatomy
“Hourglass” Constriction of tendons
1st Dorsal Compartment
EPB Compressed in separate compartment
Occasional bony & prominent radius
![Page 105: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/105.jpg)
Diagnosis
• Painful inflammation of 1st dorsal extensor compartment
• + Finkelstein’s test
- Ulnar deviation of
the wrist
- Passive thumb
flexion
![Page 106: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/106.jpg)
Differential Diagnosis
• Basal joint arthritis
• Grind test +
with CMC joint arthritis only
• X-Rays
1. Both cause pain with thumb motion
2. Both produces + Finkelstein’s test
![Page 107: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/107.jpg)
Treatment
• Anti-inflammatory
• Steroid injections with 1% xylocaine
• Pain control with cryotherapy, US, iontophoresis
• Limitation of activity
• Thumb spica splint for three to six weeks
Conservative
![Page 108: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/108.jpg)
Results
• Usually improve patients
• Not usually cured
• Key is avoidance of overuse
• Usually not surgical- only 10% of time
![Page 109: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/109.jpg)
Arthritis of the CMC Joint
![Page 110: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/110.jpg)
Epidemiology
• Most common joint disorder in hand
• More common in females (10-15:1)
• Most often idiopathic
![Page 111: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/111.jpg)
Radiographic Staging
• Stage I: – Normal joint, possibly widening from synovitis
• Stage II: – Joint space narrowing with debris and osteophytes <2mm
• Stage III: – Joint space narrowing with debris and osteophytes >2mm in size
• Stage IV: – Scaphotrapezial joint space involvement in addition to narrowing of
the TM joint
EATON AND
LITTLER
![Page 112: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/112.jpg)
![Page 113: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/113.jpg)
Physical Examination
• Inspection and palpation
• Assess thumb adduction deformity and hyperextension MCP joint
• Assess pain, pinch strength with thumb metacarpal extension
• Poor correlation between xray and physical findings
![Page 114: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/114.jpg)
Non-operative Management
• Splinting (thumb spica)
• NSAIDS
• Rest
• Activity modification
• Intra-articular injection of corticosteroids
• Effective in almost 75% of patients
![Page 115: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/115.jpg)
Indications for Surgery
• Pain despite non-operative Rx
• Deformity impairing function
• Weakness impairing function
• Do not operate based only on radiology!
![Page 116: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/116.jpg)
LRTI • Burton and Pellegrini 1986
• Three fundamental principles:
– Partial or complete resection of the trapezium to remove arthritic joint surfaces
– recreation of the anterior oblique ligament to restore thumb MC stability and prevent axial shortening
– Fascial interposition to reduce the likelihood of impingement between neighboring bony surfaces
![Page 117: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/117.jpg)
LRTI • Curvilinear incision over volar-radial CMC
• Harvest FCR (12 cm, distally based)
![Page 118: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/118.jpg)
LRTI
• Resection/debridement trapezium
• Drill hole into MC base
• Passage of FCR through MC drill hole
![Page 119: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/119.jpg)
In Summary • OA of the thumb CMC is common
• Majority can be treated non-operatively
• LRTI is the gold standard – used in this centre
• Good results described in literature for pain relief,
strength, function
• Many other options have been trialed
![Page 120: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/120.jpg)
Trigger Finger
• Stenosing Flexor Tenosynovitis
• “Trigger finger” (TF) / “trigger thumb” (TT)
• First description Notta (Paris 1850) advocated surgical release.
![Page 121: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/121.jpg)
Trigger Finger
– Flexor sheath is narrowest at MCP / A1 pulley level
• Prevents ulnar / radial drift of flexor tendons
• Prevents strength & range of motion from bowstringing
![Page 122: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/122.jpg)
![Page 123: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/123.jpg)
Etiology
Sheath is initial site of injury: • Repeated use friction edema fibrocartilaginous
metaplasia
• A1 sheath histology: sheath thickening in 66% in one series
• In either case, triggering phenomenon requires mismatch of calibre of tendon and fibro osseous sheath through which is passes, at A1 pulley level
![Page 124: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/124.jpg)
Flexor tenosynovitis
• Primary Flexor Tenosynovitis:
– No clear predisposing conditions
– Middle-age onset
– More common in women
– Repeated & sustained hand stresses (dominant hand more common)
– Usually single digit involved
![Page 125: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/125.jpg)
• Secondary Flexor Tenosynovitis – Occurring in the setting of underlying disease
– Higher incidence in diabetes mellitus, rheumatoid arthritis, hypothyroidism, gout, renal disease
– Higher incidence of multiple-digit involvement
• Primary & secondary types commonly associated with related conditions, e.g. de Quervain’s disease, carpal tunnel syndrome
Flexor tenosynovitis
![Page 126: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/126.jpg)
• Non-Surgical: – Conservative management should be the initial
mode of treatment in almost all cases, except in neglected fixed PIP flexion contracture: • Rest, splinting, avoidance of repetitive activities,
NSAIDs – 52% success in symptom relief in early, mild disease
• Local corticosteroid injection – 49% success with single injection, 74% with multiple injections
• Lower success rate in secondary cases (DM, RA, etc.)
Treatment
![Page 127: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/127.jpg)
• Surgical:
– Open A1 pulley release: gold standard (excellent lasting improvement)
• Operative Indications: • Failure to improve with conservative management;
(some advocate immediate release in all patients, but not widely supported in literature)
Treatment
![Page 128: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/128.jpg)
Dupuytren’s Disease Etiology and Pathology
![Page 129: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/129.jpg)
The Prevalence of Dupuytren’s Disease
MEN 60-75
Iceland - 33%
Norway - 46%
Scotland - 35%
Australia - 28%
Spain - 19%
England - 17%
Japan - 15%
![Page 130: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/130.jpg)
![Page 131: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/131.jpg)
![Page 132: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/132.jpg)
DUPUYTREN TYPE
Knuckle Pad Plantar Fibromatosis
![Page 133: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/133.jpg)
Typical Patient
• Predomiately male
• Onst 45+ years
• Contracture 50+ yrs
• Bilateral but more severe on one side
![Page 134: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/134.jpg)
Less Severe Patient
• Often female
• Onset 50+ yrs
• Contracture +/- 60 yrs
• Often bilateral and not enough contracture to need an operation
• Non European
![Page 135: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/135.jpg)
The Severe Patient An Increased Diathesis
• Onset before age 40
• Family history: 2 or more relatives
• Knuckle pads, foot, penis involved
• Extensive disease
-more than 2 rays
-bilateral
-radial side disease
• Recurrence and extension
![Page 136: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/136.jpg)
Non Operative Treatment
Collagenase Injection-Xiaflex
Failed Treatments
Radiation
Steroid Injection
Skeletal or Soft Tissue Traction
![Page 137: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/137.jpg)
Indications For Operation
![Page 138: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/138.jpg)
Aponeurotomy or Fasciotomy
![Page 139: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/139.jpg)
Local Fasciotomy
![Page 140: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/140.jpg)
Regional Fasciectomy
![Page 141: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/141.jpg)
The Use of Skin Grafts (relative)
• Severe Diathesis
• Recurrent Contracture
• PIP Contracture
- severe
- with an open palm
![Page 142: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/142.jpg)
Results of Operation
CORRECTION OF MCP JOINT
- usually complete and permanent
CORRECTION OF PIP JOINT
- usually some residual contracture
- recurrence is likely
![Page 143: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/143.jpg)
Conclusions
• MCP joint can be corrected
• PIP joint can be improved
• Plan an operation according to diathesis factors and severity of disease
![Page 144: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/144.jpg)
Special Consideration Injuries
![Page 145: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/145.jpg)
Compartment Syndrome
• Involved compartments include the thenar, hypothenar, adductor pollicis and 4 interossei
• Edema due to crush injury in any of these compartments may lead to elevated pressures
• This can result in tissue necrosis and subsequent loss of hand function due to contracture
![Page 146: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/146.jpg)
Compartment Syndrome
• May result from: – Burns, fractures, high pressure injections, bites
• Signs & Symptoms: – Pain & paraesthesias – early – Pallor & pulselesness – late
• Physical exam: – Intrinsic minus position at rest (MCP extension with PIP
slightly flexed) – Pain with passive stretch – Tense swelling of the affected compartment
![Page 147: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/147.jpg)
High Pressure Injection Injuries
• Injection of substances into hand at high pressure (2,000-10,000 psi)
• Most common substances include: – Grease – Paint – Hydraulic fluid – Diesel fluid – Paint thinner – Water
![Page 148: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/148.jpg)
High Pressure Injection Injuries
• Do not be fooled on the benign appearance of how these injuries can present
• With time the digit(s) may become edematous, pale and severely tender due to ischemia
![Page 149: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/149.jpg)
Management of CS and HPI
• Immediate recognition is necessary
• Appropriate documentation of neurovascular compromise and radiographs are helpful
• Splint affected extremity in non-circumferential splint
• Ensure Td coverage, IV antibiotics, analgesia, NPO
• Immediate surgical consultation is warranted
![Page 150: Common Hand Injuries · Diagnostic Imaging •Primary Care –Xray •PA, lateral, oblique views –CT •Hand Specialists ... Mallet Finger Deformity •Avulsion or rupture of the](https://reader030.vdocuments.net/reader030/viewer/2022041016/5ec8955586ef5541f57baeb8/html5/thumbnails/150.jpg)
Conclusion
• Acute hand injuries are frequent and should be managed by standard protocols
• Early intervention based on the understanding of anatomy and biomechanics predictably produces better results.