Transcript Hand Injuries

The Hand
Bucky Boaz, ARNP-C
Examination of the Upper Extremity
A detailed history should include:
Patient’s age
Handedness
Occupation
Hobbies
Chief complaint
Description of how and when the problem
started
Duration of symptoms
Aggravating and alleviating factors
Examination of the Upper Extremity
If an injury is involved:
The environment in which the injury or
insult occurred should be determined.
If crush injury, are heat or chemicals
involved?
Was the environment clean or dirty?
Past medical history is useful in the
presence of systemic conditions that
have manifestations in the hand.
Anatomy Review
Bones
Distal radius and
ulna
Carpals metacarpals
Phalanges
Proximal
Middle
Distal
Anatomy Review
Joints
DIP
PIP
M-P
C-M
DRUJ
DRUJ
Carpal-Metacarpal
MetacarpalPhalangeal
Proximal
Interphalangeal
Distal
Interphalangeal
Anatomy Review
Muscles & Tendons
Extrinsic
Flexor tendons
Flexor carpi ulnaris
Flexor carpi radialis
Palmaris longus
Flexor pollicis longus
(FPL)
Flexor digitorum
profundis (FDP)
Flexor digitorum
superficialis (FDS)
Anatomy Review
Muscles & Tendons
Extrinsic
Extensor tendons
Abductor pollicis
longus
Extensor pollicis
brevis
Extensor carpi
radialis longus and
brevis
Extensor digitorum
Extensor digiti
minimi
Extensor carpi
ulnaris
Anatomy Review
Muscles & Tendons
Extrinsic
Extension of MP
Flex of IP
Intrinsic
Abduct and adduct
fingers
Flexion of MP
Extension of IP
Anatomy Review
Nerves
Median
Ulnar
Radial
Examination of the Hand and
Wrist
Complete exam:
Observation
Palpation
Range of motion
Neurologic testing
Vascular assessment
Stability testing
Observation
Hands at rest
Curved posture
Look for one finger
curved
Asymmetry
Color
Spooning or
clubbing
Muscle atrophy
Palpation
Lateral epicondyle
Radial head
Groove of ulnar nerve
Olecranon
Lister’s tubercle
Radial/ulna styloid
Snuffbox
Carpals
Metacarpals
Phalanges
Neurologic Testing
Sensory
Light touch – pin
prick
Two-point
descrimination
Motor
Median
Ulnar
Radial
Neurologic Testing
Motor testing
OK sign
FDP
FDS
FPL
Vascular Examination
Radial artery
Located radial to
the FCR
Ulnar artery
Located radial to
the FCU
Allen test
Stability Testing
Ulnar collateral
ligaments
Radial collateral
ligaments
Gamekeeper’s/
skier’s thumb
Special Tests
TAP
Finklestein’s test
Froment’s sign
Watson test
Shuck test
Basal joint grind
Compression test
Phalen’s test
Tinel’s sign
Common Traumatic Injuries
of the Hand
Bone and Soft Tissue
Considerations on Treating
Hand Injuries
Type of injury
The patient
Associated diseases
Socioeconomic factors
Ability to cooperate with treatment plan
Motivation to get well
Managing the patient
Recognizing the injury
Making the proper diagnosis
Initiating the appropriate care plan
Referrals
Emergent referrals
Open fractures
Fractures with neurovascular
compromise
Significant soft tissue injury
Irreducible dislocations or fractures
with significant deformity
Referrals
Urgent referrals (next day or two)
Closed flexor or extensor tendon
injuries
Displaced, angulated, or malrotated
closed fractures
Carpal bone and distal radius fractures
History
Complete history
Hand dominance
Occupation
Avocations
Circumstances surrounding the injury
When and where
Mechanism of injury
Location and character of pain
Numbness or tingling
Radiographs
Examine prior to ordering films
Stress views are useful in
demonstrating injuries not present on
plain views
Occasionally CT scan or MRI are
needed to evaluate an injury
Description of Fractures
Be able to accurately describe a
radiograph to a colleague
Correct name of bone or joint involved
Open or closed fracture
Intraarticular or extraarticular
Whether the fracture is shortened,
displaced, malrotated, or angulated
Fracture pattern
Description of Dislocations
Be able to accurately describe a
dislocation
Described with the position of the distal
bone relative to the proximal bone
Dorsal vs volar dislocation
Radial vs ulnar dislocation
Can have a combination of two
Complications
By far, the largest potential problem with
any hand or wrist injury is stiffness.
Soft tissue complications:
Tendon adhesions
Capsular contractures
Fracture healing time
Hand: 3-4 weeks
Distal radius: 5-7 weeks
Complications
Bony complications:
Malunion
Angulation
Malrotation
Shortening
Intra-articular step-off
Nonunion is uncommon in hand or wrist
Fractures of the Distal Phalanx
The distal phalanx is the most
common fracture in the hand,
accounting for approximately 50% of
hand fractures
Fractures of the Distal Phalanx
Applied Anatomy
Extensor and flexor
tendons insert into
the base of the
distal phalanx
Routinely not a
deforming fracture
Fractures of the Distal Phalanx
Mechanism of Injury
Crush injury
Sudden extension
against a flexed finger
(rugger jersey)
Sudden flexion against
an extended finger
(baseball hitting end of
extended finger)
Fractures of the Distal Phalanx
Associated
Injuries
Nailbed lacerations
Nail plate avulsion
Skin lacerations
Subungal hematoma
History and
Physical Exam
Check both flexor
and extensor
function
Document sensory
exam
Fractures of the Distal Phalanx
Radiographs
2 – 3 views to look
for fracture
Use hot light if
needed
Classification
Longitudinal
Transverse
comminuted
Treatment
Non-displaced or
minimally displaced can
use variety of splints
Immobilize the DIP
only
Reduce displaced
fractures
Open wounds may need
more definitive
treatment
Fractures of the Distal Phalanx
Outcomes
Cold intolerance
Tip sensitivity
Stiffness
Nailplate
irregularities
When to refer
Open fractures in
need of nail bed
repair
Large skin loss
Suspected flexor or
extensor tendon
involvement
Nailbed Injury
Nailbed lacerations
need to be repaired
Use 6-0 absorbable
to repair matrix
Prevents nail
growth problems
Reinsert nail and
secure
Subungual Hematoma
Results from blunt trauma to nail
Very painful
Relieved by
Cautery
Heated paperclip
18g needle
Subungual Hematoma
Clean with alcohol
Instrument of
choice
Pierce nail
Gauze for 24 hours
Mallet Fingers
(soft tissue and bony)
Applied Anatomy
Terminal extensor
tendon inserts into the
dorsum of the distal
phalanx
Mechanism of injury
Occurs with a sudden
flexion force against an
extended digit
Results in flexion
deformity of the DIP
joint
Mallet Fingers
(soft tissue and bony)
History and
Physical Exam
Pain and deformity
of the DIP joint
after bumping the
end of the finger
Inability to
straighten the end
joint
Test for tendon
function
Mallet Fingers
(soft tissue and bony)
Radiographs
2 views looking for
dorsal avulsion
fragment
May be negative
Classification
Soft tissue (- x-ray)
Bony (+ x-ray)
Fleck
Dorsal articular piece
Subluxation of DIP
joint
Mallet Fingers
(soft tissue and bony)
Treatment
Closed reduction
Continuously splint DIP in full extension
for 6 to 10 weeks
Only immobilize the DIP
Acceptable results may still be obtained
with continuous extension splinting if it
is as long as 2-3 months after initial
trauma
Flexor Tendon Avulsion
Applied Anatomy
Flexor digitorum
profundus tendon
inserts into the
base of the distal
phalanx
Flexor Tendon Avulsion
Mechanism of
Injury
Hyperextension
against a flexed
DIP joint
Relatively
uncommon, but
devastating is
missed
Ring finger most
commonly involved
Flexor Tendon Avulsion
Associated injuries
None
History and Physical Exam
Pain on volar surface of digit
May extend into palm with eccymosis
Cannot flex tip
Resting hand has extension of DIP joint
No active flexion
Flexor Tendon Avulsion
Radiographs
DIP to look for
avulsion, but also
hand to look for
retracted segment
Most are normal
Classification
Pure tendon avulsion
Bony avulsion
Flexor Tendon Avulsion
Treatment
Should be splinted
and referred in a
semi-urgent fashion
Surgery is required
Outcomes
Results correlate
with delay in
treatment
Early do well
Postoperative hand
therapy is important
Middle and Proximal Phalangeal
Fractures
Applied Anatomy
The central slip
inserts into the
proximal dorsal
middle phalanx
The flexor
digitorum
superficialis (FDS)
inserts into each
side of the base of
the middle phalanx
Middle and Proximal Phalangeal
Fractures
Applied Anatomy
Intrinsic muscles of
the hand act to flex
the MCP joints and
extend the PIP and
DIP through the
actions of the
lateral bands
Middle and Proximal Phalangeal
Fractures
Mechanism of Injury
Direct blow to the digit
or a twisting injury
Associated Injuries
Open injuries
Lacerations to tendons
or neurovascular
bundles
Important to evaluate
for DIP injuries
History and
Physical Exam
Evaluate for
malrotation
Subtle fractures on
x-ray can have
significant
malrotation when
flexed
Middle and Proximal Phalangeal
Fractures
Radiographs
3 views
Evaluate joint
proximal and distal
Spiral fracture may
appear on only 1 view
Classification
Location
Midshaft
Condylar
Intra-articular
Pattern
Spiral
Oblique
Comminuted
Transverse
Avulsion
Middle and Proximal Phalangeal
Fractures
Treatment
Most can be treated non-surgically
Protect range of motion
Buddy tape
What to refer
Displaced, malrotated, joint involvement
Comminuted, spiral, and oblique are unstable
Stable nondisplaced
Splint 8-10 days followed by buddy tape
Follow-up x-ray 8-10 days to ensure no displacement
Boutonniere
Applied Anatomy
When the central
slip insertion at the
base of the middle
phalanx is
disrupted, active
PIP joint extension
may be limited
Boutonniere
Applied Anatomy
The flexed position of
the PIP joint then
allows the lateral bands
to fall volar to the axis
These lateral bands
then act to flex the PIP
joint further
Tension pulls the DIP
joint into extension
Boutonniere
Mechanism of Injury
Acute flexion force to
PIP joint
PIP does not
immediately fall into a
flexed position
Several weeks after
the injury the digit
assumes a buttonhole
posture.
Other mechanism
include PIP dislocation
and central slip
lacerations
History and Physical
Exam
Pain and swelling about
PIP
Inability to fully extend
PIP
DIP flexion is limited
Longstanding cases
PIP flexion
Passive extension not
possible
Boutonniere
Radiographs
Most often negative
Occasionally small
fragments dorsally
off middle phalanx
Classifications
Acute
Chronic
Stiff
supple
Boutonniere
Treatment
If not sure of central slip, assume it is and
splint the PIP in full extension
Acute boutonnieres
4 weeks of full extension splinting of PIP with active
DIP flexion exercises
Occasionally need surgery
Chronic boutonnieres
Hand therapy
Possible surgery
Proximal Interphalangeal Collateral
Ligament Injuries and Dislocations
Most common orthopedic hand injury
that can result in long-term digital
stiffness and impairment
Proximal Interphalangeal Collateral
Ligament Injuries and Dislocations
Applied Anatomy
PIP is a hinge
Ligaments along
palmar aspect volar plate
Prevents
hyperextension
Related to volar
plate are collateral
ligaments
Proximal Interphalangeal Collateral
Ligament Injuries and Dislocations
Applied Anatomy
Each PIP joint has a
radial and ulnar
collateral ligament
Tethers the PIP
joint in its side-toside motion
Ligaments fail when
they are stretched
past a certain point
Proximal Interphalangeal Collateral
Ligament Injuries and Dislocations
Mechanism of
Injury
Sudden force
directed to tip of
digit results in
hyperextension
Spectrum ranging
from slight
hyperextension
grade I sprain to
frank dislocation
Associated Injury
If the skin tears open,
it is an open dislocation
History and Physical
Exam
Joint swollen and
tender
Test collateral
ligaments to ascertain
partial vs complete
Proximal Interphalangeal Collateral
Ligament Injuries and Dislocations
Radiographs
2 views to check for
fractures
Post-reduction films if
done
Classifications
I – do not compromise
stability
II – partial compromise,
at risk for complete
disruption
III- complete
disruption, can
compromise stability
Proximal Interphalangeal Collateral
Ligament Injuries and Dislocations
Treatment
Early mobilization after a few days of splinting
Buddy tape for 4 weeks
A rare volar PIP joint dislocation requires 3-4
weeks of splinting in extension
Outcomes
These injuries can heal with some permanent
fusiform swelling from scar tissue.
Long term problem is not recurrent instability,
but stiffness
For this reason, early range of motion program is
most often recommended
Ulnar Collateral Ligament Injuries to
the Thumb (Gamekeeper’s Thumb)
The ulnar collateral
ligament of the
thumb is important
for pinch strength
and stability
Because of its
location, it is
particularly
vulnerable to injury
Ulnar Collateral Ligament Injuries to
the Thumb (Gamekeeper’s Thumb)
Mechanism of
Injury
Combination of
hyperextension and
a radially directed
force at the thumb
MP joint (fall with a
pole in the hand
while skiing)
History and
Physical Exam
Moderate swelling
and eccymosis over
ulnar side of MP
joint
In complete tears
stress testing of
UCL shows a poor
endpoint
Ulnar Collateral Ligament Injuries to
the Thumb (Gamekeeper’s Thumb)
Radiographs
Typically negative
Possible avulsion
fragment off proximal
phalanx or metacarpal
Treatment
Incomplete – nonoperatively (splint)
Complete - surgically
Bennett's Fracture Dislocation
Most frequent of all thumb fracture
Described in 1882 by Dr. Edward
Bennet
It is a fracture dislocation, intraarticular fracture at base of
carpometacarpal (CMC) joint of the
thumb
Bennett's Fracture Dislocation
Mechanism of
Injury
Results from axial
blow directed
against the partially
flexed metacarpal;
(ie. from fist
fights)
History and
Physical Exam
Moderate swelling
and eccymosis over
the CMC joint
Pain with ROM or
palpation
Bennett's Fracture Dislocation
Radiographs
Oblique fracture line with a
triangluar fragment at ulnar
base of metacarpal
Triangular fragment remains
attached to trapezium w/
proximal displacement of the
metacarpal
Treatment
Immobilization
Referral for surgical pinning
Infections of the Hand
Conditions That Mimic Infection
Gout
Pyogenic granuloma
Acute calcification
Foreign body
reaction
Herpetic whitlow
Metastatic lesions
Pseudogout
Rheumatoid
arthritis
Granuloma annulare
Local reactions
Paronychia
Infection localized to the proximal
and lateral skin folds of fingers and
toes
Staph aureus
Group A or D Strep
Pseudomonas
Gram-negative bacteria
anerobes
Paronychia
Clean area with alcohol
or betadine
Perform digital nerve
block
Area of greatest
fluctuance
Remove pus
Debride nail if
necessary
Antibiotics
Dressing
Paronychia
Felon
Abscess of distal
pulp
Results from
penetrating trauma
Bacteria trough
eccine sweat glands
Pulp is tense and
tender
Significant edema
Felon
Fish-mouth incision
Hockey-stick/
J-incision
Transverse palmar
incision
Questions?