Transcript Injuries To The Hand And Digits

Injuries To The Hand
And Digits
Chrisnel Jean, D.O.
May 30, 2006
Reviewed by Dr. Batizy
Outline
 Anatomy
 Principles of Evaluation
 General Hand Examination
 Anesthesia and Direct Wound
Examination
 Radiographs, Consultation,
and Disposition
 Tendon Injuries
 Flexor / Extensor Tendons
 Ligaments And Dislocation
Injuries
 Compartment Syndrome
 High-Pressure Injection Injury
Hand Anatomy
 Hand consist of 27
bones:
 14 Phalangeal bones
 5 Metacarpal bones
 8 Carpal bones
 Carpal bones are
made up of two rows of
four bones bridged by
flexor retinaculum
which forms the carpal
tunnel.
 Carpal tunnel consist
of the median nerve
and the nine long
flexor of the fingers
Hand Anatomy
 Intrinsic muscle of the
hand:
 Have their origins and
insertions within the
hand.
 Consist the following:
 Thenar, Hypothenar,
adductor pollicies, the
interossei and the
lumbricals. (Refer to pg
1665 for anatomical
description)
Hand Anatomy
 Extensor Tendons:
 Courses over the dorsal side of the forearm,
wrist and hand.
 9 extensor tendons pass under the extensor
retinaculum and separate into 6
compartments
Surface anatomy of the hand.
The tendons that are
palpated with thumb
abducted and extended form
an anatomic snuff-box.
Hand Anatomy
 Extensor Tendons:
The extensor tendons gain entrance to
the hand from the forearm through a
series of six canals, five fibroosseous
and one fibrous The communis
tendons are joined distally near the
MP joints by fibrous interconnections
called juncturae tendinum. Beneath
the retinaculum, the extensor tendons
are covered with a synovial sheath.
Hand Anatomy
 Extensors digitorum communis are
connected by junctura.
 Because of this, a complete tendon
laceration proximal to the junction may
still result in normal extensor fuction.
Hand Anatomy
 Flexor Tendons:
 Courses over the volar side of the forearm, wrist,
and hand.
 Unlike the extensor tendons, the flexor tendons are
enclosed in synovial sheaths making them prone
to deep space infections.
Hand Anatomy
 Flexor Tendons:
 Flexor carpi
radialis, flexor
carpi ulnaris,
and palmaris
longus primarily
flex the wrist
Hand Anatomy
Hand Anatomy
 9 flexor tendons pass through the carpel
tunnel:
 1 tendon go to the base of the dist. Phalanx of the
thumb
 The other 4 digit has 2 tendon each (FDS / FDP).
Hand Anatomy
 Flexor digitorum
superficialis (FDS)
insert into middle
phalanx.
 Flexor digitorum
profundus (FDP) runs
deep to the FDS until
the level of the MP joint
where FDS bifurcates.
 FDP inserts at the base
of the distal phalanx
and acts primarily to
flex the DIP joint as well
as all other joints flexed
by FDS. (Figure 268-5).
Hand Anatomy
 Blood supply (BS):
 Hand and digits has
dual (BS) with
contributions from
the radial and ulnar
arteries.
Hand Anatomy
 Blood supply (BS):
 Proximal portions of the hand (BS) come from
the deep and superficial arches on the palmar
and dorsal side.
 BS of the fingers is distributed by the digital
arteries that arises from the superficial palmer
arch.
Hand Anatomy - Blood supply
The Allen's test.
Hand Anatomy
The cutaneous nerve supply in the hand. M, median; R, radial; U,
ulnar; PCM, palmar cutaneous branch of median nerve; DCU,
dorsal cutaneous branch of ulnar nerve
Principles of Evaluation
 History:
 Should include the time, the cause of the
injury and eval for the possibility of crush,
burn, or chemical exposure.
 The patient’s occupation, prior hand injuries,
and handedness should be documented
Principles of Evaluation
 The position of the hand at the time of
injury should be determined.
 Injuries with the digits in flexion may
result in retraction of the cut end of the
tendon when the digit is examined in
neutral position.
Principles of Evaluation
 Physical Exam
 Should detail the extent of injury by
documenting the following:
 Amount of devascularization
 Status of the skin
 Posture of the fingers
 Presence of deformity
 Active bleeding
 B/L grip strength
Principles of Evaluation
 Physical Exam
 ROM and strength should be tested against
resistance.
 Nerve testing:
 Test median nerve:
 Have the pt flex the distal phalanx of the thumb against
resistance
 Test opposition by touching the tip of the thumb to the tip of
the little finger
 The pt will be unable to oppose against resistence if
median nerve function is lost.
Principles of Evaluation
 Nerve testing
 Test median nerve:
 Test thumb abduction by placing the hand palm up
and raising the thumb to the perpendicular while
palpating the belly of the abductor pollicis muscle
to insure it is contracting.
Principles of Evaluation
 Nerve testing:
 To test ulnar nerve
 Spread the fingers apart against resistance and
then push them together against resistance.
 Test the hypothenar muscle, extend the fingers
and then move the fifth finger away from the others
 Test thumb adduction (ulnar nerve innervates the
adductor pollicis muscles) bring the thumb tightly
against the side of the index finger.
Principles of Evaluation
 Nerve testing:
 To test ulnar nerve
 Adductor strength can be further tested by
interposing a piece of paper between the thumb
and the side of the index finger and then trying to
pull the paper away.
 To test radial nerve:
 Extend the fingers and wrist.
 With the thumb in the hitchhiking position, test its
resistance to further extension.
Principles of Evaluation
 Nerve testing: Sensation
 Determined by 2-point discrimination.
 Normal 2-point discrimination is <6 mm at the
fingertips and is often <2 mm. Both injured
and non-injured fingers must be compared.
 Repeat 2-point discrimination testing 2 – 4
times on each side of the digit (80% accuracy
is considered acceptable)
Principles of Evaluation
 Nerve testing: Sensation
 A sensory deficit implies a potential digital
artery laceration because of the close
proximity of the two.
 Tendon testing:
 Full ROM of each tendon against resistance
should be assessed and compared with the
uninjured side.
Principles of Evaluation
 Tendon testing:
 Important to test resistance because up to
90 % of a tendon can be lacerated with
preservation of ROM without resistance.
 Pain along the course of the tendon during
resistance testing suggests a partial
laceration even if the strength appears
adequate.
Principles of Evaluation
 Tendon testing:
 FDP is tested by flexing the DIP against
resistance while the MP and PIP are held in
extension.
 FDS is tested by flexing the PIP against
resistance while the remaining fingers are
held.
Principles of Evaluation
 FDP is tested
To test for an intact
profundus tendon, the
examiner maintains the digit
in extension while the patient
attempts to flex the terminal
phalanx.
Principles of Evaluation
 FDS is tested
Examination to assess function of
flexor digitorum superficialis.
Principles of Evaluation
 Anesthesia and Direct Wound
Examination:
 Sensation and ROM should be tested before
anesthesia applied.
 Exam should be done under a bloodless field
by applying local tourniquet or penrose drain
around the base of the finger.
Principles of Evaluation
 Radiographs, Consultation, and
Disposition:
 XRAY: should include a PA, lateral , and
oblique view.
 Injuries requiring immediate and delayed
follow-up by a hand surgeon are listed in
Tables 268-1 and 268-2.
 Guidelines for adequate immobilization and
follow-up for specific hand injuries are listed in
Tables 268-3
Principles of Evaluation
 Tendon injuries: Flexor tendons
 Most common cause of flexor tendon injury is
a laceration.
 A distal to proximal five zone (I – V)
classification system for flexor tendon injuries
has been developed based on location,
treatment considerations, and prognosis.
 Refer to pg 1670 for specific descriptions.
Principles of Evaluation
 Tendon injuries: Extensor tendons
 Are the most common site of tendon injuries
because of the superficial nature of the
tendons on the dorsum of the hand.
 A separate zone classification system (I – VIII)
has been developed for assessing injury
patterns, repair techniques, and rehabilitation.
 Refer to pages 1670 – 1671 for specific
description.
Ligament and Dislocation injuries
 DIP
Dislocation at DIP are uncommon because of
the firm attachments of the skin and subq
tissue to the underlying bone.
Dislocations at the DIP are usually dorsal.
Reduction can be done by longitudinal
traction and hyperextension, followed by
direct dorsal pressure to the base of the distal
phalanx after a digital block.
Ligament and Dislocation injuries
Dorsal dislocation at the DIP jt
without associated fracture
Volar dislocation of DIP joint of little
finger.
Ligament and Dislocation injuries
 PIP Dislocation:
One of the most common ligamentous injuries
Mechanism:
Usually due to axial load and hyperextension.
Dorsal dislocation occurs when the volar plate
ruptures.
Lateral dislocation occurs when one of the
collateral ligaments ruptures with at least a partial
avulsion of the volar plate form the middle phalanx.
Volar dislocations are rare.
Ligament and Dislocation injuries
Lateral dislocation of middle
finger PIP joint.
Ligament and Dislocation injuries
 PIP Dislocation:
 Reduction
Perform similarly to DIP dorsal dislocations
Active ROM and strength should be tested after
reduction.
If testing is normal, then splint in 30-degree flexion
for 3 wks.
If the joint is irreducible or there is evidence of
complete ligamentous disruption, operative repair
is required.
Ligament and Dislocation injuries
 MP dislocation:
Less common than at the PIP jt
Mechanism:
Usually due to hyperextension forces that rupture
the volar plate causing dorsal dislocation.
In subluxation (simple dislocation) – the jt appears
to be hyperextended 60 – 90 degrees and the
articular surfaces are still in contact.
Volar dislocation are rare and usually require
operative reduction.
Ligament and Dislocation injuries
 MP dislocation:
Reduction:
Does not involve hyperextension (this might
convert it from a simple to a complex dislocation)
Performed with the wrist flexed to relaxed the
flexor tendon and applying pressure over the
dorsum of the proximal phalanx in a distal and
volar direction.
Splint the MP jt in flexion after reduction.
Ligament and Dislocation injuries
 CMC jt dislocation:
Are uncommon because the jt is supported by
strong dorsal, volar, and interosseous
ligaments and reinforced by the broad
insertions of the wrist flexions and extensors.
Ligament and Dislocation injuries
 CMC jt dislocation:
 Mechanism:
Usually due to high-speed mechanisms (MVC,
falls, crushes, or clenched fist trauma).
Usually occurs via dorsal and with associated
fractures.
Ligament and Dislocation injuries
 CMC jt dislocation:
 Reduction:
Attempt after regional anesthesia with traction and
flexion with simultaneous longitudinal pressure on
the metacarpal base.
Pt need early referral after reduction to determine
if further fixation is needed.
Ligament and Dislocation injuries
 Thumb IP dislocation
Are rare but, if present, usually open.
Mechanism:
Usually hyperextension with rupture of the volar
plate.
Reduction:
Similar to the IP jt of the other digits
Immobilized for 3wks in mild flexion.
Ligament and Dislocation injuries
 Thumb MP dislocation:
Usually dorsal
Can be simple (subluxation) or complex
Mechanism:
Hyperextension force causing rupture of the volar
plate.
Ligament and Dislocation injuries
 Thumb MP dislocation:
Reduction:
After a radial nerve block.
Performed with pressure directed distally on the
base of the proximal phalanx with the metacarpal
flexed and abducted.
Ligament and Dislocation injuries
 Thumb MP Collateral Ligament Rupture:
Rupture of the ulnar collateral ligament
(gamekeeper’s thumb, skier’s thumb)
Occurs when the mechanism causes radial
deviation (abduction) of the MP jt.
Tear usually occur at the insertion into the
proximal phalanx.
Significant injury occurs to the dorsal capsule and
volar plate.
Ligament and Dislocation injuries
 Thumb MP Collateral Ligament Rupture:
Rupture of the ulnar collateral ligament
(gamekeeper’s thumb, skier’s thumb)
Type 1 Avulsion fracture, nondisplaced
Type 2 Avulsion fracture, displaced
Type 3 Torn ligament, stable in flexion
Type 4 Torn ligament, unstable in flexion
Ligament and Dislocation injuries
 Gamekeeper's thumb.
(1.) The normal thumb
MCP jt ulnar collateral
ligament. (2.)Tear in the
extensor mechanism
overlying the disrupted
ligament acts as a
buttonhole and (3.) traps
the ligament end. In this
position, spontaneous
healing and recovery of
stability is prevented.
Ligament and Dislocation injuries
 Thumb MP Collateral Ligament Rupture:
Rupture of the ulnar collateral ligament
Hand surgery referral is recommended for all
patients with weakness of pincer function and
point tenderness at the volar – ulnar aspect of
the thumb MCP jt resulting from a forced
abduction mechanism of injury.
Ligament and Dislocation injuries
 Thumb MP Collateral Ligament Rupture:
Rupture of the ulnar collateral ligament
If XRAY negative for fracture, then abduction
stress testing of the ulnar collateral ligament
maybe performed for added information.
Test the thumb MCP both in full extension and 30degree flexion, by stabilizing the metacarpal with
one hand while applying lateral (radial) stress on
the proximal phalanx with the other.
Ligament and Dislocation injuries
 Thumb MP Collateral Ligament Rupture:
 Rupture of the ulnar collateral ligament
 More than 40 degrees radial angulation indicates
complete rupture and requires surgical
consultation.
 Repair best accomplished in 1 wk.
 Rupture of the radial collateral ligament
 Not as common
 Mechanism is forced adduction
Ligament and Dislocation injuries
 Thumb CMC:
 Isolated dislocation is rare compared to the
more common Bennett fracture dislocation.
 Easy to reduce but unstable after reduction.
 Apply thumb spica splint after reduction.
 Need surgical referral.
ROM of the Thumb
Fractures
 Distal Phalanx:
 Account for 15 – 30 present of all hand
fractures.
 Are usually from crush or shearing forces.
 Can be classified as tuft, shaft, or
intraarticular.
 Tuft fractures – can be associated with nail
bed lacerations
Fractures
 Distal Phalanx:
 Fractures at the base
may be associated
with flexor or extensor
tendon involvement.
 These fractures are
treated as soft tissue
injuries with protective
splinting.
Fractures
 Proximal and Middle Phalanx
 Proximal phalanx
 Has no tendinous attachments
 Fractures frequently have volar angulation from the
forces of the extensor and interosseous muscles.
Fractures
 Proximal and Middle Phalanx
 Middle Phalanx:
 Has the FDS insert on the entire volar surface and
the extensor tendon insert at the proximal base
 Fractures at the base have dorsal angulation and
fractures at the neck result in volar angulation.
 Most often these fractures are stable and
nondisplaced.
 Can be treated with early protected motion by
buddy taping.
Fractures
 Proximal and Middle Phalanx
 Unstable fractures amenable to closed
reduction can be splinted from the elbow to
the DIP with the wrist at 20-degree extension
and the MP jt in 90-degree flexion.
 Midshaft transverse fractures, spiral fractures
and intraarticular fractures often require
internal fixation.
Fractures
 Metacarpal (II to V) Fractures
 2nd and 3rd metacarpals are relatively
immobile and fractures require anatomic
reduction.
 4th and 5th MC have 15 to 20-degree AP
motion, which allows for some compensation.
 MC fractures are categorized as head, neck,
shaft, or base fractures.
Fractures
 Metacarpal (II to V) Fractures
 Head:
 Usually caused by a direct blow, crush or missile.
 Fractures are distal to the insertion of the collateral
ligaments and are often comminuted.
 If a laceration is present a human bite must be
considered.
 Treatment:
 Ice, elevation, immobilization, and referral to a hand
surgeon.
Fractures
 Metacarpal (II to V) Fractures
 Neck:
 Usually caused by a directed impaction force.
 Fracture of the fifth MC neck is often referred to as
a boxer’s fracture
 Fracture are usually unstable with volar angulation.
 Angulation of < 20 degrees in the 4th and 40
degrees in the 5th MC will not result in functional
impairment
Fractures
 Metacarpal (II to V) Fractures
 Neck:
 If greater angulation in these MC occur, reduction
should be attempted
 Fractures should be splinted with the wrist in 20degree extension and the MP flexed at 90
degrees.
 In the 2nd and 3rd MC, angulation of <15 degrees is
acceptable. If significantly displaced or angulated
then anatomic reduction and surgical fixation is
needed
Fractures
 Metacarpal (II to V) Fractures
 Shaft:
 Usually occur via a direct blow
 Rotational deformity and shortening are more often
in shaft fractures than in neck fractures.
 If reduction is needed, than operative fixation is
usually indicated.
Fractures
 Metacarpal (II to V) Fractures
 Base
 Usually caused by a direct blow or axial force.
 They are often associated with carpal bone
fractures.
 Fractures at the base of the 4th and 5th MC can
result in paralysis of the motor branch of the ulnar
nerve.
Fractures
 Thumb MC
 Because of the mobility of the thumb MC,
shaft fractures are uncommon
 Fractures usually involve the base.
 Two type:
 Extraarticular
 Intraarticular
Fractures
 Thumb MC
 Extraarticular:
 Are caused by a direct blow or impaction
mechanism.
 Mobility of the CMC jt can allow for 20-degree
angular deformity. Angulation greater than this
requires reduction and thumb spica splint for 4
wks.
 Spiral fractures often require fixation.
Fractures
 Thumb MC
 Intraarticular
 Caused by impaction from striking a fixed object
(two type)
 Bennett fx
 Is an intraarticular fx with associated subluxation or
dislocation at the CMC jt.
 The ulnar portion of the MC usually remains in place.
 The distal portion usually subluxes radially and dorsally
from the pull of abduction pollicis longus and the
adductor pollicis
 Treatment – thumb spica and referral
Fractures
Bennett's fracture
 Avulsion fracture of
the articular surface
of the first
metacarpal with
subluxation at the
CMC jt.
Fractures
 Thumb MC
 Intraarticular
 Rolando fracture
 An intraarticular comminuted fracture at the base of the
metacarpal.
 Mechanism of injury is similar to the Bennett fracture, but
less common.
 Treatment – thumb spica splint and surgery consultation.
COMPARTMENT SYNDROME
 May occur in crush injury of the hand with
or without associated fracture.
 Involved compartments of the hand
includes:




Thenar
Hypothenar
Adductor pollicis
Four interossei
COMPARTMENT SYNDROME
 Cross section
through the palm
showing
compartments of
the hand
COMPARTMENT SYNDROME
 Edema of tissues or hemorrhage within
any of these compartments may lead to
elevated pressures that result in tissue
necrosis and subsequent loss of hand
function due to contracture.
 Sign and symptoms:
 Pain and paresthesias occur early
 Paralysis and pulselessness occurring later
COMPARTMENT SYNDROME
 Sign and symptoms:
 Pain
 Most consistent clinical sign
 usually described as deep, constant, poorly
localized and disproportionate to clinical findings.
 PE findings:
 “intrinsic minus” position at rest (MCP
extended with PIP slightly flexed)
 Pain with passive stretch of the involved
compartmental muscle
COMPARTMENT SYNDROME
 PE findings:
 Pain with passive stretch of the involved
compartmental muscle
 Interosseous: performed with MCP extended and
PIP fully flexed with slight radial ulnar deviation
 Thenar / Hypothenar: performed by extension of
MCP
 Tense swelling of the affected compartment
COMPARTMENT SYNDROME
 Diagnosis
 Confirmed by compartment pressure
measurement – high rate of false readings.
 In the setting of severe crush injury with signs
and symptoms suggestive of compartment
syndrome, emergent hand surgeon
consultation for fasciotomy is mandatory.
High – Pressure Injection Injury
 The initial dissipation of kinetic energy
through the soft tissue of the hand
produce tissue edema and resultant
ischemia of the tissue.
 Most common injected substances include
grease, paint, hydraulic fluid, diesel fuel,
paint thinner, and water.
High – Pressure Injection Injury
 Definitive treatment of high – pressure injection
injuries is early surgical decompression and
debridement of injected areas.
 These must be recognized as surgical
emergency and obtain immediate hand surgery
consultation, immobilize and elevate the affected
hand, initiate tetanus prophylaxis, broadspectrum antibiotics and provide adequate
analgesia.