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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
Hand injuries
Hand injuries – the commonest of all injuries – are important out of all proportion to their
apparent severity, because of the need for perfect function.
Nowhere else do painstaking evaluation, meticulous care and dedicated rehabilitation
yield greater rewards.
The outcome is often dependent upon the judgement of the doctor who first sees the
patient.
If there is skin damage the patient should be examined in a clean environment with the
hand displayed on sterile drapes.
A brief but searching history is obtained; often the mechanism of injury will suggest the
type and severity of the trauma.
The patient’s age, occupation and ‘handedness’ should be recorded.
Superficial injuries and severe fractures are obvious, but deeper injuries are often poorly
disclosed.
It is important in the initial examination to assess the circulation, soft-tissue cover,
bones, joints, nerves and tendons.
X-rays should include at least three views (posteroanterior, lateral and oblique), and with
finger injuries the individual digit must be x-rayed.
GENERAL PRINCIPLES OFTREATMENT
Circulation If the circulation is threatened, it must be promptly restored, if necessary by
direct repair or vein grafting.
Swelling Swelling must be controlled by elevating the hand and by early and repeated
active exercises.
Splintage Incorrect splintage is a potent cause of stiffness; it must be appropriate and it
must be kept to a minimum length of time. If a finger has to be splinted, it may be possible
simply to tape it to its neighbour so that both move as one; if greater security is needed,
only the injured finger should be splinted.
If the entire hand needs splinting, this must always be in the ‘position of safety’ – with
the metacarpo-phalangeal joints flexed at least 70 degrees and the interphalangeal joints
almost straight.
Sometimes an external splint, to be effective, would need to immobilize undamaged
fingers or would need to hold the joints of the injured finger in an unfavourable position
(e.g. flexion of the interphalangeal joints). If so, internal fixation may be required (K-
wires, screws or plates).
Skin cover Skin damage demands wound toilet followed by suture, skin grafting, local
flaps, pedicled flaps or (occasionally) free flaps. Treatment of the skin takes precedence
over treatment of the fracture.
Nerve and tendon injury Generally, the best results will follow primary repair of tendons
and nerves. Occasionally grafts are required
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
METACARPAL FRACTURES
The metacarpal bones are vulnerable to blows and falls upon the hand, or the longitudinal
force of the boxer’s punch.
Injuries are common and the bones may fracture at their base, in the shaft or through the
neck.
Angular deformity is usually not very marked, and even if it persists, it does not interfere
much with function.
Rotational deformity, however, is serious. Close your hand with the distal phalanges
extended, and look: the fingers converge across the palm to a point above the thenar
eminence; malrotation of the metacarpal (or proximal phalanx) will cause that finger to
diverge and overlap one of its neighbours.
Thus, with a fractured metacarpal it is important to regain normal rotational alignment.
The fourth and fifth metacarpals are more mobile at their base than the second and third,
and therefore are better able to compensate for residual angular deformity.
Fractures of the thumb metacarpal usually occur near the base and pose special problems.
They are dealt with separately below.
FRACTURES OF THE METACARPAL SHAFT
A direct blow may fracture one or several metacarpal shafts transversely, often with
associated skin damage.
A twisting or punching force may cause a spiral fracture of one or more shafts.
There is local pain and swelling, and sometimes a dorsal ‘hump’.
Treatment
Oblique or transverse fractures with slight displacement require no reduction.
Splintage also is unnecessary, but a firm crepe bandage may be comforting; this should
not be allowed to discourage the patient from active movements of the fingers,
Transverse fractures with considerable displacement are reduced by traction and pressure.
Reduction can sometimes be held by a plaster slab extending from the forearm over the
fingers (only the damaged ones)
The slab is maintained for 3 weeks and the undamaged fingers are exercised.
However, these fractures are usually unstable and should be fixed surgically with
compression plates or percutaneous K-wires placed either across the fracture or
transversely through the neighbouring undamaged metacarpals.
Spiral fractures are liable to rotate; if so, they should be perfectly reduced and fixed with
lag screws and a plate, or percutaneous wires.
FRACTURES OF THE METACARPAL NECK
A blow may fracture the metacarpal neck, usually of the fifth finger (the ‘boxer’s
fracture’) and occasionally one of the others.
There may be local swelling, with flattening of the knuckle.
X-rays show an impacted transverse fracture with volar angulation of the distal fragment.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
Treatment
The main function of the fifth and fourth fingers is firm flexion (‘power grip’) and, as can
be readily demonstrated on a normal hand, there is ‘spare’extension available at the
metacarpo-phalangeal (MCP) joint.
Therefore in these digits, a flexion deformity of up to 40 degrees can be accepted; as long
as there is no rotational deformity, a good outcome can be expected. The hand is
immobilized in a gutter splint with the MCP joint flexed and the interphalangeal (IP)
joints straight until discomfort settles – a week or two – and then the hand is mobilized.
Complications
Malunion, with volar angulation of the distal fragment, is poorly tolerated if this occurs in
the second or third rays.
FRACTURES OF THE METACARPAL HEAD
These fractures occur after a direct blow.
They are often quite comminuted and sometimes ‘open’. Operative reduction is usually
required and fixation with small headless buried screws is ideal. Occasionally the joint is
so badly damaged that primary replacement is considered (Silastic, pyrocarbon or
polythene– metal).
FRACTURES OF THE METACARPAL BASE
Excepting fractures of the thumb metacarpal, these are usually stable injuries which can
be treated by ensuring that rotation is correct and then splinting the digit in a volar slab
extending from the forearm to the proximal finger joint. The splint is retained for 3 weeks
and exercises are then encouraged.
Displaced intra-articular fractures of the base of the fourth or fifth metacarpal may cause
marked incongruity of the joint. This is a mobile joint and it may, therefore, be painful.
The fracture should be reduced by traction on the little finger and then held with a
percutaneous K-wire or compression screw.
In the long term, if painful arthritis supervenes, treatment would be with either
arthrodesis or joint excision.
FRACTURE OF THE THUMB METACARPAL
Three types of fracture are encountered:
o Impacted fracture of the metacarpal base;
o Bennett’s fracture-dislocation of the carpo-metacarpal (CMC) joint;
o
Rolando’s comminuted fracture of the base.
Impacted fracture
A boxer may, while punching, sustain a fracture of the base of the first metacarpal.
Localized swelling and tenderness are found,
x-ray shows a transverse fracture about 6 mm distal to the CMC joint, with outward
bowing and impaction.
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Treatment
DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
If the angulation is less than 20–30 degrees and the fragments are impacted, the thumb is
rested in a plaster of Paris cast extending from the forearm to just short of the
interphalangeal thumb joint with the thumb fully abducted and extended.
The cast is removed after 2–3 weeks and the thumb is mobilized.
If the angulation is greater than 30 degrees, so the fracture should be reduced.
The surgeon pulls on the abducted thumb and, by levering the metacarpal outwards
against his own thumb, corrects the bowing.
A plaster cast is applied.
If the fracture is still unstable, then a percutaneous K-wire is inserted.
Bennett’s fracture-dislocation
This fracture, too, occurs at the base of the first metacarpal bone and is commonly due to
punching;
however the fracture is oblique, extends into the CMC joint and is unstable.
The thumb looks short and the carpo-metacarpal region swollen.
X-rays show that a small triangular fragment has remained in contact with the medial
edge of the trapezium, while the remainder of the thumb has subluxated proximally,
pulled upon by the abductor pollicis longus tendon.
Treatment
It is widely supposed (with little evidence) that perfect reduction is essential.
It should, however, be attempted and can usually be achieved by pulling on the thumb,
abducting it and extending it.
Reduction can then be held in one of two ways:
o plaster or
o internal fixation.
ROLANDO’S FRACTURE
This is an intra-articular comminuted fracture of the base of the first metacarpal with a T
or Y configuration.
Closed reduction and K-wiring or open reduction and plate fixation can be used. With
more severe comminution, external fixation is needed.
FRACTURES OF THE PHALANGES
The fingers are usually injured by direct violence, and there may be considerable swelling
or open wounds.
Injudicious treatment may result in a stiff finger which, in some cases, can be worse than
no finger.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
FRACTURES OF THE PROXIMAL AND MIDDLE PHALANGEAL SHAFTS
The phalanx may fracture in various ways:
• Transverse fracture of the shaft, often with forward angulation.
• Spiral fracture of the shaft, from a twisting injury.
• Comminuted , usually due to a crush injury may with tendon damage and skin loss.
• Avulsion of a small fragment of bone.
• Metaphyseal fracture at the base of the proximal phalanx,
• Intra-articular fractures: At the distal end of the phalanx, the entire head may rotate or, more
commonly, one condyle rotates through a longitudinal midline fracture into the joint. At the
proximal end, displacement tends to lead to an angular deformity.
Treatment
UNDISPLACED FRACTURES
o
These can be treated by ‘functional splintage’. The finger is strapped to its
neighbour (‘buddy strapping’) and movements are encouraged from the
outset.
o Splintage is retained for 2–3 weeks, but during this time it is wise to check the
position by x-ray in case displacement has occurred.
DISPLACED FRACTURES
o Displaced fractures must be reduced and immobilized.
o It is essential to check for rotational correction by
(1) noting the convergent position of the finger when the MCP joint is flexed,
and
(2) seeing that the fingernails are all in the same plane.
FRACTURES OF THE TERMINAL PHALANX
The terminal phalanx, is subject to five different types of fracture:-
1) Fracture of the tuft
o The tip of the finger may be struck by a hammer or caught in a door, and the bone
shattered.
o The fracture is disregarded and treatment is focused on controlling swelling and
regaining movement.
o The painful haematoma beneath the finger nail should be drained by piercing the nail
with a hot paper clip.
o If the nail bed is shattered and cosmesis is important, it should be meticulously
repaired under magnification.
2) Mallet finger injury
o After a sudden flexion injury (e.g. stubbing the tip of the finger) the terminal phalanx
droops and cannot be straightened actively.
o Three types of injury are recognized:
avulsion of the most distal part of the extensor tendon;
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
avulsion of a small flake of bone from the base of the terminal phalanx;
and
avulsion of a large dorsal bone fragment, sometimes with subluxation of
the terminal interphalangeal (TIP) joint.
TREATMENT
o The TIP joint should be immobilized in slight hyperextension, using a special mallet-
finger splint which fixes the distal joint but leaves the proximal joints free.
o For tendinous avulsions (which usually occur painlessly) the splint should be kept in
place constantly for 8 weeks and then only at night for another 4 weeks. Even if there has
been a delay of 3 or 4 weeks after injury, this prolonged splintage is usually successful.
o Bone avulsions are also treated in a splint, but 6 weeks should suffice as bone heals
quicker than tendon.
o Operative treatment is generally avoided, even for large bone fragments, unless there is
subluxation.
o Surgery carries a high complication rate (wound failure, metalwork problems) without
evidence that the outcome is improved. However, if there is subluxation then K-wires or
small screws are used to fix the fragment in place.
COMPLICATIONS OF MALLET FINGER
o Non-union This is usually painless and treatment is not needed.
o Persistent droop About 85 per cent of mallet fingers recover full extension. If there is a
persistent droop this can be treated by tendon repair supported by K-wire fixation of the
joint, but the results are often disappointing. The alternative would be joint arthrodesis,
o Swan neck deformity Imbalance of the extensor mechanism can cause this in lax-jointed
individuals. A central slip tenotomy is straightforward and can give a very good result.
3) Fracture of the terminal shaft
o Undisplaced fractures of the shaft need no treatment apart from analgesia.
o If angulated, they should be reduced and held with a longitudinal K-wire through the
pulp for 4 weeks.
o The nail is often dislocated from its fold; if so it must be carefully tucked back in and
held with a suture in each corner.
4) Avulsion of the flexor tendon
o This injury is caused by sudden hyperextension of the distal joint, typically when a
game player catches his finger on an opponent’s shirt.
o The ring finger is most commonly affected.
o The flexor digitorum profundus tendon is avulsed, either rupturing the tendon itself or
taking a fragment of bone with it.
5) Physeal fracture
o The basal physis can break, usually producing a Salter–Harris I fracture (Seymour
fracture).
o
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DR.JAMAL AL-SAIDY
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o The nail may be dislocated from its fold and the germinal matrix can be trapped in the
fracture.
o The injury is easily overlooked if the finger is very swollen.
o The nail must be cleaned and carefully replaced into its bed.
JOINT INJURIES
Any finger joint may be injured by a direct blow (often the overlying skin is damaged), or
by an angulationforce, or by the straight finger being forcibly stubbed.
The affected joint is swollen, tender and too painful to move.
X-rays may show that a fragment of bone has been sheared off or avulsed.
CARPO-METACARPAL DISLOCATION
The thumb is most frequently affected and clinically the injury then resembles a
Bennett’s fracturedislocation; however, x-rays reveal proximal subluxation or dislocation
of the first metacarpal bone without a fracture.
The displacement is easily reduced by traction and hyperpronation, but reduction is
unstable and can be held only by a K-wire driven through the metacarpal into the carpus.
The wire is removed after 5 weeks but a protective splint should be worn for 8 weeks
because of the risk of instability.
Chronic instability
METACARPO-PHALANGEAL DISLOCATION
Usually the thumb is affected, sometimes the fifth finger, and rarely the other fingers.
The entire finger is suddenly forced into hyperextension and the capsule and muscle
insertions in front of the joint may be torn.
There are two types of dislocation:
o Simple dislocation The finger is extended about 75 degrees. It is easily
reduced by traction, firstly in hyperextension then pulling the finger
around. The finger is strapped to its neighbour and early mobilization is
encouraged.
o Complex dislocation The avulsed palmar plate sits in the joint, blocking
reduction. Furthermore, the metacarpal head can be clasped between the
flexor tendon and lumbrical tendon. The finger is extended only about 30
degrees and there is usually a tell-tale dimple in the palm. Very
occasionally the fracture can be reduced closed by hyperextending the
MCP joint and flexing the IP joints to release the clasp. If this fails, open
reduction is required. A dorsal approach is safest. After reduction the
joint is stable and should be mobilized in a neighbour-splint.
Chronic instability in the thumb MCP joint This is treated by a sesamoid arthrodesis. An
alternative is formal arthrodesis. The functional result is usually very good.
INTERPHALANGEAL JOINT DISLOCATION
Distal joint dislocation is rare; proximal joint dislocation is more common. The
dislocation is easily reduced by pulling. The joint is strapped to its neighbor for a few
days and movements are begun immediately.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
LIGAMENT INJURIES
PROXIMAL INTERPHALANGEAL LIGAMENTS
o Partial or complete tears of the proximal interphalangeal ligaments are quite
common. Mild sprains require no treatment but with more severe injuries the
finger should be splinted in extension for 2 or 3 weeks, If the joint is frankly
unstable, repair is considered.The joint is likely to remain swollen and slightly
painful for at least 6–12 months. If the instability persists – reconstruction.
METACARPO-PHALANGEAL JOINTS
o The radial collateral ligament of the index finger is most vulnerable, although
with a suitable force any ligament can be injured.
ULNAR COLLATERAL LIGAMENT OF THE
THUMB METACARPO PHALANGEAL JOINT
(‘GAMEKEEPER’S THUMB’; ‘SKIER’S THUMB’):-
In former years, gamekeepers who twisted the necks of little animals ran the risk of
tearing the ulnar collateral ligament of the thumb metacarpo-phalangeal joint, either
acutely or as a chronic injury.
Nowadays this injury is seen in skiers who fall onto the extended thumb, forcing it into
hyperabduction.
A small flake of bone may be pulled off at the same time.
Theresulting loss of stability may interfere markedly with prehensile (pinching)
activities.
The ulnar collateral ligament inserts partly into the palmar plate.
In a partial rupture, only the ligament proper is torn and the thumb is unstable in flexion
but still more or less stable in full extension because the palmar plate is intact.
In a complete rupture, both the ligament proper and the palmar plate are torn and the
thumb is unstable in all positions. If the ligament ruptures Completely, it will not heal
unless it is repaired; this is because the proximal end gets trapped in front of the adductor
pollicis aponeurosis (the Stener lesion).
Clinical assessment
On examination there is tenderness and swelling precisely over the ulnar side of the
thumb metacarpo-
phalangeal joint.
An x-ray is essential, to exclude a fracture before carrying out any stress tests.
Laxity is often obvious but if in doubt, then the joint can be examined under local
anaesthetic. If there is no undue laxity (compare with the normal side) in both extension
and 30 degrees flexion, then a serious injury can be excluded. If there is more than a few
degrees of laxity there is probably a complete rupture which will require operative repair.
Treatment
Partial tears can be treated by a short period (2–4 weeks) of immobilization in a splint
followed by increasing movement. Pinch should be avoided for 6–8 weeks.
Complete tears need operative repair.
THANK YOU……
DR.JAMAL AL-SAIDY
M.B.CH.B..…… F.I.C.M.S