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

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

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

Principles of Evaluation & Management

Brief Review of Anatomy

The Bony Hand

• Hand injuries are a common presentation to the clinic and ER

• The best outcome depends on accurate initial evaluation and treatment

Principles of Evaluation

• History

• General Hand Examination

• Testing of nerves & tendons

• Anesthesia & direct wound inspection

• Radiographs, consultation & disposition

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.

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?

General Hand Examination

• Extent of injury

– Local swelling

– Deformity

– Dislocation

– Angulation

– Displacement

– Rotational malalignment

General Hand Examination

• Observation

– Open wound

– Location

– Soft tissue injuries

– Skin violation

– Contamination

– Damage to neurovascular supply, tendons, bones

– Foreign bodies

General Hand Examination

• Check:

– grip strength

– ROM

– evidence of scissoring

– pincer function

– vascular supply

– motor/sensory/tendon function

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

Vascular Testing

• Hand has a dual blood supply

– Radial & Ulnar arteries

• Fingers

– Digital arteries

Testing of Tendons

• ROM against resistance

• Pain against resistance despite good strength indicates a partial laceration

• FDP, FDS, Extensor tendons should be examined

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

Diagnostic Imaging

• Primary Care

– Xray

• PA, lateral, oblique views

– CT

• Hand Specialists

– MRI

– Ultrasound

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

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

Acute Injuries

Ligamentous Tendinous Fracture

Ligamentous Injuries

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

PIP Joint Dislocations

• Dorsal dislocation – volar plate

• Volar dislocation – central slip

• Lateral dislocation – collateral ligaments

Ligamentous Injuries

PIP Joint Injuries

• Dorsal lip fractures

• Volar lip fractures

• Condylar fractures

• Pilon fractures

Skeletal Injuries

Dorsally Directed Force Volar Plate Injuries

• Mechanism of Injury:

– Sudden Impact

– Force – Volar To Dorsal

– Tearing – Directory of force

– May involve collateral ligament

Classification Of

Volar Plate Injuries

• Grade 1 – SPRAIN – Partial disruption of major

retaining ligament (MRL)

– Joint stable to Active or Passive stress

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

Treatment Of Grade I Injuries

Grade II Volar Plate Injuries

• Complete disruption of single MRL

• Joint functionally stable

• Passively stressed beyond usual limits

• Joint may not sublux or dislocate

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

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

Hand Therapy Displaced Reducible & Undisplaced Joints

• Splint PIP – 60 degrees of flexion

• PIP dorsal blocking splint

• PIP AROM with buddy tape

•

• FDP gliding exercises

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

Hand Therapy

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

Management of Volar Dislocation

• Similar to closed Boutonniere Injury

• Splint PIP in extension upon reduction – 6+ weeks

• DIP free to move

Hand Therapy

Results

Laterally Directed Force Lateral Dislocation

• Trauma to the collateral ligament

• Accessory collateral

• Volar plate

• Lateral bands

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

PIP Joint Dislocation

Results

Tendon Injuries

Extensor Tendon Ruptures

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

Traditional Management

STACK -SPLINT

• Splinting –4-6weeks

• Gradual weaning over next 4-6 weeks

• Depending on the symptoms

Complication of Mallet Finger Deformity

Swan Neck Deformity

Patho-mechanics of Swan Neck in Mallet

Mallet Finger Management

Boutonniere Deformity

• Avulsion or rupture of the central tendon

• Laceration of the central tendon

• Laceration of EDC distal to the MCP joint

Boutonniere Deformity • Upon Central Slip

Avulsion/laceration

• Lateral Bands Fall Volar to Joint Axis

• Increased Intrinsic Load at DIP

Treatment of Boutonniere Deformity

Splinting

• PIP joint in full extension leaving DIP free for 6-8 weeks

• DIP joint active flexion with splint

Results

Flexor Tendon Ruptures

Jersey Finger Classification Leddy & Packer

• Grade I

• Grade II

• Grade III

Management of Zone I Injuries Jersey Finger

Management of Zone I Injuries Jersey Finger

Fractures of the Hand

Typical Displacement Patterns • Metacarpal Neck & Shaft –

Volar angulation

• Proximal Phalanx – Dorsal angulation

• Spiral & Oblique – Proximal displacement & rotation

• Comminuted - Compression

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

Malrotation

• Common with spiral and oblique fractures

• Over 10 degrees of malrotation not acceptable due to scissoring of the digit

Malrotation

Management of Metacarpal Fractures

Intrinsic Plus Splint

Bivalve Splint reduces motion at the hameto-metacarpal joint

3 – 4 Weeks

Buddy Taping reduces rotational deformity

Tendon Gliding

Upon Discontinuing the splint

Displaced Metacarpal Fractures

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

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

Treatment Consideration

• Intrinsic plus splinting

• Buddy taping

• Early active tendon gliding exercises

• Early contracture control

Treatment Results

Middle Phalangeal Shaft Fractures

Middle Phalangeal Fractures

• Occur with less frequency (8 – 12%)

• Main cause – crush injury

• Distal portion most common

Management Post Fracture Reduction

Management

• Volar gutter splint – worn at all times

• Gutter splint – stabilizing middle and distal phalanx to allow active PIP ROM

Management

• Gutter splint – stabilizing proximal and middle phalanx to allow active DIP ROM

• Facilitating excursion of FDS and FDP while fracture is healing

Results

Intra-articular Fractures

Types of Intra-articular Fractures

Xi-Scan Method of Fracture Evaluation

• Distraction force

• Specific positioning

• Safe permissible motion in the splint

Fracture Reduction With Traction

Motion Within Traction Splint

Results of Traction Splinting

Complications

• Swan neck or boutonniere

• Severe extension/flexion contracture

• Pain & stiffness

• Joint instability

Complications

Goal of Hand Therapy

• Minimize PIP Flexion/Extension contracture

• Minimize tendon adhesions

• Minimize secondary deformities

• Maximize Range of motion

• Maximize function

Choice of Treatment

Understanding of tissue compliance

Common Hand Disorders

• Nerve compression syndromes

• Tendinitis/tennosynovitis

• Hand arthritis and other syndromes

Nerve compression syndromes

• Median

– Carpal tunnel

– Pronator teres

• Ulnar

– Cubital tunnel

– Guyon’s canal

• Radial nerve

– Radial tunnel

– Wartenburg’s

Tendinitis/Tenosynovitis

• Trigger finger

• DeQuervain’s

• Tennis Elbow

– Wrist extensors

– Finger extensors

Other disorders

• Vibration Syndrome (White finger)

• Vascular Spasms (Raynaud’s)

• Arthritis

• Reflex sympathetic dystrophy/CRPS

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

Carpal Tunnel Syndrome

• Most common – studies vary in incidence

• Diagnosis – best established on physical exam EMG and NCV secondary

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

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 +)

Physical Findings

Tinel’s sign

Tapping over volar wrist skin crease

Symptoms produced Tingling or electric shock sensation (test +)

Sensory Exam

Treatment

• Initially non operative

• B6? B12?

• Treat any associated conditions

Treatment Conservative

• Patient education

• Splinting

• AROM digits

• Tendon & nerve gliding exercises

• Sensory re-education

• Avoiding provocative tasks

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

Surgical Complications

• Hypersensitivity

• Hypertrophic Scarring

• Pillar pain

• Tightness along the mid point between thenar & hypothenar eminence

• Recurrance of CT symptoms

DeQuervain’s Tenosynovitis

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

Abnormal Anatomy

“Hourglass” Constriction of tendons

1st Dorsal Compartment

EPB Compressed in separate compartment

Occasional bony & prominent radius

Diagnosis

• Painful inflammation of 1st dorsal extensor compartment

• + Finkelstein’s test

- Ulnar deviation of

the wrist

- Passive thumb

flexion

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

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

Results

• Usually improve patients

• Not usually cured

• Key is avoidance of overuse

• Usually not surgical- only 10% of time

Arthritis of the CMC Joint

Epidemiology

• Most common joint disorder in hand

• More common in females (10-15:1)

• Most often idiopathic

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

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

Non-operative Management

• Splinting (thumb spica)

• NSAIDS

• Rest

• Activity modification

• Intra-articular injection of corticosteroids

• Effective in almost 75% of patients

Indications for Surgery

• Pain despite non-operative Rx

• Deformity impairing function

• Weakness impairing function

• Do not operate based only on radiology!

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

LRTI • Curvilinear incision over volar-radial CMC

• Harvest FCR (12 cm, distally based)

LRTI

• Resection/debridement trapezium

• Drill hole into MC base

• Passage of FCR through MC drill hole

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

Trigger Finger

• Stenosing Flexor Tenosynovitis

• “Trigger finger” (TF) / “trigger thumb” (TT)

• First description Notta (Paris 1850) advocated surgical release.

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

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

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

• 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

• 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

• 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

Dupuytren’s Disease Etiology and Pathology

The Prevalence of Dupuytren’s Disease

MEN 60-75

Iceland - 33%

Norway - 46%

Scotland - 35%

Australia - 28%

Spain - 19%

England - 17%

Japan - 15%

DUPUYTREN TYPE

Knuckle Pad Plantar Fibromatosis

Typical Patient

• Predomiately male

• Onst 45+ years

• Contracture 50+ yrs

• Bilateral but more severe on one side

Less Severe Patient

• Often female

• Onset 50+ yrs

• Contracture +/- 60 yrs

• Often bilateral and not enough contracture to need an operation

• Non European

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

Non Operative Treatment

Collagenase Injection-Xiaflex

Failed Treatments

Radiation

Steroid Injection

Skeletal or Soft Tissue Traction

Indications For Operation

Aponeurotomy or Fasciotomy

Local Fasciotomy

Regional Fasciectomy

The Use of Skin Grafts (relative)

• Severe Diathesis

• Recurrent Contracture

• PIP Contracture

- severe

- with an open palm

Results of Operation

CORRECTION OF MCP JOINT

- usually complete and permanent

CORRECTION OF PIP JOINT

- usually some residual contracture

- recurrence is likely

Conclusions

• MCP joint can be corrected

• PIP joint can be improved

• Plan an operation according to diathesis factors and severity of disease

Special Consideration Injuries

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

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

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

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

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

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.