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Common Finger Injuries

Common Finger Injuries. Wes Bailey Emory Family Medicine Thursday, December 11, 2008. DIP Injuries. Ouch!!! … <BLEEP>!! ... <BLEEP> !!!. http://radiographics.rsnajnls.org/cgi/content-nw/full/24/4/1009 /F2. http://www.hughston.com/hha/b_16_4_2a.jpg. Mallet Finger 1. Mechanism of Injury

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Common Finger Injuries

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  1. Common Finger Injuries Wes Bailey Emory Family Medicine Thursday, December 11, 2008

  2. DIP Injuries

  3. Ouch!!! … <BLEEP>!! ... <BLEEP> !!! http://radiographics.rsnajnls.org/cgi/content-nw/full/24/4/1009/F2 http://www.hughston.com/hha/b_16_4_2a.jpg

  4. Mallet Finger1 • Mechanism of Injury • Flexion force or axial loading during DIP extension. • Terminal extensor tendon avulsion. • Presentation • DIP Flexion +/- edema. • Exam Deficit • Active Extension (Extensor Lag). • Imaging • AP, lateral, oblique. http://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformities.pdf http://www.eorthopod.com/images/ContentImages/hand/finger_mallet/finger_mallet_diagnosis01.jpg 1. http://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformities.pdf

  5. Mallet Finger1 • Conservative Treatment • Full extension splinting X 6 wks, then wean and start AROM regimen. • If persistent extension lag, then continued & varied splinting for ≥ 3 wks. Refer to hand surgeon if no improvement. • Surgical Treatment • Pin large fracture fragments, then splinting. • Extensor tendon repair.

  6. DIP Dislocations2 • Uncommon • Typically dorsal. • Reduction Method • 1. Longitudinal traction and hyperextension. • 2. Direct dorsal pressure to dp base. 2. http://www.cchseast.org/Portals/33/Residency/InjuriesToTheHand2%5B1%5D.ppt

  7. DIP Dislocation2 Volar dislocation of DIP joint of little finger. Dorsal dislocation at the DIP jt without associated fracture

  8. DP Fractures1 • 15 - 30% of hand fx’s. • Mechanism: Crush or shearing forces. • Types: tuft (+/- nail bed lac), shaft, or intraarticular. 1. http://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformities.pdf

  9. DP Fracture2 • Fx’s at the base may be associated with flexor or extensor tendon involvement. • Tx: Protective splinting.

  10. PIP Injuries

  11. PIP Joint1 • Features • Hinge Joint. • 100- 110 degrees motion. • 2 condyles at proximal phalynx end which fit into middle phalynx fossae. • Collateral ligaments protect against deviation forces.

  12. Somethin’ Isn’t Right … http://farm1.static.flickr.com/230/513015968_5954ba9891.jpg

  13. Boutonniere Deformity1 • Presentation • PIP flexion +/- contracture, DIP extension. • Up to 3 wks after injury. • Mechanism of Injury • Forceful flexion • Central Slip tear. • Exam Deficit • Active PIP extension. • Imaging • AP, lat, oblique.

  14. BoutonniereDeformity1 • Treatment • Continuous PIP extension splinting for up to 6 wks followed by night-time splinting for 3 wks. • AROM regimen. http://www.abledata.com/product_images/images/01A1041.jpg

  15. BoutonniereDeformity1

  16. Think of Birds…or Types of Diving http://www.ortho.hyperguides.com/tutorials/hand/swanneck/art/slide1.jpg http://surgeonsblog.blogspot.com/2007/03/swan-thing-or-another.html

  17. Swan Neck Deformity1 • Mechanisms of Injury • Central slip tear. • Volar slipping of lateral bands • Volar capsule w/dorsal LB displacement. • Increased terminal tendon tension. • Presentation • PIP extension, DIP flexion, MP flexion. • MP volarsubluxation w/ulnar drift in Rheumatoid Arthritis (RA). • Deficit • Active +/- Passive PIP Flexion. • Imaging • PA, lat, oblique.

  18. Swan Neck Deformity in RA http://i90.photobucket.com/albums/k245/keshblog/MSK%20spondyloarthropathies/RA/handadvancedRA.jpg

  19. Swan Neck Deformity1 • Treatment • Indefinite splinting in slight flexion. • Reconstructive surgery for RA-associated deformity.

  20. PIP Sprains1 • The key is joint stability

  21. PIP Dislocation2

  22. PIP Dislocation1

  23. MP & PP Fractures2 • 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 volarangulation. • Proximal phalanx • Fractures frequently have volarangulation from the forces of the extensor and interosseous muscles.

  24. MP & PP Fractures2 • Treatment • Stable & Non-displaced  buddy taping • Unstable fx’s amenable to closed reduction: • Splint from elbow to the DIP w/wrist at 20-degree extension and the MP jt in 90-degree flexion. • Midshaft transverse/spiral/intraarticular fxs • Often require internal fixation.

  25. MCP Injuries

  26. MCP Joint Dislocation2 • Uncommon. • Mechanism: • Typically 2/2 hyperextension forces that rupture the volar plate, causing dorsal dislocation. • Subluxation (simple dislocation)  joint appears hyper-extended. Articular surfaces remain in contact. • Volar • Rare and usually require operative reduction.

  27. MCP Joint Dislocation2 • Reduction • Flex wrist to relax the flexor tendon. • Apply pressure over the dorsum of the proximal phalanx in a distal and volar direction. • Splint the joint in flexion.

  28. Thumb MP Joint Dislocation2 • Collateral ligaments arise from MC lateral condyles and insert volar oblique on proximal phalynx. • Abductor Pollicis Brevis & Flexor Pollicis Brevis insert on radial sesamoid. Adductor pollicis inserts on ulnar sesamoid. http://www.eorthopod.com/images/ContentImages/hand/hand_ulnar_collateral/ulnar_collateral_thumb_anat02.jpg

  29. Thumb MP Joint Dislocation2 • Radial collateral ligament Rupture • Uncommon • Mechanism • Forced adduction. • Ulnar Collateral Ligament Rupture(A.K.A. “gamekeeper’s thumb” or “skier’s thumb”) • Mechanism • Excessive radial deviation (abduction) of the MP jt. • Tear usually occurs at the insertion into the proximal phalanx. • Significant injury occurs to the dorsal capsule and volar plate.

  30. Thumb MP Joint Dislocation2 • Evaluation of Stability • If XRAY negative, then abduction stress testing for added information re: stability. • Test the thumb MCP both in full extension and 30-degree flexion, by stabilizing the metacarpal with one hand while applying lateral (radial) stress on the proximal phalanx with the other. • Sx if >40° radial angulation.

  31. Thumb MP Joint Dislocation2 • Treatment • Simple Dislocation • Reduction with pressure directed distally on the base of the proximal phalanx with the metacarpal flexed and abducted. • Partial Tear: • Spica cast w/free IP for 2-4 wks. • Then splint & ROM. • 2+ months for full recovery. • Fractures • Surgery including UCL reaatachment, MP jt pinning. Then thumb spica cast for 4 wks. AROM. Spica splint for up to 8 wks. http://farm1.static.flickr.com/14/92816768_3e54451173.jpg?v=0

  32. Metacarpal Fractures

  33. 1st MC Fractures2 • Extraarticular (Not crossing the joint surface) • Via 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.

  34. 1st MC Fractures2 • Intra-articular • Caused by impaction from striking a fixed object (two type) • Bennett fx • Associated w/subluxation or dislocation at the CMC jt. • The distal portion usually subluxesradially and dorsally from the pull of abduction pollicislongus and the adductor pollicis • Treatment: Thumb spica and sx referral.

  35. 2nd - 5th MC Fractures2 • Head: • Caused by direct blow, crush, missile, or human bite. • Distal to the CL and often comminuted. • Treatment: • Ice, elevation, immobilization, and sx referral.

  36. 2nd - 5th MC Fractures2 • Neck • Caused by directed impaction force. • Management: • Reduction for significant deviation to prevent functional impairment, • Fractures should be splinted with the wrist in 20-degree extension and the MP flexed at 90 degrees. • Shaft: • Via direct blow. • Rotational deformity and shortening are more common. • If reduction is needed, than operative fixation is usually indicated.

  37. 2nd - 5th MC Fractures2 • Base • Via direct blow or axial force. • Often associated with carpal bone fractures. • 4th and 5th MC fx’s can result in paralysis of the motor branch of the ulnar nerve.

  38. References • http://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformities.pdf • http://www.cchseast.org/Portals/33/Residency/InjuriesToTheHand2%5B1%5D.ppt

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