5HAND & FINGER ANATOMY 9 Finger Flexors Median nerve Transverse carpal ligament5 deep flexors pass through superficialis tendons and insert on distal phalanx of each finger and thumb4 superficial flexors insert on middle phalanx of digits 2-5Annular ligaments = pulleys (A1-A5)PREVENT BOWSTRINGING
7HAND ANATOMY VOLAR PLATE COLLATERAL LIGAMENTS Thickened portion of joint capsuleStatic stabilizer (hyperextension)COLLATERAL LIGAMENTSMedial and lateral stabilityMaximally tight at____ degrees MCP flexion____ degrees PIP flexion____ degrees DIP flexionCollaterals will be maximally lengthened at this tightness so beneficial for immobilizing703015
8HAND ANATOMY digits FLEXOR Extensor FDP FDS Volar plate Central bands Lateral bands
9Finger AnatomyFigure 1.Anatomy of the finger. (A) Joints and ligaments. (B) Tendons.
10NERVES OF THE HAND RADIAL MEDIAN ULNAR WRIST AND FINGER EXTENSION THENAR COMPARTMENT, OPPOSITION, PINCER GRIPINTRINSIC MUSCLESPOWER GRIP
11How I Will Approach Each Problem What is it?Does it need any special imaging?How do I treat it?What are the indications for surgery?I will give a case for many of themReferral different for each person- non-dominant pinky vs. dominant, concert pianist
12Finger Injury PearlsTreatment should restrict motion of the injured structures while allowing uninjured joints to remain mobilePatients should be counseled that it is not unusual for an injured digit to remain swollen for some time and that permanent deformity is possible even after treatment
14MALLET FINGER ANATOMY MECHANISM: TREATMENT: COMPLICATIONS: Dorsal avulsionExtensor digitorum tendon tearMECHANISM:Forced flexion of extended digitTREATMENT:No fracture: DIP extended for 6-8 weeksFRACTURE: if <30% joint surface, splint x 4 weeksIf >30% Might need ORIFLess than full passive extension?????COMPLICATIONS:Pressure necrosis from splintPermanent extensor lag
15Mallet Finger Presentation Pain at dorsal DIP jointInability to actively extend the jointCharacteristic flexion deformityOn exam, very important to isolate the DIP joint to ensure extension from DIP and not the central slipIf can’t passively extend consider bony entrapmentAll of these need x-raysFigure 2.Injury to the joint extensor tendon at the distal interphalangeal joint (mallet finger)
16Flexor Digitorum Profundus Tendon Injury (jersey finger) Athlete’s finger catches another player’s clothingForced extension of the DIP joint during active flexion75% occur in the ring fingerForce can be concentrated at the middle or distal phalanx-Flexor digitorum profundus tendon inserts into the base of the distal phalanx- volar base-Relatively uncommon, but devastating is missedThe true definition is a bony injuryIf not fixed by 2 weeks the blood supply is so limited that it needs to necrosis of the finger
17JERSEY FINGER ANATOMY: MECHANISM: TREATMENT: Tendon retracts Avulsion fragment may limit retractionBlood supply compromisedMECHANISM:Forced extension of flexed fingerTREATMENT:Refer immediatelyCOMPLICATIONS:Permanent loss of flexion
18JERSEY FINGER EXAM FINDINGS: Unable to flex isolated DIP Localized tenderness along flexor tendonFDP: hold PIP straight and flex DIPFDS: hold MCP straight and flex PIP or hold all fingers in extension except affected and flex
19Jersey Finger Treatment/ Referral All need to be referred for surgery immediatelyTendon retractsAvulsion fragment may limit retractionBlood supply compromisedPermanent loss of flexion
20CENTRAL SLIP AVULSION ANATOMY MECHANISM: Extensor digitorum communis tendon disruptionLateral bands migrate in volar directionMECHANISM:Volar-directed force on middle phalanx against semi-flexed finger attempting to extend
21CENTRAL SLIP AVULSION EXAM: TREATMENT COMPLICATIONS: Pain, swelling over dorsal PIPPIP in degrees flexionMay have limited extension (better at 0 degrees than 30 degrees)TREATMENTSurgery if >30% joint surface involved with avulsion fxPIP splint in full extension 4-5 weeksProtect 6-8 weeks for sports*allow DIP to flex- relocates lateral bandsCOMPLICATIONS:Boutonierre deformity
22Central Slip Extensor Tendon Injury- Boutonnière deformity PIP joint is forcibly flexed while actively extendedVolar dislocation of the PIP jointExamine with PIP joint in degrees of flexion, can’t active extend but can passively extendTenderness over dorsal aspect of the middle phalanxCommonly occurs in basketballFigure 6.Boutonniére deformity caused by a central slip extensor tendon injury. (A) Normal alignment. (B) Boutonniére deformity.
23Central Slip Extensor Tendon Injury Treatment A delay in proper treatment will cause boutonniere deformityDeformity can develop over several weeks or occasionally acutelySplint PIP in extension for 6 weeksCan still play sportsBoutonnier- flexion of PIP coupled with extension of MCP and DIPTakes several weeks- lateral bands slip inferiorly
24Central Slip Extensor Tendon Injury ,Surgery Avulsion fracture involving more than 30 percent of the jointInability to achieve full passive extension
25Volar Plate Injury Hyperextension, such as dorsal dislocation PIP is usually affectedCollateral damage is often presentThe loss of joint stability can cause hyperextension deformity
26VOLAR PLATE RUPTURE EXAM FINDINGS: MECHANISM: Tender volar PIP Bruising, swellingMECHANISM:Hyperextension injuryRuptures distally from attachment at middle phalanx
27VOLAR PLATE RUPTURE TREATMENT: COMPLICATIONS: Early mobilization Extension block splintBuddy tapeSurgery if >30% joint involvedCOMPLICATIONS:Swan neck deformity: extensor tendons pull PIP into hyperextension, DIP flexionSwan Neck Deformity
28Volar Plate Injury- Treatment Progressive splinting starting at 30 degrees flexionFollowed by buddy tapingIf less severe, can buddy tape immediatelyCan play sports if splinted
30Collateral Ligament Injuries Forced ulnar or radial deviationCan cause partial or complete tearPIP is usually involvedPresent with pain at the affected ligamentEvaluate with involved joint at 30 degrees of flexion and MCP at 90 degrees of flexion
31Collateral Ligament Injuries- Treatment If joint stable and no large fracture- can buddy tapeNever leave the pinky alone?Physical Therapy- if joint stiffFigure 7.Buddy taping for the treatment of finger injuries. (A) Self-adhesive wrap. (B) Velcro wrap.
32Finger CaseUltimate frisbee player tried dove to block an opponents disc and he jammed his thumb on the ground. He was able to keep playing but it swelled and became ecchymotic.
33GAMEKEEPER’S THUMB Hyperabduction of thumb EXAM: Weak, painful pinch MECHANISMHyperabduction of thumbEXAM:Weak, painful pinchPain over ulnar thumbXRAYS BEFORE STRESSType I: avulsion, no displacement; Type II: avulsion, displaced; Type III: torn ligament, stable in flexion; Type IV: torn ligament, unstable flexion
34GAMEKEEPER’S THUMB SIGNS Pain over ulnar thumb Stress testing positive Testing in Extension and 40 degrees of FLEXION of MCPWith extension or slight flexion the normally taut volar plate gives MCP stabilityType I: avulsion, no displacement; Type II: avulsion, displaced; Type III: torn ligament, stable in flexion; Type IV: torn ligament, unstable flexion
35Ulnar Collateral Ligament Injury of the Thumb (Skier’s Thumb) Caused by forced abduction of the 1st MCP jointLeft untreated the joint will be unstable with weak grip strength
36Skier’s Thumb- Diagnosis Difficulty opposing pinky to thumbSwelling and black and blue over thenar eminenceCan’t hold an OK signConsider digital block and to facilitate ligament testingKim does not digital block, nor has she ever seen anybody do it
37Stener LesionFigure 8. Stener lesion. Note that the proximal end of the UCL displaces outside of the adductoraponeurosis. (UCL = ulnar collateral ligament.)Adductor Aponeurosis: fibers of the adductor pollicis tendon (intrinsic hand muscle) with fibers of the extensor aponeurosisOne of the big debate is when to get the MRI.Pt. wants to avoid the OR. Fine after a cast for 6 weeks because stiff but will loosen up. MRI can help show the patient.
38Skier’s Thumb Grading/Treatment Grade 1Pain without instability with stressSplinting 1-2 weeksGrade 2Pain with mild instability: gapping <20 degreesCasting 3-6 weeksGrade 3Stenner’s LesionInstability: gapping > 20 degrees or > 35 degrees compared to unaffect thumbEarly surgical intervention within 2-3 weeks
41Distal Tuft Fractures Common due to crush injuries Painful Splint in extension for 3 weeks
42Proximal and Middle Phalange Fractures Most common in athletesFall or direct blunt traumaMore difficult than metacarpal fracturesClose relationship between fractured bone and pulley system
43Rotational Alignment Figure 4. Detecting rotation in middle phalanx fractures. If no rotation is present, all fingertips will be on the same plane and pointing toward the scaphoid bone. (A) No rotation. (B) Rotation.Reducing fractures?Hematoma block?Check the other hand, it can be the baselineCan passively extend the wrist and will cause the fingers to flex
44Middle and Proximal Phalangeal Fractures Might need Surgery:Inability to maintain proper alignmentRotationIrreducible InjuryIntra-articular fracture
45Finger Case16 year old baseball player had a frustrating discussion with his coach about playing time so punched a locker.He immediately developed pain over the outside aspect of his right hand and lost the normal morphology of the 5th knuckle.
46Metacarpal Fractures Common hand fracture Usually involves the neck 30-35%Usually involves the neckFight or fall common mechanism4TH and 5th most common fractures
47Metacarpal Fracture Treatment Angulation up to 40+ degrees can be toleratedAttempt reduction?Different cast typesStatius, et al, Immediate immobilization gives good results in boxer’s fractures with volar angulation up to 70 degrees: a prospective randomized trial comparing immediate mobilization with cast immobolization. Arch Orthop Trauma Surg 2003;123:534-7Kim rarely operates on theseStatius, Arch Orthop Trauma Surg 2003;123:534-7
48Metacarpal Shaft Fractures Diagnosis Present with edema over the dorsum of the handPoint tenderEcchymosisThe distal fragment usually displaces volarly due to the interosseous musclesRadiographs: AP, lateral, oblique
49Metacarpal Fracture-Complications MalrotationCommon with spiral or oblique fracturesGreater than 10% malrotation leads to scissoring effect of the fingersMetacarpal headLoss of knuckleCan you feel the metacarpal head in the palm- if hockey or stick handling can be a problemCan have an extensor lag that gets better over time
50THUMB CMC FRACTURE DISLOCATION (BENNETT’S FRACTURE) Anatomy:Anterior oblique carpometacarpal ligament holds palmar fragment in normal anatomic positionAbductor pollicis longus (APL) pulls metacarpal shaft fragment radial & dorsalTreatmentReductionTraction, abduction, extension, pronationOften unstable, requires surgeryAOCMC ligament also attaches to trapeziumTriangular fragment = palmar beak fragment
51ROLANDO’S FRACTURE ANATOMY TREATMENT 3 part fracture at metacarpal baseComminuted with “Y” or “T” fragmentTREATMENTMay be non-surgical if highly comminutedSurgery if fragments are large and amenable
52DIP JOINT DISLOCATION MECHANISM ANATOMY TREATMENT Hyperextension, varus/valgus forcesANATOMYUsually dorsalRareStrong collateral ligaments usually preventTREATMENTReduction: digital block firstSplint in degrees flexion for days
53PIP JOINT DORSAL DISLOCATION (COACH’S FINGER) MECHANISMHyperextension with disruption of volar plateANATOMYLoss of volar stabilizing force causes phalanx to ride dorsallyTREATMENTReduction: avoid longitudinal tractionPost-reduction: dorsal extension block splint with PIP blocked at degrees flexionBEWARE OF THE VOLAR DISLOCATIONPROXIMAL PHALANX CONDYLE BUTTONHOLES THROUGH THE TORN EXTENSOR MECHANISMOFTEN CAN’T BE CLOSED REDUCEDBayonet deformityTraction allows for soft tissue interposition
54Proximal PIP dorsal dislocation (Coach’s Finger) Most common dislocated joint in the bodyCan injure the volar plate or cause an avulsion fracture of the middle phalanxThe severity of this injury often is underestimated and improper treatment can cause long-term morbidityFigure 2.Reduction technique for proximal interphalangeal joint dislocations. Apply distal tension on the injured finger while applying volarly directed pressure to the middle phalanx. Hold the proximal phalanx in place while applying counterpressure.
55Proximal PIP dorsal dislocation- Reduction Reduce via minimal longitudinal tractionIf initially unsuccessful should hyperextend the distal portion to unlockI had to use sticky spray during football game one timePut the wrist into flexion because it relaxes the flexor tendonThere is often a rotator component- a Chinese finger trap- gently
56Post Reduction CareRadiographs should be obtained to ensure joint congruityExamine collateralsPIP should be splinted in less than 30 degreesX-ray in the splintLocal for the dorsal V sign on the lateral
59Ganglion CystAccount for 60% of soft tissue, tumor-like swelling affected the hand and wristDevelop spontaneously in year oldsFemale to male, 3:1Cyst filled with soft, gelatinous, sticky, and mucoid fluidLocation65% dorsal scapholunate joint20-25% volar distal aspect of the radius10-15% flexor tendon sheathMass generated from chronic irritation of the wrist that cause fluid productionExcess fluid leaks into subcutaneous space where a cyst is formed
60Ganglion Cyst Diagnosis Usually obvious on exam- may be helpful to flex and extend wristRadiographs, ultrasound, or MR not usually indicatedIf they have had trauma look for scapholunate dissocationThey come from the SC joint
61Ganglion Cyst- Treatment Watchful waiting- most resolve spontaneously over timeAspiration/InjectionNo recurrence in 27-67% of patientsGive patients reassurance when they see gelitanous fluid that it is not a cystCan transiluminate
62Ganglion Cyst Surgery Patient preference Pain Cosmetic? 20% recurrence ratesBump vs. a scarThe smaller ones tend to be more painful-proximal interosseous nerve- motor branch of the radial nerve
63Wrist Case24-year-old male FOOSH (fell on outstretched hand) while skiing over the weekendSeen at the mountain clinic and told “wrist sprain”
64Scaphoid Fracture Most common fractured bone in the wrist Peanut shaped bone that spans both row of carpal bonesDoes not require excessive force and often not extremely painful so can be delayed presentationI have missed one of these- football player, initial x-ray was normal and pain was on his distal radiusIf missed can develop long term arthritis
65Scaphoid Fracture Presentation Pain over the anatomic snuff boxPain is not usually severeOften present late
66Scaphoid Fracture Pathoanatomy Blood supplied from distal poleIn Adolescents, mostly involve distal poleIn adults, mostly involve waistTreatment depends on location of fracture
67Imaging AP, lateral, oblique and scaphoid view Radiographs can be delayed for up to 4 weeks?MRI, bone scan, or treat and repeat film
69Scaphoid Fracture Imaging Initial plain films often normalBone scan 100% sensitive and 92% specific at 4 daysMRI, CT scan
70SCAPHOID FRACTURE TREATMENT Initial radiographs positive distal third heal in approx 6-8 weeksmiddle third frx heal in 8-12 weeksproximal third heal in weeksInitial radiographs negativeMRIImmobilize thumb spica cast x 7-14 daysTake out of cast, re-evaluate for tendernessIf +tenderness but neg radiographs….
71Scaphoid Fracture Surgery: Angulated or displaced (1mm) Non-union or AVNScapholunate dissociationProximal fracturesLate presentationEarly return to play
72Non Operative Treatment- Disadvantages Nonunion rate could be HIGHMal-union“cast disease”- joint stiffnessProlonged immobilization- sometimes >12 weeksLoss of time from employment
73Union Rates 100%High Union Rates- approaches 100%73
74Wrist Case34-year-old female hairdresser with thumb pain for 2-3 monthsGradual onsetNow thumb hurts with any movement
75Wrist Case 4The College player starting softball shortstop presented with pain at the base of her left thumb.It was aggravated by hitting when she rolled her left hand over the top.
76DeQuervain’s Tenosynovitis Pain due to inflammation of the short extensor and abductor tendons of the thumbRepetitive or unaccustomed griping and grasping causes friction over the distal radial styloid
77DeQuervain’s Tenosynovitis: Diagnosis Swelling and pain over 1st dorsal compartment+Finkelstein’s test
78DeQuervain’s Tenosynovitis: Treatment SplintInjection- 1st lineup to 90% are pain free if injected within 6 monthsSplinting performs poorly in comparison to steroid injectionPost injection flare!Splint for a couple weeks after the injectionColdham F.. British Journal of Hand Therapy.2006
79DeQuervain’s Tenosynovitis, Surgery Recurrence despite repeated injectionsIf don’t respond cut the sheet volarly
80Wrist CaseAn College crew athlete presented following spring break training trip in Georgia.She reported pain distal dorsal forearm, accompanied by swelling, and palpable/audible crepitus.
81Intersection syndrome Friction point where muscle bellies of 1st compartment- APL, EPB cross 2nd and 3rd dorsal compartmentsInflammatory peritendinitisCommon with rowers due to clenched fist and thumb abductionFriction and crepitus felt 4-5cm proximal to radial styloid with rest flexion and extension and radial deviationCompartment1: (APL) abductor pollicus longus (mid ulna-base of 1st metacarpal), (EPB) Extensor pollicis brevis (distal ulna-base of proximal phalange)Compartment 2: Extensor carpi radialis longus (humerus-base of 2nd metacarpal), Extensor carpi radialis brevis (common extensor bundle to base of 3rd metacarpal)Compartment 3: Extensor pollicis Longus (distal to APL and proximal to EPB on the ulna-base of distal thumb phalange)About a 60 degree angle between.Also seen in skiers due to poling
82Intersection Syndrome Diagnosis Pain and swelling about 2-3 finger breadths proximal to dorsal wrist jointPalpable crepitus (“squeaker’s wrist”)Fig. 2A. —28-year-old male tennis player who presented with tender mass on distal forearm. Axial T2-weighted fat-suppressed fast spin-echo image (TR/TEeff, 2,300/88) shows peritendinous and subcutaneous edema (arrow) in region of intersection of first extensor compartment and second extensor compartment tendons. Individual tendons are not well discerned.
88Scapholunate Dissociation Most common ligamentous instability of the wristPatients may have high degree of pain despite apparently normal radiographsPhysicians should suspect this injury if patient has wrist effusion and pain seemingly out of proportion to the injuryIf improperly diagnosed can lead to chronic painLocated proximal axial line from 3rd metacarpalAlso can lead to arthritis in years
89Scapholunate Dissociation- Diagnosis ExamWatson’s testScaphoid shuck testPain/swelling over dorsal wrist, proximal rowImagingPlain films: >3mm difference on clenched fist viewScaphoid ring signGrab the distal pole scaphoid and then when radial deviate you should feel it push your finger awayAlways get comparison viewsThe scaphoid falls into flexion and looks like a ring
90Scapholunate Dissociation Treatment If discovered within 4 weeks, surgeryAfter 4 weeks, conservative treatment reasonableBracingNSAIDSDelayed Surgery
91Triangular Fibrocartilage Complex (TFCC) Tear Fall on dorsiflexed and ulnar deviated wristAxial load with forearm in hyperpronation
93TFCC Tear Pathoanatomy Tear in structures of TFCCPositive ulnar variance predisposes to injury
94Triangular Fibrocartilage Complex (TFCC) Tear Fall on dorsiflexed and ulnar deviated wristAxial load with forearm in hyperpronationPositive ulnar variance predisposes to injuryBecause they bear more weight at the wrist,Normally 80/20 but longer ulna is 60/40- Measurement: - requires zero rotation view: (measured on PA radiograph w/ wrist in neutral supination/pronation); - draw transverse line at the level of the lunate fossa, and a second transverse line at the level of the ulnar head; - the difference indicates ulnar variance;
95TFCC Tear HistoryUlnar-sided wrist pain aggravated by pronation/ supination
100GOLFER’S FRACTURE Hook of hamate fracture Swing of golf club2% of all carpal fractures1/3 of all hamate fractures = golf relatedDistal lateral border of Guyon’s CanalHigh rate of non-unionMay consider early operative treatment
111Climbing InjuriesClimbers are susceptible to overuse injuries of the upper limb: Studies consistently report a high prevalence of finger related injuries (Jones et al, 2008; Shoffl et al, 2003)Disruption of the annular pulley system (particularly A2)Rotator cuff and shoulder impingement syndromes which are associated with prolonged and repeated reaching overhead (Peters, 2001)Tendonopathies
112Why are the fingers susceptible ? During the crimp grip wrist extension increases the mechanical advantage of the finger flexors and reduces active insufficiency (Lockwood, 1998)Paradoxically this hand position may increase the pre-disposition of the climber to injury (Joel et al, 2000)
113Why the 3rd & 4th fingers ?Flexion of the remaining fingers when holding a one finger pocket may increase the maximum holding force up to 48% (Shweizer, 2001)Lumbrical tears to the third or fourth lumbrical may occur if the finger is dynamically loaded (Shweizer 2003)Due to the musculotendonous interconnection of flexor digitorum profundus
114Carpal Tunnel Syndrome Most common nerve entrapment disorderPain and parasthesias from high pressures in the carpal tunnel causing compression and inflammation of the median nerveCarpal bones dorsally and transverse carpal ligament (flexor retinaculum) ventrallyMedian nerve compression: osteoarthritis, rheumatoid arthritis, diabetes, hypothyroidism, repetitive use, trauma, pregnancy
116Hand Diagrams Tinel + hand diagram – PPV = 0.71 Ann Intern Med 1990 Mar 1;112(5):321-7.
117Carpal Tunnel Syndrome Always compare with the unaffected sideDocument when phalen’s becomes +Durken’s compressive test- higher sensitivity
118Sensitivity and Specificity For both Phalen’s and Tinel’s is LOWHigh Combined with hand diagram and historyAnn Intern Med 1990 Mar 1;112(5):321-7
119Nerve Conduction Study Can be painful and costlyReserve for patients whohave failed conservative therapydiagnosis is uncertainlate presentation with thenar wasting and motor dysfunctionFalse negative rates as high as 10%AAOS guidelineHowever, does not help surgery decisionCan help with mild carpal tunnel-night time symptomsOperateAlways have symptomsDennervation of thenar musclesJ Hand Surg [Am] 1995 Sep;20(5):848-54
120Carpal Tunnel Syndrome Diagnosis Pain involves thumb, first two fingers and radial half of the fourth fingerPalpation: thenar eminence wastingROM: thumb weakness and difficulty pincher graspingDiagnostic Tests or special maneuversNerve conduction studiesTinel’sPhalen’sNight time symptoms most common
122Carpal Tunnel Injection Short term efficacy: RCT, 70% vs 34% at 2 weeksLong-term benefits are more variable43% of patients above required referral to surgeryShould not inject into the nerve-the median nerve can go out- should not inject severe carpal tunnel- wrist to surgeryGood for pregnant peopleKim does not inject-PregnancyOld peopletraumaInjection technique: 23-25g needle: 20-40mg Methylprednisolone.Muscle Nerve 2004 Jan;29(1):82-8
123Carpal Tunnel Syndrome Surgery Constant numbness and tinglingThenar eminence wastingIf get EMG: Severe carpal tunnel or dennervation