Injuries and Diseases of Hand and Wrist Su-Yang Hwa Department of Orthopaedics Tri-Service General Hospital National Defense Medical Center

Contents Anatomy and Physical Examination of the Hand Phalangeal Fractures and Dislocations Fractures and Dislocations Involving the Metacarpal bone Fractures and Dislocations of the Thumb Thumb Reconstruction Distal Radius Fractures Distal Radio-ulnar Joint and Triangular Fibro- cartilage Complex Scaphoid Fractures and Nonunions Kienbock disease Carpal Bone Fractures Excluding the Scaphoid Carpal Instability including Dislocations

Anatomy and Physical Examination of the Hand

Fig. Terminology for describing forearm, hand, and digital motion Fig. Terminology for describing forearm, hand, and digital motion. (From Seiler JG III. Essentials of hand surgery, Lippincott Williams & Wilkins, Philadelphia, PA, 2002, with permission)

Fig. The biconcave surfaces of the thumb carpometacarpal joint allow thumb rotation, flexion/extension, and abduction/ adduction. MCI, Thumb metacarpal; Tz, trapezium. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Hand dressing: “safe” position of fingers. (From Seiler JG III Fig. Hand dressing: “safe” position of fingers. (From Seiler JG III. Essentials of hand surgery, Lippincott Williams & Wilkins, Philadelphia, PA, 2002, with permission)

Fig. Surface anatomy if the palm Fig. Surface anatomy if the palm. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Felon, pulp infection (pain, flexion deformity, swelling, warm , pus formation) Fig. Drainage of a felon using a mid-lateral incision. Complete division of the vertical septae should be performed. (From Seiler JG III. Essentials of hand surgery, Lippincott Williams & Wilkins, Philadelphia, PA, 2002, with permission)

Fig. Anatomy of the palmar plate if the proximal interphalangeal joint Fig. Anatomy of the palmar plate if the proximal interphalangeal joint. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Palmar extraarticular wrist ligaments Fig. Palmar extraarticular wrist ligaments. C, Capitate; H, Hamate; L, Lunate; P, Pisiform; R, Radius; S, Scaphiod; Tp, Trapezoid; Tz, Trapezium; U, Ulna. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Diagrammatic representation of the extraarticular dorsal wrist ligaments. C, Capitate; H, Hamate; L, Lunate; P, Pisiform; R, Radius; S, Scaphoid; Tp, Trapezoid; Tz, Trapezium; U, Ulna. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Schematic representation of the Guyon’s canal add its contents Fig. Schematic representation of the Guyon’s canal add its contents. FCU, Flexor carpi ulnaris. (Courtesy of Jason R. Izzi, D.M.D.) Guyon canal

Fig. The six dorsal compartments of the extensor tendons Fig. The six dorsal compartments of the extensor tendons. APL, Abductor pollicis longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDM, extensor digiti minimi; EIP, extensor indicis proprius; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; MC, metacarpal. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

De Quervian’s disease (stenosing of first extensor retinaculum (APL De Quervian’s disease (stenosing of first extensor retinaculum (APL. EPB tendons) Fig. Clinical photograph of the Finkelstein’s test.

Fig. The flexor tendon sheath is composed of annular pulleys and crucuate pulleys. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Sagittal bands of the extensor mechanism provide for extension of the metacarpophalangeal joint. FDP, Flexor digitorum profundus; FDS, flexor digitorum superficialis. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.) Fig. The transverse band of the extensor mechanism provides for flexion of the metacarpophalangeal joint. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Four dorsal interossei provide abduction and three volar interossei provide adduction of the fingers. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Intrinsinc minus Intrinsinc plus Fig. The lumbrical muscles function to the flex the metacapophalangeal joint and extend the proximal interphalangeal joint. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. The muscles of the thenar eminence include the abductor pollicis brevis (APB), flexor pollicis brevis (FPB), opponens, and adductor pollicis. FCR, Flexor carpi radialis; FCU, flexor carpi ulnaris; FDS, flexor digitorum superficialis; FPL, flexor pollicis longus. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Sensory patterns of the median ulnar and radial nerves for the palm (left view) and dorsum (right view) of the hand. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Anatomy of the dorsal sensory nerves of the hand on the palm (left view) and dorsum (right view). (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. Positive Froment’s sign with thumb interphalangeal joint flexion to compensate for paralysis of abductor pollicis muscle indicates a low ulnar nerve palsy. EPL, Flexor pollicis longus. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. The Allen test to evaluate patency of the radial and ulnar arteries. (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)

Fig. A: When the digit is flexed, the deformity is quite apparent Fig. A: When the digit is flexed, the deformity is quite apparent. B: Active finger flexion generates malrotation of ring finger with digital overlapping. (From Seiler JG III. Essentials of hand surgery, Lippincott Williams & Wilkins, Philadelphia, PA, 2002, with permission)

Fig. Rupture of ulnar collateral ligament of the metacarpophalangeal joint of the thumb. (From Seiler JG III. Essentials of hand surgery, Lippincott Williams & Wilkins, Philadelphia, PA, 2002, with permission)

Fig. A: Mechanism. Due to the extensor apparatus lesion, the digital phalanx flexes by effect of the flexor profundus tendon. The proximal stump of the distal conjoined extensor tendon retracts in a proximal direction and consequently the lateral bands are slack initially and later contract and displace dorsally. Due to the concentration of the extension forces over the middle phalanx, the PIP joint is progressively set in hyperextension. B: Various splints (dorsal padded aluminum splint, volar padded aluminum splint, concave aluminum splint). Dorsal padded aluminum splint allows adjustable fixation of the DIP joint. (From Peimer CA. Surgery of the hand and upper extremity. New York: McGraw-Hill, 1996, with permission.)

Fig. Hand dressing: “safe” position of fingers. (From Seiler JG III Fig. Hand dressing: “safe” position of fingers. (From Seiler JG III. Essentials of hand surgery, Lippincott Williams & Wilkins, Philadelphia, PA, 2002, with permission)

Fig. Retinacular pulley system Fig. Retinacular pulley system. A, Annual pulley, with flexor digitorum superficialis omitted. B and C, demonstration of function of annual pulleys and tendon bowstringing with absent A-2 and A-4. Fig. Zones of flexor tendon injury. Zone II: “no man’s land.”

Stage I Kienböck’s disease.

Fig. Schematic drawing of the arterial supply of the palmar aspect of the carpus. Circulation of the wrist is obtained through the radial, ulnar, and anterior interosseous arteries and the deep palmar arch: 1, palmar radiocarpal arch: 2, palmar branch of anterior interosseous artery; 3, palmar intercarpal arch; 4, deep palmar arch; and 5, recurrent artery. (From Bucholz RW, Heckman, JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Fig. Schematic drawing of carpal instability Fig. Schematic drawing of carpal instability. (A) Normal longitudinal alignment of the carpal bones with the scaphoid axis at a 47-degree angle to the axes of the capitate, lunate, and radius. (B) A volar intercalated segmental instability (VISI) deformity is usually associated with disruption of the lunatotriquetral ligament. (C) A dorsal intercalated segmental instability (DISI) deformity is associated with scapholunate ligament disruption or a displaced scaphoid fracture. (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Baltimore: Lippincott Williams & Wilkins, 2005.)

Fig. Vulnerable zones of the carpus Fig. Vulnerable zones of the carpus. (A) A lesser arch injury follows a curved path through the radial styloid, midcarpal joint, and the lunatotriquetral space. A greater arc injury passes through the scaphoid, capitate, and triquetrum. (B) Lesser and greater arc injuries can be considered as three stages of the perilunate fracture or ligament instabilities. (From Johnson RP. The acutely injured wrist and its residuals. Clin Orthop 1980;149:33-44.)

Fig. Left: The collateral ligaments of the metacarpophalangeal joints are relaxed in extension, permitting lateral motion, but they become taut when the joint is fully flexed. This occurs because of the unique shape of the metacarpal head, which acts as a cam. Right: The distance from the pivot point of the metacarpal to the phalanx in extension is less than the distance in flexion, so the collateral ligament is tight when the joint is flexed. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:659.)

Fig. Redcution of metacarpal fractures can be accomplished by using the digit to control the distal fragment, but the proximal interphalangeal joint should be extended rather than flexed. (From Bucholz RW, Heckman, JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Fig. Displacement if Bennett fractures is driven primarily by the abductor pollicis longus and the adductor pollicis resulting in flexion, supination, and proximal migration. (From Bucholz RW, Heckman, JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Fig. Top: A lateral view, showing the prolonged insertin of the superficialis tendon into the middle phalanx. Center: A fracture through the neck of the middle phalanx is likely to have a volar angulation because the proximal fragment is flexed by the strong pull of the superficialis. Bottom: A fracture through the base of the middle phalnx is more likely to have a dorsal angulation because of the extension force of the central slip on the proximal fragment and a flexion force on the distal fragment by the superficialis. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:627.)

Fig. Simple metacrpophalangeal joint dislocations are spontaneusly reducible and usually present in an extended posture with the articular surface of P1 sitting on the dorsum of the metacarpal head. Complex dislocations have bayonet apposition with volar plate interposition that prevents reduction. (From Bucholz RW, Heckman, JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Fig. The Stener lesion: The adductor aponeurosis proximal edge function as a shelf that blocks the distal phalangeal insertion of the ruptured ulnar collateral ligament of the thumb metacarpophalangeal joint from returning to its natural location for healing after it comes to lie on top of the aponeurosis. (From Bucholz RW, Heckman, JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)

Fig. Galeazzi fracture in a 40-year-old male.

Fig. Intraarticular distal radius fractures Fig. Intraarticular distal radius fractures. (Reproduced by permission from Melone CP Jr: Open treatment for displaced articular fractures of the distal radius. Clin Orthop 1986; 202:103.)

Fig. Distal radius fracture treated with external and internal fixation.

A B Fig. A. PA view of perlinate dislocation. B. Lateral view of perilunate dislication.

Fig. Unstable transverse fracture of metacarpal shat.

Fig. Forces causing unstable proximal phalanx fracture Fig. Forces causing unstable proximal phalanx fracture. [Reproduced and modified with permission from the American Society for Surgery of the Hand (ASSH): Fracture of the hand. In ASSH 1996 Regional Review Course Syllabus. Englewood, CO: 1996;9-6.]

Fig. Salter type IV fracture of proximal phalanx.

Fig. Complex dorsal dislocation MP joint with interposition Volar plate. [Reproduced and modified with permission from the American Society for Surgery of the Hand (ASSH): Articular fractures and joint injuries. In ASSH 1996 Regional Review Course Syllabus. Englewood, CO: 1996;9-14.]

Fig. Stener lesions (interposition of adductor aponeurosis) Fig. Stener lesions (interposition of adductor aponeurosis). [Reproduced and modified with permission from the American Society for Surgery of the Hand (ASSH): Articulr fractures and joint injuries. In ASSH 1996 Regional Review Course Syllabus. Englewood, CO: 1996;9-16.]