1. Michael Shuler, MD Athens Orthopedic Clinic Aug 2018
Common Hand Injuries
Michael Shuler, MD
Athens Orthopedic Clinic
Aug 2018

2. Overview: Start at finger tips work proximal Review
Anatomy
Physical Exam
Studies
Treatment
Focus on common injuries

3. Finger Injuries: Mallet Finger Jersey Finger Phalanx Fractures
Dislocations
Flexor Tendon Injuries
Extensor Tendon Injuries

4. Mallet Finger: Forced flexion of extended finger
Attachment of terminal slip (ext tendon)
Boney or tendon only
Intra-articular fx of
dorsal lip of distal phalanx

5. Mallet Fx:
DIP sag/droop
No active Extension

6. Imaging Always get Xrays Boney involvement?
Joint dislocation/subluxation?
Amount of articular involvement?

7. Treatment:
Sometimes can be treated with splint if no boney involvement or small boney fx
Must keep splint on (at all times) x 8 wks
Must start over if let finger droop

8. Treatment Surgery: CRPP vs. ORIF MUST BE COMPLIANT IF NON-OP!
>30-50% of joint
Joint subluxation
Unreliable Pt
(will not wear splint)
CRPP vs. ORIF
MUST BE
COMPLIANT IF
NON-OP!

9. Mallet Finger
These can be a mess if you do not treat them appropriately

10. Complications
If not treated…
Swan Neck Deformity

11. Jersey Finger
This is not a Jersey Finger!

12. Jersey Finger Fracture or rupture of FDP Rupture occurs at insertion
of distal phalanx
Forced extension with
finger flexed
Most commonly
the ring finger

13. Jersey Finger

14. Exam Finger fully extended at DIP Disruption of the normal cascade of
No counter balance to extensor tendon
Unable to flex DIP
Disruption of the
normal cascade of
fingers

15. Classification Zone 1: Zone 2 Zone 3 Retraction to palm-
Urgent treatment needed
Within 1-2 wks or
cannot repair primarily
Zone 2
Retraction to PIP joint- Urgent repair
Zone 3
No retraction
Typically associated with boney fragment
Less urgent (3-4 weeks)

16. Imaging Clinical Dx Xrays for boney fragment MRI- but can take a
long time to get

17. Treatment This is a surgical injury Repair flexor tendon
All should be treated as
Type I (FDP in palm)
Treat within 1-2 wks
or cannot fix primarily

18. Jersey Finger If not treated acutely… Tendon grafts & staged repair
Must graft or fuse
Tendon grafts &
staged repair

19. Central Slip Rupture Similar mech to Boney Mallet
But unable to extend PIP
Can lead to Boutonniere Deformity
Can sometimes treat with splint
PIP in extension (MCP & DIP free)
Can repair late but must have good motion before surgery

20. Phalanx Fx Finger fractures
Balance between holding still (fracture) & getting stiff
Do not splint >3-4 wks
Intrinsic plus splints
Limit the joints you immobilize
Buddy tape to provide stability

21. Intrinsic Plus MCP’s flexed IP’s Extended
Vital for preventing/limiting stiffness

22. Intrinsic Plus MCP flexed- PIP Extended Collateral ligament tension
Volar plate contracture

23. Surgical Indications Intra-articular Displaced Angulated Rotated
All fingers should point
to the proximal pole of
scaphoid
Fingers are not straight-
some rotation is normal

24. Phalanx Fx Seems innocuous & can be But can cause a lot of morbidity
Malunions can be very difficult to correct
Easier to treat
correctly initially

25. Finger Dislocations Typically easily reducible- traction
If stable- buddy tape & let move
If unstable- refer to specialist
Do not splint for extended periods of time
< 1-2 wk in a static splint

26. Buddy Taping

27. Finger Dislocations Irreducible? MCP: PIP: Do not pull traction-
Manually manipulate
MCP:
Volar plate interposition
PIP:
Caught between
lateral band &
central slip

28. Flexor Tendon Injuries

29. Flexor Tendons Very common injury
Reason why hand surgery specialty was invented
Historically terrible outcomes
Balance between stiffness & rupture of repair
Goal is to repair well enough to allow immediate motion

30. Flexor Tendons
It’s a tight fit

31. Anatomy Two Tendons: FDS & FDP Camper’s Chiasm Vincula- Vascular
supply

32. Anatomy Pulley System A1-A5
Must preserve/repair A2 & A4 (Bowstringing)
C1-C3 (over joints)

33. Vascular & Nerve Injury
Very common with flexor tendon lacerations
Check with any lacerations
Nerve (2 per finger)
Digital nerve on each side of Finger
Decreased LT
2pt Discrimination (>6-8mm)
Vascular (2 per finger)
Digital artery on each side of finger
Digital Allen’s Test

34. Vascular Injuries: ADD- Artery Dorsal Digit
Nerve out likely vessel out too
Cap refill?
Prick finger with small needle (25-30g needle)
Disvascular- urgent care (referral to specialist)
Replant, revasc, facilities, team, experience…
Cut/saw/stretch/crush/tear…
As long as vascularized- can typically be sutured & seen in am for definitive correction

35. Exam
Inspection:
Normal Cascade?

36. Tenodesis Flex Wrist > Extension of Fingers
Extend Wrist > Flexion of Fingers

37. Always examine each finger independently!
Exam: Movement
FDP
L-R-S single muscle belly
Bend DIP (tip)
FDS
Bend PIP
Independent muscle bellies
Small absent 21%
Always examine each finger independently!

38. Imaging This is a clinical Dx X-rays for boney injury MRI Ultrasound
Always check for
boney injury
MRI
Can take several days
Ultrasound
Quicker to get- more difficult to read?

39. Treatment CLOSE all wounds! Surgery required-
Simple approximation of skin
Tendons/Nerve/Arteries dry out
Surgery required-
Notify patient
Urgent referral to surgeon (same or next day) Best results with timely treatment
Nerves- 3-5 days
Tendons- 1-2 weeks

40. Extensor Injuries
Walk in the park compared to flexors

41. Extensor Tendons
Concern with
dorsal lacerations
Can be subtle

42. Anatomy DIP PIP Terminal Slip (Mallet Finger) Central slip
(Boutonnière deformity)

43. Exam Test each finger separately Test for strength
IF & SM
“Hook ‘em Horns”
IF- EDC & IP
SF- EDC & IDM
Flex & hold others down
Junctura tendinae can
mask proximal lacerations
Tenodesis

44. Hand Injuries Boxer’s Fracture Metacarpal Fractures
Ulnar Collateral Ligament Tear (Gamekeeper’s)

45. Boxer’s Fx
Not usually the smartest thing the patient has done…

46. Boxer’s Fx (Small Finger MC)
MC Fx of the small finger
Can accept a fair
amount of flexion
IF- 10º
MF- 20º
RF- 30º
SF- 40º

47. Metacarpal Fx Need to make sure angulation/rotation is correct
Oblique fractures typically are
unstable & require surgery
Look at arcade of MC heads
If shortened- lose tension
Extension lag

48. MC FX

49. MC FX

50. MC FX

51. Ulnar Collateral (Gamekeeper’s) Thumb
Etiology
Forced Abd of the thumb
Fall, Skiing
Acute vs. Chronic
Gamekeep- Old Europe
Ringing necks of small game
Presentation
Painful mass, unable to pinch/write, weakness…

52. Exam Instability/pain with radial deviation? Strain vs. Tear?
Ligament vs. boney fracture?
Test in extension & flexion
Use contralateral side as control
>15º difference abnormal
>30º of angulation abnormal
Pain with stress

53. Imaging
Xrays always first
Stress views & fluoroscopy
MRI
Ultrasound

54. Stener’s Lesion Avulsion fx Will not heal Add Aponeurosis
off proximal phalanx
Will not heal
Add Aponeurosis
blocks reduction
Needs surgery
with immobilization

55. Treatment Strain: No instability! Tear: Chronic (>6 weeks?):
Splint- custom made orthoplast
Tear:
Repair Ligament
Chronic (>6 weeks?):
Graft-palmaris longus tendon,APL,EPB

56. Infections: Less is not more Aggressive irrigation
Don’t be afraid to make large incisions in the skin
Blunt deep dissection (Scissors)
Aggressive irrigation
Leave it open/pack it
Less packing each time
Soaks with Betadine
(10-25%)
Make a fist x 20 times

57. Injection Injuries: High Power Injections
Power washers, oil or paint guns
Don’t be fooled- more than what meets the eye

58. Injection Injuries

59. Injection Injury Water/Water soluble: Can consider watching closely
Oil/Paint/Other: needs surgical debridement sooner rather than later
Tracks along path of least resistance- even to the forearm!

60. Injection Injuries

61. Infections: Fight Bites: Animal Bites Human bite- Augmentin
Seed the joint- infection common
Animal Bites
Cats worse than dogs
Small teeth- wound
sealed more common

62. HAND INFECTIONS Do not under estimate Treat aggressively ABX I&D
ER/Admission
Surgical Debridement

63. Necrotizing Fasciitis
Quick progressing
Surgical emergency
Anaerobic- Exposure to air helps
Aggressive debridement
Can be innocuous injury

64. Hand Infections
Necrotizing Fasciitis Case

65. Hand Infections
Necrotizing Fasciitis Case

66. Motor Cycles
Work of the Devil…

67. Referrals: F/u sooner rather than later
F/u next day in UCC if nothing else
NPO after midnight- may be able to/need to operate next day
Do not tell patient we will operate the next day!
Nerves/Tendons need repair within 2-3 days

68. Don’t be afraid!

69. Don’t be stupid!

70. Don’t Give Up!

71. Thank You
Questions…