26488443 Hand Amp Wrist Injuries

8/8/2019 26488443 Hand Amp Wrist Injuries

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Hand and Wrist InjuriesHand and Wrist Injuries

Allyson S. Howe, MDAllyson S. Howe, MD

January 17, 2008January 17, 2008


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HAND AND WRISTHAND AND WRIST

HANDHAND WRISTWRIST


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HAND FUNCTIONSHAND FUNCTIONS

4545% GRASP% GRASP

4545% PINCH% PINCH

Side pinch (key pinch)Side pinch (key pinch) Tip pinch (writing)Tip pinch (writing)

Chuck pinch (thumb to index/ring)Chuck pinch (thumb to index/ring)

55% HOOK% HOOK Carry bagCarry bag

55% PAPERWEIGHT% PAPERWEIGHT


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HAND & FINGER ANATOMYHAND & FINGER ANATOMY

99 Finger FlexorsFinger Flexors

Median nerveMedian nerve

Transverse carpal ligamentTransverse carpal ligament

55 deep flexors pass through superficialisdeep flexors pass through superficialistendons and insert on distal phalanx of eachtendons and insert on distal phalanx of eachfinger and thumbfinger and thumb

44 superficial flexors insert on middle phalanx ofsuperficial flexors insert on middle phalanx of

digitsdigits 22--55

Annular ligaments = pulleys (AAnnular ligaments = pulleys (A11--AA55)) PREVENT BOWSTRINGINGPREVENT BOWSTRINGING


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HAND ANATOMYHAND ANATOMY

VOLAR PLATEVOLAR PLATE

Thickened portion of joint capsuleThickened portion of joint capsule

Static stabilizer (hyperextension)Static stabilizer (hyperextension)COLLATERAL LIGAMENTSCOLLATERAL LIGAMENTS

Medial and lateral stabilityMedial and lateral stability

Maximally tight atMaximally tight at

____ degrees MCP flexion____ degrees MCP flexion

____ degrees PIP flexion____ degrees PIP flexion

____ degrees DIP flexion____ degrees DIP flexion

70

30

15


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HAND ANATOMYHAND ANATOMYdigitsdigits

FLEXORFLEXOR

FDPFDP

FDSFDS Volar plateVolar plate

ExtensorExtensor

Central bandsCentral bands

Lateral bandsLateral bands


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NERVES OF THE HANDNERVES OF THE HAND

RADIALRADIAL

MEDIANMEDIAN

ULNARULNAR

WRIST AND FINGER EXTENSIONWRIST AND FINGER EXTENSION

THENAR COMPARTMENT,THENAR COMPARTMENT,

OPPOSITION, PINCER GRIPOPPOSITION, PINCER GRIP

INTRINSIC MUSCLESINTRINSIC MUSCLES

POWER GRIPPOWER GRIP


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MALLET FINGERMALLET FINGER

ANATOMYANATOMY Dorsal avulsionDorsal avulsion

Extensor digitorum tendonExtensor digitorum tendonteartear

MECHANISM:MECHANISM: Forced flexion of extendedForced flexion of extendeddigitdigit

TREATMENT:TREATMENT: No fracture: DIP extendedNo fracture: DIP extended

for 6for 6--8 weeks8 weeks

FRACTURE: if 30% refer for ORIFrefer for ORIF

Less than full passiveLess than full passiveextensionextension referrefer

COMPLICATIONS:COMPLICATIONS: Pressure necrosis fromPressure necrosis from

splintsplint

Permanent extensor lagPermanent extensor lag


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MALLET FINGERMALLET FINGER


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JERSEY FINGERJERSEY FINGER


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ANATOMY:ANATOMY: Tendon retractsTendon retracts

Avulsion fragment mayAvulsion fragment may

limit retractionlimit retraction Blood supplyBlood supply

compromisedcompromised

MECHANISM:MECHANISM: Forced extension ofForced extension of

flexed fingerflexed finger

TREATMENT:TREATMENT: Refer immediatelyRefer immediately

COMPLICATIONS:COMPLICATIONS:

Permanent loss ofPermanent loss of

flexionflexion


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EXAM FINDINGS:EXAM FINDINGS:

Unable to flexUnable to flex

isolated DIPisolated DIP

LocalizedLocalized

tenderness alongtenderness along

flexor tendonflexor tendon

FDP: hold PIPFDP: hold PIP

straight and flex DIPstraight and flex DIP

FDS: hold MCPFDS: hold MCP

straight and flex PIPstraight and flex PIPor hold all fingers inor hold all fingers in

extension exceptextension except

affected and flexaffected and flex


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VOLAR PLATE RUPTUREVOLAR PLATE RUPTURE

EXAM FINDINGS:EXAM FINDINGS:

Tender volar PIPTender volar PIP

Bruising, swellingBruising, swelling

MECHANISM:MECHANISM:

Hyperextension injuryHyperextension injury

Ruptures distally from attachment at middleRuptures distally from attachment at middle

phalanxphalanx


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VOLAR PLATE RUPTUREVOLAR PLATE RUPTURE

TREATMENT:TREATMENT: Early mobilizationEarly mobilization

Extension block splintExtension block splint

Buddy tapeBuddy tape Refer if >Refer if >3030% joint% joint

involvedinvolved


Swan neck deformity:Swan neck deformity:extensor tendons pullextensor tendons pullPIP intoPIP intohyperextension, DIPhyperextension, DIPflexionflexion

Swan Neck Deformity


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CENTRAL SLIP AVULSIONCENTRAL SLIP AVULSION

ANATOMYANATOMY

Extensor digitorum communis tendonExtensor digitorum communis tendon

disruptiondisruption

Lateral bands migrate in volar directionLateral bands migrate in volar direction


VolarVolar--directed force on middle phalanxdirected force on middle phalanx

against semiagainst semi--flexed finger attempting toflexed finger attempting toextendextend


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CENTRAL SLIP AVULSIONCENTRAL SLIP AVULSION

EXAM:EXAM: Pain, swelling over dorsal PIPPain, swelling over dorsal PIP

PIP inPIP in 1515--3030 degrees flexiondegrees flexion

May have limited extension (better atMay have limited extension (better at 00 degrees thandegrees than3030 degrees)degrees)

TREATMENTTREATMENT Refer if >Refer if >3030% joint surface involved with avulsion fx% joint surface involved with avulsion fx

PIP splint in full extensionPIP splint in full extension 44--55 weeksweeks

ProtectProtect 66--88 weeks for sportsweeks for sports *allow DIP to flex*allow DIP to flex-- relocates lateral bandsrelocates lateral bands

COMPLICATIONS:COMPLICATIONS: Boutonierre deformityBoutonierre deformity


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COLLATERAL LIGAMENT TEARSCOLLATERAL LIGAMENT TEARS

ANATOMY:ANATOMY:

Partial or complete tear of ulnar or radialPartial or complete tear of ulnar or radial

ligamentsligaments


Varus or valgus stress to PIP, DIP or MCPVarus or valgus stress to PIP, DIP or MCP

EXAM: (flex MCP, PIPEXAM: (flex MCP, PIP 3030 degrees flex)degrees flex)

Laxity with varus or valgus stressLaxity with varus or valgus stress

Possible instability with active flex/extendPossible instability with active flex/extend


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COLLATERAL LIGAMENT TEARSCOLLATERAL LIGAMENT TEARS

TREATMENT:TREATMENT:

Buddy tape for 3 weeksBuddy tape for 3 weeks

If unstable with active ROM or obviousIf unstable with active ROM or obviousdeformitydeformity referrefer


Unstable jointUnstable joint


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GAMEKEEPERS THUMBGAMEKEEPERS THUMB

MECHANISMMECHANISM

Hyperabduction ofHyperabduction of

thumbthumb

>30 degrees or > 20>30 degrees or > 20degrees differencedegrees difference

EXAM:EXAM:

Weak, painful pinchWeak, painful pinch Pain over ulnar thumbPain over ulnar thumb

XRAYS BEFOREXRAYS BEFORE

STRESSSTRESS


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SIGNSSIGNS Pain over ulnar thumbPain over ulnar thumb

Stress testing positiveStress testing positiveTesting in FULL FLEXION of MCPTesting in FULL FLEXION of MCP


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TREATMENTTREATMENT No instability, no fracture=No instability, no fracture=

thumb spica x 6 weeksthumb spica x 6 weeks

No instability, smallNo instability, smallavulsion = thumb spicaavulsion = thumb spica

Large avulsion orLarge avulsion orinstabiliy= thumb spicainstabiliy= thumb spicaand REFERand REFER

COMPLICATIONSCOMPLICATIONS STENER lesionSTENER lesion

InstabilityInstability


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THUMB CMC FRACTURETHUMB CMC FRACTURE

DISLOCATIONDISLOCATION(BENNETTS FRACTURE)(BENNETTS FRACTURE)

Anatomy:Anatomy: Anterior obliqueAnterior oblique

carpometacarpal ligamentcarpometacarpal ligamentholds palmar fragment inholds palmar fragment innormal anatomic positionnormal anatomic position

Abductor pollicis longusAbductor pollicis longus(APL) pulls metacarpal(APL) pulls metacarpalshaft fragment radial &shaft fragment radial &dorsaldorsal

TreatmentTreatment Reduction (TAPE)Reduction (TAPE)

Traction, abduction,Traction, abduction,extension, pronationextension, pronation

Often unstable, requiresOften unstable, requiressurgerysurgery


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ROLANDOS FRACTUREROLANDOS FRACTURE

ANATOMYANATOMY 3 part fracture at3 part fracture at

metacarpal basemetacarpal base

Comminuted with YComminuted with Yor T fragmentor T fragment

TREATMENTTREATMENT May be nonMay be non--surgical ifsurgical if

highly comminutedhighly comminuted

Surgery if fragmentsSurgery if fragmentsare large andare large andamenableamenable


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DIP JOINT DISLOCATIONDIP JOINT DISLOCATION

MECHANISMMECHANISM

Hyperextension, varus/valgus forcesHyperextension, varus/valgus forces

ANATOMYANATOMY

Usually dorsalUsually dorsal

RareRare

Strong collateral ligaments usually preventStrong collateral ligaments usually prevent

TREATMENTTREATMENT Reduction: digital block firstReduction: digital block first

Splint in 20Splint in 20--30 degrees flexion for 1030 degrees flexion for 10--14 days14 days


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WRISTWRIST


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Wrist #Wrist #11

2424--yearyear--old male FOOSH while skiing overold male FOOSH while skiing over

the weekendthe weekend

Seen at the mountain clinic and told wristSeen at the mountain clinic and told wristsprainsprain


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Scaphoid FractureScaphoid Fracture

PathoanatomyPathoanatomyBlood suppliedBlood suppliedfrom distal polefrom distal pole

In children, 87%In children, 87%involve distal poleinvolve distal pole

In adults, 80%In adults, 80%

involve waistinvolve waist


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Scaphoid Fracture ImagingScaphoid Fracture Imaging

Initial plain filmsInitial plain filmsoften normaloften normal

Bone scan 100%Bone scan 100%

sensitive and 92%sensitive and 92%specific at 4 daysspecific at 4 days

MRI, CT scanMRI, CT scan


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SCAPHOID FRACTURESCAPHOID FRACTURE

TREATMENTTREATMENT

Initial radiographs positiveInitial radiographs positive

distal third healdistal third heal in approx 6in approx 6--8 weeks8 weeks

middle third frxmiddle third frx heal in 8heal in 8--12 weeks12 weeks

proximal thirdproximal third heal in 12heal in 12--23 weeks23 weeks

Initial radiographs negativeInitial radiographs negative

Immobilize thumb spica cast x 7Immobilize thumb spica cast x 7--14 days14 daysTake out of cast, reTake out of cast, re--evaluate for tendernessevaluate for tenderness

If +tenderness but neg radiographs.If +tenderness but neg radiographs.


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TreatmentTreatment

Suspected fracture withSuspected fracture with

normal plain filmsnormal plain films

Short arm thumbShort arm thumb

spica (splint or cast)spica (splint or cast)

F/U inF/U in 22 weeksweeks

Consider bone scanConsider bone scan


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TreatmentTreatment

NonNon--displaceddisplacedfracturefracture

Long arm thumbLong arm thumbspica cast 6spica cast 6weeksweeks

Then, short armThen, short arm

thumb spica castthumb spica castfor 4for 4--14 weeks14 weeks


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Refer to OrthoRefer to Ortho

Angulated orAngulated or

displaced (displaced (11mm)mm)NonNon--union or AVNunion or AVN

ScapholunateScapholunatedissociationdissociation

Proximal fracturesProximal fractures

Late presentationLate presentation

Early return to playEarly return to play


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Wrist #Wrist #22

3434--yearyear--old femaleold female

hairdresser withhairdresser with

thumb pain forthumb pain for 22--33

monthsmonthsGradual onsetGradual onset

Now thumb hurts withNow thumb hurts with

any movementany movement


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DEQUERVAINS TENOSYNOVITISDEQUERVAINS TENOSYNOVITIS

TREATMENT: consider injection every timeTREATMENT: consider injection every time

May need second injection to improveMay need second injection to improve


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DEQUERVAINSDEQUERVAINS

TENOSYNOVITISTENOSYNOVITIS


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Wrist #3Wrist #3

35 y/o35 y/o

seamstressseamstress

c/o R dorsalc/o R dorsalwrist pain for 4wrist pain for 4

monthsmonths


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Kienbock DiseaseKienbock Disease

LunatomalaciaLunatomalacia

Avascular necrosis/vascular insufficiencyAvascular necrosis/vascular insufficiency

?repetitive microfractures of lunate?repetitive microfractures of lunateYoung adults 15Young adults 15--40 yo40 yo

Risk factors: negative ulnar varianceRisk factors: negative ulnar variance


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EXAM::EXAM::

Wrist pain thatWrist pain that

radiates up theradiates up the

forearmforearm stiffness, tenderness,stiffness, tenderness,

swelling over lunateswelling over lunate

passive dorsiflexion ofpassive dorsiflexion of

middle finger producesmiddle finger producescharacteristic paincharacteristic pain


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Stage IStage I IVIV

Stage I: MRI onlyStage I: MRI only

Stage II: SclerosisStage II: Sclerosis Stage III: SomeStage III: Some

collapsecollapse

Stage IV: TotalStage IV: Total

collapsecollapse


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TREATMENT:TREATMENT:

Primarily surgicalPrimarily surgical

EARLY: Radial shortening, ulnar lengtheningEARLY: Radial shortening, ulnar lengthening

LATE: proximal row carpectomy, arthrodesisLATE: proximal row carpectomy, arthrodesis


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Wrist #Wrist #44

2525--yearyear--oldold

tennis playertennis player

twists wrist as hetwists wrist as hefalls backwardsfalls backwards

reaching for areaching for a

loblob


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SCAPHOLUNATE DISSOCIATIONSCAPHOLUNATE DISSOCIATION


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SCAPHOLUNATE DISSOCIATIONSCAPHOLUNATE DISSOCIATION

EXAMEXAM

Watsons test (scaphoid shift test)Watsons test (scaphoid shift test)

Scaphoid shuck testScaphoid shuck test

Pain/swelling over dorsal wrist, prox rowPain/swelling over dorsal wrist, prox row

DIAGNOSISDIAGNOSIS

Plain films: >Plain films: >33mm difference on clenched fistmm difference on clenched fist

Scaphoid ring signScaphoid ring sign


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TREATMENTTREATMENT

If discovered within 4 weeks, surgeryIf discovered within 4 weeks, surgery

After 4 weeks, conservative treatmentAfter 4 weeks, conservative treatment

reasonablereasonable

BracingBracing

NSAIDSNSAIDS

Consider eval by hand surgery to confirm noConsider eval by hand surgery to confirm nosurgery neededsurgery needed


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Wrist #Wrist #55

Soccer playerSoccer player

has pain inhas pain in

pinky side ofpinky side ofwrist after awrist after a

fallfall


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Triangular FibrocartilageTriangular Fibrocartilage

Complex (TFCC) TearComplex (TFCC) Tear

Fall onFall on

dorsiflexed anddorsiflexed and

ulnar deviatedulnar deviated

wristwrist

Axial load withAxial load with

forearm inforearm in

hyperpronationhyperpronation


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TFCC Tear PathoanatomyTFCC Tear Pathoanatomy

Tear inTear in

structures ofstructures of

TFCCTFCCPositive ulnarPositive ulnar

variancevariance

predisposes topredisposes toinjuryinjury


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TFCC AnatomyTFCC Anatomy


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TFCC Tear HistoryTFCC Tear History

UlnarUlnar--sided wrist painsided wrist pain

aggravated by pronation/aggravated by pronation/

supinationsupination


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TFCC Tear PhysicalTFCC Tear Physical

Press testPress test

TFCC grind testTFCC grind testCheck for DRUJCheck for DRUJ

injuryinjury


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TFCC Tear ImagingTFCC Tear Imaging

Plain films mayPlain films mayshow positiveshow positive

ulnar varianceulnar varianceAssess forAssess forfracture or ulnarfracture or ulnar

subluxationsubluxationMRI orMRI orArthrographyArthrography


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TFCC Tear TreatmentTFCC Tear Treatment

Long armLong armcast withcast with

forearm neutforearm neut

for 4for 4--6 wks6 wksRefer for associatedRefer for associated

injuries including ulnarinjuries including ulnar

instabilityinstability


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GOLFERS FRACTUREGOLFERS FRACTURE

Hook of hamate fractureHook of hamate fracture

Swing of golf club, batSwing of golf club, bat

22% of all carpal fractures% of all carpal fractures

11//33 of all hamate fractures = golf relatedof all hamate fractures = golf related

Distal lateral border of Guyons CanalDistal lateral border of Guyons Canal

High rate of nonHigh rate of non--unionunion

May consider early operative treatmentMay consider early operative treatment


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GOLFERS FRACTUREGOLFERS FRACTURE

CARPAL TUNNEL VIEWCARPAL TUNNEL VIEW


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GUYONS CANAL SYNDROMEGUYONS CANAL SYNDROME

ANATOMYANATOMY

Ulnar nerve rides between pisiform andUlnar nerve rides between pisiform andhamatehamate

Feeds interosseous muscles, hypothenarFeeds interosseous muscles, hypothenarmuscles, lumbricals (intrinsic muscles)muscles, lumbricals (intrinsic muscles)

TREATMENTTREATMENT

Pad areaPad area

NSAIDSNSAIDS

r/o hamate fracturer/o hamate fracture


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MEDIAN NERVE:MEDIAN NERVE:ANTERIOR INTEROSSEOUS SYNDROMEANTERIOR INTEROSSEOUS SYNDROME

EXAM FINDINGSEXAM FINDINGS Proximal forearm pain, worse with exerciseProximal forearm pain, worse with exercise

Weak pinchWeak pinch cant form Ocant form O

ANATOMYANATOMY Compression of anterior interosseus median nerveCompression of anterior interosseus median nerve

branch from deep fascia of pronator teres or flexorbranch from deep fascia of pronator teres or flexordigitorum superficialis tendondigitorum superficialis tendon

Innervates:Innervates:

flexor pollicis longusflexor pollicis longus

flexor digitorum profundusflexor digitorum profundus

pronator quadratuspronator quadratus

26488443 Hand Amp Wrist Injuries

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