Injuries to MC & phalangesInjuries to MC & phalanges General principlesGeneral principles: Every effort is made to limit swelling as it may lead to : Every effort is made to limit swelling as it may lead to chronic edema and irrecoverable fibrosis ultimately leading to stiffness and poor chronic edema and irrecoverable fibrosis ultimately leading to stiffness and poor functional outcome. Admission, elevation, NSAID’s, anti-inflammatory drugs etc.functional outcome. Admission, elevation, NSAID’s, anti-inflammatory drugs etc. If injury is less severe, it can be treated on OPD basis, elevation of arm in a If injury is less severe, it can be treated on OPD basis, elevation of arm in a sling is helpful, provided that sling is applied in such a way that the hand is not sling is helpful, provided that sling is applied in such a way that the hand is not dependant.dependant.

Injuries to MC & phalangesInjuries to MC & phalanges Principles of splintagePrinciples of splintage: If # or joint is unstable, stabilize it, but as few joints : If # or joint is unstable, stabilize it, but as few joints as possible and for as short time as possible is the rule. The arm should be removed as possible and for as short time as possible is the rule. The arm should be removed from sling 2-3 times per day and elbow and shoulder put through a full range of from sling 2-3 times per day and elbow and shoulder put through a full range of movement, free fingers should be vigorously exercised.movement, free fingers should be vigorously exercised. MP joints of the fingers should never be splinted in extension. MP joints MP joints of the fingers should never be splinted in extension. MP joints flexed 90º, IP joints extended and thumb abducted. Often difficult to splint in this flexed 90º, IP joints extended and thumb abducted. Often difficult to splint in this position but MP joint extension must be studiously avoided.position but MP joint extension must be studiously avoided.

Injuries to MC & phalangesInjuries to MC & phalanges This position reduces the effects of fibrosis in collateral ligaments and places This position reduces the effects of fibrosis in collateral ligaments and places the finger joints in a favorable position for mobilization. It must be carefully the finger joints in a favorable position for mobilization. It must be carefully differentiated from position of fixation where no movement is expected and in that differentiated from position of fixation where no movement is expected and in that case MP and IP joints are put in mid flexion. Where a finger injury requires case MP and IP joints are put in mid flexion. Where a finger injury requires stabilization in AP plane (IP collateral ligament avulsion # or un displaced # of stabilization in AP plane (IP collateral ligament avulsion # or un displaced # of phalanx) where minimal fixation is required, “garter” strapping to an adjacent finger phalanx) where minimal fixation is required, “garter” strapping to an adjacent finger with inter digital felt padding often provides ideal combination of stability while with inter digital felt padding often provides ideal combination of stability while retaining movement.retaining movement.

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Injuries to MC & phalangesInjuries to MC & phalanges Rotational (torsional) deformity of a MC or phalanx may not be noticeable in Rotational (torsional) deformity of a MC or phalanx may not be noticeable in extension, but cause obvious deformity and functional impairment in flexion.extension, but cause obvious deformity and functional impairment in flexion. In presence of gross instability or persistent angulations, especially where # In presence of gross instability or persistent angulations, especially where # are multiple and involves the joints internal fixation is helpful. Percutaneous K-wires are multiple and involves the joints internal fixation is helpful. Percutaneous K-wires are easiest, removed after 3 weeks. Alternatively plates and screws from AO small are easiest, removed after 3 weeks. Alternatively plates and screws from AO small fragment set can be used.fragment set can be used.

Injuries to MC & phalangesInjuries to MC & phalanges Soft tissue managementSoft tissue management: When there is necrotic or foreign material, a : When there is necrotic or foreign material, a thorough debridement performed under tourniquet. There is little tissue in the hand so thorough debridement performed under tourniquet. There is little tissue in the hand so wide excision of the wounds is to be avoided.wide excision of the wounds is to be avoided. Where there is skin loss and if situation permits a primary skin graft of plastic Where there is skin loss and if situation permits a primary skin graft of plastic repair should be carried out.repair should be carried out. If there is division of both neurovascular bundles to a finger, amputation If there is division of both neurovascular bundles to a finger, amputation should be advised unless a facility for microsurgery is there. In amputation all should be advised unless a facility for microsurgery is there. In amputation all attempts should be made to preserve maximum length of thumb or finger.attempts should be made to preserve maximum length of thumb or finger.

Injuries to MC & phalangesInjuries to MC & phalanges If there is appreciable risk of infection (for e.g. ragged or contaminated If there is appreciable risk of infection (for e.g. ragged or contaminated wound) primary sutures of the nerves, wound and also of tendons in the no man’s landwound) primary sutures of the nerves, wound and also of tendons in the no man’s land of the tendon sheaths should not be undertaken.of the tendon sheaths should not be undertaken.

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Injuries to the thumbInjuries to the thumb BaseBase: Commonest injuries are Bennett's # dislocation, # of the base of the : Commonest injuries are Bennett's # dislocation, # of the base of the thumb and CMC dislocation of the thumb. These injuries result from force applied thumb and CMC dislocation of the thumb. These injuries result from force applied along the long axis of thumb e.g. fall or blow on the clenched fist or forced abduction along the long axis of thumb e.g. fall or blow on the clenched fist or forced abduction of the thumb. May be mistaken for scaphoid # but tenderness is maximal distal to the of the thumb. May be mistaken for scaphoid # but tenderness is maximal distal to the snuff box.snuff box.

Bennett’s #Bennett’s # Small medial fragment of bone which may tilt, but maintains its relationship Small medial fragment of bone which may tilt, but maintains its relationship with the trapezium, the vertical # line involves the trapezometacarpal joint; most with the trapezium, the vertical # line involves the trapezometacarpal joint; most important is the proximal and lateral subluxation of the thumb MC.important is the proximal and lateral subluxation of the thumb MC. Treatment is reduction by applying traction to thumb, abducting it and Treatment is reduction by applying traction to thumb, abducting it and applying pressure to the lateral aspect of the base under GA or Bier block.applying pressure to the lateral aspect of the base under GA or Bier block.

Bennett’s #Bennett’s # Maintaining reduction can be troublesome. Cast should be carefully moulded. Maintaining reduction can be troublesome. Cast should be carefully moulded. Check x-rays are taken to confirm reduction. Arm should be elevated in the sling. Check x-rays are taken to confirm reduction. Arm should be elevated in the sling. Weekly x-rays should be taken. If cast appears loose at any stage or # is slipping, a Weekly x-rays should be taken. If cast appears loose at any stage or # is slipping, a new cast should be applied. Plaster cast should be maintained for 6 weeks.new cast should be applied. Plaster cast should be maintained for 6 weeks.

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Bennett’s #Bennett’s # Alternative methods are AO small fragment screw fixation, IM K-wire, K-Alternative methods are AO small fragment screw fixation, IM K-wire, K-wire fixation of thumb to index and middle MC or use of 2 K-wires to stabilize the 1wire fixation of thumb to index and middle MC or use of 2 K-wires to stabilize the 1stst MC.MC.

# of base of 1# of base of 1 stst MC MC Greenstick # of this type are common in children. Angulation is usually slight Greenstick # of this type are common in children. Angulation is usually slight to moderate and should be accepted, gross angulation should be manipulated. to moderate and should be accepted, gross angulation should be manipulated. In this types there is no subluxation.In this types there is no subluxation. Plaster fixation for about 5 weeks is desirable.Plaster fixation for about 5 weeks is desirable.

CMC dislocation of thumbCMC dislocation of thumb Thumb may dislocate at the jointThumb may dislocate at the joint between MC base and trapezium or between MC base and trapezium or trapezium remains with the MC and dislocation taking place between trapezium and trapezium remains with the MC and dislocation taking place between trapezium and the scaphoid. Both these injuries result from forcible abduction of the thumb. Reduce the scaphoid. Both these injuries result from forcible abduction of the thumb. Reduce by applying traction to thumb and local pressure over the base F/B well padded cast by applying traction to thumb and local pressure over the base F/B well padded cast of scaphoid type for 3 weeks.of scaphoid type for 3 weeks.

Injuries at the MP joint of thumbInjuries at the MP joint of thumb Posterior dislocation: Results from forcible hyperextension of thumb. There Posterior dislocation: Results from forcible hyperextension of thumb. There may be button holing of the capsule by MC head and closed reduction may fail. may be button holing of the capsule by MC head and closed reduction may fail. Reduction is achieved by applying traction to thumb with simultaneous pressure over Reduction is achieved by applying traction to thumb with simultaneous pressure over the MC Head. When OR is required it should be done through a lateral incision under the MC Head. When OR is required it should be done through a lateral incision under tourniquet. In all cases cast is worn of 2-3 weeks.tourniquet. In all cases cast is worn of 2-3 weeks.

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Gamekeeper’s thumbGamekeeper’s thumb Caused by forcible abduction of thumb leading to rupture of ulnar collateral Caused by forcible abduction of thumb leading to rupture of ulnar collateral ligament. If unrecognized or untreated, there is progressive MP subluxation, ligament. If unrecognized or untreated, there is progressive MP subluxation, interference with grasp and disability.interference with grasp and disability. Extend the MP joint fully and apply stress to UCL by abducting PP, repeat Extend the MP joint fully and apply stress to UCL by abducting PP, repeat with thumb flexed at MP joint and see for laxity.with thumb flexed at MP joint and see for laxity. If in doubt stress X-rays should be taken. Look for avulsion # on x-ray, if # is If in doubt stress X-rays should be taken. Look for avulsion # on x-ray, if # is there note its position (Marked displacement, rotation so that its articular surface is there note its position (Marked displacement, rotation so that its articular surface is pointing distally are indications of surgery.pointing distally are indications of surgery.

Gamekeeper’s thumbGamekeeper’s thumb Mild laxity or minimally displaced #, fixation in scaphoid type cast for 6 Mild laxity or minimally displaced #, fixation in scaphoid type cast for 6 weeks.weeks. Gross laxity (complete tear) or rotated #, surgical repair of torn ligament or Gross laxity (complete tear) or rotated #, surgical repair of torn ligament or repositioning of # and cast for 6 weeks.repositioning of # and cast for 6 weeks. Long standing lesions with marked symptoms, MP joint fusion.Long standing lesions with marked symptoms, MP joint fusion.

# of PP of thumb# of PP of thumb Severely angled # reduced by traction and local pressure and held with a Severely angled # reduced by traction and local pressure and held with a dorsal or volar slab to which is added a girder extension. Minimally angled fracture ordorsal or volar slab to which is added a girder extension. Minimally angled fracture or splinter # protected by local slab.splinter # protected by local slab.

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IP joint dislocation of thumbIP joint dislocation of thumb Reduce by traction in usual manner, rarely ring or Bier block is required. Reduce by traction in usual manner, rarely ring or Bier block is required. Thereafter splint for 2-3 weeks with slab.Thereafter splint for 2-3 weeks with slab. # of terminal phalanx# of terminal phalanx : Crushing injuries are usual cause and any soft tissue : Crushing injuries are usual cause and any soft tissue damage takes priority in management.damage takes priority in management.

Injuries of 5Injuries of 5 thth MC MC TypesTypes: # of the neck, spiral # of shaft usually UN displaced, transverse # of : # of the neck, spiral # of shaft usually UN displaced, transverse # of shaft often angulated, # of the base and # of the head.shaft often angulated, # of the base and # of the head. # of the neck# of the neck : Caused by banging a clenched fist as in fight, angulation and : Caused by banging a clenched fist as in fight, angulation and impaction are common. When angulation is slight, it is accepted and # supported for impaction are common. When angulation is slight, it is accepted and # supported for 3-4 weeks with dorsal slab with finger extension and garter strapping of ring and little3-4 weeks with dorsal slab with finger extension and garter strapping of ring and little finger.finger.

Injuries of 5Injuries of 5 thth MC MC If angulation is gross, reduction is achieved by flexing MP joint and applying If angulation is gross, reduction is achieved by flexing MP joint and applying pressure to head via PP using thumb while the fingers apply counter pressure to the pressure to head via PP using thumb while the fingers apply counter pressure to the shaft. Reduction should be checked and maintained while slab is appliedshaft. Reduction should be checked and maintained while slab is applied Spiral #, transverse # of shaft with mild to moderate angulation or Spiral #, transverse # of shaft with mild to moderate angulation or displacement and # of base may be treated adequately by application of a Colles’s displacement and # of base may be treated adequately by application of a Colles’s plaster for 3-4 weeksplaster for 3-4 weeks

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Injuries of 5Injuries of 5 thth MC MC Marked angulation of shaft # treated by traction and local pressure prior to Marked angulation of shaft # treated by traction and local pressure prior to POP. Displaced # may be similarly reduced but soft tissue interposition requires open POP. Displaced # may be similarly reduced but soft tissue interposition requires open reduction. In those cases reduction is maintained by PC or IM k-wire.reduction. In those cases reduction is maintained by PC or IM k-wire. # of head of 5# of head of 5thth MC are treated by garter strapping and early mobilization. If MC are treated by garter strapping and early mobilization. If symptoms are marked a dorsal slab may be applied for initial 1-2 weeks.symptoms are marked a dorsal slab may be applied for initial 1-2 weeks.Injuries of 5Injuries of 5 thth MC MC Dislocation of the base of 5Dislocation of the base of 5thth MC is usually easily reduced with traction, but MC is usually easily reduced with traction, but may need K-wire stabilization.may need K-wire stabilization.Injuries to index, middle & ring MCInjuries to index, middle & ring MC Commonest is spiral # of shaft, but # involving base and neck are frequent. UnCommonest is spiral # of shaft, but # involving base and neck are frequent. Un displaced # may be supported by a Colles’s type slab but watch for swelling which displaced # may be supported by a Colles’s type slab but watch for swelling which can be severe especially in multiple #.can be severe especially in multiple #. Displaced # are managed as mentioned in 5Displaced # are managed as mentioned in 5thth MC by reduction either closed or MC by reduction either closed or open F/B k-wire either IM or trans fixation kept for 3 weeks F/B plaster fixation for open F/B k-wire either IM or trans fixation kept for 3 weeks F/B plaster fixation for further 2 weeks.further 2 weeks.

# of PP and MP# of PP and MP Un displaced simple # of shaft, base, neck, intercondylar region or epiphyseal Un displaced simple # of shaft, base, neck, intercondylar region or epiphyseal injuries seldom present any problem. Garter strapping for 3-4 weeks may give injuries seldom present any problem. Garter strapping for 3-4 weeks may give adequate support but if symptoms are marked this may be supplemented by use of adequate support but if symptoms are marked this may be supplemented by use of volar or dorsal slab with finger extension. volar or dorsal slab with finger extension. There is tendency for angulation sue to intrinsic muscle pull and if more than There is tendency for angulation sue to intrinsic muscle pull and if more than 15º it should be corrected by gentle traction using thumb as a fulcrum. These # are 15º it should be corrected by gentle traction using thumb as a fulcrum. These # are stable in flexion and affected finger is required to be fixed initially in this position.stable in flexion and affected finger is required to be fixed initially in this position. IM k-wires are used in case of open and multiple #.IM k-wires are used in case of open and multiple #.

# of PP and MP# of PP and MP Care is taken to keep uninjured fingers free and exercised. Rigid fixation Care is taken to keep uninjured fingers free and exercised. Rigid fixation should be discarded as soon as possible.should be discarded as soon as possible. Finger stiffness is commonest and most disabling complication due to joint Finger stiffness is commonest and most disabling complication due to joint adhesions, fibrosis in the adjacent flexor tendon sheaths and collateral ligament adhesions, fibrosis in the adjacent flexor tendon sheaths and collateral ligament shortening.shortening. Infection in open # is another major contributing factor in stiffness.Infection in open # is another major contributing factor in stiffness.# of PP and MP# of PP and MP Amputation as primary treatment is required in compound # with flexor Amputation as primary treatment is required in compound # with flexor tendon division or division of one or both neurovascular bundles, skin loss or severe tendon division or division of one or both neurovascular bundles, skin loss or severe crushing.crushing.

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Mal union: Arise from recurrence of deformity, failure to correct initial Mal union: Arise from recurrence of deformity, failure to correct initial deformity torsional deformity or epiphyseal displacement. In latter case, remodeling deformity torsional deformity or epiphyseal displacement. In latter case, remodeling may lead to correction.may lead to correction.# Of DP# Of DP Often comminuted, are at neck or base. Painful but relatively unimportant so Often comminuted, are at neck or base. Painful but relatively unimportant so treatment of associated soft tissue injury takes priority. Strapping the finger to a treatment of associated soft tissue injury takes priority. Strapping the finger to a spatula or use of a plastic finger splint is helpful. spatula or use of a plastic finger splint is helpful.

Mallet fingerMallet finger Caused by forcible flexion of finger from the extended position. Distal slip of Caused by forcible flexion of finger from the extended position. Distal slip of EDP tears from its attachment to the base of DP or avulses a fragment of bone. PatientEDP tears from its attachment to the base of DP or avulses a fragment of bone. Patient is unable to extend the distal IP joint fully; drooping of the DP may be slight or is unable to extend the distal IP joint fully; drooping of the DP may be slight or severe. In late cases there is hyperextension of PIP joint. If more than 1/3severe. In late cases there is hyperextension of PIP joint. If more than 1/3rdrd of articular of articular surface is detached subluxation of the DIP joint may occur.surface is detached subluxation of the DIP joint may occur.

Mallet fingerMallet finger In last case ORIF using K-wires is done and kept for 4 weeks. In last case ORIF using K-wires is done and kept for 4 weeks. Otherwise hold the DIP in extension for 6 weeks using Abuna splint or mallet Otherwise hold the DIP in extension for 6 weeks using Abuna splint or mallet splint.splint. If deformity recurs, immediate surgery is not advised as disability may be If deformity recurs, immediate surgery is not advised as disability may be slight, spontaneous fibrotic healing may occur after 6 months.slight, spontaneous fibrotic healing may occur after 6 months. Results of tendon suture are uncertain Results of tendon suture are uncertain IP fusion gives the best overall results.IP fusion gives the best overall results.

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MP & IP joint dislocationMP & IP joint dislocation Simple or multiple and as they result from hyperextension are almost Simple or multiple and as they result from hyperextension are almost posterior.posterior. Reduce them as for thumb, thereafter garter strapping applied for 2 weeks Reduce them as for thumb, thereafter garter strapping applied for 2 weeks unless there is any evidence of instability where POP splintage may be required for a unless there is any evidence of instability where POP splintage may be required for a longer period.longer period.

# dislocation# dislocation It is important that joint surface is correctly relocated and mobilization started It is important that joint surface is correctly relocated and mobilization started as early as possible.as early as possible. ORIF is usually required with an IM k-wire which is removed after 2-3 weeks ORIF is usually required with an IM k-wire which is removed after 2-3 weeks and mobilization started using garter strapping for the first week or more until the # and mobilization started using garter strapping for the first week or more until the # becomes more stable.becomes more stable.

Sprains and lateral subluxationSprains and lateral subluxation Caused by falls in which side of a finger strikes an object. Avulsion or tearing Caused by falls in which side of a finger strikes an object. Avulsion or tearing of a collateral ligament.of a collateral ligament. Diagnosis is based on history and presence of local tenderness which is Diagnosis is based on history and presence of local tenderness which is confirmed by noting instability on stressing the collateral ligament.confirmed by noting instability on stressing the collateral ligament. Radiographs may show a tell tale avulsion #. If doubt remains stress films mayRadiographs may show a tell tale avulsion #. If doubt remains stress films may be taken.be taken. Treated by garter strapping for 5 weeks, but if avulsion # is there and rotated itTreated by garter strapping for 5 weeks, but if avulsion # is there and rotated it should be fixed.should be fixed. Complication: Fusiform swellings of finger may persist for many months.Complication: Fusiform swellings of finger may persist for many months.

TenosynovitisTenosynovitis Direct trauma to or excessive use of a tendon and its synovial sheath causes Direct trauma to or excessive use of a tendon and its synovial sheath causes synovial inflammation. The synovial surface becomes dry and covered with fibrin. synovial inflammation. The synovial surface becomes dry and covered with fibrin. Movement of a tendon produces clinically detectable crepitations. Inflammation is Movement of a tendon produces clinically detectable crepitations. Inflammation is

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greatest at the MT junction. Clinically pain is experienced over course of muscle and greatest at the MT junction. Clinically pain is experienced over course of muscle and tendon and is accentuated by active or passive movement. Tenderness and crepitationstendon and is accentuated by active or passive movement. Tenderness and crepitations detected.detected. Mild cases treated by rest, cool packs and gentle exercise to prevent adhesions.Mild cases treated by rest, cool packs and gentle exercise to prevent adhesions. Severe cases may be splinted temporarily.Severe cases may be splinted temporarily.Trigger fingerTrigger finger Fusiform swelling of sublimis tendon at its bifurcation as it passes through Fusiform swelling of sublimis tendon at its bifurcation as it passes through thickened and constricted sheath over the MC Head.thickened and constricted sheath over the MC Head. On movement the sudden escape of the nodule from the narrowed canal is On movement the sudden escape of the nodule from the narrowed canal is accompanied by an audible snap. Later on disproportion becomes too great to permit accompanied by an audible snap. Later on disproportion becomes too great to permit passage and finger becomes locked usually in flexion.passage and finger becomes locked usually in flexion. Conservative treatment includes local injections of corticosteroids, rest by Conservative treatment includes local injections of corticosteroids, rest by splinting finger in extension and avoidance of direct pressure on the nodule.splinting finger in extension and avoidance of direct pressure on the nodule. Surgery if needed is done. The thickened sheath over MC head is incised.Surgery if needed is done. The thickened sheath over MC head is incised.

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