Hand Deformities, Fractures, and palsy

1

NOTE

• The following subjects are NOT mentioned in the guidelines– Dupuytren contracture (slides 28-31)– Hand fractures (32-45)– Hand palsy (46-57)

• Sry, but I got the guidelines after finishing the seminar

2

-Mallet deformity

-Trigger Finger

-Boutonniere Deformity

-Swan – Neck deformity

-Dupuytren contracture

3

Mallet Finger

• Aka: baseball finger• Deformity in which the

fingertip is curled in and cannot straighten itself

• Due to injury to extensor digitorium tendons at DIPJ

4

5

Mallet Finger/Causes

Forced flexion of the finger when finger is extended:

. Sport Injury: Finger struck by volleyball, basketball or baseball when it is in extension

. Other common mechanisms of injury include forcefully tucking in a bedspread or slipcover or pushing off a sock with extended fingers.

6

Mallet Finger/Presentation

• After DIPJ forced flexion: inability to actively extend the distal joint, intact full passive extension

• Often injury is painless or nearly painless• Dorsum of joint may be slightly tender and swollen

• Order X-ray to make sure there are no fractures

7

Despite active extension effort, the distal interphalangeal joint of the index finger rests

in flexion, characteristic of a mallet finger

8

This x-ray depicts a large, dorsal-lip avulsion fracture from the distal phalanx, a bony

mallet injury.

9

Mallet Finger/Managment

• Mallet finger splint (6-10 weeks)

• Surgery:– In case of volar

sublaxation of distal phalanx or avulsion fracture

– K-wire (Kirschner wire)

10

Anteroposterior radiographic view of finger after 4 weeks. The longitudinal K-wire is blocking the distal

interphalangeal joint from flexion to protect the repair

11

Trigger Finger

• Trigger finger is the popular name of stenosing tenosynovitis, a painful condition in which a finger or thumb locks when it is bent (flexed) or straightened (extended).

12

Trigger Tension• Due to narrowing of the sheath that surrounds the tendon in

the affected finger, or a nodule forms on the tendon.

• Trigger finger is often an overuse injury because of repetitive or frequent movement of the fingers (ex. hobbies as playing a musical instrument or crocheting)

• Trigger finger may also result from trauma or accident

• It is called trigger finger because when the finger unlocks, it pops back suddenly, as if releasing a trigger on a gun.

13

Trigger Tension• Clinical Picture:

– Affected digits may become painful to straighten once bent

– May make a soft crackling sound when moved.– It props back suddenly when straightened– Symptoms are usually worse in the morning and improve

during the day

• Treatment:– local steroid injections and splinting (weeks to months)– Surgery: cut the sheath that is restricting the tendon.

14

Trigger Tension

15

Introduction of the needle into the tendon sheath at 45° to the

palm for injection treatment.

16

Boutonniere Deformity

• Aka: Buttonhole Deformity

• Hyperflexion at the PIP joint with hyperextension at the DIP

• Passive extension of the PIP joint is easy.

17

Boutonniere Deformity

18

Boutonniere Deformity

• Flexion deformity of the PIP joint, due to interruption of the central slip of the extensor tendon:– The lateral bands separate – The head of the proximal

phalanx pops through the gap like a finger through a button hole

– The DIP joint is drawn into hyperextension.

Central Slip

Lateral Band

19

20

Boutonniere Deformity

• The 3 main etiologies: – RA and other inflammatory arthritides (most often) – mechanical trauma– burns and infections

• An X-ray should be done to detect avulsion fractures

21

Boutonniere Deformity• BD in patients with RA can be classified into 1 of the following 3

stages, which serve as a guide to the appropriate management:– Stage I (mild) is the earliest stage and is the result of PIP joint synovitis

with mild extensor lag that still can be corrected passively. The metacarpophalangeal (MP) joint usually is normal, and the DIP may or may not be hyperextended.

– Stage II (moderate) is characterized by 30-40° of flexion contracture at the PIP joint and hyperextension of the MP joint as a compensatory mechanism. The finger has increased functional loss. Early passive extension still is possible. With time, soft-tissue contractures develop, and passive extension becomes restricted.

– Stage III (severe) begins when the PIP joint can no longer be extended passively. Radiographs demonstrate destruction of the joint surfaces

22

Boutonniere Deformity

Treatment:• Splinting 4 weeks minimal (6 weeks preferable):

– safety-pin splint (<40 degree)– Dynamic spring splints (> 40)

• Surgery: When the deformity is the result of a dislocation of the PIP joint

• Surgery carries a relatively high risk of FAILURE to achieve completely normal functioning extension mechanism of the finger.

23

Bunnell Safety Pin Finger Splint

Dynamic spring extension splint

24

Swan-Neck deformity

• -the PIP joint is hyper extended . DIP joint is flexed.

• Cause:– Volar plate becomes

weak -> hyperextension of PIPJ -> flextion of DIFJ

• Due to injury or inflammation (RA)

25

Swan-Neck deformity

26

Swan-Neck deformity• Swelling and pain due to inflammation from

injury or disease (RA)• X-ray is done to evaluate the joints (RA) and look

for fractures.

• Treatment:– A boutonnière deformity caused by an extensor

tendon injury can usually be corrected with a splint (Murphy Ring Splints) that keeps the middle joint fully extended for 6 weeks

– When splinting is ineffective, surgery may be needed.MURPHY RING SPLINTS

27

Dupuytren contracture

• Pathologic condition of the hand in which the fascia of the palm are shortened and thickened

• Common in south europe

28

Dupuytren contracture

29

Dupuytren contracture

• Dupuytren's contracture is more common among people with diabetes, alcoholism, or epilepsy

• The disorder affects both hands in 50% of people

• The disorder is occasionally associated with other disorders:– Garrod's pads: thickening of fibrous tissue above the

knuckles– Penile fibromatosis: shrinking of fascia inside the penis

that leads to deviated and painful erections– Plantar fibromatosis: nodules on the soles of the feet

30

Dupuytren contracture

• Symptoms:– The first symptom is usually a tender nodule in the palm– Gradually, the fingers begin to curl. – Eventually, the curling worsens, and the hand can become

arched (clawlike)

• Treatment:– Surgery to correct contracted (clawed) fingers

31

32

Hand Fractures/Hx• Hand trauma, industrial• Hand dominance• Hand injured• Mechanism of injury:

– Clean/dirty environment– Position of the hand– Thermal, electric or chemical injury– Wearing jewelry on finger, removed

• In assault:– Hand open or fist clenched– Lacerations (tendon injury)– Contact with mouth, teeth

• Years since last tetanus immunization (esp. in lacerations and abrasions)

33

Hand Fractures/ P/E

• Hand examination:– Compare with uninjured– Signs of inflammation, abrasions, erosions– Abnormal position (esp. fingers): rotational

deformity– Location of injury– Capillary refill

• Neurology: radian, median and ulnar nerve

34

With fingers flexed at the metacarpophalangeal and proximal interphalangeal joints and

extended at the distal interphalangeal joints, fingers should all point toward the scaphoid

bone

35

Examination of the patient's hand with the fingers flexed may clearly reveal a rotational

deformity

36

Hand Fractures

• Imaging:– X-ray: AP, lateral and oblique view– MRI, CT, Bone scan seldom needed

• ED care:– Pain management, reduction, splinting, referral– Primary concern is preservation of function– Except for distal phalanx fracture, all pts. Should be

referred to a hand surgeon

37

Boxer’s Fracture

• A break in one or more metacarpal bones, usually the fourth or the fifth, caused by punching a hard object. Such a fracture is often distal, angulated, and impacted

• Finger shorten posteriorly

Fourth and fifth metacarpal fractures,

oblique view

38

Scaphoid Fracture

• Epidemiology– common in young men;

not common in children or in patients beyond middle age

• Mechanism– FOOSH resulting most

commonly in a transverse fracture through the waist (middle) of the scaphoid

Scaphoid fracture in the middle third or waist

39

Scaphoid Fracture• Clinical Features:

– pain on wrist movement– tenderness in scaphoid region (anatomical "snuff box")– usually undisplaced

• Investigations:– x-ray (AP/lat/scaphoid views with wrist exended and ulnar deviation)– +/- bone scan and CT scan

• Note: a fracture may not be radiologically evident up to 2 weeks after acute injury, so if a patient complains of wrist pain and has anatomical snuff box tenderness but a negative x-ray, treat them as if they have a scaphoid fracture and repeat x-ray 2 weeks later to rule out a fracture

• Treatment:– Undisplaced: cast– Displaced = open (or percutaneous) screw fixation

40

Colles’ and Smith Fracture

• Colles’ Fracture:– Due to FOOSH– > 40 yrs, female (esp. osteoperosis)– Fx fragment: upward-dorsal angulation (fork-like

appearance)

• Smith Fracture:– Aka: reverse Colles’ fracture– Falling on the back of a flexed hand– Fx fragment: volar (palmar) displacment

41

42

Colles’ Fracture

43

Smith Fracture

44

Both Bones Fracture (Radius & Ulna)

• FOOSH, direct blow

• Internal fixation by plates and screws

• Complications:– Compartment syndrome– malunion Anteroposterior radiograph of a

displaced, midshaft both-bone forearm fracture in an adolescent

with a transitional growth plate

45

46

Ulnar nerve palsy

• This occurs due to nerve compression at the elbow (cubital tunnel) or at the wrist (Guyon's canal) (Ulnar canal)

• Muscle weakness and atrophy predominate the clinical presentation

47

Ulnar nerve palsy/CausesCubital Tunnel Syndrome• Frequent bending of the elbow• Leaning on the elbow, resting

it on an elbow, rest during a long distance drive or running machinery may cause repetitive pressure and irritation on the nerve.

• A direct hit on the cubital tunnel may damage the ulnar nerve

Guyon's Canal Syndrome• A cyst within the canal.• Clotting of the ulnar artery.• Fracture of the hamate bone.• Arthritis of the wrist bones

48

Ulnar nerve palsy/Causes• Symptoms & signs:

– numbness and tingling in the ring and little finger and the sides and back of the hand. At Guyon's Canal, sensory supply to the skin of the back of the hand is spared.

– The hand may become weaker resulting in trouble opening bottles or jars

– Clawing may occur in the ring and little fingers– Froment's test: by asking the patient to hold a piece of paper

between their thumb and index finger (hence checking adductor pollicis). In a patient with Ulnar nerve palsy the interphalangeal joint of the thumb will flex to compensate

• Treatment:– Nonsurgical therapy: elbow or wrist splints to limit mobility in addition

to an anti-inflammatory drug such as ibuprofen.– Surgical decompression maybe required in some cases

49

50

Froment's test

51

Radial nerve palsy

• Aka: – wrist drop – Saturday night palsy

52

• Causes– Caused by excessive compression of the radial nerve

against a hard surface in individuals insensitized by the intake of alcohol or sedatives

– Broken humerus– lead poisoning – Stab wounds to the chest at or below the clavicle. Damage

the posterior cord of the brachial plexus

• Symptoms:– Wrist drop– Occasionally, the back of the hand may lose feeling

53

Wrist Drop

54

Erb’s Palsy

• Aka:– Waiter's tip deformity – Erb-Duchenne Palsy

55

Erb’s Palsy• Due to brachial plexus damage, by excessive lateral neck flexion

away from sholder:– Forceps delivery– Falling on the neck

• Leads to loss of the lateral rotators of the shoulder, arm flexors, and hand extensor muscles.

• The position of the limb, under such conditions, is characteristic: – the arm hangs by the side and is rotated medially;– the forearm is extended and pronated. – The hand is flexed– The arm cannot be raised from the side; all power of flexion of the

elbow is lost, as is also supination of the forearm

56

Erb’s Palsy• The three most common treatments from Erb's

Palsy are: – Nerve transfers (usually from the opposite leg), – Sub Scapularis releases– and Latissimus Dorsi Tendon Transfers.

• Although range of motion is recovered in many children under one year in age, individuals who have not yet healed after this point will rarely gain full function in their arm and may develop arthritis

57