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Common Orthopedic Conditions of the Hand

John Hubert C. Pua, M.D.

Carpal Tunnel Syndrome

The median nerve is compressed in the
carpal tunnel
It is the most common nerve entrapment
condition in the hand
Signs and symptoms
o Wrist pain
o Numbness in the thumb, index, and
middle finger
o Night time awakening
o Dropping
objects,
clumsiness,
weakness
o Thenar muscle wasting
Provocative tests
o Phalens test
o Tinels sign
o Durkans carpal compression test
Treatment
o Conservative management:
Splinting
Non-steroidal anti-inflammatory
drugs
Steroid injection
Physical therapy
o Surgical management:
Open carpal tunnel release
Endoscopic carpal tunnel release
Trigger Digit
Can either be a trigger finger or trigger
thumb
Characterized by catching, snapping or
locking of the involved digit flexor tendon
associated with dysfunction and pain
Also known as stenosing flexor tenosynovitis
Flexor Pulley System
o Annular pulley (A1, A2, A3, A4, A5)
o Cruciate Pulley (C1, C2, C3)
Signs and symptoms
o Locking or catching during digit
motion
o Stiff digit
o Pain radiating along the digit and
over palm
o Triggering
o Palpable snapping sensation or
crepitation
o Tenderness

Fixed flexion deformity in late

presentations
Quinnell Classification
Grade 0 Mild crepitus in the nontriggering finger
Grade 1 No triggering, but uneven
finger movements
Grade 2 Triggering
is
actively
correctable
Grade 3 Usually correctable by the
other hand
Grade 4 The digit is locked
Treatment
o Conservative management:
Splinting
NSAIDs
Steroid injection
Physical therapy
o Surgical management:
Percutaneous release of A1
pulley
Open release of A1 pulley

De Quarvain Syndrome
It is the inflammation of the tendons located
at the level of the wrist near the base of the
thumb
Dorsal compartment (APL, EPB)
It is also known as Gamers Thumb or
Washerwomans Sprain
Dorsal Wrist Compartment
o 1st: APL, EPB
o 2nd: ECRL, ECRB
o 3rd: EPL
o 4th: EDC, EIP
o 5th: EDM
o 6th: ECU
Signs and symptoms
o Pain and tenderness at the base of
the thumb (radial styloid process
area) aggravated by movement
o Localized swelling
Special test
o Finkelsteins Test
Treatment
o Conservative management:
Splinting
NSAIDs
Steroid injection
Physical therapy
o Surgical management:
Open release of the 1st dorsal
compartment

Ganglion Cyst
It is the most common soft tissue lesion of
the hand
It is a tumor or swelling usually found at the
back or palmar area of the wrist (dorsal volar
ganglion cyst)
It is cystic with a thick sticky, clear, colorless,
jelly-like material inside
Also known as Bible Cyst
Signs and symptoms
o Mass change in size
o May cause some degree of pain
o Mass is firm, non-tender, and
transilluminates
Treatment
o Conservative management:
Observation (50% spontaneously
resolves)
o Surgical management:
Indications:
Cosmetic reasons
Symptomatic pain
Neuromuscular
impingement
Aspiration
Surgical excision
Arthroscopic excision
Tendon Injuries
Flexor Tendons in the Hand
o FDP, FDS, FPL
Extensor Tendons in the Hand
o EDC, EIP, EDM, EPB, EPL
o Extensor Mechanism
Verdan Zones
Physical Examination
o Evaluate the skin for any signs of
infection,
open
wounds
or
lacerations
o AROM and PROM
o Asses for strength and pain with
resistance
Flexion Cascade
o Observe posture of hand
o There is a normal flexion cascade of
the hand
Index finger: least flexion
Little finger: greatest flexion
o Physical examination
Note position of the finger at the
time of injury
Flexor tendon testing

Extensor tendon testing

Elsons Test
For acute tears of the
central slip
Passive Tenodesis Test
Cause: laceration or puncture wounds on the
hand (open injury)
Damage:
o Single or multiple tendons
o Neighboring structures e.g. nerve,
blood vessels and bone
Tendons can also snap if overtressed such as
in sports (closed injury

Flexor Tendon Injuries

Zone 1
Jersey Finger
Contains only the FDP
Tendon laceration is usually very close to its
insertion
Tendon to bone repair usually is required
instead of tendon to tendon repair
Zone 2
No mans land
FDS and FDP within one flexor tendon
sheath
Adhesion formation is amplified at Campers
chiasm
Repair both FDP & FDS tendons
Zone 3
Lumbrical muscle origins in the zone
prevents the profundus tendons from over
retracting
Delayed repairs have been successful even
weeks after the injury
Zone 4
Tendon injuries in this zone are rare because
of the protection provided by the stout
transverse carpal ligament
Zone 5
Proximal
portion
meets
the
musculotendinous junctions
Poor site of repair because tendons become
thinner and fan out into fibers that merge
with the muscle belly
Extensor Tendon Injuries
Zone 1
Mallet Finger
Disruption of the extensor mechanism at the
DIPJ (terminal slip)

Forced flexion on an extended DIPJ resulting

to tendon rupture, avulsion from its
insertion or bony avulsion (bony mallet)

Zone 2
Most result from laceration and crush
injuries
Lacerations distal to the central slip result in
a mallet deformity
Zone 3
Boutonniere deformity
Disruption of the central slip
Lateral bands sublux volarly and flex the PIPJ
while extending the DIP
(+) Elsons Test
Zone 4
Partial lacerations are treated with splinting
Complete laceration are repaired and
associated phalangeal fractures are fixed to
restore length and allow early AROM
Zone 5
Fight bite
Wound can involve the underlying extensor
mechanism and extend into the joint
Rupture of sagittal band
Debridement and assessment of depth to
prevent infection
Zone 6
Proximal tendon lacerations frequently
retract
Repair should be done if appropriate
Juncturae tendinae injuries are frequently
missed
Zone 7
Lacerations at the level of the extensor
retinaculum
Tendons retract, scar under the retinaculum
after repair
Complete release of the retinaculum results
in bowstringing
Zone 8
Wrist and thumb extension should be
priorities when sorting out multiple extensor
lacerations
Muscle bellies are repaired
Management of Tendon Injuries
Tendon Repair
o <50% laceration non-operative
management
o >50%
laceration

surgical
management

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Repair tendon injuries early

Perform within the first 2 weeks
after injury because the tendon ends
and sheaths become scarred and
retract
Repairs after 2 weeks may decrease
the ultimate mobility of the fingers
Tendon repairs are weakest at 7-10
days
Most of its original strength is
regained at 21-28 days
Maximum strength is achieved at 6
months
Early mobilization allows increased
ROM but results in decreased
tendon repair strength
Immobilization leads to increased
tendon substance strength at the
expense of ROM