1 Injuries to MC & phalanges General principles: Every effort is made to limit swelling as it may lead to chronic principles: edema and

irrecoverable fibrosis ultimately leading to stiffness and poor 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 sling is helpful, provided that sling is applied in such a way that the hand is not dependant.

Injuries to MC & phalanges Principles of splintage: If # or joint is unstable, stabilize it, but as few joints as splintage: 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 movement, free fingers should be vigorously exercised. 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 position but MP joint extension must be studiously avoided.

Injuries to MC & phalanges 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 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 stabilization in AP plane (IP collateral ligament avulsion # or un displaced # of phalanx) where minimal fixation is required, “garter” strapping to an adjacent finger with inter digital felt padding often provides ideal combination of stability while retaining movement.

2 Injuries to MC & phalanges Rotational (torsional) deformity of a MC or phalanx may not be noticeable in extension, but cause obvious deformity and functional impairment in flexion. In presence of gross instability or persistent angulations, especially where # 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 fragment set can be used.

Injuries to MC & phalanges Soft tissue management: When there is necrotic or foreign material, a thorough management: debridement performed under tourniquet. There is little tissue in the hand so wide excision of the wounds is to be avoided. Where there is skin loss and if situation permits a primary skin graft of plastic repair should be carried out. 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 attempts should be made to preserve maximum length of thumb or finger.

Injuries to MC & phalanges 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 land of the tendon sheaths should not be undertaken.

3 Injuries to the thumb Base: Commonest injuries are Bennett's # dislocation, # of the base of the thumb Base: 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 of the thumb. May be mistaken for scaphoid # but tenderness is maximal distal to the snuff box.

Bennett’s # Small medial fragment of bone which may tilt, but maintains its relationship with the trapezium, the vertical # line involves the trapezometacarpal joint; most important is the proximal and lateral subluxation of the thumb MC. 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.

Bennett’s # 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. 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.

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Bennett’s # 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 1st MC.

# of base of 1st MC Greenstick # of this type are common in children. Angulation is usually slight to moderate and should be accepted, gross angulation should be manipulated. In this types there is no subluxation. Plaster fixation for about 5 weeks is desirable. CMC dislocation of thumb Thumb may dislocate at the joint between MC base and trapezium or 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 by applying traction to thumb and local pressure over the base F/B well padded cast of scaphoid type for 3 weeks. Injuries at the MP joint of thumb Posterior dislocation: Results from forcible hyperextension of thumb. There 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 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.

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Gamekeeper’s thumb Caused by forcible abduction of thumb leading to rupture of ulnar collateral ligament. If unrecognized or untreated, there is progressive MP subluxation, interference with grasp and disability. Extend the MP joint fully and apply stress to UCL by abducting PP, repeat 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 there note its position (Marked displacement, rotation so that its articular surface is pointing distally are indications of surgery.

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

# of PP of thumb 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 or splinter # protected by local slab.

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

Injuries of 5th MC Types: # of the neck, spiral # of shaft usually UN displaced, transverse # of shaft Types: often angulated, # of the base and # of the head. # of the neck : Caused by banging a clenched fist as in fight, angulation and 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 little finger.

Injuries of 5th MC 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 shaft. Reduction should be checked and maintained while slab is applied Spiral #, transverse # of shaft with mild to moderate angulation or displacement and # of base may be treated adequately by application of a Colles’s plaster for 3-4 weeks

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Injuries of 5th MC Marked angulation of shaft # treated by traction and local pressure prior to 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. # of head of 5th MC are treated by garter strapping and early mobilization. If symptoms are marked a dorsal slab may be applied for initial 1-2 weeks. Injuries of 5th MC Dislocation of the base of 5th MC is usually easily reduced with traction, but may need K-wire stabilization. Injuries to index, middle & ring MC Commonest 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 can be severe especially in multiple #. Displaced # are managed as mentioned in 5th 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 further 2 weeks. # of PP and MP Un displaced simple # of shaft, base, neck, intercondylar region or epiphyseal 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 volar or dorsal slab with finger extension. 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 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 #.

# of PP and MP Care is taken to keep uninjured fingers free and exercised. Rigid fixation should be discarded as soon as possible.

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Finger stiffness is commonest and most disabling complication due to joint

adhesions, fibrosis in the adjacent flexor tendon sheaths and collateral ligament shortening. Infection in open # is another major contributing factor in stiffness. # of PP and MP Amputation as primary treatment is required in compound # with flexor tendon division or division of one or both neurovascular bundles, skin loss or severe crushing. Mal union: Arise from recurrence of deformity, failure to correct initial deformity torsional deformity or epiphyseal displacement. In latter case, remodeling may lead to correction. # Of DP 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 spatula or use of a plastic finger splint is helpful.

Mallet finger 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. Patient 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 1/3rd of articular surface is detached subluxation of the DIP joint may occur.

Mallet finger 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 splint.

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If deformity recurs, immediate surgery is not advised as disability may be slight,

spontaneous fibrotic healing may occur after 6 months. Results of tendon suture are uncertain IP fusion gives the best overall results.

MP & IP joint dislocation Simple or multiple and as they result from hyperextension are almost posterior. 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 longer period. # dislocation It is important that joint surface is correctly relocated and mobilization started as early as possible. 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 # becomes more stable.

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

10 Tenosynovitis 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. Movement of a tendon produces clinically detectable crepitations. Inflammation is 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 crepitations detected. Mild cases treated by rest, cool packs and gentle exercise to prevent adhesions. Severe cases may be splinted temporarily. Trigger finger Fusiform swelling of sublimis tendon at its bifurcation as it passes through thickened and constricted sheath over the MC Head. 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 passage and finger becomes locked usually in flexion. Conservative treatment includes local injections of corticosteroids, rest by 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.