CLINICAL APPLICATION:

CASE 1.
Scaphoid fracture
MOI: Fall on outstretched of hand (FOOSH)
Pain: tenderness at ANATOMIC SNUFFBOX
Mgt: Displaced fx-ORIF, Screw fixation
Complication: Avascular non union (Preiser’s disease)
-Due to retrograde blood supply
-Might lead to OA if not treated effectively and (+) permanent weakness and pain of the wrist.
Common: in YOUNG ADULTS

CASE 2.
Boxer’s fracture or Street fighter’s fx
MOI: direct violence such as clenched fist striking a hard object.
Angulation Fx: DORSAL
Produces: Oblique fx of the NECK OF THE 5TH and sometimes 4th METACARPAL BONES
Displaced: Distal fragment is commonly displaced PROXIMALLY, resulting to shortening the
finger POSTERIORLY.

CASE 3.
Carpal Tunnel Syndrome ( CTS)
MOI: Prolonged compression of your carpal tunnel
Cause: may be variable, but thickening of the synovial sheaths of the flexor tendons or arthritic changes in the carpal
bones.
Can also be found in pregnant women.
S&Sx: burning pain or “pins and needles” sensation along the median nerve distribution (Lateral 3 and lateral ring
finger: refer to the chart for the picture, and weakness of the thenar muscles)
(-) paresthesia at thenar eminence due to palmar cutaneous branch of the median nerve.
Mgt: Decompressing the tunnel via longitudinal incision through flexor retinaculum

CASE 4.
Suppurative Flexor Tenosynovitis/ Tenosynovitis of Flexor Tendon Synovial Sheaths
Cause: Infection of flexor tendon sheath due to bacteria penetrating the sheath. ( point of a
needle or thorn)
(+) distention of the sheath with pus
Sign consists of four components: KANAVEL’s Signs
1. The affected finger is held in slight flexion.
2. There is fusiform swelling over the affected tendon
3. There is tenderness over the affected tendon
4. There is pain on passive extension of the affected finger
Mgt: Zigzag volar incision

CASE 5
Dx: Infection on THENAR SPACE
S&Sx: pain and swelling of thenar eminence and first web space.
Thumb is held abducted and flexed
-THENAR SPACE contains the 1st lumbrical muscle and lies deep to the long flexor tendons to the index finger and
superficial to the adductor pollicis muscle.

CASE 6
Dx: Pulp Spcae Infection ( Felon)
-infection is common and serious, most often in the thumb and index finger due to pinpricks or sewing needles.
-If infection is left without decompression, infection of the terminal phalanx can occur.
-PULP SPACE of the fingers is a closed fascial compartment situated anterior to the terminal phalanx of each finger.
Mgt: Volar longitudinal incision ( starts 3 to 5mm from the DIP joint)

CASE 7
Dx: Extensor Pollicis Longus Tendon Rupture
Causes: can occur after fx of the distal third of the radius. Roughening of the dorsal tubercle of the radius by the
fx line can cause excessive friction on the tendon, which can then rupture.
-Intra-op rupture due to screw penetration
-RA can also cause rupture of this tendon
Difficulty: Extending the IP joint of the thumb

Components of your Extensor Compartment of the Wrist

 1st Compartment- Abductor pollicis longus and extensor pollicis brevis tendons,
having separate synovial sheaths but sharing a common compartment
2nd Compartment- Extensor carpi radialis longus and brevis tendons, sharing a
common synovial sheath
3rd Compartment- Extensor pollicis longus tendon, winding around the medial side
of the dorsal tubercle of the radius
4th Compartment -Extensor digitorum and extensor indicis tendons, sharing a
common synovial sheath and situated on the lateral part of the posterior surface of
the radius.
5th Compartment -Extensor digiti minimi tendon, situated posterior to the distal
radioulnar joint.
6th Compartment -Extensor carpi ulnaris tendon, which grooves the posterior
aspect of the head of the ulna.

CASE 8
Dx: Trigger Finger/ Snapping Finger/ Digital Tenovaginitis Stenosans
S&Sx: (+) palpable nodule and audible snapping
(+) Mechanical locking at A1 pulley
Commonly seen: MCP, but can also be seen at 3rd and 4th digits
(when the fingers are flexed, the node moves proximal to the pulley, when pt attempts to
extend the digit .This node fails to pass back under the pulley then mechanical locking occurs in
a flexed position)
Cause: localized swelling of one of the long flexor tendons
Mgt: Conservative treatment: splinting of the affecting digit.
Surgical incision at fibrous flexor sheath

ANNULAR PULLEYS

A1 – overlies the metacarpophalangeal joint

A2 – overlies the proximal aspect of the proximal phalanx

A3 – overlies the proximal interphalangeal joint

A4 – overlies the mid-portion of the middle phalanx

A5 – overlies the distal interphalangeal joint

CRUCIATE PULLEYS

C1 – located between A2 and A3

C2 – located between A3 and A4

C3 – located between A4 and A5

FLEXOR PULLEY SYSTEM OF THE THUMB

Reinforced by 3 pulleys:

A1 – overlies the metacarpophalangeal joint

Oblique – overlies the proximal half of proximal phalanx

A2 – overlies the distal half of proximal phalanx

CASE 9

Dx: Median Nerve Palsy “ Benedictian Sign”

S&Sx: Skin sensation is lost on the lateral half or less of the palm of the hand and palmar aspect of the 3 lateral three
and a half fingers and distal part of the dorsal surfaces of the lateral three and a half fingers.
Disability: Loss of the ability to oppose the thumb to the other fingers ( OPPOSITION) with the loss of sensation over the
lateral fingers.
Test: Ask the patient to make a fist and the ring and little finger flex but the index and middle finger can’t flex at the
MCP and IP joint.

CASE 10

Dx: Ulnar Nerve Lesion

Affected structures: Hypothenar muscles and loss of the convex curve to the medial border of the hand.
Sensory loss: palmar surface of the medial third of the hand and the medial one and a half fingers and to the
dorsal aspects of the middle and distal phalanges of the same fingers.
Clawlike deformity can be see in long standing cases, most pronounced on the medial (ulnar) aspect of the hand.
Good pincer-like action of the thumb and index finger.

CHART FOR SENSORY INNERVATION OF THE SIN OF THE VOLAR AND DORSAL ASPECTS OF THE HAND