Sophia Marie S Chiong
Level III
Injuries to the Hand and Digits
TENDON INJURIES
Flexor Tendons
-Most common cause of flexor tendon injury is
laceration
Distal-to-proximal Five Zone Classification
Zone 1 extends from the insertion of the flexor
digitorum superficialis to the profundus tendon.
-lose flexion at the DIP
-retrieval of the proximal tendon is often
difficult
Zone II involves the portion of the digital canal
occupied by both flexor digitorum superficialis
and flexor digitorum profundus tendons.
-it is essential for exact repair with minimal
operative trauma
-laceration in this zone are common
Zone III extends from the distal edge of the
carpal tunnel to the proximal edge of the flexor
sheath. The lumbrical muscles originate from
the flexor digitorum profundus tendons in this
region.
-outcomes are generally favourable
Zone IV involves the carpal tunnel and related
structures.
-area must be explored carefully because so
many vital structures traverse this region
Zone V involves injuries to tendons proximal to
the carpal tunnel.
-injuries are severe and involve multiple tendon
-examine and test all major structures
-primary repair should occur within 12 hours
-secondary repair upto 4 weeks after injury
-typically results from a graspin motion against
high-speed resistance.
-patient is unable to flex the distal phalanx
*Flexor tendon injuries are relatively rare in
children. Emergent management of these
patients is the same as for adults.
Extensor Tendons
-the most common site of tendon injuries
because of the superficial nature of the tendons
on the dorsum of the hand.
Zone Classification
Zone I involves the area over the distal phalanx
and DIP
-can occur from blunt or sharp trauma
-“mallet finger” –complete laceration or rupture
of the tendon resulting in DIP flexion at 40
degrees
Type I- tendon rupture only
Type II- there is a small avulsion fracture
Type III- >25% of the articular suface is
involved
-Type 1 and type II treated with DIP immobilized
in continuous slight hyperextension for 6 to 10
weeks.
-chronic untreated mallet finger may result in
swan neck deformity
Zone II involves the area over the middle
phalanx.
-usually a result of laceration
-treatment similar to one 1 injuries
Zone III involves the area over the PIP
-central tendon is the most commonly injured
structure
-complete disruption of the central tendon may
result in the volar displacement of the lateral
bands, causing them to be flexors, along with
the unopposed flexor digitorum profundus
-boutonniere deformity
-initially reated with the PIP immobilized in
extension for 5 to 6 weeks and should be
followed closely by a hand specialist.
Zone IV involves the area over the proximal
phalanx
-clinical findings similar to zone III injuries
-less problematic because the joint is not
involved and tendon at this level is broad and
flat
Zone V involves the area over the MCP
-open injuries in this area should be considered
human bites until proven otherwise
-wounds from human bites should have delayed
repair for following a course of broad-spectrum
antibiotics to ensure a minimum risk of
infection
-clean wounds repaired primarily using mattress
sutures to reapproximate tendon edges

Zone VI involves the area over the dorsum of
the hand.
-minor-appearing lacerations may be associated
with one or more tendon inuries
-zone VI, VII, VIII typically require operative
fixation with K wires and advanced suture
techniques
Zone VII involves the area over the wrist
-repair can be difficult because of the presence
of the extensor retinaculum
Zone VIII involves the area of the distal forearm
-require a thorough exploration to identify all
injured structures.
-tendons frequently retract into the forearm
and must be retrieved and repaired
-laceration of <25% do not require repair; 25-
50% need simple suture repair; >50% need
specialized repair
-splinting should occir with the wrist in 15-
degree extension, the MCP in 15 degree flexion,
the interphalangeal joint in 15 degree flexion in
the involved and adjacent digit
*Pediatric patients with extensor injuries should
be treated similarly to adults with the same
injury. However, greater emphasis should be
placed on hand surgery follow-up within 24
hours to maximize function and minimize
morbidity.
LIGAMENTOUS INJURIES AND DISLOCATIONS
Distal Interphalangeal Joint
-uncommon because of the firm attachments of
the skin and subcutaneous tissue to the
underlying bone by ostoecutaneous fibers.
-disloacations are usually dorsal
-longitudinal traction and hypersextension
followed by direct dorsal pressure to the base
of the distal phalanx usually accomplish
reduction
-Irreducible cases maybe due to the entrapment
of an avulsion fracture, the profundus tendon or
volar plate.
Proximal Interphalangeal Joint
-dislocation of the PIP are common hand
injuries
Sophia Marie S Chiong
Level III
-due to axial load and hyperextension
-dorsal dislocation occurs when the volar plate
ruptures
-lateral dislocation occur when one of the
collateral ligaments ruptures with at least a
partial avulsion of the volar plate from the
middle phalanx; digits usually ulnarly deviated
-volar dislocation are rare
-dorsal dislocations are reduced similarly to
dorsal distal interphalangeal joint dislocation
-active motion and strength should be tested
following reduction
-normal –joint should be splinted at 30-
degree flexion for 3 weeks
-irreducible or eveidence of complete
ligamentous disruption –operative
repair is required
Metocarpopharlangeal Joint
-usually due to hyperextension forces that
rupture the volar plate, cause dorsal dislocation
-sublaxation is more common than dislocation
-in sublaxation, joint appears to be
hyperextended 60-90 degrees and the articular
surfaces are still in contact
-reduction by flexing the wrist to relax the flexor
tendon then applying pressure over the dorsum
of the proximal phalanx in a distal and volar
direction
-after reduction, MCP should be splinted in
flexion
Carpometacarpal Joint
-uncommon because the joint is supported by
strong dorsal, volar and interosseous ligaments
and reinforced by the broad insertion of the
wrist flexion and extensors
-usually result of high-speed mechanisms such
as moror vehicle crashes, falls, crushes or
clenched fist trauma
-dislocation is usually dorsally oriented and
associated with fractures
-reduction can be attempted after regional
anesthesia; traction and flexion with
simultaneous longitudinal pressure on the
metacarpal base should be re-establish normal
anatomic alignment

-early referral is needed to determine need for
further fixation
-volar CMC dislocation should be referred to a
hand specialist
Thum Interphalangeal Joint
-rare; usually open
-typically hyperextension with rupture of the
volar plate
-reduction is similar to intarphalangeal joints of
the other digits
-after reduction, joint should be immobilized in
mild flexion for 3 weeks
FRACTURES
Distal Phalanx
-usually result from crush or shearing forces
-classified as tuft, shaft or intra-articular
-tuft –can be associated with flexor and
extensor tendon involvement
-treated as soft tissue injurieswith protective
splinting
Proximal and Middle Phalanx
-proximal phalanx, fractures frequently result in
volar angulation from the forces of the extensor
an intraosseous muscles
-middle phalanx, fractures at the base
demonstrate dorsal angulation; fractures at
then neck result in volar anugulation
-direct blow mechanism usually causes a
transverse or comminuted fracture
-twisting mechanisms will result in a spiral
fracture
-stable and nondisplaced fractures, can be
treated with early protected motion by buddy
taping
-unstable fractures, closed reduction can be
splinted from the elbow to the DIP with the
wrist at 20 degree extension and the MCP in 90
degree flexion
-midshaft transverse fractures, spiral fractures
and intra-articular fractures often require
internal fixation
Metacarpal Fractures
Metacarpal Head Fractures
Sophia Marie S Chiong
Level III
-usually caused by a direct blow, crush or
missile
-fractures are distal to the insertion of the
collateral ligaments and are often comminuted.
-treatment: ice, elevation, immobilization with
referral to hand surgeon
Metacarpal Neck Fractures
-usually caused by a direct impaction force
-fraction of 5th metacarpal neck – boxer’s
fracture
-angulation of <20 degrees in the fourth and 40
degrees in the fifth metacarpal will not result in
functional impairment. If greater angulation in
these metacarpals occurs, reduction should be
attempted. Following splinting, these patients
may have residual cosmetic deformity, but, in
most cases, regain full function. The amount of
angulation at the time of injury does not
correlate with resultant cosmetic defect.
-with second and third metacarpal fractures,
angulation of <15 degrees is acceptable.
Metacarpal Shaft Fractures
-usually from direct blow
-rotational deformity and shortening are more
likely in shaft than in neck fractures
-operative fixation is usually indicated
Metacarpal Base Fracture
-usually caused by a direct blow or axial force
-often associated with carpal bone fractures
-fractures at 4th and 5th can result in paralysis of
the motor branch of the ulnar nerve
Thumb Metacarpal Fractures
Extra-articular Fractures
-caused by a direct blow or impact mechanism
-more than 20 degree angulation requires
reduction and thumb spica splint for 4 weeks
-spiral fractures often require fixation
Intra-articular Fractures
-caused by impact from striking a fixed object
-Bennett Fracture- with associated sublaxation
or dislocation at the CMC joint. Treatment:
application of a thumb spica splint and surgical
referral.
-Rolando Fracture –intra-articular comminuted
fracture at the base of the metacarpal. MOI is
similar to Bennet fracture but less ommon.
 Sophia Marie S Chiong
Level III

Treatment: thumb spica splint and surgical

consultation.
RAYNAUD’S PHENOMENOM
Clinical Manifestaion
-episodic digital ischemia (digital blanching,
cyanosis, and rubor of the fingers or toes after
cold exposure and subsequent rewarming)
-color changes are usually well demarcated and
are confined to the fingers or toes
-blanching or pallor when patient is exposed to
a cold environment – ischemic phase result
from vasospasm of the digital arteries
-cyanosis – when capillaries and venules dilate
-sensation of cold or numbness or paresthesia
accompanies the phases of pallor and cyanosis
-bright red color of the digits- reactive
hyperaemia when digital vasospasm resolves
and blood flow into the dilated arterioles and
capillaries
-throbbing, painful sensation
Clinical Manifestation
-triad of claudication of the affect extremity,
Raynaud’s phenomon and migratory superficial
vein thrombophlebitis
-claudication usually is confined to the calves
and feet or the forearms and hands
-trophic nail changes, painful ulcerations and
gangrene may develop at the tips of the fingers
or toes
-reduced or absent radial, ulnar and/or tibial
pulses
Treatment
-no specific treatment except abstention from
toacco
-Arterail bypass of the larger vessels
-local debridement
-antibiotics
-anticoagulants and glucocorticoids
-if all measures fail, amputation may be
required

Treatment
-instruct to dress warmly and avoid unnecessary
cold exposure
-patient should protect the trunk, head and feet
with warm clothing to prevent cold-induced
reflex vasoconstriction
-tobacco use is contraindicated
Pharmacotherapy
-reserved for severe cases
-dihydropyridin calcium channel antagonists
(nifedipine, isradipine, felodipine, and
amlodipine ) –decreases frequency and severity

THROMBOANGITIS OBLITERANS (BUERGER’S

DISEASE)
-inflammatory occlusive vascular disorder
involving small and medium-size arteries and
veins in the distal upper and lower extremities
-cerebral , visceral and coronary vessels may be
affected rarely
-most frequent in men <40 years of age