Common Finger Injuries

dr Izaak Zoelkarnain Akbar

DIP Injuries
Ouch!!! … <BLEEP>!! ...
<BLEEP> !!!

/F2
http://radiographics.rsnajnls.org/cgi/content-nw/full/24/4/1009

http://www.hughston.com/hha/b_16_4_2a.jpg
 Mallet Finger 1

 Mechanism of Injury  Exam Deficit

 Flexion force or axial loading  Active Extension (Extensor
during DIP extension. Lag).
 Terminal extensor tendon  Imaging
avulsion.  AP, lateral, oblique.
 Presentation
 DIP Flexion +/- edema.

http://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformities.pdf

http://www.eorthopod.com/images/ContentImages/hand/finger_mallet/finger_mallet_diagnosis01.jpg

1. http://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformities.pdf
 Mallet Finger 1

 Conservative Treatment
 Full extension splinting X 6 wks, then wean and start AROM regimen.
 If persistent extension lag, then continued & varied splinting for ≥ 3
wks. Refer to hand surgeon if no improvement.

 Surgical Treatment
 Pin large fracture fragments, then splinting.
 Extensor tendon repair.
 DIP Dislocations 2

 Uncommon
 Typically dorsal.
 Reduction Method
 1. Longitudinal traction and hyperextension.
 2. Direct dorsal pressure to dp base.

2. http://www.cchseast.org/Portals/33/Residency/InjuriesToTheHand2%5B1%5D.ppt
 DIP Dislocation 2

Dorsal dislocation at the DIP Volar dislocation of DIP joint

jt without associated fracture of little finger.
 DP Fractures 1

 15 - 30% of hand fx’s.

 Mechanism: Crush or shearing forces.
 Types: tuft (+/- nail bed lac), shaft, or intraarticular.

1. http://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformities.pdf
 DP Fracture 2

 Fx’s at the base may be

associated with flexor or
extensor tendon
involvement.
 Tx: Protective splinting.
PIP Injuries
 PIP Joint 1

 Features
 Hinge Joint.
 100- 110 degrees motion.
 2 condyles at proximal phalynx end which fit into middle phalynx
fossae.
 Collateral ligaments protect against deviation forces.
Somethin’ Isn’t Right …

http://farm1.static.flickr.com/230/513015968_5954ba9891.jpg
 Boutonniere Deformity 1

 Presentation
 PIP flexion +/- contracture,
DIP extension.
 Up to 3 wks after injury.
 Mechanism of Injury
 Forceful flexion
 Central Slip tear.
 Exam Deficit
 Active PIP extension.
 Imaging
 AP, lat, oblique.
 Boutonniere Deformity 1

 Treatment
 Continuous PIP extension splinting for up to 6 wks followed by night-
time splinting for 3 wks.
 AROM regimen.

http://www.abledata.com/product_images/images/01A1041.jpg
Boutonniere Deformity 1
Think of Birds…or Types of
Diving

http://www.ortho.hyperguides.com/tutorials/hand/swanneck/art/slide1.jpg

http://surgeonsblog.blogspot.com/2007/03/swan-thing-or-another.html
 Swan Neck Deformity 1

 Mechanisms of Injury  Imaging

 Central slip tear.  PA, lat, oblique.
 Volar slipping of lateral bands
 Volar capsule w/dorsal LB
displacement.
 Increased terminal tendon
tension.
 Presentation
 PIP extension, DIP flexion, MP
flexion.
 MP volar subluxation w/ulnar
drift in Rheumatoid Arthritis
(RA).
 Deficit
 Active +/- Passive PIP Flexion.
Swan Neck Deformity in RA

http://i90.photobucket.com/albums/k245/keshblog/MSK%20spondyloarthropathies/RA/handadvancedRA.jpg
 Swan Neck Deformity 1

 Treatment
 Indefinite splinting in slight flexion.
 Reconstructive surgery for RA-associated deformity.
 PIP Sprains 1

 The key is joint stability

PIP Dislocation 2
PIP Dislocation 1
 MP & PP Fractures 2

 Middle Phalanx
 Has the FDS insert on the entire volar surface and the extensor tendon
insert at the proximal base
 Fractures at the base have dorsal angulation and fractures at the neck
result in volar angulation.
 Proximal phalanx
 Fractures frequently have volar angulation from the forces of the
extensor and interosseous muscles.
 MP & PP Fractures 2

 Treatment
 Stable & Non-displaced  buddy taping
 Unstable fx’s amenable to closed reduction:
 Splint from elbow to the DIP w/wrist at 20-degree extension and the
MP jt in 90-degree flexion.
 Midshaft transverse/spiral/intraarticular fxs
 Often require internal fixation.
MCP Injuries
 MCP Joint Dislocation 2

 Uncommon.
 Mechanism:
 Typically 2/2 hyperextension forces that rupture the volar plate,
causing dorsal dislocation.
 Subluxation (simple dislocation)  joint appears hyper-extended.
Articular surfaces remain in contact.
 Volar
 Rare and usually require operative reduction.
 MCP Joint Dislocation 2

 Reduction
 Flex wrist to relax the flexor tendon.
 Apply pressure over the dorsum of the proximal phalanx in a distal and
volar direction.
 Splint the joint in flexion.
 Thumb MP Joint Dislocation 2

 Collateral ligaments arise from MC lateral condyles and insert volar oblique on
proximal phalynx.
 Abductor Pollicis Brevis & Flexor Pollicis Brevis insert on radial sesamoid.
Adductor pollicis inserts on ulnar sesamoid.

http://www.eorthopod.com/images/ContentImages/hand/hand_ulnar_collateral/ulnar_collateral_thumb_anat02.jpg
 Thumb MP Joint Dislocation 2

 Radial collateral ligament Rupture

 Uncommon
 Mechanism
 Forced adduction.

 Ulnar Collateral Ligament Rupture(A.K.A. “gamekeeper’s

thumb” or “skier’s thumb”)
 Mechanism
 Excessive radial deviation (abduction) of the MP jt.
 Tear usually occurs at the insertion into the proximal phalanx.
 Significant injury occurs to the dorsal capsule and volar plate.
 Thumb MP Joint Dislocation 2

 Evaluation of Stability
 If XRAY negative, then abduction stress testing for added
information re: stability.
 Test the thumb MCP both in full extension and 30-degree
flexion, by stabilizing the metacarpal with one hand while
applying lateral (radial) stress on the proximal phalanx with the
other.
 Sx if >40° radial angulation.
 Thumb MP Joint Dislocation 2

 Treatment
 Simple Dislocation
 Reduction with pressure directed distally on the base of the proximal
phalanx with the metacarpal flexed and abducted.

 Partial Tear:
 Spica cast w/free IP for 2-4 wks.
 Then splint & ROM.
 2+ months for full recovery.

 Fractures
http://farm1.static.flickr.com/14/92816768_3e54451173.jpg?v=0

 Surgery including UCL reaatachment, MP jt pinning. Then thumb spica cast

for 4 wks. AROM. Spica splint for up to 8 wks.
Metacarpal Fractures
 1 MC Fractures
st 2

 Extraarticular (Not crossing the joint surface)

 Via direct blow or impaction mechanism.
 Mobility of the CMC jt can allow for 20-degree angular deformity.
Angulation greater than this requires reduction and thumb spica splint
for 4 wks.
 Spiral fractures often require fixation.
 1 MC Fractures
st 2

 Intra-articular
 Caused by impaction from striking a fixed object (two type)
 Bennett fx

 Associated w/subluxation or dislocation at the CMC jt.

 The distal portion usually subluxes radially and dorsally from the
pull of abduction pollicis longus and the adductor pollicis
 Treatment: Thumb spica and sx referral.
 2 - 5 MC Fractures
nd th 2

 Head:
 Caused by direct blow, crush, missile, or human bite.
 Distal to the CL and often comminuted.
 Treatment:
 Ice, elevation, immobilization, and sx referral.
 2 - 5 MC Fractures
nd th 2

 Neck
 Caused by directed impaction force.
 Management:
 Reduction for significant deviation to prevent functional impairment,
 Fractures should be splinted with the wrist in 20-degree extension
and the MP flexed at 90 degrees.

 Shaft:
 Via direct blow.
 Rotational deformity and shortening are more common.
 If reduction is needed, than operative fixation is usually indicated.
 2 - 5 MC Fractures
nd th 2

 Base
 Via direct blow or axial force.
 Often associated with carpal bone fractures.
 4th and 5th MC fx’s can result in paralysis of the motor branch of the
ulnar nerve.
THANK YOU