8977 Lecture Notes - Lecture 5: Ulnar Artery, Necrosis, Scalene Muscles
3 Jul 2018
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Department
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Hand & Finger Pain
COMMON Description Onset/Mechanism Clinical Features Test Treatment/Evaluation
BASE OF 1ST
METACARPAL #
Two main # types:1) Extra-articular
transverse # of base of the 1st MC
about 1cm distal to the jt,
1) Commonly occur
because of a punch
connecting with a hard
object, or a fall on the
abducted thumb.
Thumb lies flexed across
the palm.
X-ray and
Clinical
examination
Reduction involves extension of the
distal segment of the MC. Normally
immobilized in a short arm spica cast.
2ND-5TH MC # Most commonly seen in the 4th and 5th
MC (Boxers #).
Occur as a result of a
punch.
Presence of considerable
flexion deformity of the
distal fragment. Little
functional disability
present. Up to 30o
angulation acceptable for
4th and 5thwithout
rotational deformity, up to
10o angulation acceptable
in 2nd & 3rd. However
prominence of the MC
head in the palm of the
hand may be a problem for
tennis players and athletes
who require a firm grip.
X-ray and
clinical
examination
Splinting or casting in a position of 90o
flexion of the MCP jts to prevent
shortening of the collateral ligament
and subsequent stiffness. Need to
make sure position doesn’t displace #.
Splint may be removed after 2-3wks
and sport resumed immediately w
protection.
INTRA-ARTICULAR
MC #
Requires anatomical correction. Kirschner wiring used in displaced #s. Long spiral # may require internal fixation or percutaneous pining if they are angulated
or rotated. Check for rotation of finger #s clinically. Immobilised using a gutter splint w flexion of the MCP jt.
PROXIMAL
PHALANX #
May lead to functional impairment
due to extensor and flexor tendons
coming into contact with callus and
exposed bone.
Force to the jt. Pain at the Proximal
phalanx. Swelling and
possibly bruising.
Rotational deformity of
phalangeal # may not be
obvious in extension so
the fingers should be
examined end on w PIP
and DIP flexion to reveal.
X-ray and
clinical
examination
To reduce the MCP jt should be flexed
to 70o. The PIP jt is then flexed and
longitudinal traction is applied in line w
the shaft w the shaft of the distal
fragment to oppose the #. # is
immobilized w the wrist slightly
extended & at 70o flexion of the MCP jt.
Buddy straps may be applied. Motion is
essential at 3-4wks. Unstable # may
need surgical intervention. ORIF
needed if rotation found.
MIDDLE PHALANX
#
Involve hard cortical bone. Generally
oblique or transverse. Heal slowly.
Avulsion of volar plate can also occur,
very common and usually ignored due
Normal # can occur due to
trauma. Avulsion of the
Volar plate occurs
following a hyperextension
# distal to the flexor
tendon attachment shows
flexion of the proximal
fragment & extension of
x-ray and
clinical
examination
Stable # are immobilised in a splint for
3 wks in 70o of MCP jt flexion & 0o of
PIP flexion. When splint is removed,
begin ROM exercises. Unstable # or
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to unawareness of consequences. injury. the distal fragment. intra-articular # involving >25% of the
PIP jt surface require ORIF. ROM
exercises can begin as soon as fixation
is considered to be stable.
COMMON CONT.Description Onset/Mechanism Clinical Features Test Treatment/Evaluation
DISTAL PHALANX
#
Usually non-displaced. Usually caused by crushing
injuries such as fingers
being jammed between a
fast moving ball and a stick
or bat
Most of the pain is due
to subungual
haematomas. Pain and
swelling of distal
phalanx
X-ray and
clinical
examination.
Non-displaced #- splint and compression
dressing. Severe subungual haematomas
require nail bed exploration and excision as
nail bed is often disrupted. Surgical repair
may be required to prevent future nail
deformity occurring. Doing this transforms
the # into a compound #.
DISLOCATION OF
THE PIP JT
Dorsal dislocation most common.
Volar dislocations of the PIP jt are
uncommon.
Swan neck deformity: many possible
causes arising from DIP, PIP, MCP
joints or OA, RA. In all cases VP
stretched at PIP to allow hypext, plus
some degree of damage to ext tendon
attachment to base of DIP producing
mallet finger.
Result from a
hyperextension stress w
some degree of
longitudinal compression
such as may occur in ball
sports.
May disrupt volar plate
and at least 1 collateral
ligament, central slip.
Pain and swelling.
Associated rupture of 1
or more collateral lig
(true & accessory)
along w disruption of
the extensor central
slip insertion almost
always occurs. This can
predispose to the
development of
boutonniere deformity.
X-ray prior to
treatment
Reduction of dislocation, application of a
splint that allows full flexion but blocks the
final 30o PIP extension for 3 wks.
Hyperextension deformity and instability
may result if left untreated. If no
hyperextension following reduction is seen,
finger is splinted for several days then
buddy strapped to allow motion. Swelling
managed using coban, soft tissue treatment
and EPAs. If # of volar lip of middle phalanx
involving >1/3 of jt surface = ORIF.
Boutonniere deformity treated w splint,
holding the PIPJ of the affected finger in
extension for 6 wks while encouraging DIP
movement or surgical repair.
ULNAR
COLLATERAL LIG
SPRAIN/TEAR, 1ST
MCP JT.
One of the most common hand
injuries seen in athletes. Commonly
known as ‘Skiers Thumb’.
Results from forced
abduction and
hyperextension of the
MCP jt. Mechanism is
characteristic.
Patient may complain
of weakness of thumb-
index (tip) pinch grip.
Examination reveals
swelling and
tenderness over the
ulnar aspect of the 1st
MCP jt. Pain occurs
with both partial (10-
20o deviation) and
complete tears of the
UCL.
X-ray prior to
testing
stability, to
rule out #.
Ligament
Stability
testing.
Treated w immobilization in a splint w the
MCP jt in slight flexion for 6 wks. Further
protective splinting is required during
return to sport & may be required for up to
12 months. Thumb may also be taped w the
index finger which acts as a less secure
check rein to prevent hyperabduction.
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PIP JT SPRAIN Common injury. Occur due to sideways
force on the finger.
Damage to Collateral
ligaments.
Partial tears are painful
but remain stable on
lateral stress.
Complete tears shows
marked instability w
lateral stress. Also
includes
hyperextension stress
to the volar plate,
which may avulse its
insertion from the base
of the MC.
Partial Tears: buddy taping and active
exercises
Complete Tears: should ideally be treated w
surgical repair, although in most cases
conservative management provides
adequate result.
COMMON CONT.Description Onset/Mechanism Clinical Features Test Treatment/Evaluation
LACERATIONS AND
INFECTIONS OF
THE HAND
Occur frequently in sport as a result of contact w equipment such as the undersurface of a football boot. All lacerations have the potential for infection,
clean with antiseptic and therefore should be watched carefully. A particular concern is a laceration of the hand (esp MCP/PIP jt) caused by teeth, usually
from a punch to the mouth, always assume injury to be contaminated and an immediate course of a broad-spectrum antibiotics should be commenced. Do
not close the wound. Lacerations over the volar DIP or PIP jts may represent compound dislocations. If so, the jt has been contaminated and the patient
requires hospital admission for surgical debridement and repair. Otherwise septic arthritis may follow.
SUBUNGUAL
HAEMATOMA
Blunt or sharp trauma to
the finger bed
Presence of blood
under the finger nail.
Pain due to ↑ pressure
under the nail
Depends on how bad it is. If severe nail bed
trephination (drainage of the nail bed).
LESS COMMON Description Onset/Mechan
ism
Clinical Features Test Treatment/Evaluation
BENNETT’S # #/dislocation of the 1st CMC jt. occurs as a result
of axial
compression
when the 1st MC is
driven prox
shearing off its
base
a small medial fragment of the MC
remains attached to the strong
volar lig & the main shaft of the MC
is pulled proximally by the
unopposed pull of the Abductor
pollicis longus muscle.
X-ray and Clinical
examination
Closed reduction and
percutaneous Kirschner
wire fixation together with
cast immobilization for 4-
6wks. Upon removal of
cast, mobilization of the
surrounding jts is required
with possible use of
protective device (splint or
soft).
DISLOCATION OF
THE MCP JT
Dorsal dislocation of the MCP jt of the
fingers is uncommon & usually occurs
in the index finger or thumb. Called
the ‘irreducible dislocation’ because
Suspect this injury involved MCP jt
w ulnar deciation ofthe finger
overlapping the adjacent finger
X-ray and Clinical
examination
An attempt to reduce the
dislocation may be made
increasing the deformity
and pushing the proximal
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Document Summary
Two main # types:1) extra-articular transverse # of base of the 1st mc about 1cm distal to the jt, Most commonly seen in the 4th and 5th. Onset/mechanism: commonly occur because of a punch connecting with a hard object, or a fall on the abducted thumb. Reduction involves extension of the distal segment of the mc. Normally immobilized in a short arm spica cast. Splinting or casting in a position of 90o flexion of the mcp jts to prevent shortening of the collateral ligament and subsequent stiffness. Need to make sure position doesn"t displace #. Splint may be removed after 2-3wks and sport resumed immediately w protection. Presence of considerable flexion deformity of the distal fragment. However prominence of the mc head in the palm of the hand may be a problem for tennis players and athletes who require a firm grip.
