HAND, WRIST AND FINGER INJURIES Most Common

Transcription

HAND, WRIST AND FINGER INJURIES
Most Common Closed Hand, Wrist and Finger Injuries
Katherine Dec, MD, CAQ
76
Copyright (c) 2011, Katherine Dec, MD
The Most
ClosedDec,
Hand,
Copyright
(c)Common
2011, Katherine
MD
Wrist & Finger Injuries
Katherine
L. Dec, MD, CAQ
Copyright (c) 2011,
Katherine
Dec, MD
Medical Director, Women’s Sports Medicine
CJW Sports Medicine, LLC
Team Physician, Longwood University
Wrist Injuries:
DRUJ injury, “Sprain”, Scaphoid Fracture
Ulnar Collateral Ligament Injury (Gamekeeper’s)
Metacarpal Fracture
Finger Injuries:
Phalanx Fracture,
Volar Plate Injury,
Boutonniere
CopyrightProximal
(c) 2011,
Katherine
Dec,
MD
Deformity, Mallet Finger, Jersey Finger
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Page 1
Nerves are ulnar and radial side
Copyright
(c) 2011, Katherine Dec, MD
digits
•Interdigital blocks
•27-30 gauge needle
Copyright
(c) 2011,
•All four branches,
dorsal Katherine Dec, MD
and volar
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Page 2
Volar view
CopyrightDorsal
(c)view2011, Katherine Dec, MD
1.
Radiocarpal joint
Carpometacarpal
joint
Copyright
(c)(CMC)
2011,
Katherine Dec, MD
2.
3.
1st Metacarpal (MCP) joint
4.
Interphalangeal (IP) joint Thumb
2 MCP joint
Copyright
5.
nd
6.
PIP joint
7.
Distal interphalangeal (DIP) joint
History:
mechanism
of injury is
key
Active
range of
motion
Observe:
“attitude”
hand at
rest
Passive
range of
motion
Palpate
masses
Test
sensation
Test joint
mechanics
Test
intrinsic
strength
Check
vascular
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Page 3
a: Lister’s tubercle
b: Lunate
Copyright (c) 2011, Katherine
Dec, MD
MC: Metacarpal
 AP and True Lateral
 Oblique (esp.
children)Katherine
Copyright
(c)in2011,
Dec, MD
 Fan digits, foam wedges

Carpal Tunnel view
Robert’s view:
Copyright (c) 2011, Katherine Dec,
MD
--true AP thumb

MOI: Fall outstretched hand

Forearm is pronated; wrist flex and forearm
supination is painful
 Closed Reduction with post-reduction X-ray
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
Immobilize: including elbow

Follow-up X-ray, modify to SAC

Range of motion
80
Page 4
MOI: chronic, repetitive, weight-bearing stress to wrist
in ‘round-off’ / wrist extension position
 Differential(c)
includes:
Copyright
2011, Katherine Dec, MD
 Dorsiflexion Jam Syndrome (gymnastics)
 Tendinitis: deQuervain’s, or, Intersection Syndrome
 TFCC injury
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 Carpal instability
 Fractures
Dec,differs
MD
Location of symptoms
TFCC injury > Triangular Fibrocartilage Complex
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Page 5
Pain distal to Lister’s tubercle
“Terry
Thomas
sign”
(c) 2011,
Katherine
 Lateral X-ray: “spilled tea cup”

 PA X-ray:
Copyright
Dec, MD
 angulation between scaphoid & lunate
is > 70 degrees
Copyright
Complication: Lunate osteonecrosis
(Kienbock’s disease)
82
Page 6
Copyright (c) 2011, Katherine Dec,
MD
If no change @
Specific
diagnosis
Ice, NSAIDs,
splint or tape
Relative rest
2 weeks: further
work-up
Copyright (c) 2011,
Katherine
Dec, MD
Alternate
Cycle training
with rest
equipment
(gymnastics)

MOI: fall on outstretched hand

Percussion of thumb tip elicits pain

Pronation with ulnar deviation elicits pain

Clenched fist PA X-ray
Copyright
(c) 2011,
Katherine
 Pain in “snuffbox”:
APL/EPB
& EPL Dec, MD
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Dec,or,MD
If displaced,
nonIf X-ray negative:
• immobilize thumb
If follow-up X-ray
positive:
• immobilize 6-20
displaced proximal
area:
• surgical
spica 2 weeks then
weeks
Copyright
(c) 2011,
Katherineconsultation
Dec, MD
re-X-ray
Pain at ulnar base of
thumb, first
web
space
Copyright
(c)
2011,


Katherine Dec, MD
Test MP joint in extension
& flexion
 Stener’s lesion:
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interposition of Adductor
Pollicis aponeurosis
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Page 8
Imaging:

2-3 views, non-stress view; may do stress views
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 Bilateral thumbs w/ stress view x-ray
 young child, grade III Salter-Harris fracture
 With surgery
gold standard,
MR imaging
Copyright
(c)as2011,
Katherine
Dec, MD
identified UCL tears 96% sensitivity and 95%
specificity
Conservative:
Copyright
(c)cast
2011,
Katherine
 Thumb spica
or splint
4-8 wks Dec, MD
 Thumb spica cast position: 20º flex &
40-45º abd (w/ or w/o IP joint)
Copyright
(c)@2011,
 Gentle ROM
4-6 wksKatherine Dec, MD

Splint or tape during sports up to 3
months post-injury
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Important to return full functional stability:

Recurrent injury with laxity
Copyright
 Decreased pinch strength
 Inability to ‘palm basketball’
 MP joint deformity to improve functional position

Don’t forget to strengthen FPB

Radial collateral ligament injury - can be missed
Surgical referral:
 Stress >/= 30-35
º, unstable
Copyright
(c) 2011,
Katherine Dec, MD

Avulsion fracture & displaced
 Complete tear, or, Stener’s lesion
Copyright
10-14 days post-op: AROM & advance
to progressive resistive exercise (while
immobilized)
Copyright
(c) 2011, Katherine Dec,

MD
86
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 Acceptable angulation varies
 Closed reduction, ORIF
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(c)(include
2011,
Katherine
Dec,
 Immobilize
MCP
joint) and AROM
MD
unaffected fingers
 Repeat x-ray & modify cast in 7-10 days
80% Conservative TX:
Acceptable:

MC 4th / 5th : </= 40-50º
 <30º if neck or proximal
Copyright
nd
rd

MC 2 / 3 : < 10-15º
20% Surgical:
Copyright
(c) 2011,
Dec, MD
 Closed reduction:
pin or Katherine
plate
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Brewerton view
Copyright
(c) 2011,
Dec, MD
 Fractures base
proximalKatherine
phalanx

MCP joint and metacarpal head fractures
Norgaard view
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 Metacarpal fractures base of 5th digit

Most common hand fracture young child
Copyright
(c) 2011,
Katherine
Dec, MD
 Base fracture
epiphyseal
injury adolescents

MOI: digit hyper-extension or -abduct

Clinically: mild swelling, pain at fx site, w/ or

Look for rotational malalignment by passively
flexing wrist & MCP joint
Copyright
(c) 2011,
Katherine Dec, MD
w/o displacement
deformity

Blue
Copyright (c) 2011, Katherine Dec, Arrow
MD
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Immobilize gutter splint: WE 40 deg., MCP flex, PIP/DIP extended for 3-4 weeks
6 weeks Katherine
if condylar or articular
CopyrightImmobilize:
(c) 2011,
Dec, MD
Repeat X-ray in 1-2 weeks
AROM 2-3 weeks post-injury
Surgery recommended if:
displacement > 3mm
involves > 1/3 articular surface
subluxated or angulated > 25 degrees
Do not buddy tape in athletes with open growth
plates
Copyright
 Risk for rotation and poor functional results increases
 Immobilize with padded metal splint until xray and
assess further
Copyright
 Option clinical test for rotational deformity:
 Wrist & MCP flexion with PIP and DIP joints extended

“Jammed finger”: axial load to finger tip
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 Differential Diagnoses: systemic laxity,
 A3 pulley rupture
 FDS rupture
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Clinically:

Tender volar PIP (w/ & w/o motion)

Check integrity collateral ligaments

Swollen; holds in slight flexion
Copyright
2011,
Katherine
Dec, w/
MD
 Xray: if (c)
fracture
& > 25%
articular surface
displacement, surgery considered
Non-displaced MF
volar plate avulsion fx
Treatment:
Copyright
 Buddy tape, gutter splint, or extension block splint for
2-3 wks in 20-30º flexion

Splint continuous 7-10 days; next 2 weeks--intermittent
removal for(c)
AROM
Copyright
2011, Katherine Dec, MD
 prolonged splinting in flex may

contracture
Splint or buddy tape with sport additional 3-4 wks
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
Giant Cell Tumor
 Slow-growing
Dec, MD
 Can occur after
collateral ligament
or tendon
injury
Dec,
MD
2nd most common closed hand injury
MOI:
Copyright
(c) 2011, Katherine Dec,


MD
 dorsal trauma PIP jt. Or forced PIP flexion while trying
to extend
 Acute: swelling
 Later: deformity
Copyright
(c) 2011,
Katherine Dec, MD
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Final Deformity:
Tear of central slip with migration
of the lateral bands
Usually conservative treatment
Splint in extension 3-6 weeks, DIP free
AROM at Katherine
3 weeks, nighttime
splint MD
Copyright (c) 2011,
Dec,
Protective splint until 40 degrees active
flexion & full extension without pain

MOI: axial load to fingertip when attempting to
Copyright
extend (c) 2011, Katherine Dec, MD
 most common middle or ring finger
Anatomy:
lat. bands merge & form 1 tendon attaching
Copyright
(c) 2011,
Katherine
MD
distal to articular
surface.
Pull of flexorDec,
tendons
results in flexion of DIP joint.

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 Splint in extension with PIP free;
Copyright
“stack splint”

Duration: 6-8 weeks, then ROM
Copyright
2011,
Katherine
Dec, MD
 Nighttime(c)
splint
2- 4 more
weeks

Splint with sports up to 4 months
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Surgical if:
Primarily
conservative
treatment
Chronic: can benefit
w/ splint >/= 3 months
post-injury
>25% articular &
>2mm displace,
OR > 30% articular
Cannot play with
splint

MOI: attempting to flex digit

Pain on DIP volar surface
Copyright
(c)into
2011,
Katherine Dec, MD
while forced
DIP extension
Copyright
(c) 2011,
Dec, MD
 No active distal
phalanxKatherine
flexion

Surgical Consultation!
Anatomy:

Flexor retinacular system: 5 annular bands &
3 cruciform ligaments.
 A2 pulley ruptures—
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▪ rock climbers
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Anatomy:
 Hand divided into zones:
Copyright
(c) 2011,
Katherine
Dec, MD
 Zone 2: between
metacarpal
head &
insertion of FDS
 Interconnection FDS & FDP
Vincula system—
Carries nutrients
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Type III
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HAND, WRIST AND FINGER INJURIES Most Common

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