Hand and Wrist Injuries Nursing 870 This Presentation Developed and Used With Permission: Philip J. Bosha, M.D. Penn State Orthopaedics

Objectives To review the diagnosis and treatment of common hand and wrist injuries in the college population To review pertinent anatomy of the hand and wrist To improve your comfort level in managing hand and wrist injuries

Hand and Wrist Very intimidating body part 29 bones, 34 muscles, 18 mobile joints Injuries range from subtle to obvious Common site of acute injury

Subungual Hematoma Caused by bleeding from rich vascular nail bed Usually from a crush injury Presents with throbbing pain, discolored nail X-ray to evaluate the distal phalanx

Subungual Hematoma Consider drainage if acute (less than 36 hrs.) No increase in complications if nail edges are intact Drainage will improve comfort, but does not affect healing time Betadine, +/- digital block Can use cautery unit or 18g needle Still likely to have a poor outcome May lose nail, or have deformed nail

Paronychia Infection of nail fold Presents with pain, erythema, fluctuance Related to nail biting, trauma, manicure, skin breakdown Examine for spread of infection to deeper structures Staph aureus, Strep species, oral flora

Paronychia Treatment If no sign of abscess If abscess is present Warm soaks, oral antibiotics If abscess is present Drainage, +/- local anesthetic 11 blade held parallel to nail, elevate nail fold, this should allow drainage of pus

Nail Bed Lacerations Very difficult repair Usually due to a crush or high-energy injury Friable tissue, 6-0 or 7-0 absorbable suture needed, sometimes under magnification Nail or xeroform gauze makes a good dressing until this can be definitively treated Poor repair can lead to inhibited or irregular nail regrowth

Mallet Finger (baseball finger) Caused by forced flexion of the DIP joint during extension, disruption of extensor mechanism Presents with swollen finger, unable to extend at DIP DIP in flexed position at rest, due to unopposed flexor tendon X-rays should be done bony vs. tendinous mallet finger

Mallet Finger - treatment Most managed non-operatively (tendinous injury, or small bony avulsion Splint DIP joint in neutral to extended position Continuous stack splint or Alumafoam splint use for 6 weeks A drop into flexion will reinjure healing tendon Keep finger flat on table when changing splint Watch for maceration or pressure ulcer of fingertip or dorsal surface of finger

Mallet Finger - treatment Injuries in which >1/3 of joint surface is disrupted, or distal phalanx is volarly displaced may need surgical repair Complication – swan neck deformity The extensor tendon may become imbalanced and begin to pull the PIP joint into hyperextension

Mallet Finger - Anatomy

Jersey Finger Flexor digitorum profundus (FDP) rupture Flexed DIP joint is forced into extension Ring finger most commonly injured Physical exam: Tender at volar aspect of DIP joint, unable to flex DIP joint FDP must be isolated for exam. FDS and lumbricals can provide some flexion if the DIP is not isolated FDP may retract into palm X-rays should be done to assess for avulsion Prompt ortho referral, repair within 7-10 days

Jersey Finger Anatomy and Exam

PIP Joint Dislocations Most commonly dislocated joint, usually dorsally dislocated OK to attempt reduction on sideline, buddy tape and return to play. Follow-up x-rays in office Reduction performed with distal distraction, then volar force applied to proximal phalanx

PIP Joint Dislocations In the office, do pre-reduction x-rays, anesthetize with digital block, reduce, splint in 30o of flexion, do post-reduction x-ray Splint for 2-3 weeks, follow-up x-rays Treatment of DIP dislocation is very similar Volar dislocations and MCP dislocations are more rare Should be referred Greater chance of structural injury

Phalanx Fractures Distal phalanx is the most commonly fractured bone in the hand, usually from crush injury If fracture is nondisplaced, then splint OK to attempt closed reduction of minimally displaced fracture Open fractures or fractures involving >1/3 of joint surface should be referred

Phalanx Fractures Proximal and middle Assess for rotation or shortening Rotation can be reduced in the office if acute Referral needed: If the fracture involves more than1/3 of the joint surface Rotation cannot be corrected Shortening

Fifth Metacarpal (Boxer’s) Fracture Most common metacarpal fracture Usually occurs at metacarpal neck or shaft, volarly angulated Assess for rotation, angulation, shortening Any malrotation is not acceptable 40o of angulation and 3-4mm of shortening is acceptable

Boxer’s Fracture Reduction The fracture is anesthetized with a hematoma block. (5-10mL 1% Lidocaine w/o epi) The affected finger MCP joint and the PIP joints are flexed to 90° The fracture is reduced by applying upward (dorsal)pressure on the middle phalanx and downward (volar)pressure over the proximal portion of the fracture Confirm reduction

Boxer’s Fracture Treatment Immobilization Ulnar gutter splinting if more swelling is expected immediately after closed reduction acute injury Casting Should go up to middle phalanx Should keep MCP joint flexed at approx. 70o Galveston splint if casting is not realistic

Boxer’s Fracture - Complications Hand exhibits loss of dorsal contour, or sinking of 5th MCP joint Prominence of the MC head in the palm Pain or weakness with grasp, worsened by a digital overlap from a rotational malunion MCP joint stiffness if the metacarpal head was involved Can be improved surgically later

Reverse Bennett Fracture Similar mechanism to Boxer’s fracture Fracture - dislocation at 5th metacarpal base/CMC joint Presents with swelling at 5th CMC joint Unstable due to pull of surrounding muscles

Fight Bite Potentially very serious injury Clenched fist strikes another person’s teeth Tooth may penetrate skin, soft tissue, tendon, or MCP joint, and introduce skin and oral flora Treatment X-ray to exclude fractures, foreign bodies Empiric antibiotics (Augmentin) Irrigation Referral to hand surgeon for debridement

Skier’s (Gamekeeper’s)Thumb Disruption of the ulnar collateral ligament (UCL) at the 1st MCP joint Important ligament for pinch grip Usually caused by a forced abduction of the 1st MCP joint Presents with pain, swelling, and weakness of thumb

Skier’s Thumb - Exam Swelling at the MCP joint, tenderness to palpation along the ulnar aspect Pinch strength may be decreased, and the thumb may deviate radially. Stress testing should be performed to assess the stability of the UCL

Skier’s Thumb Routine x-rays should be performed, stress views if concerned about instability Stable injuries can be placed in a thumb spica splint or gamekeeper’s splint May continue activity with splint on, may need to continue with taping or splinting for sports or heavy manual activity for an additional 6 weeks

Skier’s Thumb - Referral If the joint is unstable, or no endpoint If greater than 35o of laxity is felt Stener lesion Torn UCL sticks out from under adductor aponeurosis Presents with laxity, tenderness and mass at ulnar side of 1st MCP joint UCL healing is not possible

Stener Lesion

Wrist - Anatomy Somebody Likes The Parties That The Cops Hit

Wrist - Anatomy

Wrist - Anatomy Radial nerve Median nerve Ulnar Nerve Runs along radial side of forearm Gives sensation to the dorsum of the hand from the thumb to the third finger Innervates hand and wrist extensors Median nerve Travels through carpal tunnel Gives sensation to the thumb, 2nd, 3rd, and radial side of the 4th finger. Innervates thenar muscles Ulnar Nerve Travels through Guyon's canal, formed by the pisiform and hamate Supplies sensation to the 5th finger and ulnar side of 4th finger Innervates intrinsic muscles of the hand and 4th and 5th finger flexors

Scaphoid Fracture Most commonly fractured carpal bone Most commonly seen in 15-30 year-old males Usual mechanism is FOOSH, extended and radially deviated wrist Most sensitive exam finding is snuff box tenderness Tenuous blood supply distal>proximal higher rate of non-union proximally

Scaphoid Fracture - Workup Wrist x-ray series with scaphoid view Fracture may not be visible initially Splint or cast (thumb spica) if concerned about a fracture despite appearance on x-ray Repeat x-ray in 1-2 weeks, consider bone scan or MRI if still equivocal

Scaphoid Fracture - Workup

Scaphoid Fracture -Treatment Conservative treatment 8-12 weeks of immobilization Start with cast, transition to splint Surgical repair Displaced fractures, esp. proximal pole If faster recovery is needed Non-unions after 12 weeks of immobilization

Scapholunate Ligament Injury Can be seen with scaphoid fracture Easily missed on x-ray Clenched fist view will accentuate this injury Scapholunate ligament disruption can lead to carpal instability and SLAC (scapholunate advanced collapse)

Hamate Fracture Likely underdiagnosed cause of ulnar and volar wrist pain, difficult to see on X-ray Usual mechanism is FOOSH, on to ulnar and volar aspect of wrist Also seen in club, racquet, and bat sports from the hypothenar eminence being struck repeatedly by handle Examine ulnar nerve, hamate makes up wall of Guyon’s canal

Hamate Fracture Imaging: wrist series with carpal tunnel view Treatment Conservative Surgical – hook of hamate excision

How Could We Forget About…. DeQuervain’s tenosynovitis Carpal tunnel syndrome Guyon’s canal syndrome Osteoarthritis Dupuytren’s contracture Trigger finger TFCC injuries Distal radial and ulnar fractures

This Presentation Developed and Used With Permission: Philip J This Presentation Developed and Used With Permission: Philip J. Bosha, M.D. Penn State Orthopaedics