Michael Shuler, MD Athens Orthopedic Clinic Aug 2018 Common Hand Injuries Michael Shuler, MD Athens Orthopedic Clinic Aug 2018

Overview: Start at finger tips work proximal Review Anatomy Physical Exam Studies Treatment Focus on common injuries

Finger Injuries: Mallet Finger Jersey Finger Phalanx Fractures Dislocations Flexor Tendon Injuries Extensor Tendon Injuries

Mallet Finger: Forced flexion of extended finger Attachment of terminal slip (ext tendon) Boney or tendon only Intra-articular fx of dorsal lip of distal phalanx

Mallet Fx: DIP sag/droop No active Extension

Imaging Always get Xrays Boney involvement? Joint dislocation/subluxation? Amount of articular involvement?

Treatment: Sometimes can be treated with splint if no boney involvement or small boney fx Must keep splint on (at all times) x 8 wks Must start over if let finger droop

Treatment Surgery: CRPP vs. ORIF MUST BE COMPLIANT IF NON-OP! >30-50% of joint Joint subluxation Unreliable Pt (will not wear splint) CRPP vs. ORIF MUST BE COMPLIANT IF NON-OP!

Mallet Finger These can be a mess if you do not treat them appropriately

Complications If not treated… Swan Neck Deformity

Jersey Finger This is not a Jersey Finger!

Jersey Finger Fracture or rupture of FDP Rupture occurs at insertion of distal phalanx Forced extension with finger flexed Most commonly the ring finger

Jersey Finger

Exam Finger fully extended at DIP Disruption of the normal cascade of No counter balance to extensor tendon Unable to flex DIP Disruption of the normal cascade of fingers

Classification Zone 1: Zone 2 Zone 3 Retraction to palm- Urgent treatment needed Within 1-2 wks or cannot repair primarily Zone 2 Retraction to PIP joint- Urgent repair Zone 3 No retraction Typically associated with boney fragment Less urgent (3-4 weeks)

Imaging Clinical Dx Xrays for boney fragment MRI- but can take a long time to get

Treatment This is a surgical injury Repair flexor tendon All should be treated as Type I (FDP in palm) Treat within 1-2 wks or cannot fix primarily

Jersey Finger If not treated acutely… Tendon grafts & staged repair Must graft or fuse Tendon grafts & staged repair

Central Slip Rupture Similar mech to Boney Mallet But unable to extend PIP Can lead to Boutonniere Deformity Can sometimes treat with splint PIP in extension (MCP & DIP free) Can repair late but must have good motion before surgery

Phalanx Fx Finger fractures Balance between holding still (fracture) & getting stiff Do not splint >3-4 wks Intrinsic plus splints Limit the joints you immobilize Buddy tape to provide stability

Intrinsic Plus MCP’s flexed IP’s Extended Vital for preventing/limiting stiffness

Intrinsic Plus MCP flexed- PIP Extended Collateral ligament tension Volar plate contracture

Surgical Indications Intra-articular Displaced Angulated Rotated All fingers should point to the proximal pole of scaphoid Fingers are not straight- some rotation is normal

Phalanx Fx Seems innocuous & can be But can cause a lot of morbidity Malunions can be very difficult to correct Easier to treat correctly initially

Finger Dislocations Typically easily reducible- traction If stable- buddy tape & let move If unstable- refer to specialist Do not splint for extended periods of time < 1-2 wk in a static splint

Buddy Taping

Finger Dislocations Irreducible? MCP: PIP: Do not pull traction- Manually manipulate MCP: Volar plate interposition PIP: Caught between lateral band & central slip

Flexor Tendon Injuries

Flexor Tendons Very common injury Reason why hand surgery specialty was invented Historically terrible outcomes Balance between stiffness & rupture of repair Goal is to repair well enough to allow immediate motion

Flexor Tendons It’s a tight fit

Anatomy Two Tendons: FDS & FDP Camper’s Chiasm Vincula- Vascular supply

Anatomy Pulley System A1-A5 Must preserve/repair A2 & A4 (Bowstringing) C1-C3 (over joints)

Vascular & Nerve Injury Very common with flexor tendon lacerations Check with any lacerations Nerve (2 per finger) Digital nerve on each side of Finger Decreased LT 2pt Discrimination (>6-8mm) Vascular (2 per finger) Digital artery on each side of finger Digital Allen’s Test

Vascular Injuries: ADD- Artery Dorsal Digit Nerve out likely vessel out too Cap refill? Prick finger with small needle (25-30g needle) Disvascular- urgent care (referral to specialist) Replant, revasc, facilities, team, experience… Cut/saw/stretch/crush/tear… As long as vascularized- can typically be sutured & seen in am for definitive correction

Exam Inspection: Normal Cascade?

Tenodesis Flex Wrist > Extension of Fingers Extend Wrist > Flexion of Fingers

Always examine each finger independently! Exam: Movement FDP L-R-S single muscle belly Bend DIP (tip) FDS Bend PIP Independent muscle bellies Small absent 21% Always examine each finger independently!

Imaging This is a clinical Dx X-rays for boney injury MRI Ultrasound Always check for boney injury MRI Can take several days Ultrasound Quicker to get- more difficult to read?

Treatment CLOSE all wounds! Surgery required- Simple approximation of skin Tendons/Nerve/Arteries dry out Surgery required- Notify patient Urgent referral to surgeon (same or next day) Best results with timely treatment Nerves- 3-5 days Tendons- 1-2 weeks

Extensor Injuries Walk in the park compared to flexors

Extensor Tendons Concern with dorsal lacerations Can be subtle

Anatomy DIP PIP Terminal Slip (Mallet Finger) Central slip (Boutonnière deformity)

Exam Test each finger separately Test for strength Duplication @ IF & SM “Hook ‘em Horns” IF- EDC & IP SF- EDC & IDM Flex & hold others down Junctura tendinae can mask proximal lacerations Tenodesis

Hand Injuries Boxer’s Fracture Metacarpal Fractures Ulnar Collateral Ligament Tear (Gamekeeper’s)

Boxer’s Fx Not usually the smartest thing the patient has done…

Boxer’s Fx (Small Finger MC) MC Fx of the small finger Can accept a fair amount of flexion IF- 10º MF- 20º RF- 30º SF- 40º

Metacarpal Fx Need to make sure angulation/rotation is correct Oblique fractures typically are unstable & require surgery Look at arcade of MC heads If shortened- lose tension Extension lag

MC FX

MC FX

MC FX

Ulnar Collateral (Gamekeeper’s) Thumb Etiology Forced Abd of the thumb Fall, Skiing Acute vs. Chronic Gamekeep- Old Europe Ringing necks of small game Presentation Painful mass, unable to pinch/write, weakness…

Exam Instability/pain with radial deviation? Strain vs. Tear? Ligament vs. boney fracture? Test in extension & flexion Use contralateral side as control >15º difference abnormal >30º of angulation abnormal Pain with stress

Imaging Xrays always first Stress views & fluoroscopy MRI Ultrasound

Stener’s Lesion Avulsion fx Will not heal Add Aponeurosis off proximal phalanx Will not heal Add Aponeurosis blocks reduction Needs surgery with immobilization

Treatment Strain: No instability! Tear: Chronic (>6 weeks?): Splint- custom made orthoplast Tear: Repair Ligament Chronic (>6 weeks?): Graft-palmaris longus tendon,APL,EPB

Infections: Less is not more Aggressive irrigation Don’t be afraid to make large incisions in the skin Blunt deep dissection (Scissors) Aggressive irrigation Leave it open/pack it Less packing each time Soaks with Betadine (10-25%) Make a fist x 20 times

Injection Injuries: High Power Injections Power washers, oil or paint guns Don’t be fooled- more than what meets the eye

Injection Injuries

Injection Injury Water/Water soluble: Can consider watching closely Oil/Paint/Other: needs surgical debridement sooner rather than later Tracks along path of least resistance- even to the forearm!

Injection Injuries

Infections: Fight Bites: Animal Bites Human bite- Augmentin Seed the joint- infection common Animal Bites Cats worse than dogs Small teeth- wound sealed more common

HAND INFECTIONS Do not under estimate Treat aggressively ABX I&D ER/Admission Surgical Debridement

Necrotizing Fasciitis Quick progressing Surgical emergency Anaerobic- Exposure to air helps Aggressive debridement Can be innocuous injury

Hand Infections Necrotizing Fasciitis Case

Hand Infections Necrotizing Fasciitis Case

Motor Cycles Work of the Devil…

Referrals: F/u sooner rather than later F/u next day in UCC if nothing else NPO after midnight- may be able to/need to operate next day Do not tell patient we will operate the next day! Nerves/Tendons need repair within 2-3 days

Don’t be afraid!

Don’t be stupid!

Don’t Give Up!

Thank You Questions… msimmss@hotmail.com 706 424 8438