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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Mallet Finger - Anatomy

13. 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

14. Jersey Finger Anatomy and Exam

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Stener Lesion

30. Wrist - Anatomy
Somebody Likes The Parties That The Cops Hit

31. Wrist - Anatomy

32. 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

33. Scaphoid Fracture Most commonly fractured carpal bone
Most commonly seen in 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

34. 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

35. Scaphoid Fracture - Workup

36. 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

37. 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)

38. 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

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

40. 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

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