common hand injuries

Common Hand Conditions

Dan PurtellHand / Occupational

Therapist

Common Hand ConditionsTrigger finger / thumb

De Quervain’s

Mallet Finger

PIPJ Dislocations

Dupuytren’s disease

Simple #’s

Trigger finger Definition

Not clearly / consistently defined

Triggering of the digital flexor tendons at the fibrooseous tunnel formed by the metacarpal neck and A1 pulley

In thumb the sesamoid bones may also be site of constriction

Generally affects FDS rather than FDP because it lies directly under A1 pulley

Anatomy

Trigger fingerIncidence

Primary trigger finger most commonly found in middle aged women, 2–6 X more than men

Most commonly affects thumb (30-50%)

Then ring, long, index, & little

Trigger fingerCausative Agents

Stenosing tendovaginitis Digital flexors susceptible to

compression and shear at level of wrist and MP joints where they enter fibrooseous tunnels

Blunt trauma or sustained tool use causing direct compression at A1 pulley

Secondary TF in individuals with connective tissue disorders

Pathophysiology Discrepancy between

the size of the A1 finger pulley lumen and tendon volume

Hypertrophy of the pulley

Poor tendon vascularity between A1 and A2 pulley makes tendons more susceptible to degenerative changes

Tendons develop nodules from tenosynovitis

Clinical and diagnostic features Pain over site of tendon disorder

aggravated by movement Symptoms vary from stiffness, to

uneven movement, catching, blocking, or complete locking of tendon

Pain can also be referred to distal joint or proximally up forearm

Local swelling and thickening creating a palpable nodule over distal palmar crease (A1 pulley area)

Local tenderness over A1 Patient may present with acute,

subacute or chronic disorder

Management - ConservativePatients often reluctant

tohave cortico-steroid

injection,even more reluctant to

have surgery

Conservative measures should

be trialled for 4-6 weeks

Thermoplastic hand based splint to limit MCP flexion (stops triggering through A1 pulley)

Splinting works better for fingers than for thumbs

Management - Conservative

Trigger Thumb -Thermoplastic barrel splint, IP joint at 10 degrees flexion

Passive tendon gliding exercises

Soft tissue massage of nodule and tendon.

+/- Ultrasound +/- NSAID gel

Management - Cortico-steroid injection

Cortisone injection for trigger fingers and thumbs relieves symptoms in 47% to 94% of affected digits.

Management - Surgery Most reported success

rates are above 90%. Decompression of pulley

to allow flexor tendon to glide

Turowski, 1997: n=59, 97% complete resolution. No post-op nerve or tendon damage.

Eastwood, 1992: Percutaneous release, n=35, 94% complete resolution. No complications. Not for thumb

Thorpe, 1988: n = 53, 60% complete resolution, success correlated with surgeon skill.

Post operative management

Oedema and wound management Scar management once wound healed Active tendon gliding exercises Stretching long finger flexors Strengthening only if necessary Conclusion Surgery remains the most successful

treatment option Splinting and exercise program good

alternative for those patients reluctant to consider a CSI or surgery

De Quervain’s

de Quervain’s tenosynovitis is the entrapment tendonitis/tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius

De Quervainne’s

Most cases it is a tendinopathy like trigger finger, tennis elbow etc that leads to tenosynovitis.

De Quervain’s

Finklesteins test and clinical Hx confirm diagnosis.

De Quervain’s

10 x more Common in Women than men.

Common in pre-post natal and menopause.

Often caused by repetitive strain or sustained posture of the wrist = strain on EPB and APL.

Can occur post direct trauma to the area (rare)

De Quervain’s

Treatment: Steroid (won’t fix

tendinopathy)

Splint and rest

Kinesio tape

Surgery (last resort)

De Quervain’s

Surgery

Mallet Finger Definition

Any injury that causes a mallet deformity of the distal phalangeal joint

Diagnosis

Disruption of the terminal extensor tendon as it inserts into distal phalanx +/- fracture

Anatomy

Causative agents

MECHANISM OF INJURY

Flexion force on extended DIP joint

Direct crush Ball to tip of

finger Often occurs in ball sports.

Clinical and diagnostic features

Signs & Symptoms

Inability to extend distal phalanx actively

Can still passively extend within pain limits

Swelling Bruising Redness

Similar PresentationsVolar plate laxity =

swan neck deformity

Management

depends on size of fragment and position of jointIf complete tendon rupture without

fractureIf # is less than 30% joint surface→ Conservative management - splinting

If # greater than 30% joint surface or joint is significantly displaced needs surgical intervention

Conservative management

Mallet splint reduces the fragment

Conservative management Splinting

Splint DIP in hyperextension 6 – 8/52 Splint strictly 24/24 Clear instructions and demonstration re

changing and wearing routine Advice re skin care PIP flexion exercises May return to sport with splinting

Mallet Splinting

Off the shelf stack splint often fit poorly

Patient may end up with a lag at DIP joint

Conservative Management Wean splint slowly

after 6-8 weeks Keep on at night and

for work a further 2 weeks

Initially active flexion exercises to gain full flexion

Start off 30 degrees flexion first week and increase slowly ie 20 degrees per week

May take 4 – 6 weeks to regain full flexion

If lag reoccurs → RESPLINT

Passive flexion only added if needed

Mallet Finger

Large Fragment Fixed with K-wire or 2

Middle Phalanx #’sCentral Slip avulsion

Middle Phalanx #’s

- Conservative approach only if small fragment with no joint subluxation. - Splint for 6/52 in barrel splint DIPJ can be free.- Larger fragments with joint subluxation can be ORIF’d.

= Boutonniere Deformity= FFD of PIPJ

= Very hard to fix

PIPJ DISLOCATIONS/VOLAR PLATE DISRUPTION

PIPJ dislocation Mechanism of Injury – hyperextension of

the PIP joint with or without dislocation often initial injury seems trivial

X-ray

Dislocation of the PIPJ

Avulsion # of middle phalanx

Disruption of volar plate over the PIP joint

PIPJ dislocation Signs &

Symptoms

• Swelling• Bruising• Pain volar aspect

of PIP joint• Instability or pain

on stress of volar plate

• Decreased range of motion particularly flexion

PIPJ dislocation

If dislocation without # OR If # fragment less than 30%

joint surface

→ reduce then manage conservatively in dorsal

blocking splint (DBS)

Dorsal blocking splint

• PIPJ in 30 degrees flexion

• volar structures off stretch

• slowly increase out to neutral

Not this please !

Because!

Treatment splint 4 - 6/52 weekly adjustments PIPJ from 30

flexion → full extension as stability increases

• Coban for swelling • Flexion exercises within splint• Isolated FDP & FDS flexion

important to prevent adherance to volar plate

• Early mobilisation also assists oedema

PIPJ DISLOCATION

• If collaterals involved need to buddy strap when out of splint• Tape/splint for work for 6 -8/52• Watch for FFC PIPJ in late stages → may need to include extension splinting

Volar Plate Injury / surgery If volar plate repaired post

surgical management same but progress slower

Occasionally flexion exercises are delayed if stability is a concern

#’s

5th Metacarpal Assess ROM and digit

Rotation Usually managed

conservatively

#’s

4th Metacarpal Spiral # Assess ROM and digit

Rotation Tendency to rotate Impacted #’s result in

extension lag = poor function.

UCL Avulsion #

Treat conservatively in splint unless joint subluxation occurring

Skier’s thumb

Treat conservatively in splint unless joint subluxation or stenners lesion is present.

- Usually characterised by lots of oedema, nil end point of stability.- Very difficult to assess with certainty- U/s scan to confirm