Trauma muskuloskeletal

Arterial injuries associated with fractures or dislocations

Clavicle fracture subclavian artery

Shoulder fxdislocation axillary artery

Supracondylar humerus fx brachial artery

Elbow dislocation brachial artery

Pelvic fracture gluteal arteries

Femoral shaft fx femoral artery

Distal femur fracture popliteal artery

Knee dislocation popliteal artery

Tibial shaft fx tibial arteries

Incidence

Overall uncommon

bull 3 of long bone fractures

Specific circumstances

bull Fractures with GSW (up to 38)

bull Knee dislocations (16-40)

Mechanism of Injury

bull Penetrating trauma

ndash GSW

ndash Stab

bull Blunt trauma

ndash High energy

ndash Low energy

bull iatrogenic

Consequences of vascular injury

bull Blood loss

bull Ischemia

bull Compartment syndrome

bull Tissue necrosis

bull Amputation

bull Death

Prognostic factors

bull Level and type of vascular injury

bull Collateral circulation

bull Shockhypotension

bull Tissue damage (crush injury)

bull Warm ischemia time

bull Patient factorsmedical

conditions

Speed is crucial

bull Rapid resuscitation

bull Complete rapid

evaluation

bull Urgent surgical

treatment

PROTOCOL IS ESSENTIAL

Immediate treatment

bull Control bleeding

bull Replace volume loss

bull Cover wounds

bull Reduce

fracturesdislocations

bull Splint

bull Re-evaluate

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Arterial injuries associated with fractures or dislocations

Clavicle fracture subclavian artery

Shoulder fxdislocation axillary artery

Supracondylar humerus fx brachial artery

Elbow dislocation brachial artery

Pelvic fracture gluteal arteries

Femoral shaft fx femoral artery

Distal femur fracture popliteal artery

Knee dislocation popliteal artery

Tibial shaft fx tibial arteries

Incidence

Overall uncommon

bull 3 of long bone fractures

Specific circumstances

bull Fractures with GSW (up to 38)

bull Knee dislocations (16-40)

Mechanism of Injury

bull Penetrating trauma

ndash GSW

ndash Stab

bull Blunt trauma

ndash High energy

ndash Low energy

bull iatrogenic

Consequences of vascular injury

bull Blood loss

bull Ischemia

bull Compartment syndrome

bull Tissue necrosis

bull Amputation

bull Death

Prognostic factors

bull Level and type of vascular injury

bull Collateral circulation

bull Shockhypotension

bull Tissue damage (crush injury)

bull Warm ischemia time

bull Patient factorsmedical

conditions

Speed is crucial

bull Rapid resuscitation

bull Complete rapid

evaluation

bull Urgent surgical

treatment

PROTOCOL IS ESSENTIAL

Immediate treatment

bull Control bleeding

bull Replace volume loss

bull Cover wounds

bull Reduce

fracturesdislocations

bull Splint

bull Re-evaluate

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Incidence

Overall uncommon

bull 3 of long bone fractures

Specific circumstances

bull Fractures with GSW (up to 38)

bull Knee dislocations (16-40)

Mechanism of Injury

bull Penetrating trauma

ndash GSW

ndash Stab

bull Blunt trauma

ndash High energy

ndash Low energy

bull iatrogenic

Consequences of vascular injury

bull Blood loss

bull Ischemia

bull Compartment syndrome

bull Tissue necrosis

bull Amputation

bull Death

Prognostic factors

bull Level and type of vascular injury

bull Collateral circulation

bull Shockhypotension

bull Tissue damage (crush injury)

bull Warm ischemia time

bull Patient factorsmedical

conditions

Speed is crucial

bull Rapid resuscitation

bull Complete rapid

evaluation

bull Urgent surgical

treatment

PROTOCOL IS ESSENTIAL

Immediate treatment

bull Control bleeding

bull Replace volume loss

bull Cover wounds

bull Reduce

fracturesdislocations

bull Splint

bull Re-evaluate

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Mechanism of Injury

bull Penetrating trauma

ndash GSW

ndash Stab

bull Blunt trauma

ndash High energy

ndash Low energy

bull iatrogenic

Consequences of vascular injury

bull Blood loss

bull Ischemia

bull Compartment syndrome

bull Tissue necrosis

bull Amputation

bull Death

Prognostic factors

bull Level and type of vascular injury

bull Collateral circulation

bull Shockhypotension

bull Tissue damage (crush injury)

bull Warm ischemia time

bull Patient factorsmedical

conditions

Speed is crucial

bull Rapid resuscitation

bull Complete rapid

evaluation

bull Urgent surgical

treatment

PROTOCOL IS ESSENTIAL

Immediate treatment

bull Control bleeding

bull Replace volume loss

bull Cover wounds

bull Reduce

fracturesdislocations

bull Splint

bull Re-evaluate

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Consequences of vascular injury

bull Blood loss

bull Ischemia

bull Compartment syndrome

bull Tissue necrosis

bull Amputation

bull Death

Prognostic factors

bull Level and type of vascular injury

bull Collateral circulation

bull Shockhypotension

bull Tissue damage (crush injury)

bull Warm ischemia time

bull Patient factorsmedical

conditions

Speed is crucial

bull Rapid resuscitation

bull Complete rapid

evaluation

bull Urgent surgical

treatment

PROTOCOL IS ESSENTIAL

Immediate treatment

bull Control bleeding

bull Replace volume loss

bull Cover wounds

bull Reduce

fracturesdislocations

bull Splint

bull Re-evaluate

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Prognostic factors

bull Level and type of vascular injury

bull Collateral circulation

bull Shockhypotension

bull Tissue damage (crush injury)

bull Warm ischemia time

bull Patient factorsmedical

conditions

Speed is crucial

bull Rapid resuscitation

bull Complete rapid

evaluation

bull Urgent surgical

treatment

PROTOCOL IS ESSENTIAL

Immediate treatment

bull Control bleeding

bull Replace volume loss

bull Cover wounds

bull Reduce

fracturesdislocations

bull Splint

bull Re-evaluate

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Speed is crucial

bull Rapid resuscitation

bull Complete rapid

evaluation

bull Urgent surgical

treatment

PROTOCOL IS ESSENTIAL

Immediate treatment

bull Control bleeding

bull Replace volume loss

bull Cover wounds

bull Reduce

fracturesdislocations

bull Splint

bull Re-evaluate

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Immediate treatment

bull Control bleeding

bull Replace volume loss

bull Cover wounds

bull Reduce

fracturesdislocations

bull Splint

bull Re-evaluate

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Diagnosis

bull Physical exam

bull Doppler pressure (Anklebrachial

systolic pressure index)

bull Duplex scanning

bull Arteriogram

bull Exploration Careful physical exam and

high index of suspicion are

most important

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Physical exam

bull Major hemorrhagehypotension

bull Arterial bleeding

bull Expanding hematoma

bull Altered distal pulses

bull Pallor

bull Temperature differential between extremities

bull Injury to anatomically-related nerve

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

bull Asymmetric pulses warrant doppler examination (determine ABI)

bull Absent pulses warrant emergent vascular consultationsurgical exploration

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Doppler ultrasound

bull Determine presenceabsence of arterial

supply

bull Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT

EXCLUDE ARTERIAL INJURY

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Angiography

bull Locates site of injury

bull Characterizes injury

bull Defines status of vessels

proximal and distal

bull May afford therapeutic

intervention

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Angiography

Identify and control bleeding from pelvic fractures

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Surgical exploration

Immediate exploration is

indicated for

bull Obvious arterial injury on exam

bull No doppler signal

bull Site of injury is apparent

bull Prolonged warm ischemia time

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Crush syndrome

Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Spitak earthquake in Armenia in 1988

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Great Hanshin earthquake in Japan in 1995

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Marmara earthquake in Turkey in 1999

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

bull First described in the English language literature by Bywaters and Beal (1941)

bull Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure

bull A severe often fatal condition that follows a severe crushing injury particularly involving large muscle masses

bull Characterized by fluid and blood loss shock hematuria and renal failure

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Crush Syndrome

1048708Building collapse

1048708Earthquakes

1048708Landslides

1048708Bombings

1048708Construction accidents

1048708Heavy snow on roof

1048708Mine or trench collapse

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Signs and Symptoms of Crush Injury

bull Skin injury bull Swelling bull Paralysis ndash may cause to be mistaken as a spinal cord

injury bull Paresthesias numbness ndash may mask the degree of

damage bull Pain bull Pulses ndash distal pulses may or may not be present bull Myoglobinuria ndash the urine may become dark red or

brown indicating the presence of myoglobin

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Compartment Syndrome

bull Severe pain in the involved extremity

bull Pain on passive stretching of the muscles involved

bull Decreased sensation in branches of the involved peripheral nerves

bull Elevated intracompartmental pressures on direct manometry

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Treatment

bull The airway must be secured and protected from dust impaction

bull Adequate ventilation must be ensured and maintained along with adequate oxygenation

bull Intravenous Fluid

preexisting dehydration or fluid loss should be corrected

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

bull Intravenous (IV) fluids containing potassium (eg lactated Ringers solution) should be avoided

bull Normal saline is a good initial choice

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

bull formula that can be used to maintain an alkaline urine output of 8 Ld is the infusion of 12 Ld of Normal Saline Solution (NSS) with 50 mEq of sodium bicarbonate per liter of fluid plus 120 grams of mannitol daily to maintain this urine output

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Sodium Bicarbonate

bull reverse the preexisting acidosis

bull first steps in treating hyperkalemia

bull increase the urine pH to decrease the amount of myoglobin precipitated in the kidneys

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

bull 50 to 100 mEq of bicarbonate depending on severity of injury to be given prior to release from compression

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Treatment of Hyperkalemia

bull Insulin and glucose

bull Calcium ndash intravenously for life-threatening dysrhythmias

bull Beta-2 agonists ndash albuterol metaproterenol sulfate (Alupent) etc

bull Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate)

bull Dialysis especially in patients with acute renal failure

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Alkaline Diuresis

bull maintain a urine output of at least 300 mlh with a pH higher than 65

bull intravenous fluids mannitol and sodium bicarbonate (44 to 50 mEqliter)

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Intravenous Mannitol

bull protects the kidneys from the effects of rhabdomyolysis

bull increases extracellular fluid volume

bull increases cardiac contractility

bull relief symptoms and reduction of swelling of compartment syndrome

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

bull Mannitol can be given in doses of 1 gmkg or added to the patients intravenous fluid as a continuous infusion

bull The maximum dose is 200 gmd

bull Mannitol should be given only after good urine flow has been established

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

bull Wounds should be cleaned deacutebrided and covered with sterile dressings

bull Splinting and elevation of the limb will help to limit edema and maintain perfusion

bull Intravenous antibiotics

bull Medications for pain control can be given as appropriate

bull Tourniquets are controversial and usually not necessary

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

bull Amputation should be used only as a last resort

bull Fasciotomy

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

CONCLUSIONS

bull The development of Crush injury syndrome is preventable and treatable

bull The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine

bull The traditional treatment of compartment syndrome is fasciotomy

bull The complication rate is high with the most serious hemorrhage and sepsis

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Amputations

bull Amputations are classified at the level where the amputation takes place

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Types and levels

bull congenital

bull Acquired

bull lower extremity

bull upper extremity

bull Forequarter

bull Intrascapulothorasic

bull shoulder disarticulation

bull Transhumeral ndash above elbow

ndash Elbow Disarticulation

bull Transradial

ndash below elbow

bull wrist disarticulation

bull Transcarpal

bull Metacarpal phalangeal

bull Transphalangeal

bull partial hand

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Types of Amputations (according to soft tissues cutting)

1 Flap amputations

- single-flap amputation

- double-flap amputation

2 Circular amputations

- one-step (guillotine) amputation

- two-step amputation (variety ndash ldquocuffrdquo

method of forearm amputation)

- three-step (conical-circular)

amputation

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Sites of Election for Amputations of Upper

Extremity

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Finger Amputation

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Osteo-plastic Amputations

(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Schemes of Foot Amputations

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Syme Amputation

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Phantom limb sensationpain

bull The sensation that the amputated extremity is still there

bull Pain treated with TENS desensitization fluidotherapy US nerve blocks or surgery

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Other complications SP amputation

bull Depression is common

bull Falls

ndash stand on side of LE amputation

bull balance is greatly disturbed

ndash body center of gravity is changed

ndash balance must be relearned

ndash protective reactions must be changed

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Stump Management

bull Shape residual limb so it is tapered at the distal end to allow for prosthetic fit

bull Figure 8 ace bandage wrap ndash wrapped distal to proximal

ndash more pressure distally

ndash never wrap circular direction because of tourniquet effect

ndash pt wears wrap continually

ndash check skin 3-4 times each day

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Common Traumatic Injuries of the Hand

Bone and Soft Tissue

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

ndash Extensor and flexor tendons insert into the base of the distal phalanx

ndash Routinely not a deforming fracture

Applied Anatomy

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Nailbed Injury

bull Nailbed lacerations need to be repaired

ndash Use 6-0 absorbable to repair matrix

ndash Prevents nail growth problems

bull Reinsert nail and secure

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Subungual Hematoma

bull Results from blunt trauma to nail

bull Very painful

bull Relieved by

ndash Cautery

ndash Heated paperclip

ndash 18g needle

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Subungual Hematoma

bull Clean with alcohol

bull Instrument of choice

bull Pierce nail

bull Gauze for 24 hours

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Mallet Fingers (soft tissue and bony)

bull Applied Anatomy ndash Terminal extensor tendon

inserts into the dorsum of the distal phalanx

bull Mechanism of injury ndash Occurs with a sudden

flexion force against an extended digit

ndash Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Mallet Fingers (soft tissue and bony)

bull History and Physical Exam ndash Pain and deformity of

the DIP joint after bumping the end of the finger

ndash Inability to straighten the end joint

ndash Test for tendon function

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Mallet Fingers (soft tissue and bony)

bull Radiographs ndash 2 views looking for dorsal

avulsion fragment

ndash May be negative

bull Classification ndash Soft tissue (- x-ray)

ndash Bony (+ x-ray) bull Fleck

bull Dorsal articular piece

bull Subluxation of DIP joint

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Mallet Fingers (soft tissue and bony)

bull Treatment ndash Closed reduction

ndash Continuously splint DIP in full extension for 6 to 10 weeks

bull Only immobilize the DIP

ndash Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Flexor Tendon Avulsion

bull Applied Anatomy

ndash Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Flexor Tendon Avulsion

bull Mechanism of Injury ndash Hyperextension

against a flexed DIP joint

ndash Relatively uncommon but devastating is missed

ndash Ring finger most commonly involved

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Flexor Tendon Avulsion

bull Associated injuries ndash None

bull History and Physical Exam ndash Pain on volar surface of digit

bull May extend into palm with eccymosis

ndash Cannot flex tip

ndash Resting hand has extension of DIP joint

ndash No active flexion

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Flexor Tendon Avulsion

bull Radiographs

ndash DIP to look for avulsion but also hand to look for retracted segment

ndash Most are normal

bull Classification

ndash Pure tendon avulsion

ndash Bony avulsion

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Flexor Tendon Avulsion

bull Treatment

ndash Should be splinted and referred in a semi-urgent fashion

ndash Surgery is required

bull Outcomes

ndash Results correlate with delay in treatment

bull Early do well

bull Postoperative hand therapy is important

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Boutonniere

bull Applied Anatomy

ndash When the central slip insertion at the base of the middle phalanx is disrupted active PIP joint extension may be limited

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Boutonniere

bull Applied Anatomy ndash The flexed position of the

PIP joint then allows the lateral bands to fall volar to the axis

ndash These lateral bands then act to flex the PIP joint further

ndash Tension pulls the DIP joint into extension

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Boutonniere

bull Mechanism of Injury ndash Acute flexion force to PIP

joint

ndash PIP does not immediately fall into a flexed position

ndash Several weeks after the injury the digit assumes a buttonhole posture

ndash Other mechanism include PIP dislocation and central slip lacerations

bull History and Physical Exam ndash Pain and swelling about PIP

ndash Inability to fully extend PIP

ndash DIP flexion is limited

ndash Longstanding cases

bull PIP flexion

bull Passive extension not possible

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Boutonniere

bull Radiographs ndash Most often negative

ndash Occasionally small fragments dorsally off middle phalanx

bull Classifications ndash Acute

ndash Chronic bull Stiff

bull supple

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Boutonniere

bull Treatment

ndash If not sure of central slip assume it is and splint the PIP in full extension

ndash Acute boutonnieres bull 4 weeks of full extension splinting of PIP with active DIP flexion

exercises

bull Occasionally need surgery

ndash Chronic boutonnieres bull Hand therapy

bull Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash PIP is a hinge

ndash Ligaments along palmar aspect - volar plate

bull Prevents hyperextension

ndash Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Applied Anatomy

ndash Each PIP joint has a radial and ulnar collateral ligament

bull Tethers the PIP joint in its side-to-side motion

ndash Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Mechanism of Injury

ndash Sudden force directed to tip of digit results in hyperextension

bull Spectrum ranging from slight hyperextension grade I sprain to frank dislocation

bull Associated Injury ndash If the skin tears open it is an

open dislocation

bull History and Physical Exam ndash Joint swollen and tender

ndash Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Radiographs ndash 2 views to check for

fractures

ndash Post-reduction films if done

bull Classifications ndash I ndash do not compromise

stability

ndash II ndash partial compromise at risk for complete disruption

ndash III- complete disruption can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

bull Treatment ndash Early mobilization after a few days of splinting

bull Buddy tape for 4 weeks

ndash A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension

bull Outcomes ndash These injuries can heal with some permanent fusiform

swelling from scar tissue

ndash Long term problem is not recurrent instability but stiffness bull For this reason early range of motion program is most often

recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull The ulnar collateral ligament of the thumb is important for pinch strength and stability

bull Because of its location it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Mechanism of Injury

ndash Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over ulnar side of MP joint

ndash In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeperrsquos Thumb)

bull Radiographs ndash Typically negative

ndash Possible avulsion fragment off proximal phalanx or metacarpal

bull Treatment ndash Incomplete ndash non-

operatively (splint)

ndash Complete - surgically

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Bennetts Fracture Dislocation

bull Most frequent of all thumb fracture

bull Described in 1882 by Dr Edward Bennet

bull It is a fracture dislocation intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Bennetts Fracture Dislocation

bull Mechanism of Injury

ndash Results from axial blow directed against the partially flexed metacarpal (ie from fist fights)

bull History and Physical Exam

ndash Moderate swelling and eccymosis over the CMC joint

ndash Pain with ROM or palpation

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning

Bennetts Fracture Dislocation

bull Radiographs ndash Oblique fracture line with a

triangluar fragment at ulnar base of metacarpal

ndash Triangular fragment remains attached to trapezium w proximal displacement of the metacarpal

bull Treatment ndash Immobilization

ndash Referral for surgical pinning