Hand injuries are common in all sports. Traumatic fractures are most often seen in contact sports such as football, hockey and rugby. Adolescents are more prone to such injuries.
The mechanism of injury is helpful in diagnosing the underlying injury and planning further care. It is vital to note hand dominance.
Hand injuries need to be mobilised as soon as possible.
Examination should be divided into look (inspection), feel (move) and measure (range of movement) of the joints. It is vital to assess the neurology in any examination and the median, ulnar and the radial nerves.
The proximal and middle phalanges can be commonly injured, especially those of the index and small fingers.
Fracture classification for these injuries depends on the anatomic site of injury including condylar, neck, shaft, base or epiphyseal fractures. These patients would need a referral to decide on a management plan.
Epibasal thumb base fractures are extra-articular and treated in a thumb spica for four to six weeks.
A comminuted Bennett’s fracture is a Rolando fracture. Both fractures are usually treated operatively.
Neck fractures, particularly those involving the small finger (boxer’s fractures), are common. Angulations up to 40 degrees can be accepted.
Fractures of the metacarpal head most often involve the index finger and should be surgically treated in cases with a large intra-articular defect.
Punching injuries can affect the metacarpophalangeal joint or interphalangeal joint. These injuries are serious and need referral for a joint washout as there is a very high incidence of septic arthritis.
Subungal haematomas can be painful. If the injury involves more than 50 per cent of the nail bed, an X-ray is needed to rule out a distal phalanx fracture.
Mallet finger injuries are caused by disruption of the tendon or a fracture of the distal phalangeal dorsal base, resulting in an extension lag at the distal interphalangeal (DIP) joint.
Disruption of the extensor mechanism at its insertion into the dorsal base of the middle phalanx may present a ligamentous or bony avulsion injury similar to mallet finger. The deformity develops over two to three weeks as a flexion (boutonnière) deformity at the PIP.
Mallet fingers should be referred for an X-ray and diagnosis. A mallet splint should be worn continuously for six weeks.
Treatment of boutonnière involves extension splinting of the proximal interphalangeal (PIP) joint for five weeks, leaving the other joints free to move.
Avulsions of flexor digitorum profundus tendon is often missed as a sprained finger.
The inability to actively flex the DIP joint associated with swelling, tenderness, and ecchymosis along the flexor sheath helps differentiate this injury from less severe ones. Commonly seen in tackling sports, this is also known as ‘Jersey finger’.
Dorsal dislocations of the PIP joint can be related to injuries of the volar plate or collateral ligaments. They may need buddy strapping for four to six weeks followed by mobilisation of hand and can be painful for three to six months.
Dorsal dislocations of the metacarpal phalangeal (MCP) joint are simple or complex. The simple ones are reduced by flexing the first phalangeal base while putting dorsal pressure on the metacarpal head and holding the wrist and PIP joint slightly flexed.
Complex or irreducible dislocations can be deceptive because they do not show as much MCP hyperextension, but display near parallelism between the metacarpal and first phalangeal shafts.
Signs include puckering of the palmar skin and sesamoids in the joint showing on X-rays. These injuries need surgical treatment.
Acute abduction and extension force to the thumb can cause a partial or complete disruption of the ulnar collateral ligament (UCL) of the thumb MCP joint.
Occasionally, the UCL is completely avulsed. The adductor aponeurosis can be interposed between it and the distal insertion site, forming a Stener lesion. These injuries often need operative treatment. In the milder form it can be a sprain, which needs splinting.
|CLASSIFICATION OF HAND INJURIES
Tendon injuries with or without avulsion fractures
Sprains and dislocations
- Mr Mohan is a registrar in orthopaedics, Southampton General Hospital, Southampton