The hand and wrist
EDWARD AKELMAN AND ARNOLD-PETER C. WEISS
FRACTURES AND DISLOCATIONS OF THE HAND AND WRIST
Fractures of the distal phalanx
The most common fracture in the hand is that of the distal phalanx. These injuries are frequently associated with pulp compartmental crush, nailbed injuries, and soft tissue losses. Most are comminuted fractures, but are not displaced. Immobilization of the distal interphalangeal joint with a dorsal or volar splint allows these fractures to heal: most closed fractures heal in 14 to 21 days. Irrigation, debridement, and careful repair of the nailbed should be accomplished at the time of the initial injury to allow cosmesis of the nail and functional return. Subungual haematomas should be drained through the intact hard nail using electrocautery or a heated needle, allowing relief of pain. When the haematoma covers 50 per cent or more of the nail area, the nail should be removed and nail bed injury sought.
Most displaced distal phalanx fractures are subjected to closed reduction with the use of a digital nerve block and local anaesthesia. Flexion of the distal fragment with a dorsal splint over the distal interphalangeal joint in slight flexion overcomes the pull exerted by the flexor digitorum profundus on the proximal fragment. Unstable displaced fractures occasionally require fixation with a small Kirschner wire, placed with the distal interphalangeal joint in extension. Displacement or gapping between the two distal phalanx fracture fragments may indicate entrapment of the nail matrix. Open reduction and internal fixation with repair of the nail bed matrix is required.
Fractures of the middle phalanx
Extra-articular fractures of the middle phalanx are uncommon. Middle phalanx fractures may be displaced, depending on the level of the fracture and its relationship to the flexor digitorum superficialis insertion. An extra-articular fracture of the base of the middle phalanx may collapse and angulate dorsally. Fractures of the neck of the phalanx distal to the superficialis insertion angulate in a volar direction. A fracture located in the midshaft between these two levels may angulate in either a dorsal or volar direction.
Stable fractures of the middle phalanx should be treated with a dorsal splint allowing active distal interphalangeal phalanx motion when tolerated. Timing of motion can be determined by careful palpation of the fracture site. Most patients do not complain of pain after 2 to 4 weeks; motion is then encouraged.
Displaced fractures should be treated with closed reduction. The hand and wrist should be placed in an intrinsic plus position with the wrist resting at 20° of dorsiflexion, the metaphalangeal joints flexed to 70°, and the interphalangeal joints held in extension. If the middle phalanx fracture reduction is unstable, unacceptable, or if it is irreducible, it may be treated by either closed or open reduction and internal fixation. The best functional results are obtained in patients who are allowed to move the proximal and distal joints: early motion keeps both extensor and flexor tendons from becoming adherent to the fracture.
Proximal phalanx fractures
Fractures of the proximal phalanx of the hand are common. Stable fractures of the proximal phalanx with minimal displacement may be treated in the same manner as stable middle phalanx fractures, such as in a cast with the wrist and hand placed in an intrinsic plus position. However, many proximal phalanx fracture patterns are inherently unstable. Following high energy injuries, transverse fractures in the proximal third to middle regions of the proximal phalanx may collapse into an apex volar angular deformity. With this displacement, closed reduction is obtained by flexing the metacarpophalangeal joint to 90°, releasing the deforming forces of the intrinsic musculature. Spiral oblique proximal phalanx fractures may be unstable and are reduced by correcting distal bony deformities. Fractures at the base of the proximal phalanx can usually be reduced by this same manoeuvre.
After reduction of the proximal phalanx fracture, it should be held in an intrinsic plus position. As these fractures have a high probability of displacement, radiographs should be obtained weekly for 3 to 4 weeks to check alignment.
Unstable fractures, fractures that displace, and reductions felt to be unacceptable require either closed reduction or open reduction and internal fixation. Both methods provide excellent results. The long-term functional result seems to be improved when treatment allows early motion of the injured digit.
Fractures of the middle and proximal phalanx intracondyles are usually associated with articular cartilage displacement in the form of unicondylar, bicondylar, or osteochondral - slices - . These are common injuries in athletes. Closed reduction should be attempted, even when there is significant joint displacement, although open reduction and internal fixation is usually required. Depending on the size of the fracture fragments, multiple Kirschner wire or small screw fixation may be applicable. Early protected motion improves functional results.
Intra-articular fracture dislocations of the proximal interphalangeal joint
Fractures at the base of the middle phalanx may cause dorsal subluxation or dorsal dislocation of the proximal interphalangeal joint. Correct treatment of these injuries is most dependent on recognition of the injury pattern: anteroposterior and true lateral radiographs of the joint are required. If only one-third of the articular surface is involved, these injuries are stable. Fractures affecting more than one-third of the articular surface involved are usually unstable.
Distal interphalangeal joint dislocations
True dislocations of the distal interphalangeal joint without fracture are uncommon. They are usually dorsal and frequently open, with a tell-tale transverse laceration at the level of the distal interphalangeal joint flexion crease. They should be treated as open injuries with irrigation and debridement of the joint. Reduction is usually stable, but fixation may be necessary if the joint is truly unstable. The joint is held in 10 to 20° of flexion for approximately 4 weeks, and active motion of the metaphalangeal and proximal interphalangeal joints encouraged.
Proximal interphalangeal joint dislocations
Proximal interphalangeal joint dislocations, particularly dorsal dislocations, are common. These are usually injuries to the volar plate of the joint at its insertion on the middle phalanx. Most can be reduced with digital block anaesthesia. Treatment includes 2 weeks of dorsal proximal interphalangeal joint splinting in approximately 15 to 20° of flexion. Early motion is encouraged by taping the injured finger to an adjacent finger for the next 6 weeks. This encourages motion while using the adjacent digit as a splint. Follow-up of these injuries within the 10 days is needed to ensure that the reduction is stable. True lateral radiographs are essential. Over-zealous treatment of these injuries, such as 4 to 6 weeks of splinting or casting, gives poor results, with limitation of joint motion. Splinting for longer than 2 weeks is bad.
Volar dislocations of the proximal interphalangeal joint are rare. When reducible they may be treated with a dorsal extension splint, with the fractured joint held in extension for 6 weeks. These injuries may be associated with rupture of the central slip of the extensor tendon or herniation of the proximal phalanx through the extensor mechanism, causing irreducible dislocation of the joint. Injury usually occurs through the interval between the central slip and the ipsilateral lateral band. The condyle may become trapped, causing the joint to be irreducible: open exploration is then required. Repair of the acute boutonniere deformity, and Kirschner wire pinning of the joint in extension for 4 weeks should be carried out. If the lateral band is entrapped, the extensor mechanism is repaired. A postoperative extension splint is worn for 6 weeks.
Fractures of the metacarpals
As in most fractures, initial treatment depends on the type of fracture, the fracture pattern, whether the fracture is open or closed, and whether the fracture is intra- or extra-articular. The index and long finger metacarpals are the stabilizing central (fixed) unit of the hand. The thumb on the radial side and the ring and small finger on the ulnar side of the hand move about this central fixed unit; they have been described as the mobile units of the hand. Angulation, shortening, and displacement of these three metacarpals have less impact on the function of the hand because of their mobility. For this reason, only minimal displacement should be allowed in metacarpal fractures of the index and long fingers, whereas more displacement and angulation may be allowed in the thumb, ring finger, and small finger metacarpals.
Extra-articular metacarpal fractures
Fractures of the neck of the metacarpal are the most common of the extra-articular metacarpal fractures. These injuries are caused by a direct blow to the metacarpal heads. Depending on the level of energy imparted to the hand at the time of injury, these fractures may be unstable because of palmar comminution of fracture fragments. Radiographs are required to monitor the fracture reduction. Most of these fractures may be held using a short arm cast holding the wrist in extension, the metacarpophalangeal joints in 70° of flexion, and the proximal interphalangeal joints in full extension. The acceptable degree of residual angulation is controversial. In general, 0 to 10° of angulation is allowed in the index and long and 30 to 40° of angulation is allowed in the ring and fifth finger metacarpals.
Metacarpal shaft fractures are usually the result of direct blows to the dorsum of the hand, longitudinal compression, or torsional stresses. Angulatory or rotatory deformities may occur, depending on the pull of different muscular forces. Angulation is less acceptable in the index and long metacarpals than in the ring and small fingers. Most fractures can be reduced using longitudinal traction, wrist extension, metacarpophalangeal joint flexion, and dorsal three-point moulding. Unstable or malrotated fractures may be treated by closed or open reduction and internal fixation.
Metacarpophalangeal joint dislocations
Dorsal dislocations of the metacarpophalangeal joint are the result of a hyperextension injury with injury to the volar plate. These dislocations may be reduced using wrist block anaesthesia to allow relaxation of intrinsic musculature. The most gentle reduction is usually accomplished by flexing the wrist to relax the extrinsic flexor tendons. The metacarpal head is then reduced into the sulcus of the normal metacarpophalangeal joint with volar pressure exerted on the distally displaced proximal phalanx. Longitudinal traction will not assist, and may actually impede, reduction.
Some dorsal metacarpophalangeal dislocations may be irreducible. These complex dislocations are indicated by the classic volar skin change of puckering, most commonly at the level of the distal palmar crease of the hand. The metacarpal head is usually prominent in the palm. The structure usually preventing reduction is the volar plate. Open reduction is performed through a curving incision over the palmar portion of the metacarpophalangeal joint. The neurovascular structures are usually held in close apposition to the underlying skin, and care must be taken to avoid injury to this complex when making the incision.
Intra-articular metacarpal fractures
These fractures involve the border digits of the hand, the index finger and the little finger being most commonly involved. They are usually caused by a direct blow that causes axial compression, and are frequently associated with human bite injuries. Infection of the joint should always be considered. If large articular fragments are involved, open reduction and internal fixation with restoration of joint surface congruity is of paramount importance.
Intra-articular fractures of the base of the metacarpals are most common in the thumb and in the little finger. In these injuries, there is subluxation of either the thumb or little finger carpometacarpal joint. When this injury occurs at the base of the thumb, it is called a Bennett's fracture. The volar ulnar tubercle of the thumb metacarpal remains attached to the volar beak ligament. With continued pull of the abductor pollicis longus tendon, the large remnant thumb metacarpal subluxes dorsoradically and into relative supination. The adductor pollicis muscle pulls the shaft of the thumb metacarpal towards the second metacarpal. As in all articular fracture subluxations, it is of prime importance to restore articular congruity. This may be accomplished by either a closed or open reduction and internal fixation. Closed reduction may be carried out by pulling longitudinally on the thumb metacarpal, followed by radial abduction and pronation, placing the thumb metacarpal in relative palmar abduction.
Fractures of the little finger metacarpal base simulate Bennett's fracture dislocation of the thumb. The little finger metacarpal subluxes because of to the pull of the extensor carpi ulnaris tendon. It is also relatively adducted by the hypothenar intrinsic musculature. Again, attention must be paid to careful reduction of the joint. Reduction is carried out by relative longitudinal traction, ulnar abduction, and supination. Percutaneous pinning can then be carried out.
Carpometacarpal joint dislocations
Dislocations of the carpometacarpal joints of the metacarpals of the hand are often missed. These injuries, caused by longitudinal compression combined with flexion of the affected metacarpals, may be dorsal or volar. They are more commonly dorsal and involve the fourth and fifth metacarpal bases because of the inherent instability of the anatomy of this region. The key to this diagnosis is a - pronated 30° lateral - where the hand is actually supinated 60° from the true lateral on a radiograph.
Dislocations of the finger carpometacarpal joints are usually easy to reduce using wrist nerve block anaesthesia and finger trap traction of approximately 4.5 kg (10 pounds). Reduction may be aided by direct finger pressure on the metacarpal base, combined with extension of the metacarpal head. Maintenance of these reductions is controversial. Percutaneous Kirschner wire fixation with short arm casting for approximately 4 weeks may be required. In these casts, the metacarpophalangeal joint is usually flexed 70° with the wrist extended 20°. The pins are removed at 4 to 6 weeks and early motion is begun after that time. Pain and weakness may result from unrecognized and unreduced fracture dislocations. Treatments reported for late arthrosis have included arthrodesis or interposition arthroplasty.
Carpometacarpal dislocations of the thumb are rare and usually occur in a dorsoradial direction. These may be treated with a careful reduction confirmed by radiograph and a short arm thumb spica cast for 4 weeks, with interphalangeal motion allowed. If the joint subluxes after reduction, most patients develop pain, deformity, and pinch weakness.
The scaphoid is the most common carpal bone to be fractured.
Second in incidence only to fractures of the distal radius, this fracture is most frequent in young adult males at the level of the scaphoid waist. The scaphoid bone is almost completely covered with hyaline cartilage. The scaphoid interosseous blood supply to the proximal two-thirds of the scaphoid enters in the dorsal ridge region. Vascular injection studies of the scaphoid have shown that approximately 13 per cent of specimens would lose retrograde blood supply following a scaphoid waist fracture. Because of vascular variations from patient to patient, it is difficult to determine whether avascular necrosis will occur after a fracture.
Scaphoid fractures occur when a load is applied to the radial side of the palm with the wrist dorsiflexed 95 to 100°. With the wrist in radial deviation, there is a bending moment in the waist of a volar flexed scaphoid between the radius capitate and volar capsular ligaments. This causes a fracture between the supported and the unsupported bones.
The diagnosis of scaphoid fractures depends on an index of suspicion, a careful clinical physical examination, and good radiographs. A scaphoid fracture should be suspected if the patient complains of dorsoradial - snuff box - tenderness, pain in ulnar and radial deviation in the same area, or tenderness in the palmar pole of the scaphoid. A standard wrist radiographic series should include a posteroanterior view, a lateral view, a posteroanterior view with the wrist in ulnar deviation, and two oblique views—posteroanterior, with the wrist pronated 45° from the lateral, and posteroanterior with the wrist supinated 45° from the lateral. Any patient with tenderness on clinical examination or suspicion of fracture on a radiograph should be treated as if a fracture is present. Radiographs should be repeated in 2 to 4 weeks if there is still doubt regarding the injury.
The anatomical location of a scaphoid fracture may help determine the possibility of union because of the anatomy of the blood supply. Seventy per cent of these fractures occur in the middle third or waist of the scaphoid, 20 per cent occur within the proximal third, and approximately 10 per cent occur distally. Fractures in the proximal and to a somewhat lesser extent the middle third of the scaphoid are at higher risk for delayed union and/or avascular necrosis. If clinical examination 3 months after fracture shows pain, increasing instability, angulation, or radiographic evidence of delay in healing, open reduction and bone grafting should be carried out.
The triquetral fracture is more commonly associated with a hyperextension or hyperflexion injury of the wrist. It is frequently an avulsion fracture in the area of insertion of the extensor carpi ulnaris. The injury may also be caused by compression or impingement. Oblique and lateral radiographs are helpful in making a diagnosis. Short arm casting for 4 to 6 weeks gives excellent results. In the rare patient who experiences worsening pain during use, surgical removal of a small dorsal fragment may be required when a non-union is noted.
LIGAMENT INJURIES OF THE HAND AND WRIST
The strong ligaments of the hand and wrist complement the bony architecture and provide stability during functional activity. The most important ligaments of the human wrist joint are the volar, thick, and intracapsular ligaments.
PATHOPHYSIOLOGY OF WRIST LIGAMENT INJURIES
Perilunate dislocations are the result of a violent force exerted with the wrist in hyperextension, ulnar deviation, and intercarpal supination. Patients may present with dorsal wrist discomfort, mild swelling, and numbness. Range of motion is usually limited. True lateral radiographs will confirm the diagnosis, the capitate being dislocated dorsally on the lunate. Under either regional or general anaesthesia, the hand is suspended using finger traps with the elbow flexed 90°. Weights of 4.5 to 7 kg (10 to 15 pounds) may be needed for reduction: traction may be continued for 5 to 10 min. There is often an audible - clunk - on reduction. Alternatively, the hand may be dorsiflexed while maintaining longitudinal traction. The hand is then palmar flexed, reducing the capitate - lunate articulation. Preliminary radiographs in traction usually demonstrate satisfactory reduction, with a normal capitolunate relationship and scaphoid position without rotatory subluxation.
Radiographs are assessed weekly for the first 4 to 6 weeks. The capitolunate relationship, normally 0 to 15°, is monitored. Radiographs of the opposite wrist may be used for comparison.
Transcaphoid perilunate dislocations
Transcaphoid perilunate dislocation is uncommon. The only difference between this injury and dorsal perilunate dislocation is the location of the direction of force, which occurs through the scaphoid rather than between the scaphoid and the lunate.
Rotary subluxation of the scaphoid bone
The scaphoid is the key link between the proximal and distal carpal rows. The radial and proximal position of this carpal bone controls carpal stability of the wrist. Injury to this carpal bone predisposes the wrist and hand to functional disability. The chances of successful closed treatment depend on suspicion and early recognition of the injury. Patients frequently complain of wrist pain after an apparently trivial injury. On examination, the patient appears to have pain and tenderness in the radiocarpal area at the level of articulation between the radius and the proximal scaphoid. Watsons' test is useful. In this test, the patient's elbow rests on his lap. At all times the forearm is pronated. The examiner uses the opposite hand to take the patient's wrist into full ulnar deviation. The patient's hand is then radially deviated while the examiner pushes against the distal pole of the scaphoid with his thumb, attempting to prevent the scaphoid's normal palmar flexion. This manoeuvre forces the distal pole to sublux if the scapholunate joint is unstable. This test is painful on the injured side and reproduces symptoms.
Acute rotary subluxation of the scaphoid should be treated by open repair. A dorsal approach is used to repair the injured scapholunate ligament, with the repair stabilized by the use of Kirschner wires from the scaphoid to the capitate and lunate. A thumb spica cast is placed, with the wrist in slight flexion. Pins are removed at 6 weeks; immobilization is continued for 6 more weeks.
Ligament injuries of the thumb
The unique versatility of the thumb makes any injury to this digit extremely disabling. Injuries to the ligament complexes of the three thumb joints may cause instability during abduction and adduction stresses, diminishing pinch.
The metacarpophalangeal joint of the thumb has strong radial and ulnar collateral ligaments. Stability is enhanced by the volar plate, which inserts on the proximal phalanx. Injuries at the metacarpophalangeal joint of the thumb are common in athletes, particularly skiers and football players, and are caused when the joint is forcibly pulled into abduction or adduction.
Patients with acute injuries present with local tenderness and swelling along the injured side of the metacarpophalangeal joint. When seen 6 or more weeks after injury, patients may complain of weakness of thumb-index pinch, instability of the metaphalangeal joint, or pain on abduction stress.
FLEXOR TENDON INJURIES OF THE HAND
The function after a flexor tendon injury depends on many factors including the type of injury, the initial surgical treatment, the healing potential of the tendon ends, the experience of the surgeon, knowledge of finger and hand anatomy, and the type of rehabilitation.
The flexor tendons begin in the forearm at the musculotendinous junction. Four flexor digitorum superficialis tendons lie anterior to the four flexor digitorum profundus tendons. The superficialis muscle tendon units have separate, independently acting muscles, while the flexor profundus muscle belly pulls all of the flexor profundus tendons en masse.
The fibrous retinacular sheath, beginning at the area of the metacarpal neck and ending at the distal phalanx comprises both annular and cruciate pulleys. The pulley system is important in flexor tendon function. Bowstringing is prevented, because the pulleys hold the flexor tendons in close apposition to the phalanges during digital flexion.
Although at times difficult to perform in an unco-operative patient, good digital examination will diagnose all flexor tendon injuries. Assessment of both flexor tendon systems depends upon the unique anatomy of the profundus and superficialis systems. Testing of the flexor digitorum profundus tendon recreates the function of the individual tendon unit. Each distal interphalangeal joint in the index, ring, long, and small fingers is tested to determine whether individual flexion is intact. Injuries to the profundus tendon system are present if the distal interphalangeal joint does not flex. Individual superficialis tendons, which normally actively flex the proximal interphalangeal joints, are tested by placing the other three fingers in a position with each distal and proximal interphalangeal joint extended while asking the patient to flex the finger being examined. The pull of the profundus musculotendinous unit is negated by the passive extension of the nontested fingers. The flexor pollicis longus muscle is tested by asking the patient to flex actively the interphalangeal joint of the thumb.
Partial flexor tendon lacerations are difficult to diagnose. Partial tendon injury should be suspected in all patients with pain against resistance during an examination. If the wound is not explored, splinting should be carried out for 2 to 3 weeks to prevent rupture of the damaged tendon. If there is any doubt about the amount of tendon lacerated, exploration is recommended.
Flexor tendon injury management
Operative repair is indicated for flexor tendon lacerations. All such surgery should be accomplished with a sterile and bloodless field, a rested surgeon, regional or general anaesthesia, and optical magnification. Surgical incisions should be based on principles of an extensile approach without crossing skin creases at a right angle. The volar oblique transaxial zig-zag incision using interaxial digital lines is preferred. The best surgical results are obtained after early direct repair of complete tendon injuries. The definition of - early - is controversial, but is generally less than 2 to 3 weeks after injury.
Treatment of partial tendon injuries remains controversial. The only strong evidence available suggests that debridement and early motion are appropriate for partial injuries involving less than 60 per cent of a tendon.
EXTENSOR TENDON INJURIES
The treatment of extensor tendon injuries demands the same knowledge of anatomy, surgical technique, and postoperative rehabilitation as does treatment of flexor tendon injuries. Unfortunately, it is usually the least experienced surgeon who is called on to repair extensor tendon injuries in the emergency room, with expectation of excellent results when two tendon ends are sutured together. These injuries are not easy to treat, and poor postoperative results may cause worse impairment of function than do flexor tendon injuries. Extensor tendon injuries are common because of their superficial location on the dorsum of the hand. Injuries may be caused by lacerations, skin loss, or abrasion, and can be associated with lacerations at multiple joint levels. Bacterial contamination of joints may increase the complexity of the treatment plan; this is common when these injuries are caused by human bites.
The forearm extensor mechanism arises from the lateral portion of the distal humerus to form the multiple extensor muscle - tendon units. Independent extension is provided through the extensor pollicis longus, the extensor pollicis brevis, the extensor indicis proprius, and the extensor digiti quinti. The extensor digitorum communis tendons have limited independent action and have four distinct tendons. The extensor digitorum communis tendons enter the hand through fibro-osseous tunnels at the level of the wrist. Tendons at this level are covered with a synovial sheath. The extensor retinaculum is a fibrous band which prevents bowstringing of extensor tendons across the radiocarpal joint. It consists of two layers; the supratendinous and the infratendinous. Six dorsal compartments are separated by septae that arise from the supratendinous retinaculum and insert on to the radius. The communis tendons are joined by tendinous interconnections proximal to the metaphalangeal joint. Lacerations of an individual finger communis tendon proximal to the juncture may result in only incomplete extension loss of that finger, as extension may be provided through an adjacent extensor tendon.
Extensor tendons at the metacarpophalangeal joint level are held in place over the dorsum of the joint by the conjoined tendons of the intrinsic muscles and the sagittal bands. An injury to the extensor hood at this level may result in subluxation or dislocation of the central extensor tendon.
The six separate dorsal compartments are normally numbered from the radial to ulnar side of the wrist. The first dorsal compartment contains the abductor pollicis longus and the extensor pollicis brevis. Occasionally the extensor pollicis brevis has a partially separate sheath. The second dorsal compartment contains the tendons of the extensor carpi radialis longus and brevis. The third dorsal compartment contains the extensor pollicis longus, which runs around Lister's tubercle, angling towards the thumb. The extensor indicis proprius and the extensor digitorum communis are contained within the fourth dorsal compartment. The fifth dorsal compartment contains the extensor digiti quinti, which occasionally has a double tendon. The sixth dorsal compartment contains the extensor carpi ulnaris.
In the thumb, the distal phalanx is the distal attachment of the oblique interosseous fibres and the central slip of the extensor pollicis longus. The extensor pollicis brevis attaches to the metacarpophalangeal joint capsule and the abductor pollicis longus attaches to the base of the thumb metacarpal.
Zone I injuries occur at the level of the distal insertion of the lateral bands at the distal phalanx. These cause loss of distal interphalangeal joint extension and are commonly due to a laceration at the level of the distal interphalangeal joint. They may also be due to direct trauma to an extended fingertip. Such injuries may be associated with a closed tendon injury or a distal phalanx fracture. All open lacerations should be treated by irrigation of the joint. The extensor tendon should be sutured and the joint and distal phalanx should be splinted in extension full time for at least 6 weeks. Active motion is then encouraged. Night splinting may be required for an additional 6 weeks.
Closed injuries may be treated by extension splinting for 6 to 8 weeks with additional night splinting for up to 3 months. Open treatment of closed injuries is reserved for those injuries with large fracture fragments or subluxation of the distal interphalangeal joint.
Zone IIa injuries are extremely difficult to treat. They involve the region along the insertion of the central tendon into the middle phalanx, and may be open or closed. Open injuries overlying a joint need to be aggressively irrigated and debrided. Primary tendon repair and immobilization, with the proximal interphalangeal joint splinted or pinned in extension for 4 to 6 weeks is required. Active mobilization of the distal interphalangeal and metacarpophalangeal joints is encouraged. Treatment of closed injuries may be difficult: there is a delay in diagnosis in most cases, with subsequent development of boutonniere deformities. Treatment should be directed towards immobilizing the proximal interphalangeal joint by extension splinting or pinning for 4 to 6 weeks. Early motion of the distal interphalangeal and metacarpophalangeal joints is encouraged at 2 to 4 weeks to prevent extensor tendon adherence.
Zone IIb injuries occur over the proximal phalanx proper. Tendon lacerations in this area do not usually retract after being injured because of the joint tethers. Direct repair followed by immobilization with the metacarpophalangeal joint in flexion and the proximal interphalangeal joint in extension is the treatment for most acute lacerations. Splinting should be carried out for 4 to 6 weeks with careful mobilization.
Zone IIc injuries occur at the level of the metacarpophalangeal joint. Human bites cause injury to the central extensor tendon and the metacarpophalangeal joint: if indicated, the joint should be irrigated. If exploration reveals early inflammatory changes or infection, this should be treated first; the tendon injury is then repaired later. Most tendon injuries at this level can be treated by early controlled mobilization.
Zone III extensor tendon injuries should be treated by direct primary repair. In some cases, especially those with independent tendon function, the proximal tendon may retract up through the fibro-osseous sheath. The tendon then needs to be found and sutured primarily. Postoperatively, treatment is by early controlled mobilization or immobilization of wrist in extension, with the metacarpophalangeal joints flexed 20°.
Zone IV is a zone of fibro-osseous pulleys with multiple tendons in close proximity. Repair of all injured tendons in this area is recommended. Only compartments that hold injured tendons should be opened.
Lacerations in the first, second, and third dorsal compartments should be repaired primarily. A small portion of the dorsal retinaculum should be excised at the tendon repair site to prevent the lacerated retinaculum interfering with tendon gliding.
Injuries to extensor tendons in Zone V should be treated by primary repair of all injured structures. Most treated injuries have an excellent outcome. Postoperatively, zone V tendon injuries should be protected for 4 weeks with the wrist held in extension. Controlled assisted mobilization is then begun.
In Dupuytren's contracture, a form of nodular fibromatosis develops in the palmar fascia of the hand causing progressive fixed-flexion contractures of the thumb and fingers. Some authors have suggested that although little progress has been made in the basic understanding of Dupuytren's contracture in the past 100 years, results of treatment have improved.
The disease appears to be an active cellular process that results in the production of oriented collagen, which is subjected to intrinsic forces and external stresses. The cellular activity takes place in nodules, some of which are large enough to be palpated, some of which are microscopic, scattered throughout the diseased tissue. The removal of a nodule or incision of a contracted cord does not prevent progression of the disease because the cellular activity is widespread.
Dupuytren's contracture always involves the palmar fascia. The ring and small fingers are more frequently involved than are the index and long fingers, although the index finger, the long finger, and the thumb index web may be involved in some patients.
Gabbiani first showed that palmar fascia nodules were composed of myofibroblasts. He noted that these cells displayed structures which allowed contractile abilities. Proliferation of these cells is slowly progressive. Much recent investigative research has been directed toward discovering the cellular origin of the myofibroblast. The two most widely held theories are that the myofibroblast originates subdermally (extrinsic theory) or is actually a differentiated fascial fibroblast (intrinsic theory).
Dupuytren's disease is more common in Northern European countries and in patients originating from Northern Europe. The disease incidence increases with the age of the population studied. Dupuytren's contracture has been reported in association with epilepsy, diabetes mellitus, and alcoholism.
The treatment of Dupuytren's contracture is surgical. Indications for operative treatment include flexion contractures of the metacarpophalangeal joint at 30° or more, or any degree of contracture of the proximal interphalangeal joint. Surgical treatment of flexion deformities of the proximal interphalangeal joint does not always provide full correction: this is more likely when the contracture is small. Patients should be advised that palmar nodules alone and/or pain is not an indication for surgery. Hand function may improve with surgery, and surgery may slow the progression of the disease; it does not cure Dupuytren's disease. Closed fasciotomies have high rates of complications. Total fasciectomy has high complication rates. Complications include large haematomas causing infection, skin loss, oedema, and delay in healing.
Each patient should be carefully educated in the role of postoperative hand therapy and splinting. Orthoplast extension splints are of great help, placing the postoperative hand and finger in a position of maximum extension. Early range of motion exercises are begun, and post-surgical oedema is treated aggressively.
Hand infections continue to create serious problems for patients and surgeons.
Staphylococcus aureus and Streptococci are the most common causes of hand infections. Other organisms such as anaerobic Streptococci and Clostridia may cause severe infections in the upper extremity. Gram-negative rods such as E. coli, Proteus, and Pseudomonas may cause infections in a trauma victim or immunologically compromised host. Viral and fungal infections, although uncommon, may have serious sequelae if not considered in specific patients.
Several factors are important in determining whether an individual hand infection can be managed without operative intervention. The time from onset of pain and discomfort to the patient seeking treatment is important. Most patients treated within 24 to 48 h of initial onset of pain and swelling improve when treated with high doses of intravenous antibiotics. Immunocompromised patients, including those with diabetes, those receiving chemotherapy for cancer or connective tissue disease, and those receiving oral steroids, are less likely to improve with non-operative therapy alone. The choice of intravenous antibiotics should be based on the organism likely to be responsible for the infection. The hand should be immobilized in a splint and elevated.
In the early phase, infections of the hand present themselves as cellulitis. Patients present with a hand or finger showing diffuse swelling and erythema, with or without accompanying lymphangitis. Haemolytic streptococci most commonly cause such cellulitis. Radiographs should be obtained to rule out any underlying bony infection. These infections usually respond to intravenous antibiotics.
Paronychia is the most common of all hand infections, involving the radial and ulnar sides of the nail and surrounding tissue. If the infection also involves the eponychium as well as the lateral fold, it is called an eponychia. Extension to the opposite side of the fingernail, which is uncommon, is called a run-around abscess. The early stages of infection can be treated by soaks and warm saline solution with systemic oral antibiotics for 5 to 7 days. Pus is usually visible in more extensive or deeper paronychial infections. When such pus is visible, drainage is preferred. In these cases, the paronychia is compressed along the nail edge, trapping the abscess. All procedures that successfully treat paronychia separate it from the hard nail. If the infection is limited to less than one-half of the eponychium, a single incision placed to drain the paronychium and to elevate the eponychial fold for excision of the proximal one-third of the nail is satisfactory. If the entire eponychium is involved, two incisions are required. The entire eponychial fold is elevated with excision of at least the proximal one-third of the nail. Xeroform gauze can be placed to prevent premature closure of this area.
All patients require oral antibiotics. The gauze is removed after 72 h and gauze dressings are applied for 24 to 48 h. Hand washings are then performed, and the patient is instructed to dress the wound with sticking plaster and perform early range of motion exercises.
A felon is a potentially permanently disabling infection of the pulp tissue of the tip of a digit. It involves the multiple vertical fibrous septae that divide the fingertip pulp into several small compartments, and often follows a puncture wound, although many patients do not remember a penetrating injury. The major symptom in these patients is rapidly developing pain, usually of 12 to 24 h duration. Because of the lack of expansion through the skin, this abscess may extend proximally into the flexor tendon sheath, or into the distal phalanx, causing osteomyelitis.
All felons should be drained before any pus is seen. Many techniques are available. Once drained, a Xeroform or appropriate gauze should be packed in the wound after cultures have been obtained, and a bulky dressing should be applied. This drain is removed at 72 h. Oral antibiotics are given for 5 to 7 days.
Dressing changes with wound repacking, plus irrigation to keep the wound open in the early post-surgery period helps prevent recurrence.
Infections of the web space
The web space of the hand is defined by webbed skin dorsally, vertical septae ulnarly and radially, and volarly by the transverse palmar fascia. A laceration in the area of the finger web may place infected material in this area, causing a - collar button - abscess. Patients present with web space swelling both palmarly and dorsally; this must be drained both palmarly and dorsally. Incisions should be placed longitudinally. A through-and-through drain can be placed, and the wounds packed open. Cultures are taken, and attention is directed toward keeping the wounds open and encouraging early range of motion to improve functional outcome. Antibiotics, chosen on the basis of culture results, are given for 24 to 48 h intravenously, and are continued orally for 5 days.
Pyogenic flexor tendon tenosynovitis
Infections in the flexor tendon sheath usually follow open wounds or crush injuries. Infection within the flexor tendon sheath causes severe inflammation of both the flexor tendon and sheath structures. Chronic changes limit flexor tendon motion and cause significant functional impairment. Early recognition with surgical drainage is the treatment of choice. Historically, Kanavel was the first to recognize the four signs of flexor tendon sheath infections: tenderness over the involved flexor tendon sheath, pain on passive extension of the involved digit, flexed attitude of the involved digit, and fusiform swelling of the involved digit. The ring, middle, and index fingers are most commonly affected. Coagulase positive Staphylococcus aureus is the most common cause of infection. In the early stages, most of these infections are a flexor tendon and sheath cellulitis; intravenous antibiotics, elevation, and splinting may be curative. These patients should be admitted to hospital and placed on antibiotics. If there is no change in clinical signs, predominantly the pain on extension, the sheath must be opened and irrigated. Surgical drainage of the sheath can be carried out using open techniques, single incision techniques for antibiotic instillation, distal drainage with proximal instillation of antibiotics, through-and-through intermittent antibiotic irrigation, or closed tendon sheath irrigation. Early active range of motion exercises may improve the significant functional impairment that accompanies these infections.
Thenar space, midpalmar space, and hypothenar space infections
The three major potential deep compartments in the hand are the thenar space, the midpalmar space, and the hypothenar space. Bacterial contamination of these spaces follows direct lacerations or communications from expanding flexor tendon infections. Anatomically, the midpalmar space is bounded dorsally by the third, fourth, and fifth metacarpals, and the fascia of the volar interosseous muscles, and palmarly by the flexor tendons. Its radial border is the vertical septum between the sheath of the long finger flexor digitorum profundus and the third metacarpal. The ulnar border of this space is the fascia of the hypothenar muscles. The vertical septa of the palmar fascia is the distal margin of this space, with the proximal end bounded by the thin fascial layer at the distal end of the carpal tunnel. In these infections the palm may become flattened, although the dorsum of the hand swells because of the lymphatic drainage system. Swelling and tenderness are present over the space itself. In the later stages, erythema and fluctuation is noted, and any motion of the flexor tendons causes pain.
Treatment is incision and drainage. Multiple incisions have been recommended. An incision along the distal palmar flexion crease provides a bloodless field and avoids the contraction of a vertical scar. The abscess cavity is irrigated and left open, with a drain for 24 to 48 h. Early active assisted motion is recommended. Empirical antibiotics are started, and changed based on specific culture results.
The thenar space is located radially to the midpalmar septum and extends radially to the lateral edge of the fascia of the adductor pollicis longus muscle. Infections in this space lead to swelling towards the palm in the thenar region; this pushes the thumb into abduction. Such infections arise from puncture wounds or from extension of an infection in the midpalmar space, in the radial bursa, or in flexor tendon sheaths. The clinical presentation is one of marked thenar swelling. Incision and drainage is performed through a combined dorsal and volar approach to the space. Antibiotics are given intravenously and the wound is kept open with a drain. Early active assisted motion is encouraged.
Infections of the radial and ulnar bursa
The radial and ulnar bursae represent fascial compartments that enclose the flexor tendons. The radial bursa is the proximal extension of the flexor pollicis longus tendon sheath extending through the carpal tunnel into the forearm. The ulnar bursa is the proximal extension of the flexor sheath of the flexor digitorum profundus of the small finger. Infection in these spaces follow direct inoculation, or are extensions of an infected tendon sheath. Swelling, erythema, and tenderness are noted along the anatomical boundaries. As in all closed space infections of the hand, treatment is by either open or closed irrigation and drainage. Drains must be placed through the skin in the proximal wounds. Antibiotics are continued until the infection has cleared.
Human and animal bites
Bites of the finger and hand can be caused by humans or animals. In human beings, most injuries are caused by clenched fist blows to another person's mouth. Cultures of human bite wounds usually grow Staphylococcus aureus, Streptococci, and Eikenella corodense, an aerobic Gram-negative rod. There is usually no evidence of joint involvement; however examination is usually carried out with the finger extended, a position that masks the usual extensor tendon and encapsular injury which occurs in flexion. Admission to hospital for operative irrigation debridement and exploration of the metacarpophalangeal is essential. Administration of penicillin and a second generation cephalosporin is recommended until final cultures are available. Eikenella corodense is sensitive to both penicillin and ampicillin.
Dog and cat bites or scratches can produce cellulitis, lymphangitis, and tendon or joint infections. The chief pathogens are Streptococci and Pasteurella multocida, a small Gram-negative coccus. Most cellulitic infections respond well to treatment with intravenous penicillin. Pasteurella multocida is responsible for 50 per cent of infections associated with dog bites and 80 per cent of infected cat bites. If treatment with antibiotics alone is unsuccessful, wounds should be irrigated.
Herpes simplex infections
Herpes simplex virus causes herpetic whitlows, an infection frequently seen in medical and dental personnel. It is also sometimes seen in small children. Treatment is symptomatic. Topical acyclovir can be used in patients who complain of severe pain in the tips of their fingers. The diagnosis of herpetic whitlow can be made clinically by history and physical examination. Laboratory documentation of infection may be obtained by finding serum antibodies to viral antigens.
AMPUTATIONS OF THE HAND
Finger tip amputations
Finger tip amputations are the most commonly treated hand amputation. Most commonly there is skin or pulp tissue loss only. The size and position of the defect helps to determine appropriate treatment. Skin loss may be transverse or oblique, more radial-sided or ulnar-sided, or may involve a loss of more skin on either the volar or dorsal side. When no bone is exposed the decision must be made as to whether soft tissue cover needs to be undertaken or whether secondary healing should be allowed to occur: the finger tip has excellent self-healing and regenerative capacities, and many untreated defects become less visible as the finger tip continues to remodel. Some surgeons prefer to treat digital tip injuries with no exposed bone by conservative means with multiple dressing changes. Others resurface the distal pulp with split- or full-thickness skin grafts, or with proximal undamaged tissue.
If skin loss extends to the palmar surface of the flexor tendon and/or distal phalanx, cross-finger pedicle flaps may be useful. A dorsal flap of undamaged skin and subcutaneous tissue is elevated from the adjacent uninjured finger and attached to the defect in the injured finger. The volar surface can be repadded with excellent soft tissue cover. The donor site on the dorsal aspect of the finger is then covered with a free skin graft. Complications include stiffness of interphalangeal joints, but this can be controlled with assisted active range of motion exercises. A soft tissue defect on the palmar surface of a finger down to bone and flexor tendon can also be covered using the thenar flap. In this operation the injured finger is flexed and attached to a thenar pedicle flap raised from the skin and subcutaneous tissues. Stiffness, although reported as a complication, can be minimized by early division of the thenar pedicle. The proximal end of the flap should be allowed to settle into its bed by its own means.
Larger palmar defects can be treated with a Moberg volar advancement flap, a method that is more appropriate for the thumb than for the fingers. Complications have been reported, including fixed flexion deformity of the distal joint and necrosis of the entire volar flap.
The length of the thumb is of critical importance in the functioning of the hand. Because of its functional independence, there is a greater need for the preservation in its length and restoration of its sensitivity than is the case for other digits. Treatment of soft tissue losses should be directed toward healing by secondary intention or free skin grafting. If bone is exposed, preservation of length is critical: use of the Moberg advancement flap is recommended. In this surgical procedure, the volar tissue of the thumb is elevated along the midaxial plane with preservation of the neurovascular bundles. Attention must be paid to dissecting this volar flap free from the flexor pollicis longus sheath. The distal extent of the thumb, including the interphalangeal and metacarpophalangeal joints is then flexed to allow this volar flap to cover the distal-most tip that is exposed. After healing, actively assisted range of motion and stretching will minimize scar contractures. This type of advancement flap can cover up to 1 cm of lost palmar tissue.
Amputations with loss of more than 1 cm of thumb are challenges to the reconstructive hand surgeon. Although there has been recent interest in microvascular transfers of distant tissues, these procedures carry significant morbidity. A less sophisticated method may solve reconstructive problems, with less inherent risk. Matev has described a distraction/augmentation stage reconstruction of the thumb when the amputation is at the level of the metacarpophalangeal joint. After healing of the primary amputation, a transverse osteotomy at the level of the thumb metacarpal is made as the first stage of the procedure. This osteotomy is stabilized by transverse metallic pins which are attached to an external fixation device. After primary closure of the wounds, 1 to 2 mm of distal distraction per day is carried out. Careful attention must be paid to the vascular status of the tip of the thumb remnant during distraction. After the appropriate length of metacarpal has been obtained, a second operation is carried out. Using the same incisions, an autogenous iliac bone graft is fashioned and placed in the space available between the two thumb metacarpal fragments. This graft may be stabilized by Kirschner wire or internal fixation techniques. With length, the thumb function is significantly improved. Deepening of the first web space may be carried out to improve function of the hand.
Several options are available for the treatment of amputations at levels proximal to the metacarpophalangeal joint. Pollicization of the index finger provides excellent function. In this procedure, the normal index finger is transferred, using appropriate reconstructive principles, to the position of the amputated thumb. The procedure appears to work better in young patients. Other microsurgical techniques, including the wrap-around flap, have been developed to try to treat this special problem.
Middle phalanx amputations
Amputations of the middle phalanx are functional if the amputation is distal to the insertion of the flexor digitorum superficialis. In these amputations, length is not so important. The patient should be treated with procedures that allow primary coverage of the amputation.
Amputations through the proximal phalanx
Amputations through the proximal phalanx diminish the function of the finger remnant significantly. At this level there is no insertion of the flexor digitorum superficialis or profundus to provide power in grip. Ray resections, transposition, and/or reconstruction of the contiguous transverse metacarpal ligament should be performed. Ray amputation of an injured index finger leads to an excellent cosmetic result with good function. There may be functional disabilities, including weakness of pinch and grip after these operations. Ray amputation of the long finger may be treated in two ways. Reconstruction of the volar intermetacarpal ligament can be carried out after amputation of the long finger, suturing this anatomical structure between the metacarpals of the index and ring fingers in an attempt to close dead space and to stabilize both metacarpals. The second procedure is transposition of the index metacarpal to the position of the long finger metacarpal. In the case of ring finger resection, the fifth ray can be transposed to the ring position.
Metacarpal and carpal amputations
Carpal amputations or midpalmar amputations are difficult to treat. All attempts should be made to save the radiocarpal joint to allow wrist flexion/extension, which may be helpful in function. Patients with severe length loss may retain function by using residual carpus and metacarpals as a terminal device.
Disarticulations at the radiocarpal joint allow pronation and supination of the forearm and the hand unit.
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