Hand injuries Taiz University , faculty of medicine and health sciences By Dr : Mohammed Abdulsatar

1. HAND INJURIES
Group D
2015

2. HAND INJURIES
• The hands as the human executing organs are in the
center of daily life activities’, thus are always exposed to
injuries and overuse .
• We are more aware of our hands than any part of the
body
• Are important out of all proportion to their apparent
severity ,because of the need for perfect functions .
• Local edema and stiffness of the joints –common
accompaniments of all injuries- are more threatening in
the hand than anywhere else .

3. HAND INJURIES
• Problems of hand arise for 3 reasons :
1- the defect may be unacceptable
2- function is impaired
3- deformed part becomes nuisance during
daily activities

4. HAND INJURIES
• Superficial injuries and severe fracture are obvious but
deeper injuries are often poorly disclosed ,so it is
important in the initial examination to assess the
• circulation
• soft tissue cover
• bones
• joints and tendon
• nerves
• X-rays should include at least 3 views PA ,Lateral and
oblique

5. HAND INJURIES
• Hand injuries the commonest of all injuries .
• in avarage the hand injuries account for 14-30% of all pt
in ED .
• Fractures 46% , tendon injuries 29% and skin lesions .

6. HAND INJURIES
general principle of treatment
• ABC
• Most hand injuries can be dealt with under local or
regional anaesthesia .
• Definitive treatment is dictated by the nature of the injury
, but common to all injuries are
• safe splintage
• prevention of swelling
• dedicated rehabilitation

7. HAND INJURIES
general principle of treatment
• Safe splintage
_ incorrect splintage is a potent cause of stiffness
so must be appropriate and kept to a minimum
-if the whole hand is splinted or bandage this must be in
‘’the position of safe immobilization’’

8. Anatomy of the hand
• Bones
• Areas
• Zones
• Arches
• Ligaments
• Muscles
• Innervation
⥤is a prehensile, multi-fingered extremity located at the
end of an arm or forelimb .
⥤...& are the richest source of tactile feedback, and have
the greatest positioning capability of the body; thus the
sense of touch is intimately associated with hands.
PALMAR DORSAL

10. ZONES
Extensor Zones of
Hand

11. Flexor Zones:
Flexor Zones: The hand is divided into following 5 zones, which would determine the prognosis and approach to
treatment.
Zone 1:
Only FDP involved
Loss of flx of DIP joint
Instability in pinch
Loss of grip strength
Good prognosis
Zone 2:
“No man’s land”
Pulleys present (prevent bow stringing) A2 and A4
Vincula in area–provide vascular supply. Injury thus causes decreased tendon vascular nutrition.
Poor prognosis
Zone 3:
Good prognosis
Good vascularity and no pulleys
Zone 4:
Carpal tunnel
Usually more than 1 tendon involved
Intendinous adhesions (close proximity of tendons)
Relatively good prognosis
Zone 5:
Usually presents with nerve involvement (ulnar / median nerve)
Tendons superficial, thus adhesions to skin probable
The hand is divided into 8 zones when dealing with extensor tendon injuries.

14. Muscles & tendons
* Extensor tendons of fingers :
-of the long extrinsic muscles .
-attaches to the middle phalanx in
central slip .
* system of flexor tendons of fingers :
-functional unit of tendons, tendon sheath and
pulleys .
- flexor digitorum profundus .
- flexor digitorum superficial .
- flexor pollicis longus of the thumb .

15. FLEXORSEXTENSORS

20. ligaments
• Tow important structures called collateral ligaments are
found in either sides of each finger joint .
• Volar plate is the strongest ligament .

21. Blood Supply
1. Ulnar A.
 Forms the
superficial palmar
arch ?with
superficial palmar
br. of radial artery
 Gives 4 common
palmar digital art.
2. Radial A.
 Forms the Deep
palmar arch with
deep br. of ulnar ar. 1
cm proximal to
Superficial arch

23. Nerve supply

24. Nerve supply

25. Median
Nerve
Ulnar
Nerve
Radial
Nerve

26. Bone & joints
injuries

27. Metacarpal Fractures
 The metacarpal bones are vulnerable to blows and falls
upon the hands or the force of the boxer’s punch .
 Injuries are common
 Agulatory deformity is usually not very marked
,rotational deformity is serious .

28. 2)Metacarpal Fractures
 Head
 Intraarticular
 Neck
 Usually unstable
 Forwards tilting of distal
fragement
 Shaft
 Direct blow
 Transverse or oblique #
 Base
 Associated carpal bone injury
 Impacted #
 1st metacarpal
 Usually occurs at base

29. Presentation
 Pain/Tenderness
 Swelling
 Discoloration
 Sensation
 Circulation
 ROM
 Plain Films
 Deformity of hand
Localized tenderness
Swelling of hand
Discoloration
Decreased movement
Numbness
Unequal temperatures
What next?

30.  Midshaft vs. Base vs.
Neck
 Complete vs.
Incomplete vs.
Comminuted
 Dorsal vs. Volar
Angulation
 Transverse vs. Oblique
vs. Spiral
 Unstable vs. Stable

31. Management of metacarpal #
 A- undispalced # :
require only a firm crepe-bandage for comfort
2-3 wks

32. Management of metacarpal #
 B- dispalced # :
1-of the shaft
- reducion by traction and pressure hand then
held by plaster slap for 3 wks .
-ORIF with small plates and screws
or by percutaneous K-ware
is the best because these
unstable #

33. Management of metacarpal #
 B- dispalced # :
2- of the neck (boxer’s fracture )
* usually of the 5th finger
* angulation of upto 40 degrees can be accepted as
long as there is no rotational deformity .
* reduction traction and pressure then held by
plaster slap 1-2wks
* fixation with percutaneous
intramedullary wires
usually preferred

34. Metacarpal Neck Fractures
(Boxer’s Fracture)
 Common
 Direct impact with closed fist
 Dorsal angulation
 Unstable
 Treatment
 Reduction (90-90 method)
 Splint
 Follow-up within 1 week
 Complications
 Malunion with volar angulation
 Pain
 Rotational deformity
 Stiffness

35. Metacarpal Base Fractures
 Stable
 Infrequent
 Associated injury
 Ulnar nerve
 Carpal bone injury
 Treatment
 Volar splint
 Complications
 Tendon damage
 Stiffness

36. Thumb Metacarpal Fractures
 Uncommon
 Most involve the base
 Extraarticular
 Direct trauma or impaction
 20-30 degrees of angulation is
tolerated
 Intraarticular
 Bennett’s Fracture
 Rolando’s Fracture
 Treatment
 Thumb spica
 Complications
 Malunion and arthritis

37. Bennett’s Fracture:
 At base of first metacarpal
bone
 Oblique intra-articular #
 Unstable
 Due to punching .
 X-ray show that a small
triangular fragment has
remained in contact with
the medial edge of the
trapezium , while the
remainder of the thumb has
proximally pulled upon by
the abductor pollicis longus
tendon .

38. Bennett’s Fracture:
 Perfect reduction is essential by pulling on the thumb
,abducting it and extending it .and then held by
plaster or internal fixation
 Surgical fixation is achieved by passing a k-ware across
the metacarpal base into the carpus

39. a)Bennett’s Fracture:
 Intraarticular fracture
 Dislocation/Subluxation
 CMC joint
 Fragment pulled
dorsally
 Abductor pollicis longus
 Adductor pollicis
 Ligament disruption
 Treatment
 Thumb spica
 Early referral

40. b)Rolando’s Fracture
 Comminuted
intraarticular
fracture
 Less common than
Bennett’s Fracture
 Worse prognosis
 Treatment
 Thumb spica
 Early referral
 Complications
 Malunion and pain

41. fractures of phalanges
 Phalangeal # usually result from direct trauma and
therefore any part may be affected .
 Management :
 A) undisplaced # :
 functional splintage (buddy splintage )
for 2-3 wks .
- movement are encouraged from the outset .

42. fractures of phalanges
 B) – displaced fractures
1- of the proximal or the middle phalanx :
* the bone # reduced and immobilized under
local anaesthesia , carefully avoiding
malrotation , then splintaed leaving the other
fingers free 3 wks .

43. fractures of phalanges
 B) – displaced fractures
1- of the distal phalanx :
distal phalangeal # are usually due to crushing
injuries or a blow from a hammer .
- the soft tissue damage must be treated .
-The majority of fractures can be treated
conservatively, and it is normally the initial repair
of the surrounding soft tissues that is most
important .

44. 3) Phalanx Fractures
 15-30% of hand fxs
 Tuft
 Nail bed injury
 Shaft
 Intraarticular
 Tendon injury
 Complications
 Pain, hyperesthesia, cold
sensitivity, osteomyelitis
1)Distal Phalanx Fractures
Mechanism:

45. No Problem Refer!
 Treatment: padded or “C”
splint; extend past the tip
 Refer: transverse, angulated
 Healing Time: 3-4 weeks
 Return to Work/Sport: okay
with splint as tolerated
 exception: transverse fx –
needs longer protection
from potential re-injury
activity

46. •Mechanism: direct blow or
twisting
•Sxs & Exam: local swelling;
examine for deformity or
malrotation; check PIP and DIP
fxn
2)Middle Phalanx Fractures
•Transverse Fx or short oblique: Low risk

47. •Nondisplaced fx’s do well with buddy taping
•Healing Time: 4-6 weeks (buddy tape for 3-4 wk)
•Return to Work/Sport: okay as long as you have some
protection via splint or buddy tape
•Refer: displaced, long oblique, spiral or intra-
articular fx

48. •Mechanism:
direct blow: transverse; often unstable
due to tendon insertions
twisting: oblique or spiral; may be more
stable
Sxs & Exam: local
swelling; examine
for deformity or
malrotation
3)Proximal Phalanx Fractures

49. Apex volar angulation is common
•proximal fragment pulled into flexion by
interosseous
•distal fragment pulled into extension by
extensor mechanism

51. •Nondisplaced fx’s do well with buddy taping; use
gutter splint for additional stability
•Healing Time: 4-6 weeks (buddy tape for 3-4
wk)
•Return to Work/Sport: okay as long as you have
some protection via splint or buddy tape
•Refer: angulated, displaced, intra-articular fx
Proximal Phalanx Fx: Treatment

52. Alternative:
Burkhalter
Splint
dorsal half to
PIP
volar half to
palmar crease

53. Joints

54. CMC joint dislocation:
 Mechanism :forceful dorsiflexion of the wrist
combined with longitudinal impact ,
 Seen typically in boxers and in motorcyclists .
 Dx : X-rays
 After regional anaesthesia , the dislocation is reduced
by traction , manipulation, and pressure on the
metacarpal base , then protective slap is worn for 6
wks .

55. CMC joint dislocation
Carpometacarpal
(CMC) dislocation
(a) Thumb
dislocation.
(b) Dislocation of the
fourth and
fifth CMC joints
treated by closed
reduction and
Kirschner wires (c).
Complete CMC
dislocation (d).

56.  Thumb CMC dislocation :
 Isolated dislocation is rare
compared to the more common
Bennett fracture dislocation.
 Easy to reduce but unstable after
reduction.
 Apply thumb spica splint after
reduction.
 Need surgical referral.

57. Dislocation of MCP joint

58. Metacarpophalangeal Joint
 Relatively rare injury
 Dorsal displacement
 Hyperextension forces
 Dorsal displacement
 Volar plate can enter joint
space
 Volar dislocations
 Usually surgical
 Treatment
 Reduce
 Splint in flexion

59. Dislocation of MCP joint
 The thumb is most frequently affected and clinically
the injury resembles a BENNETT’ fracture –dislocation
 Dx : by Xrays
 The displaced is easily reduced by traction &
hyperpronation , but reduction is unstable and can be
held by a K-wire for 5 wks and then protective splint
for 8 wks because risk of instability .

60. MCP of the Thumb
 Strong but vulnerable
 5 times more likely to be injured
 Difficult reduction
 Volar plate entrapment
 Ulnar collateral ligament
injury
 Gamekeeper’s or Skier’s thumb
 Radial collateral ligament
injury
 Less common
 Forced adduction with or
without hyperextension

61. Skier’s Thumb
 Scottish gamekeeper’s
 Repeated twisting
 Forced radial deviation
 Associated avulsion fracture
 Valgus stress testing
 Extension and flexion
 Complete ligament tears
 >35 degrees of laxity
 Treatment
 Thumb spica

62. Dislocation Interphalangeal
Joint

63. 1)Proximal Interphalangeal Joint
 Dislocation pattern
 Dorsal
 Most common ligamentous hand injury
 Lateral
 Volar
 Associated fracture
 > 33% of articular surface = unstable
 Violent twist with finger
flexed (palmer) or extended
(dorsal)
 SHARP, deformity, disability
 RICE, splint, meds,
reduction/surgery, protect

64. • Nondisplaced Fx: Initially use extension block
splint for first 2-3 weeks followed by buddy
taping in sight flexion. Work on restoring ROM.
• Healing Time: 6-12 weeks; monitor progress
every 2-3 weeks

65. 2)Distal Interphalangeal Joint
 Most are dorsal
 Often open
 Reduction
 Traction
 Hyperextension
 Dorsal pressure
 Irreducible
 Avulsion fracture
 Buttonhole tear
 Open dislocation
 Irrigation
 Antibiotics

66. Tendons
Injuries

67. Tendon injuries
• Are the second most common injuries of the hand
• After clinical examination , ultrasound and MRI imaging
have provide to be important diagnostic tools .
• Treated by conservative or surgical

81. • For later case where the joint is still passively correctable
, treated by is to divide the extensor tendon in just
proximal to its insertion into the distal phalanx .
• long standing fixed deformity may be better left alone .

87. Carpal Tunnel Syndrome
pressure in carpal tunnel (swelling, inflammation) via
trauma, rep flexion
Pressure on median n
Sensory (lat palm), motor (wrist, finger flex) deficits
A. Mechanism: overuse, congenital, trauma
B. Pathology: Compression of the median nerve in the
tunnel
, surgical decompression

88. Signs and Symptoms:
Pain in wrist
Numbness and tingling in the thumb and first two fingers
Positive Phalen’s test
Positive tap test

89. Treatment
Conservative: Immobilization and Rest ice
.NSAIDS, corticosteroid injection
Radical: Surgery to increase space in the tunnel

90. ‫الجميع‬ ‫هللا‬ ‫وفق‬
‫عبدالستار‬ ‫محمد‬GD