Hand Deformities, Fractures,

and palsy
By Adnan AL-Maaitah
!"'
W 1he followlng sub[ecLs are nC1 menLloned ln Lhe guldellnes
uupuyLren conLracLure (slldes 2831)
Pand fracLures (3243)
Pand palsy (4637)
W Sry buL l goL Lhe guldellnes afLer flnlshlng Lhe semlnar
-MaIIet deformity
-Trigger Finger
-Boutonniere Deformity
-Swan - Neck deformity
-Dupuytren contracture
Nallet Finger
W a baseball flnger
W ueformlLy ln whlch Lhe
flngerLlp ls curled ln and
cannoL sLralghLen lLself
W uue Lo ln[ury Lo
exLensor dlglLorlum
Lendons aL ul!
Nallet Finger/Causes
orced flexlon of Lhe flnger
when flnger ls exLended
SporL ln[ury lnger sLruc by
volleyball baseLball or
baseball when lL ls ln
exLenslon
CLher common mechanlsms
of ln[ury lnclude forcefully
Luclng ln a bedspread or
sllpcover or pushlng off a
soc wlLh exLended flngers
Nallet Finger/Presentation
W fLer ul! forced flexlon lnablllLy Lo acLlvely exLend Lhe dlsLal
[olnL lnLacL full passlve exLenslon
W CfLen ln[ury ls palnless or nearly palnless
W uorsum of [olnL may be sllghLly Lender and swollen
W Crder xray Lo mae sure Lhere are no fracLures
Despite active extension effort, the distaI
interphaIangeaI joint of the index finger rests
in fIexion, characteristic of a maIIet finger
This x-ray depicts a Iarge, dorsaI-Iip avuIsion
fracture from the distaI phaIanx, a bony
maIIet injury.
Nallet Finger/Nanagment
W ,alleL flnger spllnL (6
10 wees)
W Surgery
ln case of volar
sublaxaLlon of dlsLal
phalanx or avulslon
fracLure
kwlre (klrschner wlre)
Anteroposterior radiographic view of finger after 4
weeks. The longitudinal K-wire is blocking the distal
interphalangeal joint from flexion to protect the repair
'rigger Finger
W 1rlgger flnger ls Lhe
popular name of
sLenoslng LenosynovlLls
a palnful condlLlon ln
whlch a flnger or Lhumb
locs when lL ls benL
(flexed) or sLralghLened
(exLended)
'rigger 'ension
W uue Lo oottowloq of tbe sheoth tbot sottoooJs tbe teoJoo ln
Lhe affecLed flnger or a ooJole fotms oo tbe teoJoo
W 1rlgger flnger ls ofLen an overuse ln[ury because of repeLlLlve
or frequenL movemenL of Lhe flngers (ex hobbles as playlng a
muslcal lnsLrumenL or crocheLlng)
W 1rlgger flnger may also resulL from Lrauma or accldenL
W lL ls called Lrlgger flnger because when Lhe flnger un|ocks lL
pops bac suddenly as lf releaslng a Lrlgger on a gun
'rigger 'ension
W llnlcal lcLure
ffecLed dlglLs may become palnful Lo sLralghLen once
benL
,ay mae a sofL cracllng sound when moved
lL props bac suddenly when sLralghLened
SympLoms are usually worse ln Lhe mornlng and lmprove
durlng Lhe day
W 1reaLmenL
local sLerold ln[ecLlons and spllnLlng (wees Lo monLhs)
Surgery cuL Lhe sheaLh LhaL ls resLrlcLlng Lhe Lendon
Trigger Tension
ntroduction of the needIe into
the tendon sheath at 45 to the
paIm for injection treatment.
Boutonniere Deformity
W a 8uLLonhole
ueformlLy
W Pyperflexlon aL Lhe l
[olnL wlLh
hyperexLenslon aL Lhe
ul
W asslve exLenslon of Lhe
l [olnL ls easy
Boutonniere Deformity
outonniere Deformity
W lexlon deformlLy of Lhe l
[olnL due Lo lnLerrupLlon of
Lhe cenLral sllp of Lhe
exLensor Lendon
1he laLeral bands separaLe
1he head of Lhe proxlmal
phalanx pops Lhrough Lhe gap
lle a flnger Lhrough a buLLon
hole
1he ul [olnL ls drawn lnLo
hyperexLenslon
entral Slip
Lateral Band
outonniere Deformity
W 1he 3 maln eLlologles
8 and oLher lnflammaLory arLhrlLldes (mosL ofLen)
mechanlcal Lrauma
burns and lnfecLlons
W n xray should be done Lo deLecL avulslon fracLures
outonniere Deformity
W 8u ln paLlenLs wlLh 8 can be classlfled lnLo 1 of Lhe followlng 3 sLages
whlch serve as a gulde Lo Lhe approprlaLe managemenL
SLage l (mlld) ls Lhe earllesL sLage and ls Lhe resulL of l [olnL synovlLls
wlLh mlld exLensor lag LhaL sLlll can be correcLed passlvely 1he
meLacarpophalangeal (,) [olnL usually ls normal and Lhe ul may or
may noL be hyperexLended
SLage ll (moderaLe) ls characLerlzed by 3040 of flexlon conLracLure aL
Lhe l [olnL and hyperexLenslon of Lhe , [olnL as a compensaLory
mechanlsm 1he flnger has lncreased funcLlonal loss Larly passlve
exLenslon sLlll ls posslble WlLh Llme sofLLlssue conLracLures develop
and passlve exLenslon becomes resLrlcLed
SLage lll (severe) beglns when Lhe l [olnL can no longer be exLended
passlvely 8adlographs demonsLraLe desLrucLlon of Lhe [olnL surfaces
outonniere Deformity
1reaLmenL
W SpllnLlng 4 wees mlnlmal (6 wees preferable)
safeLypln spllnL (40 degree)
uynamlc sprlng spllnLs ( 40)
W Surgery When Lhe deformlLy ls Lhe resulL of a s/ocoton of
Lhe l [olnL
W Surgery carrles a relaLlvely hlgh rls of lLu8L Lo achleve
compleLely normal funcLlonlng exLenslon mechanlsm of Lhe
flnger
BunneII Safety Pin Finger
SpIint
Dynamic spring
extension spIint
&an!eck deformity
W Lhe l [olnL ls hyper
exLended ul [olnL ls
flexed
W ause
volar plaLe becomes
wea hyperexLenslon
of l! flexLlon of ul!
W uue Lo ln[ury or
lnflammaLlon (8)
Swan-Neck deformity
&an!eck deformity
W Swelllng and paln due Lo lnflammaLlon from ln[ury or dlsease (8)
W xray ls done Lo evaluaLe Lhe [olnLs (8) and loo for fracLures
W 1reaLmenL
bouLonnlere deformlLy caused by an exLensor Lendon ln[ury can
usually be correcLed wlLh a spllnL (,urphy 8lng SpllnLs) LhaL eeps Lhe
mlddle [olnL fully exLended for 6 wees
When spllnLlng ls lneffecLlve surgery may be needed
MURPHY RNG SPLNTS
Dupuytren contracture
W aLhologlc condlLlon of
Lhe hand ln whlch Lhe
fascla of Lhe palm are
shorLened and
Lhlcened
W ommon ln souLh
europe
Dupuytren contracture
Dupuytren contracture
W uupuyLrens conLracLure ls more common among people wlLh
dlabeLes alcohollsm or epllepsy
W 1he dlsorder affecLs boLh hands ln 30 of people
W 1he dlsorder ls occaslonally assoclaLed wlLh oLher dlsorders
Carrods pads Lhlcenlng of flbrous Llssue above Lhe
nucles
enlle flbromaLosls shrlnlng of fascla lnslde Lhe penls
LhaL leads Lo devlaLed and palnful erecLlons
lanLar flbromaLosls nodules on Lhe soles of Lhe feeL
Dupuytren contracture
W SympLoms
1he flrsL sympLom ls usually a Lender nodule ln Lhe palm
Cradually Lhe flngers begln Lo curl
LvenLually Lhe curllng worsens and Lhe hand can become
arched (clawlle)
W 1reaLmenL
Surgery Lo correcL conLracLed (clawed) flngers
and Fractures/
W Pand Lrauma lndusLrlal
W Pand domlnance
W Pand ln[ured
W ,echanlsm of ln[ury
lean/dlrLy envlronmenL
oslLlon of Lhe hand
1hermal elecLrlc or chemlcal ln[ury
Wearlng [ewelry on flnger removed
W ln assaulL
Pand open or flsL clenched
LaceraLlons (Lendon ln[ury)
onLacL wlLh mouLh LeeLh
W ?ears slnce lasL LeLanus lmmunlzaLlon (esp ln laceraLlons and abraslons)
and Fractures/ P/
W Pand examlnaLlon
ompare wlLh unln[ured
Slgns of lnflammaLlon abraslons eroslons
bnormal poslLlon (esp flngers) roLaLlonal deformlLy
LocaLlon of ln[ury
aplllary reflll
W neurology radlan medlan and ulnar nerve
ith fingers fIexed at the metacarpophaIangeaI
and proximaI interphaIangeaI joints and
extended at the distaI interphaIangeaI joints,
fingers shouId aII point toward the scaphoid
bone
xamination of the patient's hand with the
fingers fIexed may cIearIy reveaI a rotationaI
deformity
and Fractures
W lmaglng
xray laLeral and obllque vlew
,8l 1 8one scan seldom needed
W Lu care
aln managemenL reducLlon spllnLlng referral
rlmary concern ls preservaLlon of funcLlon
LxcepL for dlsLal phalanx fracLure all pLs Should be referred Lo a hand
surgeon
oer's Fracture
W brea ln one or more
meLacarpal bones
usually Lhe fourLh or
Lhe flfLh caused by
punchlng a hard ob[ecL
Such a fracLure ls ofLen
dlsLal angulaLed and
lmpacLed
W lnger shorLen
posLerlorly
ourth and fifth
metacarpal fractures,
oblique view
&caphoid Fracture
W o|ogy
common ln young men
noL common ln chlldren
or ln paLlenLs beyond
mlddle age
W ,chans
CCSP resulLlng mosL
commonly ln a
Lransverse fracLure
Lhrough Lhe walsL
(mlddle) of Lhe scaphold
Scaphoid fracture in the middle third
or waist
&caphoid Fracture
W |nca| Iaturs
paln on wrlsL movemenL
Lenderness ln scaphold reglon (anaLomlcal snuff box)
usually undlsplaced
W nvstgatons
xray (/laL/scaphold vlews wlLh wrlsL exended and ulnar devlaLlon)
+$ bone scan and 1 scan
W noLe a fracLure may noL be radlologlcally evldenL up Lo 2 wees afLer
acuLe ln[ury so lf a paLlenL complalns of wrlsL paln and has anaLomlcal
snuff box Lenderness buL a negaLlve xray LreaL Lhem as lf Lhey have a
scaphold fracLure and repeaL xray 2 wees laLer Lo rule ouL a fracLure
W @ratnt
undlsplaced casL
ulsplaced open (or percuLaneous) screw flxaLlon
Colles' and &mith Fracture
W olles' racLure
uue Lo CCSP
40 yrs female (esp osLeoperosls)
x fragmenL upwarddorsal angulaLlon (forlle appearance)
W SmlLh racLure
a reverse olles' fracLure
alllng on Lhe bac of a flexed hand
x fragmenL volar (palmar) dlsplacmenL
olles' racture
Smith racture
oth ones Fracture
(Radius S Ulna)
W CCSP dlrecL blow
W lnLernal flxaLlon by
plaLes and screws
W ompllcaLlons
omparLmenL syndrome
malunlon
Anteroposterior radiograph of a
displaced, midshaft both-bone
forearm fracture in an adolescent
with a transitional growth plate
Ulnar nerve palsy
W 1hls occurs due Lo
nerve compresslon aL
Lhe elbow (cublLal
Lunnel) or aL Lhe wrlsL
(Cuyons canal) (ulnar
canal)
W ,uscle weaness and
aLrophy predomlnaLe
Lhe cllnlcal presenLaLlon
Ulnar nerve palsy/Causes
ubta| @unn| Synro
W requenL bendlng of Lhe
elbow
W Leanlng on Lhe elbow
resLlng lL on an elbow resL
durlng a long dlsLance
drlve or runnlng machlnery
may cause repeLlLlve
pressure and lrrlLaLlon on
Lhe nerve
W dlrecL hlL on Lhe cublLal
Lunnel may damage Lhe
ulnar nerve
uyons ana| Synro
W cysL wlLhln Lhe canal
W loLLlng of Lhe ulnar arLery
W racLure of Lhe hamaLe
bone
W rLhrlLls of Lhe wrlsL bones
Ulnar nerve palsy/Causes
W Sytos sgns
numbness and Llngllng ln Lhe rlng and llLLle flnger and Lhe sldes and
bac of Lhe hand L Cuyons anal sensory supply Lo Lhe sln of Lhe
bac of Lhe hand ls spared
1he hand may become weaer resulLlng ln Lrouble openlng boLLles or
[ars
lawlng may occur ln Lhe rlng and llLLle flngers
romenLs LesL by aslng Lhe paLlenL Lo hold a plece of paper
beLween Lhelr Lhumb and lndex flnger (hence checlng adducLor
polllcls) ln a paLlenL wlLh ulnar nerve palsy Lhe lnLerphalangeal [olnL
of Lhe Lhumb wlll flex Lo compensaLe
W @ratnt
nonsurglcal Lherapy elbow or wrlsL spllnLs Lo llmlL moblllLy ln addlLlon
Lo an anLllnflammaLory drug such as lbuprofen
Surglcal decompresslon maybe requlred ln some cases
Froment's test
Radial nerve palsy
W a
wrlsL drop
SaLurday nlghL palsy
W auss
aused by excesslve compresslon of Lhe radlal nerve agalnsL a hard
surface ln lndlvlduals lnsenslLlzed by Lhe lnLae of alcohol or sedaLlves
8roen humerus
lead polsonlng
SLab wounds Lo Lhe chesL aL or below Lhe clavlcle uamage Lhe
posLerlor cord of Lhe brachlal plexus
W Sytos
WrlsL drop
Cccaslonally Lhe bac of Lhe hand may lose feellng
rist Drop
rb's Palsy
W a
WalLers Llp deformlLy
Lrbuuchenne alsy
rb's Palsy
W uue Lo brachlal plexus damage by excesslve laLeral nec flexlon away from
sholder
orceps dellvery
alllng on Lhe nec
W Leads Lo loss of Lhe laLeral roLaLors of Lhe shoulder arm flexors and hand
exLensor muscles
W 1he poslLlon of Lhe llmb under such condlLlons ls characLerlsLlc
Lhe arm hangs by Lhe slde and ls roLaLed medlally
Lhe forearm ls exLended and pronaLed
1he hand ls flexed
1he arm cannoL be ralsed from Lhe slde all power of flexlon of Lhe
elbow ls losL as ls also suplnaLlon of Lhe forearm
rb's Palsy
W 1he Lhree mosL common LreaLmenLs from Lrbs alsy are
nerve Lransfers (usually from Lhe opposlLe leg)
Sub Scapularls releases
and LaLlsslmus uorsl 1endon 1ransfers
W lLhough range of moLlon ls recovered ln many chlldren under one year ln
age lndlvlduals who have noL yeL healed afLer Lhls polnL wlll rarely galn
full funcLlon ln Lhelr arm and may develop arLhrlLls