Hand and Wrist Injuries - Uniformed Services University …手和手腕受伤的统一服务大学…

HandandWristInjuriesAllysonS.Howe,MDJanuary17,2021HANDANDWRISTHAND WRISTHANDFUNCTIONS45%GRASP45%PINCHSidepinch(keypinch)Tippinch(writing)Chuckpinch(thumbtoindex/ring)5%HOOKCarrybag5%PAPERWEIGHTHAND&FINGERANATOMY9FingerFlexorsMediannerveTransversecarpalligament5deepflexorspassthroughsuperficialistendonsandinsertondistalphalanxofeachfingerandthumb4superficialflexorsinsertonmiddlephalanxofdigits2-5Annularligaments=pulleys(A1-A5)PREVENTBOWSTRINGINGHANDANATOMYVOLARPLATEThickenedportionofjointcapsuleStaticstabilizer(hyperextension)COLLATERALLIGAMENTSMedialandlateralstabilityMaximallytightat____degreesMCPflexion____degreesPIPflexion____degreesDIPflexion703015HANDANATOMY

digitsFLEXORFDPFDSVolarplateExtensorCentralbandsLateralbandsNERVESOFTHEHANDRADIALMEDIANULNARWRISTANDFINGEREXTENSIONTHENARCOMPARTMENT,OPPOSITION,PINCERGRIPINTRINSICMUSCLESPOWERGRIPMALLETFINGERANATOMYDorsalavulsionExtensordigitorumtendontearMECHANISM:ForcedflexionofextendeddigitTREATMENT:Nofracture:DIPextendedfor6-8weeksFRACTURE:if<30%jointsurface,splintx4weeksIf>30%referforORIFLessthanfullpassiveextensionreferCOMPLICATIONS:PressurenecrosisfromsplintPermanentextensorlagMALLETFINGERJERSEYFINGERJERSEYFINGERANATOMY:TendonretractsAvulsionfragmentmaylimitretractionBloodsupplycompromisedMECHANISM:ForcedextensionofflexedfingerTREATMENT:ReferimmediatelyCOMPLICATIONS:PermanentlossofflexionJERSEYFINGEREXAMFINDINGS:UnabletoflexisolatedDIPLocalizedtendernessalongflexortendonFDP:holdPIPstraightandflexDIPFDS:holdMCPstraightandflexPIPorholdallfingersinextensionexceptaffectedandflexVOLARPLATERUPTUREEXAMFINDINGS:TendervolarPIPBruising,swellingMECHANISM:HyperextensioninjuryRupturesdistallyfromattachmentatmiddlephalanxVOLARPLATERUPTURETREATMENT:EarlymobilizationExtensionblocksplintBuddytapeReferif>30%jointinvolvedCOMPLICATIONS:Swanneckdeformity:extensortendonspullPIPintohyperextension,DIPflexionSwanNeckDeformityCENTRALSLIPAVULSIONANATOMYExtensordigitorumcommunistendondisruptionLateralbandsmigrateinvolardirectionMECHANISM:Volar-directedforceonmiddlephalanxagainstsemi-flexedfingerattemptingtoextendCENTRALSLIPAVULSIONEXAM:Pain,swellingoverdorsalPIPPIPin15-30degreesflexionMayhavelimitedextension(betterat0degreesthan30degrees)TREATMENTReferif>30%jointsurfaceinvolvedwithavulsionfxPIPsplintinfullextension4-5weeksProtect6-8weeksforsports*allowDIPtoflex-relocateslateralbandsCOMPLICATIONS:BoutonierredeformityCOLLATERALLIGAMENTTEARSANATOMY:PartialorcompletetearofulnarorradialligamentsMECHANISM:VarusorvalgusstresstoPIP,DIPorMCPEXAM:(flexMCP,PIP30degreesflex)LaxitywithvarusorvalgusstressPossibleinstabilitywithactiveflex/extendCOLLATERALLIGAMENTTEARSTREATMENT:Buddytapefor3weeksIfunstablewithactiveROMorobviousdeformityreferCOMPLICATIONS:UnstablejointGAMEKEEPER’STHUMBMECHANISMHyperabductionofthumb>30degreesor>20degreesdifferenceEXAM:Weak,painfulpinchPainoverulnarthumbXRAYSBEFORESTRESSGAMEKEEPER’STHUMBSIGNSPainoverulnarthumbStresstestingpositiveTestinginFULLFLEXIONofMCPGAMEKEEPER’STHUMBTREATMENTNoinstability,nofracture=thumbspicax6weeksNoinstability,smallavulsion=thumbspicaLargeavulsionorinstabiliy=thumbspicaandREFERCOMPLICATIONSSTENERlesionInstabilityTHUMBCMCFRACTUREDISLOCATION

(BENNETT’SFRACTURE)Anatomy:AnteriorobliquecarpometacarpalligamentholdspalmarfragmentinnormalanatomicpositionAbductorpollicislongus(APL)pullsmetacarpalshaftfragmentradial&dorsalTreatmentReduction(TAPE)Traction,abduction,extension,pronationOftenunstable,requiressurgeryROLANDO’SFRACTUREANATOMY3partfractureatmetacarpalbaseComminutedwith“Y〞or“T〞fragmentTREATMENTMaybenon-surgicalifhighlycomminutedSurgeryiffragmentsarelargeandamenableDIPJOINTDISLOCATIONMECHANISMHyperextension,varus/valgusforcesANATOMYUsuallydorsalRareStrongcollateralligamentsusuallypreventTREATMENTReduction:digitalblockfirstSplintin20-30degreesflexionfor10-14daysPIPJOINTDORSALDISLOCATION

(COACH’SFINGER)MECHANISMHyperextensionwithdisruptionofvolarplateANATOMYLossofvolarstabilizingforcecausesphalanxtoridedorsallyTREATMENTReduction:avoidlongitudinaltractionPost-reduction:dorsalextensionblocksplintwithPIPblockedat20-30degreesflexionBEWAREOFTHEVOLARDISLOCATIONPROXIMALPHALANXCONDYLEBUTTONHOLESTHROUGHTHETORNEXTENSORMECHANISMOFTENCAN’TBECLOSEDREDUCEDWRISTWrist#124-year-oldmaleFOOSHwhileskiingovertheweekendSeenatthemountainclinicandtold“wristsprain〞ScaphoidFracturePathoanatomyBloodsuppliedfromdistalpoleInchildren,87%involvedistalpoleInadults,80%involvewaistScaphoidFractureImagingInitialplainfilmsoftennormalBonescan100%sensitiveand92%specificat4daysMRI,CTscanSCAPHOIDFRACTURETREATMENTInitialradiographspositivedistalthirdhealinapprox6-8weeksmiddlethirdfrxhealin8-12weeksproximalthirdhealin12-23weeksInitialradiographsnegativeImmobilizethumbspicacastx7-14daysTakeoutofcast,re-evaluatefortendernessIf+tendernessbutnegradiographs….ScaphoidFractureTreatmentSuspectedfracturewithnormalplainfilmsShortarmthumbspica(splintorcast)F/Uin2weeksConsiderbonescanScaphoidFractureTreatmentNon-displacedfractureLongarmthumbspicacast6weeksThen,shortarmthumbspicacastfor4-14weeksScaphoidFractureRefertoOrthoAngulatedordisplaced(1mm)Non-unionorAVNScapholunatedissociationProximalfracturesLatepresentationEarlyreturntoplayWrist#234-year-oldfemalehairdresserwiththumbpainfor2-3monthsGradualonsetNowthumbhurtswithanymovementDEQUERVAIN’STENOSYNOVITISTREATMENT:considerinjectioneverytimeMayneedsecondinjectiontoimproveDEQUERVAIN’STENOSYNOVITISWrist#335y/oseamstressc/oRdorsalwristpainfor4monthsKienbockDiseaseLunatomalaciaAvascularnecrosis/vascularinsufficiency?repetitivemicrofracturesoflunateYoungadults15-40yoRiskfactors:negativeulnarvarianceKienbockDiseaseEXAM::Wristpainthatradiatesuptheforearmstiffness,tenderness,swellingoverlunatepassivedorsiflexionofmiddlefingerproducescharacteristicpainKienbockDiseaseStageI–IVStageI:MRIonlyStageII:SclerosisStageIII:SomecollapseStageIV:TotalcollapseKienbockDiseaseTREATMENT:PrimarilysurgicalEARLY:Radialshortening,ulnarlengtheningLATE:proximalrowcarpectomy,arthrodesisWrist#425-year-oldtennisplayertwistswristashefallsbackwardsreachingforalobSCAPHOLUNATEDISSOCIATIONSCAPHOLUNATEDISSOCIATIONEXAMWatson’stest(scaphoidshifttest)ScaphoidshucktestPain/swellingoverdorsalwrist,proxrowDIAGNOSISPlainfilms:>3mmdifferenceonclenchedfistScaphoidringsignTREATMENTIfdiscoveredwithin4weeks,surgeryAfter4weeks,conservativetreatmentreasonableBracingNSAIDSConsiderevalbyhandsurgerytoconfirmnosurgeryneededWrist#5SoccerplayerhaspaininpinkysideofwristafterafallTriangularFibrocartilageComplex(TFCC)TearFallondorsiflexedandulnardeviatedwristAxialloadwithforearminhyperpronationTFCCTearPathoanatomyTearinstructuresofTFCCPositiveulnarvariancepredisposestoinjuryTFCCAnatomyTFCCTearHistoryUlnar-sidedwristpainaggravatedbypronation/supinationTFCCTearPhysicalPresstestTFCCgrindtestCheckforDRUJinjuryTFCCTearImagingPlainfilmsmayshowpositiveulnarvarianceAssessforfractureorulnarsubluxationMRIorArthrographyTFCCTearTreatmentLongarmcastwithforearmneut