42 page FINGER ORTHOPEDIC INJURY Presentation on CD

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TITLE: Athletic Injuries of the Finger, 2005, 42 pages

SLIDE TOPICS, SUBTOPICS and CONTENTS:

Athletic Injuries of the Finger Pyong Park, MD Hand Surgeon 121st General Hospital Jammed Finger (Coach’s Finger): Stiff, painful, deformed finger joint Ball handling sports Frequent failure to recognize the significance of the injury Initially trivial but undesirable long term disability Key to Functional Restoration: Timely evaluation by a qualified HCP Accurate Dx and adequate Tx Early rehabilitation and protection of the healing digit “The fate of an injured finger is dependent upon the HCP who provides the initial care of it.” Evaluation of the Injured Finger: Swelling, maximum tenderness, ROM Volar plate integrity, hyperextension laxity Collateral ligament of PIP joint Comparison exam of the uninjured hand for ligament laxity Document sensory and vascular exam Radiographic Examination: All injured fingers with Swelling Local tenderness Loss of motion No need to worry about overusing x-rays Missed Dx and poor long term functional disability PIP Joint Injuries Most commonly injured joint in the hand Must resist large angular stress by long lever arm Loss of PIP joint motion (most common) Long term functional impairment Anatomy of the PIP Joint: Simple, bicondylar, hinge joint, unstable ROM: 0/105 degrees Primary stabilizer: specialized soft tissues Collateral ligaments: cordlike, remain taut through ROM Anatomy – Volar plate Stabilize the joint in extension Prevent hyperextension Laxity in flexion Prone to becoming contracted after prolonged flexion Articular Fractures P1 condyles or articular base of P2 Condyles: uni or bicondylar Frequent displacement Loss of motion Treatment of the Condylar Fracture: Non-displaced: splint in 0-30 flexion, may include MCP and the adjacent fingers Weekly x-ray for two weeks Immobilize for 3-4 wks. Displaced Fx: ORIF P2 Base Fracture: Usually avulsion Fx Forcible hyperextension: volar plate avulsion P2 Fractures: Acute flexion against resistance: avulsion of the central slip insertion to the dorsal base Treatment: Splinting Dorsal avulsion Fx: in full extension Volar avulsion Fx: in slight flexion Rehab Dorsal = 4 – 6 weeks of PIP extension with DIP flexion exercises Volar = 1-2 weeks of splinting in slight flexion followed by buddy taping for several weeks Treatment: Indications for surgical procedure Fx involving more than 1/3 of the articular surface Displacement over 3 mm Joint Subluxation PIP Joint Dislocation (simple dislocation): Mechanism: axial loading, hyperextension dorsal or dorso-lateral dislocation Frequently reduced by coaches or trainers Injudicious early return to athletic activity without proper eval and protection Unsalvageable subluxed joint and permanent disability PIPJ Dorsal Dislocation: without Fx Volar plate disruption Collateral ligaments: usually uninjured Reduction: by traction Check collateral ligament for stability After reduction Splint in 25 degrees flexion for 2 weeks then buddy taping PIPJ Lateral Dislocation: Simple collateral ligament and a portion of the volar plate rupture Tx: controversial -buddy taping or splinting until joint is painless and stable - ? better outcome following surgical repair PIPJ Volar Dislocation: Unilateral collateral ligament rupture and central slip disruption Weak or absent extension of PIPJ Surgical repair with transarticular pinning Boutonniere deformity if untreated Boutonnière Deformity: Untreated central slip disruption from P2 base Rarely seen acutely: takes 2-3 weeks Lateral bands sublux volar to the axis of the PIPJ rotation -lateral bands become the flexors of the PIPJ Contracture: hyperextension of DIPJ and the flexion of PIPJ Boutonnière Deformity: Missed early Dx and Tx Wrong splinting in flexion, instead of in full extension Continuous splinting: 24/7 for 6 wks, then extension night splints for additional 4 wks plus Allow DIPJ motion Prevention is the most effective Tx Pseudo boutonnière Deformity: Ruptured volar plate of the PIPJ at the proximal attachment: calcification Intact central slip Flexion contracture of the PIPJ as a result of prolonged splinting in flexion Could be prevented if splinted and rehabilitated early Treatment Mild contracture – dynamic extension splint Severe contracture – surgical release Mallet Finger: Baseball finger, drop finger Disrupted extensor mechanism over the DIPJ by axial impact to an extended finger tip Forced flexion of the joint Loss of active extension of DIPJ Swelling and tenderness Mallet Finger (cont.): X-ray to r/o avulsion fracture or joint subluxation Mallet Finger- Treatment: Splint DIPJ in extension 24/7 for 6 weeks After 6 wks, continue with night splint for 4 wks. Optional: DIPJ transarticular pinning ORIF- only for large avulsion Fx with joint subluxation (controversial) Flexor Digitorum Profundus Avulsion “Jersey Finger” FDP Rupture (Jersey Finger): Traumatic avulsion of long flexor tendon insertion Forced extension of DIPJ while grasping Ring Finger affected most frequently Jersey Finger Dx and Tx: often delayed Permanent functional impairment Early DX is crucial Loss of active DIPJ flexion X-ray – usually negative Compromised blood supply Anatomy: Zone 1 Flexor Tendon System A4 and Distal FDP Insertion on P3 Proximal 1/3 Anatomy: Anatomy: Tendon Nutrition Synovial Fluid Diffusion Imbibition Vascular System Dual Supply Longitudinal Vessels Vinculae Dorsally and in Endotendinous Septae Avascular Areas P1 and P3 (FDP) Physical Examination: Appearance – Swollen Palpation – tenderness along volar aspect of the injured finger Usually you can feel a nodule which is the retracted tendon somewhere between the A1 to A4 pulley Action – Unable to flex DIP joint Classification: Leddy and Packer JHS 2:66-69,1977 Repair of Avulsions: Aftercare: Flexor Tendon Rehab protocol Early active motion Passive motion Kleinert Protocol – dynamic splint Extension Block Splint for 6 weeks with controlled motion Prognostic Factors: Level of retraction Type 1 does worst Remaining blood supply Type 1 loses the most blood supply Time elapsed between injury and treatment Presence, size and location of bony fragment 20 y/o soldier playing rugby: Ring finger pain while attempting tackle Continued to play Finger become swollen and ecchymotic Clinic appearance at one week Operative Images: 19 y/o AD SM playing flag football: Caught belt attempting to grab flag Immediate pain Rapid swelling and ecchymosis Won’t fully cooperate with examination Won’t attempt flexion Won’t let you palpate finger held in partial flexion X-ray Appearance: What do you see? What is the classification? What is the Prognosis? How would you fix this? Post-Op Fixation: Other Options: K-wire fixation, Pull Out Wire Summary: Painful, swollen finger, with limited joint motion due to injury needs an early Dx and Tx. A seemingly trivial injury may result in permanent functional disability. Remember the “fate of an injured finger may be dependent upon the HCP who renders initial care to it.” Don’t forget the fundamentals: Hx, PE and X-ray. Questions: