4. Common injuries of the athlete's hand HARVEY C. BROWN,* MD, M SC, FRCS[C], PACS
Hand injuries are among the most frequent accidents seen in sports medicine. All too commonly they are considered trivial since the athlete may continue to participate actively and neglect his injury. The consequent delay lit diagnosis and proper treatment may result In long-standing or even permanent disability. This paper describes the more commonly encountered hand injuries, their diagnosis and their optimal treatment. Included are soft-tissue Injuries, ligamentous Injuries, fractures and tendon avulsions. The basic principles applicable to skeletal and soft-tissue trauma of the hand, which physicians at all levels of sports medicine may encounter, are stressed. Les blessures aux mains sont parmi les accidents rencontr6s le plus fr6quemment en m6decine sportive. Trop souvent elles sont consld6rees comme mineures du fait que l'athl.te peut continuer de participer activement et qu'il neglige sa blessure. En cons6quence, le retard dans le diagnostic et Ia mise en route d'un traitement adequat peut entrainer une incapacit6 prolongee ou m6me permanente. Cette publication d6crit les blessures aux mains les plus couramment rencontr6es, leur diagnostic et leur traltement optimum. Ceci c,."iprend les blessures des tissus mous, les blessures des ligaments, les fractures et les avulsions des tendons. On souligne les principes fondamentaux qui s'appliquent aux traumatismes du squelette et des tissus mous de Ia i.iain qu'ont a rencontrer les medecins s'occupant de medecine sportive.
lete's hand; no attempt is made to cover the entire spectrum.
Tissue loss at finger tips More sophisticated treatment is required if there is tissue loss. In most Soft-tissue injuries instances the loss is at the finger tip. Simple, direct closure is best, provided Lacerations and abrasions no length is sacrificed. Otherwise, one Minor lacerations and abrasive burns may apply a small split-thickness skin of the hand require no special care. graft from the lateral thigh (not the Examination of motor and sensory forearm).1 During contraction (over a function related to the anatomic struc- 3- to 12-month period) the graft usually tures in the area of a full-thickness shrinks by 50% or more and tends to laceration is mandatory to rule out remodel the finger tip, especially in the nerve or tendon injury. If the latter guillotine type of amputation, seen ocis suspected, formal exploration, best casionally in skating accidents, or in done in the operating room, is obliga- avulsions of finger tips by mechanical tory. Otherwise, adequate cleansing, athletic equipment. d.bridement, closure as necessary and When bone is exposed a "free" graft application of occlusive dressings usual- is a poor choice and usually will not ly suffice. heal. Pedicled tissue should be used to avoid digital shortening. The classic cross-finger pedicle is now rarely used because (a) the donor site is usually unattractive; (b) frequently the function of the donor finger is impaired either by stiffness of the proximal interphalangeal joint secondary to immobilization, or by interference with the glide of the extensor mechanism; and (c) only protective sensation returns and the reconstructed finger tip is used little by the patient. More useful is a local pedicle with an intact nerve supply. Poy' described a simple transposition pedicle based on a digital artery and nerve; it is advanced over the defect and the donor site closed with a split-thickness skin graft. I use this type of pedicle but the graft is full-thickness skin from the wrist crease in a male or the inguinal FIG. lA-Pulp loss and exposure of ter- crease in a female (Fig. 1). I believe minal phalanx. that the tendency for split-thickness skin to contract results in some degree of flexion deformity of the distal inter-
All physicians involved in sports medicine at any level - grade school, college or professional sport - appreciate the myriad of minor and more serious injuries that may occur in the hand. The ability to recognize potentially chronic disabling injury immediately or very soon after the trauma is an important factor in the successful outcome of treatment. This paper deals with the more frequently seen and often mismanaged injuries of the ath*Assistant professor of surgery, McGill University; associate surgeon, divisions of plastic surgery, Montreal General and Montreal Children's hospitals; and chief, division of plastic surgery, Queen Mary Veterans Hospital, Montreal Reprint requests to: Dr. Harvey C. Brown, Rm. 603, Montreal General Hospital, 1650 Cedar Ave.. Montreal, PQ H3G 1A4
FIG. iB-Volar
advancement
based on neurovascular bundle.
I
FIG. iC-Pedicle donor site closed with full-thickness skin graft.
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 621
phalangeal joint and that this problem can be minimized by the use of fullthickness skin. The length one can achieve is related to the design of the pedicle. Theoretically the entire volar skin of a finger could be raised as an "island" flap and transposed; however, this is seldom required since defects usually range from 1.5 to 2.0 cm in diameter. Ligamentous injuries Perhaps the most frequently unrecognized and poorly treated injuries of the hand are those of the ligamentous system. This system consists of specialized thickenings of the joint capsule termed collateral ligaments and a firm fibrocartilaginous structure anterior to each joint termed the volar plate. The plate is attached to the neck of the proximal bone and the base of the distal bone of each joint. The collateral ligaments vary somewhat in the sites of their attachment, depending on the joint, but basically they pass from the condyle of the proximal bone to the volar plate and base of the distal bone. These structures, in concert with the joint capsule and certain extra-articular supporting structures, provide joint stability during flexion, extension and lateral stress. Strains and sprains Minor "strain" or "sprain" of a joint probably indicates small or even microscopic ruptures of ligamentous fibres. The history of injury, elucidation of pain with stress in a specific direction, and pinpoint tenderness over the injured structure make the diagnosis relatively straightforward. Expeditious recognition and treatment effect rapid cure. The joint simply is splinted in the so-called position of function for 10 to 14 days. The classic position of function was that of throwing a baseball. Today the ideal position is considered by most surgeons to be one in which the wrist is dorsiflexed 25 to 300, the metacarpophalangeal joints of the fingers are flexed nearly 900, the proximal interphalangeal joints are flexed no more than 200, and the thumb is abducted and extended in line with the radius, with its interphalangeal joint flexed 15 to 200. This position avoids the development of contractures of the small joints, especially extension contractures of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints.3 Rupture of collateral ligaments The next most serious injury of the ligamentous system is complete rupture of one collateral ligament. Excluding that of the metacarpophalangeal joint
of the thumb, these injuries have diagnostic features similar to those of sprains, plus instability with lateral stress (joint opening). Since the tear is complete an adequate period of healing necessitates immobilization in the position of function for 3½ weeks, then protective splinting or taping during athletic activities for a further 3 weeks. If both collateral ligaments have been ruptured, almost always the volar plate is detached proximally. This implies dorsal dislocation of the joint, and indeed volar dislocation of the proximal interphalangeal joint is uncommon. The mechanism of dislocation is hyperextension. The injury is easily recognized. The dislocation must be reduced precisely by increasing the hyperextension and simultaneously exerting pressure on the base of the middle phalanx. The adequacy of the reduction may be determined by putting the joint through a full range of passive motion. If, compared with the normal joint on the opposite hand, the injured joint has a normal range of motion it can be immobilized in the position of function for 3½ weeks, then splinted for a further 3 weeks. If the range of motion seems to be decreased the joint should be re-examined under digital block anesthesia. If the range of motion is still decreased the volar plate must be trapped between the joint surfaces or, less often,
there is a fracture dislocation. Radiologic study and open operative intervention are required. One of the most common and potentially most serious injuries of the hand is complete rupture of the ulnar collateral ligament of the tlipmb. This occurs with forced abduction strains at the metacarpophalangeal joint of the thumb with the first metacarpal fixed. If the injury is untreated the constant stress on the metacarpophalangeal joint secondary to repeated "key pinch" will produce a radial deviation at the metacarpophalangeal joint and eventually loss of pinch function. The anatomic feature determining the outcome in these injuries is the relation of the ulnar collateral ligament to the aponeurosis of the adductor pollicis muscle. If the ligament is avulsed completely it may be displaced proximally and not be in a reduced position, being caught behind the free proximal edge of the adductor aponeurosis. Unfortunately with a complete rupture there are no clinical signs by which to determine which ligaments are displaced. Thus I recommend operative intervention in all cases once complete rupture is diagnosed. The diagnosis is made by ulnar pressure on the joint and can be confirmed by "stress films" (Figs. 2A and 2B). Examination under anesthesia will show the abnormal lateral luxation of the joint (Fig. 2C). At operation the
FIG. 2A-"Stress film" of normal metacarpophalangeni joint of thumb.
FIG. 2B-.-Stress film of metacarpophalangeal joint of thumb with complete tear of colinteral ligament.
FIG. ZC-Lous of lateral stability of metacarpophalangeal joint demonstrated under anesthesia.
FIG. 2D-Avulsed distal end of ulnar collateral ligament.
622 CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
free distal end of the ligament is found, freshened and reinserted into the bone of the proximal phalanx (Fig. 2D). Results of early repair are uniformly excellent; however, if the diagnosis is delayed and secondary repair is required, more extensive ligamentous reconstruction, with tendon grafts or transfers, is necessitated. Results vary when reconstruction has been delayed.
Miscellaneous One must be aware of the less frequent but potentially serious injuries of the interphalangeal joints, including avulsion of the extensor middle slip to the base of the middle phalanx, intraarticular fracture and distal avulsion of the volar plate with or without volar dislocation.4 Fractures Rarely are fractures of the hand that are incurred during athletic activities compound; most are simple. The primary consideration is whether they are intra-articular. The degree of dis. placement, and especially whether there is rotation or shortening, determines treatment. Nonarticular Fractures of the distal phalanx in this category are usually phalangeal tuft crushes and result in a painful, swollen distal pulp, frequently associated with a subungual hematoma. The hematoma requires drainage by trephinement of the nail bed. The fracture heals in 3 weeks, during which period the pulp should be protected by a tip splint. Transverse fractures of the midshaft of the distal phalanx occasionally are displaced by the strong action of the deep flexor tendon and may require 3 weeks' splinting of the entire finger in the position of function. With nonarticular fractures of the middle and proximal phalanges volar displacement frequently occurs, depending on the site of fracture and the muscle forces, both extrinsic and intrinsic, acting on the fracture site. Imperfect reduction of these fractures may result in impairment of the normal tendon glide, especially of the long flexor mechanism, because of impingement on the tendon. This sequela is most common with neglected transverse fractures of the shaft. The oblique variety of fracture may present with malrotation or shortening of the phalanx, or both. Effective correction requires realignment, with the distal pulp pointing in the flexed position towards the scaphoid tubercle. Shortening occasionally may be corrected by traction manipulation and immobilization in moderate flexion. However, most mal-
rotated and shortened phalangeal fractures require operative manipulation. In an active athlete the method of choice is direct open reduction and fixation by either fine Kirschner wires or direct interosseous wires. Cumbersome external traction is now outmoded. Metacarpal fractures, excluding those of the thumb, usually involve the shafts and are usually oblique. Malrotation of these fractures is rare because of the supportive or splinting effects of the interosseous muscles (Fig. 3). Immobilization in a metacarpal plaster for 3½ weeks is adequate treatment. If shortening has occurred in a very long oblique fracture, closed traction mani-
pulation and transcutaneous pinning with Kirschner wires to an adjacent metacarpal will be necessary. Transverse fractures of the shaft are occasionally angulated but seldom severely in an athlete, and closed reduction is usually adequate. Fractures of the metacarpal bases, especially of the third and fourth fingers, are more serious. These always angulate dorsally and, if unreduced, may become the site of extensor tendon impingement and predispose to tendon rupture secondary to attrition. These injuries should be reduced by manipulation and fixation to the carpus by Kirschner wires. The extremely common Boxer's fracture, a fracture of the neck of the fifth metacarpal with volar angulation of the metacarpal head. may result in longterm disability (Fig. 4). The "dropped knuckle", if allowed to unite in an unreduced position, may result in a painful grip, which has been described as similar to gripping with a marble in the palm. Probably 250 of volar angulation is acceptable but any greater angulation of the fracture requires reduction. A simple and safe method of reduction is closed manipulation under ulnar nerve block, then transverse fixation of the distal fragment to the adjacent metacarpal. A "gutter slab" of plaster incorporating the third and fourth fingers is then applied to the ulnar border of the hand, wrist and forearm and left on for 4 weeks. Intra-articular The hand is an extremely mobile, precise, mechanical organ whose fluidity of purposeful movement depends FIG. 3-Vfrtually undisplaced spiral frac- on complex interaction between large and small muscle units controlled by hire of shaft of second metacarpal. neurologic impulses. If the skeletal architecture is not intact, function will be profoundly impaired. Nowhere is this better exemplified than in neglected intra-articular fractures of the interphalangeal joints. Anatomic reduction is mandatory; the type of fracture dictates the method. Malunion of intraarticular fractures of the hand will almost always result in degenerative osteoarthritis. A small proportion of intra-articular fractures - those with minimal displacement of fracture fragments and no articular "step" (Fig. 5) - may be treated by manipulative reduction, but
FIG. 4-Boxer's fracture.
FIG. 5-Undisplaced intra-articular frachire of base of proximal phalanx secondary to violent abduction of fourth finger.
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 623
most require some form of operative reduction, either by closed transfixion of the fracture with fine percutaneous wires or by open direct interosseous wiring. First metacarpal The first metacarpal is a particularly frequent site of fracture. The displacing forces are related to the absence of stabilizing intrinsic musculature except on the volar aspect (the thenar group). The actions of the outcropping tendons (those of the extensor pollicis longus and brevis and the abductor pollicis longus muscles) are particularly deforming. Midshaft fractures, if displaced, are managed by traction manipulation and percutaneous transfixion of the fracture site. Basal fractures of the first metacarpal require accurate diagnosis since the basal (metacarpotriquetral) joint is the key to thumb mobility. Transverse fractures of the base (Fig. 6) require only manipulation and immobilization. The problem injuries are the two types of intra-articular fracture.
FIG. 6-Transverse nonarticular fracture of base of first metacarpal.
The first is the "T"-fracture of Rolando5 (Fig. 7) - an intra-articular comminuted fracture with variable involvement of the articular surface. Recognition of this injury is important so that open reduction can be avoided. The degree of displacement of the articular surface is usually minimal, and open reduction commonly reveals a
degree of comminution that is largely irreparable. Immobilization in plaster of Paris will suffice. The second problem injury is Bennett's fracture-dislocation of the first metacarpal (Fig. 8A).6 The transarticular fracture allows subluxation of the main fragment proximodorsally by the action of the abductor pollicis longus
FIG. 8A-Bennett's fracture-dislocation of first metacarpal.
FIG. 7-"¶P'-fracture of Rolando. 624 CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
tendon attachment on the radial aspect of the base of the metacarpal. The strong anterior (volar) ligament retains the smaller fragment in the anatomic position. Anatomic reduction of the articular surface is mandatory to avoid arthritis, with decreased function and chronic pain, as well as chronic subluxation of the basal joint. I favour open direct reduction by the method of Gedda and Moberg7 (Fig. 8B). Tendon avulsions The three common forms of closed tendon avulsion in athletes are of the flexor profundus tendon, the central slip insertion of the long digital extensor tendon and the terminal insertion of the long digital extensor tendon. Football and hockey players are prone to closed avulsions of the insertion of the flexor profundus tendon at the base of the distal phalanx. This commonly occurs when the athlete is actively flexing his fingers in an attempt to restrain an opponent by clutching the sweater. Forced passive extension of the distal interphalangeal joint against an actively flexing profundus muscle may tear the insertion of the tendon. There is usually no associated avulsion fracture. Incomplete flexion of the terminal joint (Fig. 9) is evident. Early recognition of this injury is necessary since prompt reinsertion of the tendon will result in excellent functional recovery. Experience with later reinsertion - 3 to 4 weeks after the injury - has been disappointing since a flexion contracture frequently develops across the distal interphalangeal joint. I would almost always recommend tenodesis of the distal joint if
the injury had been untreated for longer than 6 weeks. Partial or complete disruption of the central slip insertion of the long digital extensor tendon at the base of the middle phalanx results in incomplete active extension of the proximal interphalangeal joint. This is usually accompanied by some degree of volar displacement of the lateral band components, and their altered action contributes to flexion of the proximal interphalangeal joint and extension of
FIG. 1OA-MaIIet fingers: recurvatum deformity of fourth finger and swan-neck deformity of third finger demonstrated in active extension.
K
the distal joint. The so-called boutonni.re deformity refers to "buttonholing" of the joint partially or completely through the tendon. This injury may be misdiagnosed as joint strain or sprain because of swelling. Digital block anesthesia will allow examination for any significant decrease in full active extension. If the athlete cannot extend fully the proximal interphalangeal joint, a presumptive diagnosis is made. Treatment requires splinting of the proximal joint in extension for 8 weeks or more. Late recognition of the injury demands open repair. Mallet or baseball finger refers to closed avulsion of the terminal insertion of the long digital extensor tendon from the base of the distal phalanx when an actively extending distal joint is passively flexed abruptly by a blow or force to the tip of the finger. The athlete will be unable to extend the distal phalanx fully. If subsequent review demonstrates no fracture or perhaps a small avulsion fracture, splinting of the distal joint in extension for at least 8 weeks is required. If the fracture is more serious there is a danger of anterior displacement of the distal fragment; thus, open repair is usually required. Many treatments of mallet finger have been recommended in the past. Most, now discarded, involved open repair and various types of internal fixation. The final result of such treatment in one patient is shown in Figs. lOA and lOB. The patient, a former professional football player, was left with two fixed recurvatum deformities of the third and fourth fingers. In spite of the inferior results of surgical treatment, his subsequent vocation was rendered more facile (Fig. lOC) as he pursued the art of dentistry. References
A
1. BRODY GS, CLOUTIER AM, WooLHousE FM: The finger tip injury. An assessment of management. Plast Reconste Surg 26: 80, 1960
FIG. lOB-Mallet fingers: active flexion.
2. PoY NG: The single pedicle neurovascular island flap: its use in 33 cases of acute partial digital amputation, in Transactions. International Congress of Plastic and Reconstructive Surgery, 5th ed, HUESTON JP (ed), New York, Appleton, 1970, p 542 3. KuczYNsiu K: The proximal interphalangeal joint. Anatomy and causes of stiffness in the fingers. J Bone Joint Surg (BrJ 50: 654, 1968 4. BURTON RI, EATON RG: Common hand injuries in the athlete. Orthop Clin North Am 4: 809, 1973 5. ROLANDO S: Fracture de Ia base du premier m.tacarpien et principalement sur une vari6t6 non encore d6crite. Presse Med 18: 303, 1910 6. BENNETT EH: Fractures of the metacarpal bones. Dublin I Med Sci 73: 72, 1882
FIG. 9-Closed avulsion of flexor profundus tendon of third finger.
FIG. lOC-Mallet fingers esthetically unattractive hut functionally acceptable outcome.
7. GEDDA KO, MosERG E: Open reduction and osteosynthesis of the so-called Bennett's fracture in carpo-metacarpal joint of the thumb. Ada Orthop Scand 22: 249, 1953
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 625
Hand injuries are among the most frequent accidents seen in sports medicine. All too commonly they are considered trivial since the athlete may continue to participate actively and neglect his injury. The consequent delay lit diagnosis and proper treatment may result In long-standing or even permanent disability. This paper describes the more commonly encountered hand injuries, their diagnosis and their optimal treatment. Included are soft-tissue Injuries, ligamentous Injuries, fractures and tendon avulsions. The basic principles applicable to skeletal and soft-tissue trauma of the hand, which physicians at all levels of sports medicine may encounter, are stressed. Les blessures aux mains sont parmi les accidents rencontr6s le plus fr6quemment en m6decine sportive. Trop souvent elles sont consld6rees comme mineures du fait que l'athl.te peut continuer de participer activement et qu'il neglige sa blessure. En cons6quence, le retard dans le diagnostic et Ia mise en route d'un traitement adequat peut entrainer une incapacit6 prolongee ou m6me permanente. Cette publication d6crit les blessures aux mains les plus couramment rencontr6es, leur diagnostic et leur traltement optimum. Ceci c,."iprend les blessures des tissus mous, les blessures des ligaments, les fractures et les avulsions des tendons. On souligne les principes fondamentaux qui s'appliquent aux traumatismes du squelette et des tissus mous de Ia i.iain qu'ont a rencontrer les medecins s'occupant de medecine sportive.
lete's hand; no attempt is made to cover the entire spectrum.
Tissue loss at finger tips More sophisticated treatment is required if there is tissue loss. In most Soft-tissue injuries instances the loss is at the finger tip. Simple, direct closure is best, provided Lacerations and abrasions no length is sacrificed. Otherwise, one Minor lacerations and abrasive burns may apply a small split-thickness skin of the hand require no special care. graft from the lateral thigh (not the Examination of motor and sensory forearm).1 During contraction (over a function related to the anatomic struc- 3- to 12-month period) the graft usually tures in the area of a full-thickness shrinks by 50% or more and tends to laceration is mandatory to rule out remodel the finger tip, especially in the nerve or tendon injury. If the latter guillotine type of amputation, seen ocis suspected, formal exploration, best casionally in skating accidents, or in done in the operating room, is obliga- avulsions of finger tips by mechanical tory. Otherwise, adequate cleansing, athletic equipment. d.bridement, closure as necessary and When bone is exposed a "free" graft application of occlusive dressings usual- is a poor choice and usually will not ly suffice. heal. Pedicled tissue should be used to avoid digital shortening. The classic cross-finger pedicle is now rarely used because (a) the donor site is usually unattractive; (b) frequently the function of the donor finger is impaired either by stiffness of the proximal interphalangeal joint secondary to immobilization, or by interference with the glide of the extensor mechanism; and (c) only protective sensation returns and the reconstructed finger tip is used little by the patient. More useful is a local pedicle with an intact nerve supply. Poy' described a simple transposition pedicle based on a digital artery and nerve; it is advanced over the defect and the donor site closed with a split-thickness skin graft. I use this type of pedicle but the graft is full-thickness skin from the wrist crease in a male or the inguinal FIG. lA-Pulp loss and exposure of ter- crease in a female (Fig. 1). I believe minal phalanx. that the tendency for split-thickness skin to contract results in some degree of flexion deformity of the distal inter-
All physicians involved in sports medicine at any level - grade school, college or professional sport - appreciate the myriad of minor and more serious injuries that may occur in the hand. The ability to recognize potentially chronic disabling injury immediately or very soon after the trauma is an important factor in the successful outcome of treatment. This paper deals with the more frequently seen and often mismanaged injuries of the ath*Assistant professor of surgery, McGill University; associate surgeon, divisions of plastic surgery, Montreal General and Montreal Children's hospitals; and chief, division of plastic surgery, Queen Mary Veterans Hospital, Montreal Reprint requests to: Dr. Harvey C. Brown, Rm. 603, Montreal General Hospital, 1650 Cedar Ave.. Montreal, PQ H3G 1A4
FIG. iB-Volar
advancement
based on neurovascular bundle.
I
FIG. iC-Pedicle donor site closed with full-thickness skin graft.
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117 621
phalangeal joint and that this problem can be minimized by the use of fullthickness skin. The length one can achieve is related to the design of the pedicle. Theoretically the entire volar skin of a finger could be raised as an "island" flap and transposed; however, this is seldom required since defects usually range from 1.5 to 2.0 cm in diameter. Ligamentous injuries Perhaps the most frequently unrecognized and poorly treated injuries of the hand are those of the ligamentous system. This system consists of specialized thickenings of the joint capsule termed collateral ligaments and a firm fibrocartilaginous structure anterior to each joint termed the volar plate. The plate is attached to the neck of the proximal bone and the base of the distal bone of each joint. The collateral ligaments vary somewhat in the sites of their attachment, depending on the joint, but basically they pass from the condyle of the proximal bone to the volar plate and base of the distal bone. These structures, in concert with the joint capsule and certain extra-articular supporting structures, provide joint stability during flexion, extension and lateral stress. Strains and sprains Minor "strain" or "sprain" of a joint probably indicates small or even microscopic ruptures of ligamentous fibres. The history of injury, elucidation of pain with stress in a specific direction, and pinpoint tenderness over the injured structure make the diagnosis relatively straightforward. Expeditious recognition and treatment effect rapid cure. The joint simply is splinted in the so-called position of function for 10 to 14 days. The classic position of function was that of throwing a baseball. Today the ideal position is considered by most surgeons to be one in which the wrist is dorsiflexed 25 to 300, the metacarpophalangeal joints of the fingers are flexed nearly 900, the proximal interphalangeal joints are flexed no more than 200, and the thumb is abducted and extended in line with the radius, with its interphalangeal joint flexed 15 to 200. This position avoids the development of contractures of the small joints, especially extension contractures of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints.3 Rupture of collateral ligaments The next most serious injury of the ligamentous system is complete rupture of one collateral ligament. Excluding that of the metacarpophalangeal joint
of the thumb, these injuries have diagnostic features similar to those of sprains, plus instability with lateral stress (joint opening). Since the tear is complete an adequate period of healing necessitates immobilization in the position of function for 3½ weeks, then protective splinting or taping during athletic activities for a further 3 weeks. If both collateral ligaments have been ruptured, almost always the volar plate is detached proximally. This implies dorsal dislocation of the joint, and indeed volar dislocation of the proximal interphalangeal joint is uncommon. The mechanism of dislocation is hyperextension. The injury is easily recognized. The dislocation must be reduced precisely by increasing the hyperextension and simultaneously exerting pressure on the base of the middle phalanx. The adequacy of the reduction may be determined by putting the joint through a full range of passive motion. If, compared with the normal joint on the opposite hand, the injured joint has a normal range of motion it can be immobilized in the position of function for 3½ weeks, then splinted for a further 3 weeks. If the range of motion seems to be decreased the joint should be re-examined under digital block anesthesia. If the range of motion is still decreased the volar plate must be trapped between the joint surfaces or, less often,
there is a fracture dislocation. Radiologic study and open operative intervention are required. One of the most common and potentially most serious injuries of the hand is complete rupture of the ulnar collateral ligament of the tlipmb. This occurs with forced abduction strains at the metacarpophalangeal joint of the thumb with the first metacarpal fixed. If the injury is untreated the constant stress on the metacarpophalangeal joint secondary to repeated "key pinch" will produce a radial deviation at the metacarpophalangeal joint and eventually loss of pinch function. The anatomic feature determining the outcome in these injuries is the relation of the ulnar collateral ligament to the aponeurosis of the adductor pollicis muscle. If the ligament is avulsed completely it may be displaced proximally and not be in a reduced position, being caught behind the free proximal edge of the adductor aponeurosis. Unfortunately with a complete rupture there are no clinical signs by which to determine which ligaments are displaced. Thus I recommend operative intervention in all cases once complete rupture is diagnosed. The diagnosis is made by ulnar pressure on the joint and can be confirmed by "stress films" (Figs. 2A and 2B). Examination under anesthesia will show the abnormal lateral luxation of the joint (Fig. 2C). At operation the
FIG. 2A-"Stress film" of normal metacarpophalangeni joint of thumb.
FIG. 2B-.-Stress film of metacarpophalangeal joint of thumb with complete tear of colinteral ligament.
FIG. ZC-Lous of lateral stability of metacarpophalangeal joint demonstrated under anesthesia.
FIG. 2D-Avulsed distal end of ulnar collateral ligament.
622 CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
free distal end of the ligament is found, freshened and reinserted into the bone of the proximal phalanx (Fig. 2D). Results of early repair are uniformly excellent; however, if the diagnosis is delayed and secondary repair is required, more extensive ligamentous reconstruction, with tendon grafts or transfers, is necessitated. Results vary when reconstruction has been delayed.
Miscellaneous One must be aware of the less frequent but potentially serious injuries of the interphalangeal joints, including avulsion of the extensor middle slip to the base of the middle phalanx, intraarticular fracture and distal avulsion of the volar plate with or without volar dislocation.4 Fractures Rarely are fractures of the hand that are incurred during athletic activities compound; most are simple. The primary consideration is whether they are intra-articular. The degree of dis. placement, and especially whether there is rotation or shortening, determines treatment. Nonarticular Fractures of the distal phalanx in this category are usually phalangeal tuft crushes and result in a painful, swollen distal pulp, frequently associated with a subungual hematoma. The hematoma requires drainage by trephinement of the nail bed. The fracture heals in 3 weeks, during which period the pulp should be protected by a tip splint. Transverse fractures of the midshaft of the distal phalanx occasionally are displaced by the strong action of the deep flexor tendon and may require 3 weeks' splinting of the entire finger in the position of function. With nonarticular fractures of the middle and proximal phalanges volar displacement frequently occurs, depending on the site of fracture and the muscle forces, both extrinsic and intrinsic, acting on the fracture site. Imperfect reduction of these fractures may result in impairment of the normal tendon glide, especially of the long flexor mechanism, because of impingement on the tendon. This sequela is most common with neglected transverse fractures of the shaft. The oblique variety of fracture may present with malrotation or shortening of the phalanx, or both. Effective correction requires realignment, with the distal pulp pointing in the flexed position towards the scaphoid tubercle. Shortening occasionally may be corrected by traction manipulation and immobilization in moderate flexion. However, most mal-
rotated and shortened phalangeal fractures require operative manipulation. In an active athlete the method of choice is direct open reduction and fixation by either fine Kirschner wires or direct interosseous wires. Cumbersome external traction is now outmoded. Metacarpal fractures, excluding those of the thumb, usually involve the shafts and are usually oblique. Malrotation of these fractures is rare because of the supportive or splinting effects of the interosseous muscles (Fig. 3). Immobilization in a metacarpal plaster for 3½ weeks is adequate treatment. If shortening has occurred in a very long oblique fracture, closed traction mani-
pulation and transcutaneous pinning with Kirschner wires to an adjacent metacarpal will be necessary. Transverse fractures of the shaft are occasionally angulated but seldom severely in an athlete, and closed reduction is usually adequate. Fractures of the metacarpal bases, especially of the third and fourth fingers, are more serious. These always angulate dorsally and, if unreduced, may become the site of extensor tendon impingement and predispose to tendon rupture secondary to attrition. These injuries should be reduced by manipulation and fixation to the carpus by Kirschner wires. The extremely common Boxer's fracture, a fracture of the neck of the fifth metacarpal with volar angulation of the metacarpal head. may result in longterm disability (Fig. 4). The "dropped knuckle", if allowed to unite in an unreduced position, may result in a painful grip, which has been described as similar to gripping with a marble in the palm. Probably 250 of volar angulation is acceptable but any greater angulation of the fracture requires reduction. A simple and safe method of reduction is closed manipulation under ulnar nerve block, then transverse fixation of the distal fragment to the adjacent metacarpal. A "gutter slab" of plaster incorporating the third and fourth fingers is then applied to the ulnar border of the hand, wrist and forearm and left on for 4 weeks. Intra-articular The hand is an extremely mobile, precise, mechanical organ whose fluidity of purposeful movement depends FIG. 3-Vfrtually undisplaced spiral frac- on complex interaction between large and small muscle units controlled by hire of shaft of second metacarpal. neurologic impulses. If the skeletal architecture is not intact, function will be profoundly impaired. Nowhere is this better exemplified than in neglected intra-articular fractures of the interphalangeal joints. Anatomic reduction is mandatory; the type of fracture dictates the method. Malunion of intraarticular fractures of the hand will almost always result in degenerative osteoarthritis. A small proportion of intra-articular fractures - those with minimal displacement of fracture fragments and no articular "step" (Fig. 5) - may be treated by manipulative reduction, but
FIG. 4-Boxer's fracture.
FIG. 5-Undisplaced intra-articular frachire of base of proximal phalanx secondary to violent abduction of fourth finger.
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most require some form of operative reduction, either by closed transfixion of the fracture with fine percutaneous wires or by open direct interosseous wiring. First metacarpal The first metacarpal is a particularly frequent site of fracture. The displacing forces are related to the absence of stabilizing intrinsic musculature except on the volar aspect (the thenar group). The actions of the outcropping tendons (those of the extensor pollicis longus and brevis and the abductor pollicis longus muscles) are particularly deforming. Midshaft fractures, if displaced, are managed by traction manipulation and percutaneous transfixion of the fracture site. Basal fractures of the first metacarpal require accurate diagnosis since the basal (metacarpotriquetral) joint is the key to thumb mobility. Transverse fractures of the base (Fig. 6) require only manipulation and immobilization. The problem injuries are the two types of intra-articular fracture.
FIG. 6-Transverse nonarticular fracture of base of first metacarpal.
The first is the "T"-fracture of Rolando5 (Fig. 7) - an intra-articular comminuted fracture with variable involvement of the articular surface. Recognition of this injury is important so that open reduction can be avoided. The degree of displacement of the articular surface is usually minimal, and open reduction commonly reveals a
degree of comminution that is largely irreparable. Immobilization in plaster of Paris will suffice. The second problem injury is Bennett's fracture-dislocation of the first metacarpal (Fig. 8A).6 The transarticular fracture allows subluxation of the main fragment proximodorsally by the action of the abductor pollicis longus
FIG. 8A-Bennett's fracture-dislocation of first metacarpal.
FIG. 7-"¶P'-fracture of Rolando. 624 CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
tendon attachment on the radial aspect of the base of the metacarpal. The strong anterior (volar) ligament retains the smaller fragment in the anatomic position. Anatomic reduction of the articular surface is mandatory to avoid arthritis, with decreased function and chronic pain, as well as chronic subluxation of the basal joint. I favour open direct reduction by the method of Gedda and Moberg7 (Fig. 8B). Tendon avulsions The three common forms of closed tendon avulsion in athletes are of the flexor profundus tendon, the central slip insertion of the long digital extensor tendon and the terminal insertion of the long digital extensor tendon. Football and hockey players are prone to closed avulsions of the insertion of the flexor profundus tendon at the base of the distal phalanx. This commonly occurs when the athlete is actively flexing his fingers in an attempt to restrain an opponent by clutching the sweater. Forced passive extension of the distal interphalangeal joint against an actively flexing profundus muscle may tear the insertion of the tendon. There is usually no associated avulsion fracture. Incomplete flexion of the terminal joint (Fig. 9) is evident. Early recognition of this injury is necessary since prompt reinsertion of the tendon will result in excellent functional recovery. Experience with later reinsertion - 3 to 4 weeks after the injury - has been disappointing since a flexion contracture frequently develops across the distal interphalangeal joint. I would almost always recommend tenodesis of the distal joint if
the injury had been untreated for longer than 6 weeks. Partial or complete disruption of the central slip insertion of the long digital extensor tendon at the base of the middle phalanx results in incomplete active extension of the proximal interphalangeal joint. This is usually accompanied by some degree of volar displacement of the lateral band components, and their altered action contributes to flexion of the proximal interphalangeal joint and extension of
FIG. 1OA-MaIIet fingers: recurvatum deformity of fourth finger and swan-neck deformity of third finger demonstrated in active extension.
K
the distal joint. The so-called boutonni.re deformity refers to "buttonholing" of the joint partially or completely through the tendon. This injury may be misdiagnosed as joint strain or sprain because of swelling. Digital block anesthesia will allow examination for any significant decrease in full active extension. If the athlete cannot extend fully the proximal interphalangeal joint, a presumptive diagnosis is made. Treatment requires splinting of the proximal joint in extension for 8 weeks or more. Late recognition of the injury demands open repair. Mallet or baseball finger refers to closed avulsion of the terminal insertion of the long digital extensor tendon from the base of the distal phalanx when an actively extending distal joint is passively flexed abruptly by a blow or force to the tip of the finger. The athlete will be unable to extend the distal phalanx fully. If subsequent review demonstrates no fracture or perhaps a small avulsion fracture, splinting of the distal joint in extension for at least 8 weeks is required. If the fracture is more serious there is a danger of anterior displacement of the distal fragment; thus, open repair is usually required. Many treatments of mallet finger have been recommended in the past. Most, now discarded, involved open repair and various types of internal fixation. The final result of such treatment in one patient is shown in Figs. lOA and lOB. The patient, a former professional football player, was left with two fixed recurvatum deformities of the third and fourth fingers. In spite of the inferior results of surgical treatment, his subsequent vocation was rendered more facile (Fig. lOC) as he pursued the art of dentistry. References
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1. BRODY GS, CLOUTIER AM, WooLHousE FM: The finger tip injury. An assessment of management. Plast Reconste Surg 26: 80, 1960
FIG. lOB-Mallet fingers: active flexion.
2. PoY NG: The single pedicle neurovascular island flap: its use in 33 cases of acute partial digital amputation, in Transactions. International Congress of Plastic and Reconstructive Surgery, 5th ed, HUESTON JP (ed), New York, Appleton, 1970, p 542 3. KuczYNsiu K: The proximal interphalangeal joint. Anatomy and causes of stiffness in the fingers. J Bone Joint Surg (BrJ 50: 654, 1968 4. BURTON RI, EATON RG: Common hand injuries in the athlete. Orthop Clin North Am 4: 809, 1973 5. ROLANDO S: Fracture de Ia base du premier m.tacarpien et principalement sur une vari6t6 non encore d6crite. Presse Med 18: 303, 1910 6. BENNETT EH: Fractures of the metacarpal bones. Dublin I Med Sci 73: 72, 1882
FIG. 9-Closed avulsion of flexor profundus tendon of third finger.
FIG. lOC-Mallet fingers esthetically unattractive hut functionally acceptable outcome.
7. GEDDA KO, MosERG E: Open reduction and osteosynthesis of the so-called Bennett's fracture in carpo-metacarpal joint of the thumb. Ada Orthop Scand 22: 249, 1953
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