Hand and fingers other

Question 1

Mallet finger

Answer 1

avulsion of extensor tendon - flexion deformity
- common in ball sports catching/bouncing • MOI
o Ball strikes extended fingertip, forcing the DIP joint into flexion while the extensor mechanism is actively contracting = disruption/stretching of the extensor mechanism over the DIP joint

Ax
palp: distal PIP tenderness
mvmt = can’t extend DIP joint and droop of distal phallanax = rupture of terminal extensor tendon (stab middle phalax and get Pt to move DIP)

Question 2

Mallet finger Mx

Answer 2

referal criteria = large avulsion # involving more than 30% of joint or can’t fully enxtend passively

differential diagnosis = jersey finger of FDS rupture

Splingting: 0-6 weeks splint DIP joint in Ext or slight HE if available (no blanching)
- don’t flex with splint changes
• 6-8 weeks: night splinting only and gradual AROM of the DIP joint
o Normal to be stiff initially but don’t push it, watch that lag doesn’t develop
• regime often successful for late presentation up to 3 months after injury

MT = regain ROM and strenght
Maintain CV fitness

Question 3

Intrinsic tightness

Answer 3

intrinsic spasticity/tightness= lumbricals and interossei = causes MCP flx and IP ext
extrinsic weakness = ED, FDS and FDP

MOI: trauma (driect/indirect, compartment syndrome, vascular) RA (MCP joint subluxation and ulnar drift), neurological

Ax: Finger naturally in MCP flx and IP ext, can’t do hook position (MCP ext and IP flx)
Compare PROM of IP in MCP ext and flx
• Positive tests: Bunnell test
o Differentiates intrinsic and extrinsic tightness = Positive when PIP flexion is less with MCP extension (than with MCP flexion)
o =intrinsic tightness

Mx
•	Passive stretches
•	Tendon gliding?
•	Heat
•	massage

Question 4

FDS

Answer 4

•	Complains of:
o	Can’t flex finger at PIP joint
Mx
•	Refer to hand surgeon
•	Requires early post-operative mobilisation 
o	Early active regime is most common now
o	SEE FLEXOR TENOSYNOVITIS REGIME

Question 5

Jersey finger

Answer 5

FDP rupture/sprain > can avulse a piece of pharangeal bone to which the tendon is still attached. FDP can retract.

MOI: grabbing onto jersey while payer is running away

Ax:
Observe: DIP in HE whilst rest of finger in flexion or finger asumes position of Ext compared to other
Palp: tendness, swelling and warmth
Mvmt: stabilise below DIP, ask patient to flex > inability to actively flex DIP

Differential diagnosis
• FDS rupture
• Mallet finger

Mx
• Refer to hand surgeon
• Offer advice and education of pain relief and RICER
• Requires early post-operative mobilisation
o Early active regime is most common now
o SEE FLEXOR TENOSYNOVITIS REGIME

Question 6

Jersey finger classes 1-4

Answer 6

1: retraction of tendon into palm - no fracture and primary tendon repair within 10 days
2: retraction to PIP - no fracture -and primary tendon repair within 10 days
3: fracture fragment retains tendon at DIP - 6 weeks for fracture fragment repair
4: fracture fragment has tendon avulse off and retraction repair of # fragment and tendon repair - 10 weeks

Question 7

Central Slip (Boutonniere)

Answer 7

• Central slip injury/disruption of the ext band of the PIP joint lateral bands SUBLUX in a volar (post) and proximal direction and don’t run in line with the finger = position of PIP flexion and DIP hyperextension
o Middle phalanx pulled into flexion by FDS
• Acute flexion - commonly seen in ball sports

MOI
o Acute flexion (ball sports) ot Direct trauma to PIP joint
• Complains of: inability to extend the PIP joint

Ax:
• Observation: PIP flx and DIP HE
palp: Swollen, Tender PIP joint
• Inability to extend the PIP joint

X-ray
o To confirm if there is an avulsion fracture involving >30% of the joint

Question 8

Central Slip (Boutonniere) Mx

Answer 8

Acute:
splinting: 0-6 wks splint PIP in full ext so tendon heals in proper align., but allow mvmt of DIP and MCP to stretch oblique retinacular ligament
6 wks: night splinting and splinting btwn exercises. Watch for LAG. start AROM and PROM of PIP
7 - 8 wks: if flx loss, start passive PIP flexion stretches and dynamic PIP flexion splinting. If lag develops- cease.

Chronic (>3 wks goes by without tx): want to restore full PIP ext.
- no or unlikely PROM and AROM ext at PIp due to flx contracture
- Regain full PIP extension via a dynamic splint that gradually extends the joint into a neutral position. Once full PIP extension is achieved:
@ 8 wks = gradual AROM and PROM of PIP joint +/- dynamic flexion splintage to regain flexion due to joint stiffness from immobilisation
* Joint enlargement and residual PIP flexion loss is common

Sx = if moe than 30% joint avulsion fracture/ PT can’t passively ext finger, open cut

Question 9

PIP dislocations/volar plate injuries

Answer 9

• most commonly disslocated joint in body
• always xray and refer when swollen and tender - early referral if in doubt
• Poor management leads to long term morbidity
• Usually DORSAL (ANTERIOR) + collat. lig damage

Dorsal dislocation:
• damage can involve volar plate injury or P2 avulsion fracture
• will need closed reduction

Dislocations
•	volar and dorsal
Subluxation
•	volar, dorsal, radial and ulnar
Avulsion or chip fractures
•	associated with ligamentous injuries
Intra-articular fractures or dislocations
•	will most likely require surgery

Question 10

PIP dislocations/volar plate injuries 2

Answer 10

• MOI = HE of the finger causing volar plate injury - Volar plate stops hyperextension
• Complains of Loss of stability in joint

Ax:
palp: very painful, wwelling +/- visible deformity
• (volar plate injury) full active extension/flexion is possible if the joint is unstable
• Decreased stability due to damage to collateral ligaments (often happen together)
• Full AROM in fl/ext will be possible if joint is stable.

Mx:
1. control odema = coban
2. splinting:
- 0-4 weeks: Splint to prevent last 15-30 degrees of extension (won’t heal if lengthened). Allow active flexion
- gradually inc. ext. during the 4 weeks until 0 degrees achieved (PIP flexion contracture less likely
• Less severe injury: Buddy strap tape 4 weeks continuous (will restrict some extension and give support)
• Address fixed flexion deformity = unlikely to respond to MT so will require splintage
o The degree of flexion determines the splint
- 50 degrees – dorsal outrigger
- 25-50 degrees – serial casting
- 0-25 degrees – static progressive splint (like for ACL brace)

MT:

• PIP can dvlp flx contracture/extensor lag so need to immobilise in ext IF STABLE. IF UNSTABLE: immob. in flx w/ xray confirmation
• start early active flx ROM
• monitor to progressively inc. ROM
• can use heat to improve range