Ligament Injuries of the Hand

Question 1

If a proximal interphalangeal (PIP) fracture/dislocation remains reduced and congruent when splinted at 30° oftlexion or less, it is considered stable and can be treated closed.

Answer 1

T

Question 2

hemihamate arthroplasty indications

Answer 2

unstable PIP fracture/dislocation injuries with destruction of the volar base
more than 4 to
6 weeks after injury

Question 3

(PIPJ) injuries are common and fall in
to three major categories

Answer 3

■ Dislocations
■ Avulsions
■ Fracture-dislocations

Question 4

The PIPJ is a bicondylar hinge with an arc of motion of 110°

Answer 4

T

Question 5

The extensor system provides the least amount
of support, to PIP

Answer 5

T

Question 6

Lateral dislocations are most common,

Answer 6

F dorsal dislocations are most common,with the
middle phalanx being driven dorsally and then proximally

Question 7

approach to PIPJ dislocations

Answer 7

■ Reduction
■ Evaluate postreduction for joint congruency through the arc of motion
■ Assess stability

Question 8

Avoid multiple attempts at closed reduction

Answer 8

T

Question 9

radial/ulnar stressing to test collateral ligament stability should be done with the finger extended only

Answer 9

F the finger extended to test the
accessory collateral, and with the PIPJ at 30° to test the proper collateral

Question 10

Evaluating joint congruency under fluoroscopy during active motion is the optimal way to test active stability

Answer 10

T

Question 11

If the joint is stable
after reduction, buddy straps/taping to facilitate early motion with
some protection is the optimal treatment

Answer 11

T

Question 12

If the subluxation or dislocation recurs with active motion what the treatment plan?

Answer 12

splinting in a position of stability-15° to 30° of flexion-may be required to facilitate ligament healing before allowing motion

Question 13

type I and II injuries rarely require surgical treatment.

Answer 13

T

Question 14

Type of PIP dislocation

Answer 14

Type I (hyperextension): Hyperextension results in the avulsion of the volar plate from the proximal phalanx This is not a complete dislocation
Type II (dorsal dislocation): Volar plate avulsion along with separation between the accessory and proper collateral ligaments( bayonet configuration)
Type III (fracture-dislocation): An additional component of impaction fracture at the volar base of the middle phalanx makes these types of injuries are more complicated

Question 15

what are the determined of the PIP stability after reduction in type 3

Answer 15

• Stable fractures tend to involve 30% or less of the articular surface.
• Some fractures between 30% and 50% will have stability although many will not

Question 16

As long as the joint exhibits stability at 30° of
flexion or less, it can be considered stable

Answer 16

T

Question 17

unstable fracture-dislocations, are prone to long-term stiffness, flexion contracture, and functional limitations

Answer 17

T

Question 18

Almost all type I and II injuries are stable after reduction and can be
treated nonoperatively with buddy straps

Answer 18

T

Question 19

For patients with stability
but substantial discomfort, extension block splinting, preventing full
extension ofthe joint, may be helpful

Answer 19

T

Question 20

Active motion therapy should begin within 2 or 3 days of injury.

Answer 20

T

Question 21

Beginning this range of motion therapy within the splint maintains reduction while preventing painful full extension

Answer 21

T

Question 22

For stable joints with more structural injury requiring mild flexion for how long should the patient keep the splint?

Answer 22

fracture-dislocationinjuries of30% to 40%
or less, extension block splinting may be needed for up to 4 weeks

Question 23

Putting splint for 4 weeks may leed to stiffness in the PIP how you can avoid this ?

Answer 23

The splint can be set to start at 30° of flexion to provide stability and be adjusted into extension progressively (e.g., 10° per week)
so that the patient slowly gets to the full extension over 4 weeks while maintaining the range of motion in flexion within the splint

Question 24

If the fracture component risks instability with early extension, what are the option in this case?

Answer 24

the splint can be maintained in the flexed position for longer, but
no longer than 3 weeks at 20° to 30° to avoid flexion contracture

Question 25

Is there is a role for surgical fixation?

Answer 25

extension block pinning may be used. passing (K-wire) through the proximal phalanx head to structurally block full proximal interphalangeal (PIP) extension. downsides are a surgical procedure with complication risks that is not amenable to progressive straightening

Question 26

Outcomes are often disappointing even with optimal treatmen in Unstable PIPJ

Answer 26

T

Question 27

Option for unstable PIP Fracture

Answer 27

Dynamic external fixation!dynamic skeletal traction Open reduction and internalfixation K-wirefixation Volar plate arthroplasty Hemihamate osteochondral arthroplasty

Question 28

When the volar base of the middle phalanx is comminuted and unstable, but the dorsal base remains intact, reconstruction of the PIPJ is possible using a nonvascularized osteochondral graft

Answer 28

T

Question 29

Long-term outcomes of Hemihamate osteochondral arthroplasty have an average range of motion between 50° and 75° of PIP flexion

Answer 29

T

Question 30

Volar PIPJ dislocation is rare.

Answer 30

T

Question 31

volar PIPJ dislocation was from a rotatory mechanism often injures both collateral ligaments

Answer 31

F

Question 32

only one of the collateral ligaments may be injured

Answer 32

T

Question 33

whereas a dislocation after central slip rupture often injures both collateral ligaments

Answer 33

T

Question 34

a volar dislocation also injures the volar plate and extensor mechanism,

Answer 34

T

Question 35

volar dislocation management?

Answer 35

Although a volar dislocation also injures the volar plate and extensor mechanism, closed reduction is usually attainable with longitudinal traction and extension

Question 36

With rotatory injuries how you can attempt to reduce the fracture?

Answer 36

the condyle of the proximal phalanx can get interposed between the central slip and the lateral band, making reduction difficult. In this situation, flexing the PIPJ to relax the lateral band (rather than pulling traction) is necessary before recreating the rotational force to facilitate reduction

Question 37

With no central slip injury, these dislocations should be splinted for approximately 2 weeks and then put into buddy straps to facility early motion

Answer 37

T

Question 38

In the setting of a central slip rupture, 6 weeks of splinting with the PIPJ in full extension is needed

Answer 38

T

Question 39

any finger deformity associated with the central slip injury is passively correctable, splinting is often adequate

Answer 39

T

Question 40

Indication of surgery with volar dislocation

Answer 40

a larger intra-articular fracture If the deformity (i.e., boutonniere) is not passively correctable

Question 41

Forced radial or ulnar deviation of the PIPJ puts stress on the contralateral collateral ligament

Answer 41

T

Question 42

In forced radial or ulnar deviation of the PIPJ rupture occurs at the site of the distal attachment

Answer 42

Often a rupture occurs at the site of the proximal attachment on the proximal phalanx.

Question 43

More severe injuries can also disrupt the volar plate

Answer 43

T

Question 44

Longitudinal traction is usually adequate for reduction

Answer 44

T

Question 45

splinting in extension for 7 days followed by protected active range of motion with buddy straps

Answer 45

T

Question 46

Stiffness and flexion contracture are commonly encountered problems after these injuries

Answer 46

T

Question 47

Collateral stiffness is the most common etiology for loss of range of motion as well as flexion contracture

Answer 47

T Volar plate stiffness contributes as well

Question 48

Treatment of stuffness

Answer 48

First-line treatment for these findings is early aggressive therapy to restore range of motion. If this is not successful, joint release by releasing the collateral ligaments, and perhaps also the volar plate

Question 49

Even after joint release, range of motion does not return to preinjury levels. For PIPJ that remain painful and stiff, conversion to arthroplasty or arthrodesis is then considered

Answer 49

T

Question 50

Long-term instability, although less frequent,

Answer 50

T

Question 51

Instability from any cause can precipitate early degenerative arthritis. Additionally, chronic hyperextension from volar plate laxity can lead to swan-neck deformity. Unrepaired central slip injuries can result in extensor lag, and if untreated can progress to boutonniere deformity

Answer 51

T

Question 52

he finger DIPJ have added hyperextensibility compared to the PIPJ Why?

Answer 52

due to shorter and more laterally positioned checkrein ligaments

Question 53

DIPJ and thumb IPJ dislocations are rare. Often when these dislocations do occur they are associated with flexor or extensor tendon insertion injuries

Answer 53

T

Question 54

Ifan isolated DIPJ dislocation occurs, it is almost always a volar dislocation

Answer 54

F Ifan isolated DIPJ dislocation occurs, it is almost always a dorsal dislocation

Question 55

Closed dislocations splint for 1 week and then begin protected active motion in a dorsal blocking splint for an additional 3 weeks

Answer 55

T

Question 56

Stiffness and even fusion of the DIPJ and thumb IPJ is much better tolerated than at the PIPJ

Answer 56

T

Question 57

The finger metacarpophalangeal joints (MCPJ) is a diarthroidal joint

Answer 57

T

Question 58

The volar plate in MCP is stout distally but much thinner proximally. Different from the PIPJ

Answer 58

T

Question 59

hyperextension of the MCP mor than PIP why?

Answer 59

there are no checkrein ligaments on the MCPJ volar plate. This facilitates some hyperextension of the MCPJ

Question 60

The extrinsic stabilizers for MCP

Answer 60

include flexor tendons, the extensor mechanism, the sagittal bands, and the transverse intermetacarpal ligament that connects across the volar plates

Question 61

function of Sagittal Band

Answer 61

They function as the primary lateral stabilizer for the extensor tendon over the MCPJ

Question 62

The diagnosis of Sagittal band

Answer 62

is usually made clinically, but ultrasound or MRI can provide confirmation in unclear cases.

Question 63

For injuries with pain and minimal tendon instability. 4 to 6 weeks of conservative treatment in a splint that holds the affected metacarpophalangeal (MCP) neutral or mildly hyperextended

Answer 63

T

Question 64

onservative treatment is appropriate first-line treatment for most patients. Even for patients who present with longer delay,

Answer 64

T

Question 65

For athletes and very high-demand patients who present with complete dislocation what is the management?

Answer 65

early surgical intervention may be appropriate, as this facilitates primary repair of the sagittal band.

Question 66

For most patients, conservative first-line treatment is appropriate as described

Answer 66

T

Question 67

if painful subluxation or dislocation persists, then sagittal band reconstruction is appropriate to correct the abnormality

Answer 67

T

Question 68

For the MCPJ, flex as far as 60° and then test stability against radial and ulnar stress

Answer 68

T

Question 69

Finger MCPJ dislocations, when they occur, are usually dorsal or ulnar. They occur most commonly to the border digits (index or small finger)

Answer 69

T

Question 70

The thumb metacarpophalangeal joint (tMCPJ) has properties of a hinge (ginglymus) joint as well as a condyloid joint

Answer 70

T

Question 71

Most of the tMCPJ stability is from soft tissue

Answer 71

T

Question 72

stabilizing structures

Answer 72

collateral ligaments and the volar plate. the adductor pollicis inserts into the ulnar sesamoid while the flexor pollicis brevis and abductor pollicis brevis insert into the radial sesamoid

Question 73

These sesamoid attachments are at the proiximal margin of the volar plate, and provide volar stability to the tMCPJ.

Answer 73

F These sesamoid attachments are at the distal margin of the volar plate,

Question 74

from where the thump can get the lateral stabilities

Answer 74

These muscular attachments also have fibrous connections to the extensor mechanism, thereby providing lateral stability as well

Question 75

Dorsal stability is the most strong site in the MCP of the thump

Answer 75

F Dorsal stability is less stout, provided mostly by the extensor pollicis longus and brevis tendons passing over the joint, along with some strength from the joint capsule itself

Question 76

Ulnar collateral ligament (UCL) tear is the most common injury to the tMCPJ

Answer 76

T

Question 77

MOA

Answer 77

It occurs due to hyperabduction and forced radial deviation of the proximal phalanx.

Question 78

The most common injury type involves avulsion off of the distal attachment on the proximal phalanx.

Answer 78

T

Question 79

evaluating these injuries what you need to know?

Answer 79

partial from a complete tear identify any fractures a Stener lesion examine the uninjured thumb

Question 80

Partial tears and small avulsion fractures that are stable can be treated conservatively in a thumb spica splint for 4 to 6 weeks

Answer 80

T

Question 81

A complete tear should be repaired

Answer 81

T

Question 82

A Stener lesion

Answer 82

UCL is torn away from the distal attachment on the proximal phalanx and mobilizes enough to allow the adductor pollicis aponeurosis to interpose between the ligament and the insertion site

Question 83

Stener lesions can occur with an associated avulsion fracture or with the ligament alone

Answer 83

T

Question 84

Examination of ulnar collateral ligament injury ?

Answer 84

Valgus stress is placed on the joint, evaluate the amount of gapping or angulation that can be created; - If there is a firm endpoint, it is likely a partial tear; if there is no resistance, the ligament is likely completely torn -If the joint can be stressed to >35° ofangulation, complete ligament tear is likely

Question 85

How you can differentiate between proper or accessory collateral ligaments

Answer 85

* If this occurs with joint flexed, it is a proper collateral tear. * If this occurs with joint fully extended, it is an accessorycollateral tear

Question 86

If the joint can be stressed >15° more than contralateral, a complete tear is likely

Answer 86

T

Question 87

f a mass is palpable proximal to the tMCPJ, this may indicate a Stener lesion. However, the absence of this finding does not rule it out

Answer 87

T

Question 88

Evaluate X-rays because avulsion fractures are common

Answer 88

T

Question 89

Finding on Xray ?

Answer 89

avulsion fractures or not Is the avulsion displaced? More than 2 mm of displacement? * Is it proximal to the level ofthe adductor hood? Ifso, this is likely a bony Stener lesion Is 20% or more of the joint surface involved?

Question 90

Is advanced imaging necessary?

Answer 90

o Ultrasound o MRI

Question 91

the examination may not be adequate for diagnosis of the combined bony and ligamentous injury

Answer 91

T

Question 92

If the distal avulsion donor site is not clear, aim to affixing the ligament 3 mm distal to the articular surface and 3 mm dorsal to the volar cortex

Answer 92

T

Question 93

Ifthe avulsion is offof the metacarpal, aim to anchor at or dorsal to bony midline

Answer 93

T

Question 94

aka Gamekeeper's Thumb)

Answer 94

symptomatic chronic UCL pain and laxity. This can occur due to chronic overuse (i.e., game keepers) or, more commonly, inadequately treated acute UCL injuries

Question 95

Chronic Thumb MCPJ UCL Injuries Management

Answer 95

if there is tMCPJ arthritis fusion may be the proper treatment. Static reconstruction options Dynamic reconstruction options

Question 96

Static reconstruction tech ?

Answer 96

Static reconstruction options are most commonly used, involving harvesting a free tendon graft and using it to recreate the ligament via bone tunnels and tenodesis screw fixation.

Question 97

Dynamic reconstruction options tech

Answer 97

Dynamic reconstruction options include transfer of adductor pollicis or extensor pollicis brevis insertion to the base of the proximal phalanx to create ulnar pull.

Question 98

RCL injuries are more likely to occur from an axial load force

Answer 98

T

Question 99

present later than UCL why?

Answer 99

because RCL instability is not as functionally limiting as UCL instability.

Question 100

the RCL most commonly ruptures off of the distal attachment.

Answer 100

F in contrast to the UCL, the RCL most commonly ruptures off of the proximal attachment.

Question 101

Stener leasion can develope with radial collateral ligaments

Answer 101

the abductor pollicis brevis inserts more distally on the radial side, covering the RCL and generally preventing a Stener-type lesion

Question 102

check for palmar subluxation when evaluating RCL injuries, as 3 mm or more of palmar subluxation is an indication of a complete tear.

Answer 102

T

Question 103

If surgical repair ofan acute tear is pursued, recommendations include fixating the joint in 30° of flexion with a K-wire, why?

Answer 103

so the ligament repair is done on maximal tension and the adductor pollicis pull is prevented

Question 104

Most tMCPJ dislocations are dorsal,

Answer 104

T

Question 105

Most dorsal dislocations are reducible. As with other MCPJ dislocations, the maneuver should avoid longitudinal traction

Answer 105

T

Question 106

Volar tMCPJ dislocations are very rare, and in general are not reducible closed.

Answer 106

T

Question 107

the volar oblique ligament is largely believed to provide the major stabilizing force against dorsal metacarpal displacement

Answer 107

T

Question 108

Thumb CMC Dislocation all dorsal dislocations

Answer 108

T

Question 109

More commonly, these injuries are partial dislocations

Answer 109

T

Question 110

Once a CMC dislocation is identified, the reduction maneuver is relatively easy compared to other hand joints

Answer 110

T