Ligament Injuries of the Hand Flashcards
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.
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hemihamate arthroplasty indications
unstable PIP fracture/dislocation injuries with destruction of the volar base
more than 4 to
6 weeks after injury
(PIPJ) injuries are common and fall in
to three major categories
■ Dislocations
■ Avulsions
■ Fracture-dislocations
The PIPJ is a bicondylar hinge with an arc of motion of 110°
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The extensor system provides the least amount
of support, to PIP
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Lateral dislocations are most common,
F dorsal dislocations are most common,with the
middle phalanx being driven dorsally and then proximally
approach to PIPJ dislocations
■ Reduction
■ Evaluate postreduction for joint congruency through the arc of motion
■ Assess stability
Avoid multiple attempts at closed reduction
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radial/ulnar stressing to test collateral ligament stability should be done with the finger extended only
F the finger extended to test the
accessory collateral, and with the PIPJ at 30° to test the proper collateral
Evaluating joint congruency under fluoroscopy during active motion is the optimal way to test active stability
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If the joint is stable
after reduction, buddy straps/taping to facilitate early motion with
some protection is the optimal treatment
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If the subluxation or dislocation recurs with active motion what the treatment plan?
splinting in a position of stability-15° to 30° of flexion-may be required to facilitate ligament healing before allowing motion
type I and II injuries rarely require surgical treatment.
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Type of PIP dislocation
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
what are the determined of the PIP stability after reduction in type 3
- 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
As long as the joint exhibits stability at 30° of
flexion or less, it can be considered stable
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unstable fracture-dislocations, are prone to long-term stiffness, flexion contracture, and functional limitations
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Almost all type I and II injuries are stable after reduction and can be
treated nonoperatively with buddy straps
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For patients with stability
but substantial discomfort, extension block splinting, preventing full
extension ofthe joint, may be helpful
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Active motion therapy should begin within 2 or 3 days of injury.
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Beginning this range of motion therapy within the splint maintains reduction while preventing painful full extension
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For stable joints with more structural injury requiring mild flexion for how long should the patient keep the splint?
fracture-dislocationinjuries of30% to 40%
or less, extension block splinting may be needed for up to 4 weeks
Putting splint for 4 weeks may leed to stiffness in the PIP how you can avoid this ?
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
If the fracture component risks instability with early extension, what are the option in this case?
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
Is there is a role for surgical fixation?
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
Outcomes are often
disappointing even with optimal treatmen in Unstable PIPJ
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Option for unstable PIP Fracture
Dynamic external fixation!dynamic skeletal traction
Open reduction and internalfixation
K-wirefixation
Volar plate arthroplasty
Hemihamate osteochondral arthroplasty
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
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Long-term outcomes of Hemihamate osteochondral arthroplasty have an average range of motion
between 50° and 75° of PIP flexion
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Volar PIPJ dislocation is rare.
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volar PIPJ dislocation was from a rotatory mechanism often injures both collateral ligaments
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only
one of the collateral ligaments may be injured
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whereas a dislocation after central slip rupture often injures both collateral ligaments
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a volar dislocation also injures the volar plate and extensor
mechanism,
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volar dislocation management?
Although a volar dislocation also injures the volar plate and extensor
mechanism, closed reduction is usually attainable with longitudinal
traction and extension
With rotatory injuries how you can attempt to reduce the fracture?
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
With no central slip injury, these dislocations should be splinted
for approximately 2 weeks and then put into buddy straps to facility early motion
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In the setting of a central slip rupture, 6 weeks
of splinting with the PIPJ in full extension is needed
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any finger deformity associated with the central slip injury is passively correctable, splinting is often adequate
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Indication of surgery with volar dislocation
a larger intra-articular fracture
If the deformity
(i.e., boutonniere) is not passively correctable
Forced radial or ulnar deviation of the PIPJ puts stress on the contralateral collateral ligament
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In forced radial or ulnar deviation of the PIPJ rupture occurs at the site of the distal
attachment
Often a rupture occurs at the site of the proximal
attachment on the proximal phalanx.
More severe
injuries can also disrupt the volar plate
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Longitudinal traction is usually adequate for reduction
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splinting in extension for 7 days followed by
protected active range of motion with buddy straps
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Stiffness and flexion contracture
are commonly encountered problems after these injuries
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Collateral stiffness is the most common etiology for loss of range of motion as well as flexion contracture
T Volar plate stiffness
contributes as well
Treatment of stuffness
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
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
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Long-term instability, although less frequent,
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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
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he finger DIPJ have added
hyperextensibility compared to the PIPJ Why?
due to shorter and
more laterally positioned checkrein ligaments
DIPJ and thumb IPJ dislocations are rare. Often when these dislocations do occur they are associated with flexor or extensor tendon
insertion injuries
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Ifan isolated DIPJ dislocation occurs, it is almost
always a volar dislocation
F Ifan isolated DIPJ dislocation occurs, it is almost
always a dorsal dislocation
Closed dislocations splint for 1 week and
then begin protected active motion in a dorsal blocking splint for
an additional 3 weeks
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Stiffness and even fusion of the DIPJ and thumb IPJ is much better tolerated than at the PIPJ
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The finger metacarpophalangeal joints (MCPJ) is a diarthroidal
joint
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The volar plate in MCP is stout distally but much thinner proximally. Different from
the PIPJ
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hyperextension of the MCP mor than PIP why?
there are no checkrein ligaments on the MCPJ volar plate.
This facilitates some hyperextension of the MCPJ
The extrinsic stabilizers for MCP
include flexor tendons, the extensor mechanism, the sagittal bands, and the transverse intermetacarpal ligament that connects
across the volar plates
function of Sagittal Band
They function as the primary lateral stabilizer for
the extensor tendon over the MCPJ
The diagnosis of Sagittal band
is usually made clinically, but ultrasound or MRI can provide confirmation in unclear cases.
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
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onservative treatment is appropriate first-line treatment for most
patients. Even for patients who present with longer delay,
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For athletes and very high-demand patients who present with
complete dislocation what is the management?
early surgical intervention may be appropriate, as this facilitates primary repair of the sagittal band.
For most
patients, conservative first-line treatment is appropriate as described
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if painful subluxation or dislocation persists, then
sagittal band reconstruction is appropriate to correct the abnormality
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For the MCPJ, flex as far as 60° and then test stability against radial
and ulnar stress
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Finger MCPJ dislocations, when they occur, are usually dorsal or
ulnar. They occur most commonly to the border digits (index or
small finger)
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The thumb metacarpophalangeal joint (tMCPJ) has properties of a
hinge (ginglymus) joint as well as a condyloid joint
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Most of the tMCPJ stability is from soft tissue
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stabilizing structures
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
These sesamoid attachments are at the proiximal margin of the volar plate, and provide volar stability to the tMCPJ.
F These sesamoid attachments are at the distal margin of the
volar plate,
from where the thump can get the lateral stabilities
These muscular attachments also have fibrous connections to the extensor mechanism, thereby providing lateral stability as well
Dorsal stability is the most strong site in the MCP of the thump
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
Ulnar collateral ligament (UCL) tear is the most common injury to
the tMCPJ
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MOA
It occurs due to hyperabduction and forced radial
deviation of the proximal phalanx.
The most common injury type involves avulsion off of the distal attachment
on the proximal phalanx.
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evaluating these injuries what you need to know?
partial from a complete tear
identify any fractures
a Stener lesion
examine the uninjured thumb
Partial tears and small avulsion fractures that are stable can be
treated conservatively in a thumb spica splint for 4 to 6 weeks
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A complete tear should be repaired
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A Stener lesion
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
Stener lesions can occur with an associated avulsion fracture or with the ligament alone
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Examination of ulnar collateral ligament injury ?
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
How you can differentiate between proper or accessory collateral ligaments
- If this occurs with joint flexed, it is a proper collateral tear.
- If this occurs with joint fully extended, it is an accessorycollateral tear
If the joint can be stressed >15° more than contralateral, a
complete tear is likely
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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
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Evaluate X-rays because avulsion fractures are common
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Finding on Xray ?
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?
Is advanced imaging necessary?
o Ultrasound
o MRI
the examination may not be adequate for diagnosis of the combined bony and ligamentous injury
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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
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Ifthe avulsion is offof the metacarpal, aim to anchor at or dorsal to bony midline
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aka Gamekeeper’s Thumb)
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
Chronic Thumb MCPJ UCL Injuries Management
if there is tMCPJ arthritis fusion may be the proper treatment.
Static reconstruction options
Dynamic reconstruction options
Static reconstruction tech ?
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.
Dynamic reconstruction options tech
Dynamic reconstruction options include transfer of adductor pollicis or extensor pollicis brevis insertion to the base of the proximal phalanx to create ulnar pull.
RCL injuries are more likely to occur from an axial load force
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present later than UCL why?
because RCL instability is
not as functionally limiting as UCL instability.
the RCL most commonly ruptures off of the distal attachment.
F in contrast
to the UCL, the RCL most commonly ruptures off of the proximal attachment.
Stener leasion can develope with radial collateral ligaments
the abductor pollicis brevis inserts
more distally on the radial side, covering the RCL and generally
preventing a Stener-type lesion
check for palmar subluxation when evaluating RCL injuries,
as 3 mm or more of palmar subluxation is an indication of a complete tear.
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If surgical repair ofan acute tear is pursued, recommendations include fixating the joint in 30° of flexion with a K-wire,
why?
so the ligament repair is done on maximal tension and the adductor pollicis pull is prevented
Most tMCPJ dislocations are dorsal,
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Most dorsal dislocations are reducible. As with other MCPJ dislocations, the maneuver should avoid longitudinal traction
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Volar tMCPJ dislocations are very rare, and in general are not reducible closed.
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the volar
oblique ligament is largely believed to provide the major stabilizing
force against dorsal metacarpal displacement
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Thumb CMC Dislocation all dorsal dislocations
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More commonly, these injuries are partial dislocations
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Once a CMC dislocation is identified, the reduction maneuver is
relatively easy compared to other hand joints
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