Contusions and Lacerations
The hand is designed for grasping, not for hitting. Hand cuts
quickly cleaned and examined for deep injury. Use cold,
elevation as necessary to reduce edema. Take care to avoid
infection from careless management of small lacerations. The hand
particularly vulnerable to infection with venous and lymphatic
Palm Injuries. Palm damage tends to injure skin,
and nerves. Palm bruises often occur over the metacarpal heads in
hand of the hockey goalie, baseball player, or handball
Injuries of the Dorsal Aspect of the Hand. Injuries to
aspect of the hand tend to damage skin, tendons, and infrequently
Highly painful compression injuries can severely damage all
Contusions of the dorsal aspect of the hand usually come from
being stepped on
when down. Cleats, sticks, and skate blades, obviously, increase
of the injury.
Two conditions are involved here that may be separate or superimposed:
Distraction of the metacarpal ligament may result in boxer's having their hands taped in full extension when the intermetacarpal ligaments are relatively slack. As the hand is flexed, the ligaments tighten and the fingers are forced into apposition, which can cause ligamentous distraction if any material becomes inserted between the fingers.
After trauma, a bursa may form over a metacarpal head and become chronically inflamed.
It is not uncommon for karate enthusiasts to scarify their
hands and feet
by striking a straw-covered pliable post (makiwara) in several
practice. The result can be extensive scar-tissue development
over the injured
part. This commonly occurs at the dorsal aspect of the 3rd and
metacarpophalangeal joints. Severe pain on flexion of the 3rd
typical. An entrapment syndrome may be produced as infiltrative
clamps the extensor tendon. In minor injuries, transient swelling
metacarpophalangeal joints develop. Occasionally, hand and wrist
will be related. Remarkably, a large number of hands that are
abused by such a severe form of hand conditioning show no visible
calcification or damage to the metacarpal heads.
Aneurysms of the Hand.
In sports where the hand is used as a bat (eg, handball,
karate) or struck
or crushed, aneurysms and thrombosis of the palm may occur. Two
are at the hook of the hamate and at the base of the thenar
branches of the radial and ulnar arteries are relatively
Tests for Damaged Tendons
Flexor Digitorum Profundus Test. This sign is based on
the fact that
flexor digitorum profundus tendons work only in unison. The
stabilize the metacarpophalangeal and interphalangeal joints in
have the patient flex the finger being tested at the distal
joint. If the patient cannot do this, the sign is positive and
indicates a cut
tendon or denervated muscle.
Flexor Digitorum Superficialis Test. To test the
integrity of the
flexor digitorum superficialis tendon, the examiner holds all of
fingers in extension except for the finger being tested. The
flexes the tested finger at the proximal interphalangeal joint.
If the patient
cannot do this, the sign is positive for a cut or absent
Extensor Digitorum Communis Test. The patient is asked
to flex and
then extend the involved finger. The inability to extend the
a lesion of that extensor digitorum communis tendon.
Pollicis Longus Test. The proximal phalanx of the
patient's thumb is
stabilized, and the patient is asked to flex and extend the
Inability to flex the phalanx suggests an injury to the tendon of
pollicis longus. Inability to extend the phalanx suggests an
injury to the
tendon of the extensor pollicis longus.
The Bunnel-Littler Test. The metacarpophalangeal joint
is held in
slight extension, and the patient tries to flex the proximal
joint of any finger being tested against resistance. If the joint
flexed in this position, it is a sign that the intrinsic muscles
are tight or
posterior capsule contractures exist.
To distinguish between intrinsic muscle tightness and capsule
the examiner lets the involved metacarpophalangeal joint flex
relaxing intrinsics, and moves the proximal interphalangeal joint
flexion. Full flexion of the joint shows tight intrinsics;
indicates probable contracture of the interphalangeal joint
procedure is sometimes called the retinacular test.
Finger and Thumb Strains
The most common trigger point found in the hand is that of the
pollicis, and the most common area of referred trigger-point pain
in the hand
is found at the distal 24 metacarpal area.
Chronic contraction of palmar fascia (and/or sometimes the
of the feet) leading to a flexion deformity of the distal palm
and digits is
most common in adult Caucasian males and gradually produces a
painless distortion of the little finger in one or both hands. A
factor is often involved, and it may be bilateral. A tense band
is felt in the
palm preceded by a tender nodular thickening that usually appears
on the ulnar
side of the palm. Involvement is usually limited to one or both
of the ring
and little fingers. Trigger points in the palmaris longus muscle
This type of contracture is painless and usually begins on the
of the hand, especially involving the ring finger. The major
deformity, itching, and late painful nodules. The major complaint
is that the
contracted fingers interfere with hand function. If laceration,
felon are excluded, the diagnosis is most likely shoulder-hand
(reflex sympathetic dystrophy), rheumatoid arthritis, chronic
diabetes mellitus, or epilepsy. A brachial plexus lesion is
origin. To distinguish between intrinsic muscle tightness and
contractures, the Bunnel-Littler test should be performed.
stretching exercises within a warm bath, trigger point therapy,
ultrasound, and active exercises of the wrist, hand, and fingers.
Supplementation with vitamin C and manganese is sometimes
beneficial. In many
cases, referral for fasciectomy is necessary for complete
The Approach of R. V. Davis.
Davis described a
to managing early Dupuytren's contracture. He explains, after
Turek, that the
pathogenesis has three stages:
(2) involutional; and
Davis believes that the pathological events
possibly amenable to
nonsurgical reduction of this lesion is limited to the
Surgery is necessary beyond the proliferative stage because as
undergoes fibrosis, it thickens and contracts and pulls the
fasciculi connected to the skin causing dimpling. With this
the circulation is occluded, resulting in atrophy of the
circulatory impairment interferes with the healing process,
or nonsurgical in character." The objective is "...to reduce the
the fibrous nodules, the fibrous band of the aponeurosis, and to
extensibility of the components of this soft-tissue complex, with
intention of disrupting the fibrous adhesions which have formed.
This may be
an intractable and frustrating process, even in the first
Davis' treatment plan consists of:
(1) Pulsed phonophoresis of trypsin, alpha chymotrypsin, and hyaluronidase to enhance proteolytic
alteration of the fibrous components with 25% lidocaine ointment in the coupling medium. Because these
compounds have relatively large molecular weights, explains
Davis, the agents will likely transfer more effectively by phonophoresis than
(2) Forceful extension of the involved fingers to attempt rupture of the skin and
contracted fascia. He warns that this may be painful. This forced extension of the involved fingers follows conditioning consisting of pulsed proteolytic enzyme/lidocaine phonophoresis using low-watt output approximately 0.75w/cm2,
or less, for 10 minutes. Several extension repetitions are usually required.
During the healing process, states Davis, the hand/finger
be maintained in a neutral position with the fingers extended.
each day, while maintaining the fingers in the neutral position,
and flexors of the fingers should be lightly contracted
voluntarily to avoid
stasis edema and enhance the transfer of interstitial fluids.
agent phonophoresis may be repeated dally during the healing
believes that this procedure may be more promising in the elderly
individuals in which surgical correction is not an option. If not
referral for surgical correction is necessary for correction.
Volkmann's Ischemic Contracture of the Hand.
This condition (postischemic fibrosis) may appear in either
the upper or
lower extremity. In the upper extremity, it grossly features
flexion deformity of the hand, atrophy of the forearm muscles,
neuritis, and muscular hypertonia, which usually follows trauma.
flexors of the digits primarily exhibit the effects of inadequate
The contracture is the result of impairment or injury to a major
nerve (eg, radial). The tissues below the blockage are cool,
painful, and swollen.
Supracondylar fracture of the humerus, elbow
hematoma causing brachial artery contusion, rupture, or
frequent origins in the upper extremity. In many instances,
muscle swelling or
prolonged spasm within a fascia-encased compartment and
edema cause or contribute to the disorder. The resulting necrosis
fibrosis and contracture. Prolonged cast pressure or prolonged
applications may be a cause. The flexor compartment of the arm
in expanding to compensate for increased internal pressure.
Once the cause has been
corrected, conservative rehabilitative procedures should be
directed to the
improvement of circulation and softening of the fibrotic tissues
mobilization, deep heat, galvanism, ultrasound, massage).
Finger sprains with or without avulsed fragments are
frequently treated in
sports care and industrial clinics. In severe acute sprain, the
and allows the bone ends to subluxate and disrupt the integrity
of the joint
structure. Local pain, tenderness, swelling, and motion
exhibited. A previously torn ligament may predispose a joint to
luxation because of laxity of the stabilizers and straps.
Metacarpophalangeal and Interphalangeal Sprains.
Metacarpophalangeal injury usually occurs from sudden
hyperextension or a
severe lateral force. Subluxation, pain, and disability are often
recovery is slow until ligaments tighten sufficiently to inhibit
The interphalangeal joints are also easily sprained, torn, and
This is due to their thin capsules, delicate collateral
ligaments, and slender
articulations. In acute sprain, the ligament tears and allow the
bone ends to
subluxate and disrupt the integrity of the joint structure. Local
tenderness, swelling, and motion restriction exhibit.
Management Considerations. A sprained finger joint usually produces painful tears of a collateral ligament, and capsulitis is a common complication. The common procedure is to immobilize in moderate flexion, and
treat as a severe sprain. Graduated exercises may begin in about
This classic deformity consists of:
(1) metacarpophalangeal hyperextension,
(2) proximal interphalangeal flexion, and
(3) distal interphalangeal hyperextension. Pain and swelling may be associated. The initial
injury mechanism is usually severe finger flexion causing proximal interphalangeal
joint disruption leading to severe contractures. Besides a
it is seen as a consequence of rheumatoid arthritis, psoriatic
systemic lupus erythematosus.
Management Considerations. Conservative care is frequently effective when trauma is the origin. Cold should be applied throughout the inflammatory stage. Once pain and swelling have been controlled, a common procedure is to
immobilize the involved proximal interphalangeal joint(s) in full extension for 2 months or more. This is followed by night splints for another 2 months. Splinting should continue until there is full joint extension and nearly half
of normal flexion. If an extension deficit remains, surgical referral should be considered.
Mallet (Baseball) Finger.
A hard object may strike a finger and injure an extensor
This can avulse the tendon from its insertion at the posterior
base of the
terminal phalanx. The jammed distal phalanx assumes a position
near 70 and
appears "dropped" and is rigidly flexed. Active distal
extension is very limited or lost. In such an injury, small bone
occur at the distal interphalangeal joint's posterior aspect.
Both phalangeal fractures and extensor tendon abnormalities
mallet finger. Unexpectedly, few such injuries are caused by a
are the result of a finger striking the ground or a hard object.
In fact, the
incidence of such injuries in baseball is far below those seen in
volleyball, football, and soccer.
Management Considerations. If severe fracture is ruled
out and the
range of joint motion is normal, a simple strapping of the
finger with its neighbor may be sufficient for stability. A
is to treat as a severe sprain, and apply a molded splint to the
finger for 5 weeks. Old injuries (eg, 45 weeks), however, do not
to splinting. There is usually no need for manipulation, but a
"milking" action massage to disperse stagnant fluids is helpful
strapping. Inspect weekly, and re-tape as is necessary for a
of healing to take place. It is the author's opinion that
seldom gives better results.
Tenosynovitis of the Extensor Carpi Radialis.
This disorder, most often seen in individual's involved in
closely resembles de Quervain's disease in clinical features and
and tenderness are focal over the tendons of the wrist extensors
If pus collects within the sheath of a palm tendon, four
features (Karavel's cardinal points) are witnessed:
(1) The finger is carried
in slight flexion for comfort.
(2) The finger is swollen in its entire
circumference in contrast to swelling from a localized
(3) Pain is
increased during involved finger extension. And
(4) marked pain is felt along
the course of the inflamed tendon sheath. Signs of warmth and
progressing upward suggest a spreading infection for which
antibiotics is usually indicated.
De Quervain's Disease.
This is a state of stenosing tenosynovitis of the thumb
abductors in which
inflammation of the synovial lining of the tunnel narrows the
causes pain on tendon motion. Thus, this is a first dorsal
compartment disorder of the wrist, essentially involving the
brevis and abductor pollicis longus where they cross over the
of the radius. The major features are pain and tenderness at the
possible radiation of the pain upward in the forearm and downward
in the thumb
that features tendon thickening and crepitus and is aggravated by
and passive motions (especially forced thumb tendon
De Quervain's disease is a particular type of painful
tenosynovitis near the styloid process of the radius due to
narrowing of the
tendon sheaths of the abductor pollicis longus and brevis and the
pollicis brevis. Persistent irritating movements produce chronic
the thumb extensors as they pass through the narrow tunnel on the
wrist. The first signs are wrist pain on movement, styloid
tendon thickening on the dorsum of the hand at the base of the
crepitus during thumb motion may exist. Repetitive wrist and
usually initiates the pain, which is perceived in the distal
radius. Turning a
key in a lock, unscrewing the lid of a jaw, piano playing, golf,
racket sports, knitting, hedge clipping, and opening a car door
A dull ache may persist at rest.
Management. Associated spinal majors will likely be
found at C6T1
and the 1st rib. Release fixations found in the fingers, wrist,
shoulder, and shoulder girdle. After relaxing the tissues and
subluxated-fixated segments, apply deep low-velocity percussion
spondylotherapy over segments C7T4 for 12 minutes. Treat
discovered, especially those found in the wrist flexors and
subscapularis, infraspinatus, and upper trapezius and latissimus
muscles. Supplemental nutrients B1, B6, C, niacin, rutin, and
zinc are often
recommended. Counsel the patient to avoid appropriate antivitamin
Other helpful forms of treatment include rest, cryotherapy,
and spray-and-stretch therapy for trigger points during the acute stage,
followed by moist
heat or pulsed diathermy, warm whirlpool hand baths,
hydrocortisone, alternating current for passive exercise, tendon
massage of involved muscles (except in the elderly). Temporary
TENS is often
helpful in situations of intractable pain. After the acute stage
demonstrate therapeutic exercises to strengthen weak muscles
and/or stretch contractures.
Trigger finger is most often seen in the thumb, but several
sometimes affected. The phrase trigger finger refers to a chronic
syndrome produced by scar tissue compressing an extensor tendon.
It is often a
consequence of de Quervain's disease. The involved finger tends
to "snap" and
sometimes lock at the metacarpophalangeal joint, which is usually
sheath tends to develop a pea-like mass distal to the thickening.
tends to improve finger function, while rest aggravates the
surgery remedies the situation. Thus, referral should be
considered if such
conservative procedures as mobilization, rest during the
moist heat, and ultrasound fail to effect an adequate response
weeks. The condition is sometimes congenitally acquired by
children, in which
case it may spontaneously disappear.
A severe sprain can occur to the inner thumb from a fall when
the thumb is
aimed outward or caught in someone's clothing during activity.
produce a complete rupture requiring surgery. The thumb can also
jammed, causing medial or lateral sprain, when hitting with the
Grade I and some Grade II sprains respond well to conservative
Grade III and frequently recurring injuries should usually be
Video Thumb. Chronic sprain associated with forearm supinator strain is quite common among video game players. Thumb pinch strength is greatly reduced, the thumb is unstable because of the ligamentous laxity, local tenderness is present, and there is often joint effusion.
Bowler's Thumb. Ulnovolar neuroma (bowler's thumb) can result from trauma to
nerve from the edge of the thumb hole in the bowling ball against
the web side
of the thumb. After repeated bowling, fibrous proliferation and
the 3rd and 2nd fingers are frequently seen. A tender mass may be
a bony callus formation may be evident on roentgenography. The
symptoms are tenderness, pain, and paresthesia over the course of
Tinel's sign may be positive. Changing the grip on the ball or
bowling is the major consideration in preventive therapy.
Skier's Thumb. A rupture to the ulnar or radial collateral ligaments of the thumb may occur during a fall when the handle of a ski pole or the leather loop of a women's purse is wrapped around the thumb. Subluxation of the proximal phalanx is likely associated.
The common procedure is to treat with standard acute sprain
then strap with a figure-8 bandage using half-inch tape. As soon
as the acute
stage passes, advise several hot soaks a day to "flood" the
thenar muscles and
help prevent joint stiffness or a "glass thumb." Squeezing a
during recuperation helps to strengthen grip and reduce
Subluxations and Simple Articular Displacements. All contact sports and heavy-labor occupations have a high
metacarpal fracture, but severe displacement is not common. Many
dislocations spontaneously reduce themselves or present as
Dislocation of the proximal interphalangeal joint usually entails
injury of the collateral ligaments and is likely to heal with an
swollen, stiff joint unless proper rehabilitative therapy is
Significant Features. During initial evaluation, the length of a suspected fracture
dislocation is judged by comparing the involved finger with its
the uninjured hand. Joint integrity is assessed by palpating the
capsule and applying axial and leverage pressure to patient
tolerance. Keep in
mind that while incomplete and impacted fractures may be present,
tendon, nerve, and vascular damage is quite rare except in
lacerating or crush
Comparative x-ray views of the sound limb are frequently
on one's expertise, roentgenography may or may not be required to
possible complications prior to considered reduction of finger
and uncomplicated dislocations.
Complicated dislocations in which there is considerable
separation are rarely possible to treat effectively by closed
these situations, the surrounding soft tissue is usually
penetrated by bone
that prevents complete reduction during adjustment. Open
reduction is the only
General Management Direction.
Articular displacements are extremely painful; thus, special
care must be
taken to assure that one attempt at correction is sufficient.
cannot be used as in many other adjustments; the pain is too
Prereduction radiographs should be taken to exclude avulsions and
Follow articular correction immediately with a finger splint
strapped to an
adjoining finger or apply a molded splint for 35 weeks.
radiographs should be taken to assure correction. Treat as a
and apply a molded splint for 46 weeks. Note that the index
metacarpophalangeal joint is extremely resistant to closed
reduction and often
Adjustment Technics. After ruling out fracture and complications requiring
of uncomplicated (simple) finger dislocations is simply made by
the patient's hand with one hand, grasping the involved digit
distal to the
lesion, and applying a quick traction force (pull) distally to
For good control and to avoid slippage, an alternative technic
placing the patient's phalanx (that distal to the injured joint)
your index and middle finger, then gently close your hand into a
your thumb over your index finger. Stabilize the patient's hand
with your free
Simple dislocations may also be reduced by slightly increasing
deformity and using leverage (and possibly traction) to slip the
articulation into normal position. In metacarpophalangeal
hyperextend the phalanx and apply pressure and traction at its
base to quickly
slip it over the metacarpal head. This is often better procedure
axial traction. If the displacement is superior-medial or
the pull and pressure should be varied accordingly.
Metacarpal Base Posterior Subluxation. A metacarpal base subluxated posteriorly is related to wrist
aggravated by wrist flexion, excessive wrist stress, wrist
restricted wrist extension. Any blow to the heel of the hand
(such as catching
a baseball low in the palm) may produce an acute subluxation.
causes, however, are chronic contractures and other soft-tissue
along the anterior surface of one or more metacarpals that tend
to force the
metacarpal base posterior relative to its carpal articulation.
these shortened tissue are properly treated, the secondary
tend to resubluxate shortly after an adjustment because its cause
Adjustment Technic. The doctor stands on the side of
the seated or supine patient. Although not always necessary, it's
the patient's pronated wrist be placed on a firm pillow. The
involved digit is grasped with the contact hand so the thumb
rests on the
proximal head of the metacarpal and the doctor's fingers wrap
involved finger for stability. With his other hand, the doctor
pisiform contact on top of the distal phalanx of his contact
distal traction is made with the contact fingers and a short,
quick thrust is
aimed downward by extending and adducting the elbows. As the
thrust is made,
the patient's wrist will dorsiflex.
Malpositions of the thumb often occur between the 1st
metacarpal and carpal
joint, and they are often difficult to detect. Sometimes they
the 1st metacarpal and phalangeal joint. The reduction of simple
and its general management are the same as for finger
dislocations. Most thumb
dislocations, however, are complex; thus, orthopedic referral is
Structural Fixations in the Hands. Gillet reported that extraspinal fixations in the hands are
frequency only to those found in the feet. It was his experience
fixations are common in "hand laborers" who must grasp their
tools tightly for
extended periods. This tends to form a pseudo "claw hand" even
during rest. If
this is the case, extension will be resisted at the involved
states that release of these fixations, for some unknown reason,
have an influence on upper midthoracic fixations, especially in
Flexion, extension, abduction, and adduction mobility
often be found at the metacarpophalangeal joints and
restrictions at the interphalangeal joints. Correction can be
by stabilizing the proximal bone and slowly moving the distal
the resistance, gradually attempting to increase the range of
Note: From this author's experience, it is not usually advisable to attempt to release any chronic fixation that is the product of degenerative or inflammatory pathology (eg, rheumatic, gouty, or septic arthritis). In these
conditions, any form of passive manipulation tends to increase the inflammatory reaction and the patient's pain. However, slow active stretching exercises (without resistance) conducted within a warm whirlpool bath or immediately after the application of any form of therapeutic heat tends to increase mobility somewhat. In many of these conditions, the
local expression in the hand(s) is only a manifestation of a systemic disorder that must be given priority concern during treatment.
General grip strength (finger flexion) can be improved by
tennis ball. General extension strength is enhanced by attempting
to open a
clenched fist against the loose grip of the other hand.
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