Orthopedic Hand Cases: A Patient's Journey, Is a Year Old a Factor?

CASE 1 A 28-year-old, right-hand-dominant male caught big air going off a jump while snowboarding for the first time. He landed awkwardly on his non-dominant left hand and immediately developed pain.
Radiographs were obtained at the slope side indicating multiple fractures in the hand (Fig. 4–1A and B).

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The most appropriate management at this time for this injury would be:

1. Short-arm splint for 6 weeks
2. Short-arm cast in intrinsic plus position for 6 weeks
3. Long-arm cast in intrinsic plus position for 6 weeks
4. Open reduction, internal fixation of all fractures

Discussion

The correct answer is (D). This patient has suffered multiple displaced metacarpal
fractures in contiguous digits. The most appropriate treatment would be an open reduction and internal fixation in order to give the patient an earlier, rehabilitative start.

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The reasons for open treatment of these contiguous fractures include which of the following?

1. Restoration of anatomy
2. Decompression of the interosseous muscles
3. Restoration of longitudinal length of metacarpals and the length–tension relationships of the intrinsic musculature
4. Restoration of the transverse arch of the hand
5. All of the above

Discussion

The correct answer is (E). The metacarpals in the hand have longitudinal arches and are arranged in the transverse arch such that the first metacarpal lies slightly volar to the second metacarpal with the apex of the arch forming at the level of the third metacarpal. In addition, the space between the metacarpals is occupied by the interossei, both the volar and dorsal. Displacement of multiple metacarpal fractures are associated with a significant degree of soft tissue swelling and are especially associated with high-energy injuries such as this one. Internal fixation of these contiguous, multiple metacarpal fractures allows for: restoration of both longitudinal and transverse arches; decompression of the interosei to reduce swelling; restoration of longitudinal length and thereby the length-tension relationship of the intrinsic muscles; and restoration of the skeletal stability which allows for early rehabilitation of the hand, optimizing his functional outcome. You notice that one of his fractures has been fixed with only interfragmentary screws while the other fractures have been fixed with plates and screws (Fig. 4–1C).

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Figure 4–1 C

Basic requirements for fixation of a tubular bone shaft fracture in the hand using only interfragmentary screws include which of the following?

1. Length of the fracture should be more than twice the diameter of the bone at the central part of the fracture.
2. The amount of bone available around the head of the screw should be at least three times the size of the screw being utilized.
3. The screws must follow the spiral of the fracture.
4. All of the above.

Discussion

The correct answer is (D). When fixing fractures with interfragmentary screws only, it is critical that they be stable enough for early motion. Interfragmentary screws, when utilized appropriately, produce interfragmentary compression thereby obviating the need for plate neutralization. To do so, the length of the fracture should be more than twice the diameter of the bone in the middle of the fracture. Furthermore, screws should be placed in the part of the bone where the amount of bone available around the screw head is three times the size of the screw head. This allows one to exert compression from the screw head during interfragmentary compression without splitting of the bone from tightening the screw. In most instances, interfragmentary screws are suitable for either long, oblique fractures, fulfilling the criteria described above, or for spiral fractures. Therefore, interfragmentary screws, which are usually placed perpendicular to the fracture line, follow the line of the spiral. Short, oblique fractures and transverse fractures are not suited for just interfragmentary screw fixation and usually require the use of a neutralization plate.

Which of the following are possible complications of such an injury and of the surgical procedure utilized for this patient?

1. Stiffness of the interphalangeal joints
2. Problems due to soft tissue irritation from the hardware
3. Extensive tendon irritation
4. Stiffness of the metacarpophalangeal joints
5. All of the above

Discussion

The correct answer is (E). Multiple metacarpal fractures as mentioned above are high-energy injuries. Every effort should be made to fix them if they are displaced and to start early rehabilitation. Failure to do so is likely to cause stiffness of the small joints in the hand. This can occur not only due to the injury itself but from: the edema of the intrinsics; the resulting atony from the injury; the loss of the length–tension relationships of the intrinsics; as well as the stiffness that can occur from swelling, bleeding, and lack of use should these fractures be treated nonoperatively. Early rehabilitation after stable internal fixation allows for the treating surgeon to minimize all of these possibilities. Plates placed over the hand, especially the metacarpals, are known to cause difficulties with tendon irritation. It is therefore critical that, after placing the plate over the dorsal aspect of the metacarpal, every effort is made to cover the metacarpal with surrounding soft tissue, namely the interosseous fascia so as to insert a layer of soft tissue between the plate and the overlying extensor mechanism. Furthermore, plates placed very distally on the metacarpals are likely to interfere with the metacarpophalangeal joint capsule causing pain and resulting in stiffness. In some studies, problems associated with symptomatic hardware after metacarpal fracture fixation are as high as 40%. However, while tendon irritation associated with metacarpal plating remains a problem, routine removal of metacarpal plates, if asymptomatic, is not

recommended. Objectives: Did you learn...? Treat for multiple metacarpal fractures?

Identify reasons for open reduction and internal fixation? Identify complications of open reduction and internal fixation? CASE 2 An 18-month-old, male child comes to your office accompanied by his parents who have recently noticed that while he is using his hand, he appears unable to extend his thumb fully (Fig. 4–2A). The child is able to use his hand very well, does not appear to be in any pain, does not cry or fuss, and his sibling does not have a similar problem. Of note, the child was born full-term, and the mother reports that she had not seen this when the child was born. The other side remains unaffected. The x-ray is shown in Figure 4–2B.

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Figure 4–2 A–B

The most likely diagnosis is:

1. Failure of development of extensive pollicis longus
2. Post-traumatic flexion contracture of the interphalangeal joint
3. Scar formation of the interphalangeal flexion crease
4. Trigger thumb
5. None of the above

Discussion

The correct answer is (D). This is a well-described and typical presentation for a trigger thumb in a child. Traditionally, trigger thumb was referred to as a congenital trigger thumb. However, there is increasing data showing that a large number of children who present with trigger thumb do not necessarily have it noted at birth. It has also been noted that developmental trigger thumb can occur in children. The exact nature of its causation remains unclear. The parents are inquiring about treatment options and are confused about what the next step in treatment should be.

The most appropriate advice to give the patient’s parents would be:

1. Nothing needs to be done
2. The child will grow out of it
3. Surgery within the next week
4. Surgery within the next month
5. Observation for 6 months, and if there is no further improvement, then consider surgery

Discussion

The correct answer is (E). Longitudinal studies on the natural history of trigger thumb suggest that most trigger thumbs that do not resolve by the age of 2 years, are likely to persist and are more likely to require surgical release. A thumb with a flexion contracture is an extremely common form of presentation, and the classical triggering with clicking and popping of the thumb in adults is not frequently noted in children. The parents are also concerned about a swelling that they noticed over the volar aspect of the thumb, and they wonder if the child is developing a cyst in this area.

After you examine the child, the most likely explanation for the swelling would be:

1. Flexor sheath ganglion
2. Hypertrophic sesamoid
3. Notta’s node
4. Subluxed metacarpophalangeal (MP) joint
5. None of the above

Discussion

The correct answer is (C). Pediatric patients with trigger thumb oftentimes will present with a localized thickening or a globular swelling over the volar aspect of the MP joint at the level of the A1 pulley. This is called a Notta’s node. It represents a thickening of the proximal pollicis longus and at the level of the A1 pulley as a response to the pulley’s stenotic condition. In most circumstances, this thickening resolves with the passage of time after the A1 pulley has been released surgically. The patient and the parents need re-assurance that this is part of the entire process, does not represent a separate, pathological process, and that resolution is commonplace after A1 pulley release. The patient returns to you at the age of 2½ years with no resolution of the thumb flexion deformity. At that stage, you elect to operatively release the A1 pulley of the thumb.

The structure which is most vulnerable to injury during the operative procedure is:

1. The flexor pollicis longus
2. The volar plate
3. The radial digital nerve
4. The ulnar digital nerve
5. All of the above

Discussion

The correct answer is (C). The radial digital nerve lies immediately subcutaneous along the MP flexion crease of the thumb. It must be noted that anatomically, when faced with the thumb in the palm up position, the flexor pollicis longus and the A1 pulley lie slightly more ulnar than would be obvious. Therefore, the incision has to be made at the MP joint flexion crease, slightly ulnar than expected. If the incision is placed a little more radial than planned, the surgeon is likely to encounter the radial digital nerve, and if not careful, the radial digital nerve which lies immediately subcutaneous is likely to get injured. The same condition applies to the adult trigger thumb release as well. During the consenting process for surgery, it is vital that patients who undergo trigger thumb release be alerted to the possibility of this occurrence, however rare. Objectives: Did you learn...? Identify the clinical presentation of trigger thumb in a child?

Treat initially for trigger thumb?

Idenfity structures at risk during surgery? CASE 3 A 24-year-old male sustained an injury to his right thumb while skiing. He was holding onto a ski pole when he fell going downhill. He immediately developed pain in the right thumb. He was seen at the mountainside and diagnosed to have a sprain. He presented to your office a week later because of ongoing pain and swelling in the thumb. Examination revealed a swollen metacarpophalangeal joint of the thumb, as well as swelling on the ulnar side of the metacarpophalangeal joint.

The most likely diagnosis is:

1. Sprain of the metacarpophalangeal joint
2. Volar plate injury
3. Gamekeeper’s thumb
4. Extensor pollicis brevis rupture

Discussion

The correct answer is (C). This is a classic mechanism of injury, and although the description of a classic gamekeeper’s thumb is a chronic injury to the ulnar collateral complex of the metacarpophalangeal joint of the thumb, in contemporary terms any injury to the ulnar collateral complex of the thumb metacarpophalangeal joint is classified as a gamekeeper’s thumb. The more contemporary name for this condition is a skier’s thumb, which implies an acute injury to the ulnar collateral complex of the thumb metacarpophalangeal joint. However, this injury can occur from various mechanisms of injury, skiing being one of them.

The pathoanatomy of gamekeeper’s thumb consists of injuries to which of the following structures?

1. Ulnar collateral complex of the metacarpophalangeal joint of the thumb
2. Volar plate junction with the ulnar collateral complex
3. Dorsal capsule
4. All of the above

Discussion

The correct answer is (D). Although classically, the description of the injury is limited to the ulnar collateral complex of the thumb, one has to remember that the ulnar collateral complex is confluent with the volar plate at the volar ulnar corner and dorsally blends in with the dorsal capsule of the metacarpophalangeal joint. Therefore, in most circumstances an injury which spans the ulnar side of the thumb includes an injury not only to the ulnar collateral ligament itself but also to the accessory collateral ligament and its confluence with the volar plate. If the injury extends dorsally, which occurs in most cases, the injury also includes the dorsal ulnar corner of the capsule of the metacarpophalangeal joint. This patient had a swelling which was noted on the ulnar side of the metacarpophalangeal joint, and upon palpation it was a localized globular swelling.

This appearance is typically associated with which of the following?

1. Stener lesion
2. Rupture of the extensor pollicis brevis
3. Rupture and proximal retraction of the volar plate
4. None of the above

Discussion

The correct answer is (A). This is the typical clinical description of a Stener lesion. A Stener lesion is an injury of the ulnar collateral complex, which includes the distal avulsion from the base of the proximal phalanx as the thumb gets radial deviation force during the act of the injury. As the deviation force continues, the ulnar collateral ligament, which has now torn off the base of the proximal phalanx, continues proximal retraction and displacement, and the thumb deviates radially. The adductor aponeurosis, which is superficial to the ulnar collateral ligament, now gets interposed between the ulnar collateral ligament and the proximal phalanx base. As a result of this, the distally avulsed ulnar collateral ligament is now superficial to the adductor aponeurosis and may sometimes be rolled upon itself giving a globular appearance, which is clinically palpable on the ulnar side of the metacarpal head. Although this appearance can signify a Stener lesion, it does not always occur, and its absence does not indicate the lack of a Stener lesion.

The most appropriate treatment for this patient would be:

1. Short-arm thumb spica cast
2. Long-arm thumb spica cast
3. Open repair of the ulnar collateral complex
4. External fixation of the metacarpophalangeal joint
5. None of the above

Discussion

The correct answer is (C). This patient has a gamekeeper’s thumb with a localized globular swelling over the metacarpal head on the ulnar side, indicating the presence of a Stener lesion. Given the pathoanatomy of the Stener lesion wherein the adductor aponeurosis is interposed between the ulnar collateral complex and the original proximal phalangeal attachment of the ligament, such an injury is highly unlikely to heal and almost inevitably leads to ongoing ulnar-sided instability of the metacarpophalangeal joint. Therefore, extraction of this ligament, re-positioning it deep to the adductor aponeurosis, and repairing it to the base of the proximal phalanx would be the most appropriate treatment so as to establish ulnar-sided stability of the metacarpophalangeal joint. Objectives: Did you learn...? Identify clinical presentation of game keepers thumb? Identify the pathoanatomy of gamekeepers thumb?

Understand the clinical description of Stener lesions? Treatment of Stener lesions? CASE 4 A 54-year-old, male banker was traveling in a bus when it jerked to a sudden stop. In an effort to stop himself from falling, he held onto the overhead bar. However, he continued to fall, and in trying to hold onto the overhead bar, he noticed immediate onset of pain in his ring finger. Thereafter, he was unable to flex it fully, immediately developed pain and swelling, and presented to your office 4 days later with a swollen and painful ring finger (Fig. 4–3B). Examination revealed a swollen finger with bruising over the pulp (Fig. 4–3A). He was able to flex his proximal interphalangeal (PIP) joint to some extent, but was unable to flex his distal interphalangeal (DIP) joint. Radiographs did not show any bony injury of the finger.

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Figure 4–3 A–B

The most likely diagnosis is:

1. Sprain of the DIP joint
2. Avulsion of the profundus tendon from its attachment to the base of the distal phalanx
3. Dislocation of the DIP joint
4. Fracture of the distal phalanx

Discussion

The correct answer is (B). This injury is also known as a “jersey finger” when the profundus tendon is detached from the base of the distal phalanx. Such patients usually present with a swollen digit and usually with bruising of the pulp. They also demonstrate lack of profundus function and the inability to flex the DIP joint. In this patient, the radiographs were unremarkable. Therefore, he does not have either a DIP dislocation or a fracture.

After evaluating the patient, the next step in management of this injury would be:

1. Gentle rehabilitation
2. Splinting for 3 weeks followed by a range of motion program
3. Open repair of the avulsed profundus tendon
4. Pinning of the DIP joint in 30 degrees of flexion
5. Primary arthrodesis of the DIP joint.

Discussion

The correct answer is (C)—early open repair of the avulsed profundus tendon. Profundus tendon avulsions are described by Leddy and Packer to be of three basic types. In type 1, the flexor tendon, which is avulsed, retracts into the palm at or proximal to the level of the A1 pulley. In type 2, the tendon is trapped at the level of the A3 pulley at the level of the PIP joint. In type 3, the tendon is usually retracted only minimally and usually lies at the level of the A4 pulley just proximal to the DIP joint. Other types include bony avulsions of the profundus tendon with a piece of the distal phalangeal base still attached to it. These usually tend to retract very minimally. In more complex types, the patient can also have avulsion of the tendon from the fragment of the bone that has also been avulsed, and in a more complex type, the distal phalangeal shaft itself can also fracture. The ideal time to repair these profundus avulsions is as soon as possible, and it appears that these are best done within the first week to 10 days. Thereafter, the musculotendinous unit undergoes a significant degree of myostatic shortening, and it may not be possible to restore the profundus tendon back to its attachment at the base of the distal phalanx, especially if the avulsion is a type 1.

Factors that adversely affect outcome of profundus avulsion include which of the following?

1. Type of avulsion
2. Time since injury
3. Presence of a bony fragment
4. Loss of vincular blood supply
5. All of the above

Discussion

The correct answer is (E). As mentioned above, outcomes are reported to be better in patients who undergo early repair, after which restoring the tendon to its attachment at the base of the distal phalanx can be extremely difficult. Furthermore, avulsions that retract to the level of the A1 or proximal to the A1 can do so only after the vincule, which supplies the tendon, are ruptured. This does affect tendon vascularity and nourishment and may adversely affect tendon healing to site of attachment. Therefore, delayed presentations and type 1 ruptures can have poorer outcomes. Furthermore, bony avulsions are likely to have better outcomes if there is a single large bony fragment, which can be restored back into its bed at the base of the distal phalanx. This is because bony healing remains a lot more predictable, and stable bony healing and fixation can be achieved to allow early mobilization. In most circumstances with the soft tissue the avulsion of the tendon without any bony fragment the tendon has to be re-attached to the base of the distal philanx either with the help of a pullout suture which is tied over a button on the dorsal aspect of the nail plate or with the help of mini-suture anchors. Biomechanical studies have shown that suture anchor repair has the same mechanical strength as a pullout suture.

Which of the following are likely associated complications of this injury?

1. Stiffness of the PIP joint
2. Stiffness of the DIP joint
3. Instability of the DIP joint
4. Nail plate deformity
5. All of the above

Discussion

The correct answer is (E). Avulsions of the profundus tendon which retract to the level of the A3 pulley or even further proximally, can compromise pull through of the FDS tendon and thereby affect flexion and extension of the PIP joint as well. This may leave the patient not only with loss of DIP flexion but may also compromise PIP flexion from the scarred tendon in the flexor sheath. Stiffness of the DIP from lack of flexion also remains a distinct possibility. In some circumstances, these patients can develop delayed instability of the DIP joint from imbalance of an extensor which is able to extend the distal phalanx in the absence of a flexor which would normally flex the distal phalanx. This instability can be disabling, and in most circumstances, once the patient develops instability, DIP arthrodesis remains a solution. Finally, patients who undergo repair of the profundus tendon with the help of a pullout suture should be cautioned preoperatively about the possibility of a dystrophic nail. This can occur if the pullout suture passes through the germinal matrix, in which case the patient may develop a dystrophic nail (Fig. 4–4). Objectives: Did you learn...? Identify the clinical presentation of avulsion of the profundus tendon? Describe the factors that affect the outcome of profundus avulsion?

Understand the complications of these injury? CASE 5 A 30-year-old male fell while he was out for a run. He landed awkwardly on his left thenar eminence sustaining an injury to this area. There were some abrasions over the base of the thenar eminence when he presented to the office 3 days later. On examination, you noted that the abrasions were healing, and you obtained a radiograph shown in Figure 4–4.

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Figure 4–4

The most likely diagnosis is:

1. Bennett’s fracture
2. Avulsion of the oblique ligament
3. Dislocation of the carpometacarpal (CMC) joint
4. None of the above

Discussion

The correct answer is (A). This injury, in which there is an intra-articular fracture at the base of the first metacarpal accompanied by subluxation of the metacarpal at the CMC joint, is called a Bennett’s fracture-dislocation. The fragment is on the volar ulnar corner, the attachment of the volar-oblique ligament at the CMC joint. The fragment itself remains in position and is not displaced. The metacarpal shaft is displaced, causing a joint subluxation or dislocation.

The deforming forces on the metacarpal include which of the following?

1. Extensor pollicis brevis
2. Abductor pollicis longus and adductor pollicis
3. Abductor pollicis brevis
4. Extensor pollicis longus
5. All of the above

Discussion

The correct answer is (B). Although the deforming force on the base of the metacarpal is the abductor pollicis longus causing subluxation of the metacarpal base at the CMC joint, the adductor pollicis also can act as a deforming force adducting the head of the metacarpal and thereby narrowing the first web space and influencing the deformity. The abductor pollicis longus has an uncontrolled pull on the first metacarpal base. These fractures are unstable and the metacarpal base can continue to subluxate or dislocate.

The most appropriate next step in the management of this patient would be which of the following?

1. Closed reduction and cast application
2. Closed reduction and splint application
3. Closed reduction and percutaneous pin fixation
4. Open reduction, internal fixation
5. All of the above

Discussion

The correct answer is (E). In fractures that are either undisplaced or minimally displaced and the joint is not subluxed to a large extent, it is possible to perform a closed reduction and a carefully molded cast or splint may be able to hold the reduction. However, due to the instability of this injury, oftentimes it is not possible to hold this injury for the 4-week period that it would take for the fracture to heal. Therefore, the most common, appropriate step would be to splint the patient in the emergency room and advise them of the possibility for surgical fixation. The choice of surgical fixation is variable and largely surgeon-dependent. There is no data to suggest the superiority of one technique over another. The simplest technique would be to perform a closed reduction and pin it such that the fracture is allowed to heal and the joint is held in the reduced position for a period of 4 to 6 weeks in a short-arm cast. The pin is then pulled, and rehabilitation commences. Open reduction internal fixation also remains a viable option. However, it does require a much larger procedure, and in situations where the fragments are extremely small, screws may not obtain an adequate purchase. In the case shown here, the fragment was large enough that it was possible to fix internally with the help of screws.

The reduction maneuver for this fracture consists of which of the following?

1. Abduction at the CMC joint
2. Pronation of the metacarpal
3. Pressure on the base of the metacarpal
4. All of the above

Discussion

The correct answer is (D). the metacarpal is displaced such that it is migrating proximally. Therefore, length has to be restored with the help of traction. Once length is restored, the metacarpal has to be brought back into the joint by placing pressure on the metacarpal base. As explained before, the adductor pollicis can cause the head of the metacarpal to adduct into the web space. Therefore, abduction allows the metacarpal base to achieve proximity with the Bennett fragment. Finally, the metacarpal must be pronated so that the fracture surfaces are allowed to approximate each other. Therefore, the correct maneuver consists of: traction; abduction of the metacarpal; pressure at the base; pronation of the metacarpal, allowing accurate approximation of fracture surfaces; and then pinning of the joint. Pinning of the fragment is not mandatory. Simply holding the joint in the reduced position so that the fragment and the parent bone are well approximated allows the fracture to unite uneventfully and the joint to be stabilized. Objectives: Did you learn...? Pinpoint the radiographic features of a Bennett’s fracture? Determine the deforming forces on the metacarpals?

Perform the reduction maneuvers for Bennett’s fractures? CASE 6 A 21-year-old male was involved in an altercation. During the course of this altercation, he struck a hard object after missing his opponent. He immediately developed pain over the ulnar side of his hand and was seen in the emergency room. X-rays are shown (Fig. 4–5A and B).

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Figure 4–5 A–B

The most likely diagnosis is:

1. Fracture of the fifth metacarpal shaft
2. Fracture of the fifth metacarpal neck
3. Dislocation of the fifth CMC joint
4. None of the above

Discussion

The correct answer is (B). This patient has sustained a fifth metacarpal neck fracture. This fracture is also known as a “boxer’s fracture.” It usually occurs from impact of the ulnar side of the hand against a hard object, leading to a sudden flexion force on the fifth metacarpal neck and distal shaft that results in a fracture of the fifth metacarpal in the very distal shaft or in the neck, with dorsal angulation of the apex. Most commonly, the patient does not have malrotation but tends to have an angulatory deformity.

A decision is made to treat the patient. Which of the following factors affect the treatment of this patient?

1. Measurement of the angulation at the fracture site
2. Presence of an open wound
3. Presence of malrotation
4. All of the above

Discussion

The correct answer is (D). Association of an open wound over a fracture dictates that the fracture should be considered an open fracture unless proven otherwise. Fractures that are open should be addressed expeditiously and emergently with irrigation and debridement of the open wound. Repair of the lacerated structures, if any, and treatment of the fracture (either with closed reduction and percutaneous pin fixation or with open reduction/internal fixation depending on the location, nature of fracture, and degree of comminution) should then be addressed. Should the injury be closed, then the degree of angulation and the presence of malrotation are essential features in decision-making. If the patient presents with malrotation, which is extremely uncommon, the fracture needs to be reduced and either pinned percutaneously or fixed internally in an open manner irrespective of the degree of angulation. In terms of angulation, these fractures are best measured on a true lateral view. A line is drawn along the axis of the distal fragment, and a line is also drawn along the axis of the proximal fragment. The angle formed by these two lines depicts the angulation at the fracture site. Any angulation in excess of 30 to 40 degrees necessitates manipulative reduction followed by either splinting or percutaneous pin fixation. A common error is to measure the angulation in an oblique view, which usually gives an erroneous impression, with magnification of the angulation leading to unnecessary manipulations. North American literature suggests that angulation in excess of 30 to 40 degrees should be manipulated closed. This is done utilizing the Jahss maneuver in which the fracture site is anesthetized with the instillation of a hematoma block, the metacarpophalangeal joint is flexed, and pressure is applied on the metacarpal head through the proximal phalanx so as to extend the metacarpal head and align it with the metacarpal shaft. The patient’s hand is then immobilized in an ulnar gutter splint, holding the finger in the correct position with the MP joint flexed 80 to 90 degrees and the IP joints straight. This is called the intrinsic plus position, and the splint usually extends onto the distal part of the forearm. Angulations of less than 30 degrees do not need manipulation and can simply be splinted and followed with radiographs on a weekly basis.

The most common complication encountered after such an injury is:

1. Avascular necrosis of the metacarpal head
2. Instability of metacarpophalangeal joint
3. Malrotation
4. Angulation apex dorsal at the fracture site

Discussion

The correct answer is (D). In most circumstances, these fractures unite in the position in which they presented in if no treatment had been carried out. This is usually an apex dorsal deformity, and in rare circumstances, patients may complain of a palmar prominence of the metacarpal head, especially during power gripping activities. Despite this angulation, most patients have very satisfactory clinical outcomes with essentially full range of motion. During the recovery period, it is not uncommon for patients to have difficulty achieving complete extension of the metacarpophalangeal joint, which does resolve with the passage of time. However, angulations which are excessive may be associated with a pseudo-claw deformity. Objectives: Did you learn...? Identify the radiographic features of a Boxers fracture? Describe complications of this injury? CASE 7 A retired, 80-year-old, Caucasian, male obstetrician is asked to see you for a painful and swollen fingertip. Three days ago, he noticed the onset of swelling and this was followed by the development of a fluctuant swelling over the dorsal aspect of the DIP joint. His primary care doctor diagnosed him with an infection and placed him on oral antibiotics. He continues to have increasing pain. There is some redness, but he denies running any fever. Of note, he is otherwise healthy apart from being hypertensive and taking hydrochlorothiazide. He denies having any other past medical history. The clinical appearance and radiograph are shown in Figure 4–6A and B.

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The mostly likely diagnosis is:

1. Acute paronychia
2. Pyoarthrosis of the DIP joint
3. Acute tophaceous gout
4. Cellulitis
5. Cutaneous wart

Discussion

The correct answer is (C). This appearance is typical of acute tophaceous gout in a patient in this age group. There is increasing evidence to show that acute tophaceous gout of the distal interphalangeal (DIP) joint is the first form of presentation in the elderly. This is typically seen in patients over the age of 70, with a pre-existing arthritic DIP joint, and who happen to be on diuretics. Gout is a disorder of purine metabolism in which there is deposition of monosodium biurate crystals in areas which are affected by arthritis. The DIP joint is one of the most commonly affected joints in the hand and therefore appears to be particularly prone to developing symptoms of acute tophaceous gout.

The most appropriate management at this stage would be to do which of the following?

1. Stop oral antibiotics and switch to intravenous antibiotics
2. Starting the patient on oral antigout medication such as allopurinol
3. Drainage of acute tophaceous gout, confirmation of the diagnosis, and starting the patient on acute gout medication such as colchicine
4. Emergent irrigation, excision, and debridement in the operating room with fusion of the DIP joint

Discussion

The correct answer is (C). Although the appearance is fairly typical and may be considered classic, it is important to confirm the diagnosis. Inflammatory markers can be elevated in gout and the uric acid levels are not always elevated. It is therefore important to acquire a fluid sample and examine it under the microscope to see the needle-shaped, negatively birefringent, monosodium biurate crystals. The technique for asipration described by Mudgal involves the placement of two large bore needles proximal to the tophaceous area without disturbing the thin, soft tissue envelope over the tophaceous area. The large bore needles allow aspiration of the material and allow the soft tissue envelope to collapse on itself. The DIP joint is then held splinted and wrapped so as to allow egress of the material. The patient is encouraged to begin soaks on a daily basis. The holes made by the needles usually don’t close for a couple days, and the saline soaks allow the material to be washed out. Gout crystals being water soluble helps in reduction of the tophus burden. After this has been done, the patient’s joint is splinted and edema control is achieved with the help of elasticated wraps. The fluid shows the presence of crystals confirming the diagnosis of gout. The patient is started on medication for his gout including colchicine and allopurinol. Eight weeks later, the patient comes in to see you, and the appearance of the digit is much better than before. However, he continues to have a painful, unstable joint, and he wonders if he can have something done so that he may be able to use the finger in a more effective fashion.

The next step in management would be which of the following?

1. QuickCast application for 8 weeks
2. Orthoplast splint application for the rest of his life
3. No active treatment required since the patient is not working
4. Arthrodesis of the DIP joint

Discussion

The correct answer is (D). The patient, albeit retired, is active and functioning. He has a painful and unstable DIP joint. Radiographs demonstrate that this joint is an extremely arthritic joint. Therefore, this joint is a nonsalvageable joint and is unlikely to have any motion that is meaningful. All these criteria make him an excellent candidate for DIP arthrodesis. Multiple techniques have been described for DIP arthrodesis including the use of wires, steel wires, and headless screws. DIP arthrodesis can be done by open techniques or by percutaneous techniques. In situations where there is no obvious deformity but there is instability and the joint is collinear, percutaneous arthrodesis is indicated. A headless screw is placed from the tip of the distal phalanx, across the DIP joint and into the medullary canal of the middle phalanx. Excellent compression is generated and, since the joint has no meaningful articular cartilage, these patients go on to develop arthrodesis over the course of the next 3 to 4 months. Percutaneous arthrodesis is a well-described technique and is suitable only for patients who have an extremely arthritic and/or painful joint without a static deformity. If the deformity of the DIP joint is fixed and noncorrectable, these patients are not suitable for percutaneous arthrodesis and need to have a formal open arthrodesis, whereby the joint surfaces are resected, the joint is realigned, and then a fusion is performed. Objectives: Did you learn...? Distinguish the clinical presentation of acute tophaceous gout? Initially treat acute tophaceous gout?

Determine definitive treatment? CASE 8 A 17-year-old male sustained an injury to his middle finger while catching a football. When examined by his coach on the field, it was felt to be a sprain, and he continued playing the game. After he finished the game, he was noted to have a finger bent at the distal interphalangeal joint, and he was unable to straighten it (Fig. 4–7). He was seen in the emergency room where x-ray showed no obvious fracture. He was then splinted and asked to see you in consultation.

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Figure 4–7

The most likely diagnosis in this situation is:

1. DIP joint dislocation
2. Flexor profundus avulsion
3. Mallet finger
4. Sprain of the DIP joint

Discussion

The correct answer is (C). This is a typical presentation of a mallet finger. A mallet finger is an injury which affects the insertion of the terminal extensor mechanism onto the base of the distal phalanx. This can present as avulsion of the tendon without a bony fragment being attached (the so-called soft tissue mallet) or there may be avulsion of a bony fragment (also known as a bony mallet). In this instance, the patient had x-rays that did not show any bony injury, so this would qualify as a soft tissue mallet. The patient is noted to have no ability to extend his DIP joint actively; however, passive extension is full. The patient wishes to continue playing football.

The most appropriate management at this time would be which of the following?

1. Application of a tip protector splint maintaining the DIP joint at neutral and the PIP joint free
2. Closed reduction and percutaneous pin fixation of the DIP joint
3. Open repair of the extensor mechanism
4. Open repair and pinning of the DIP joint

Discussion

The correct answer is (A). A soft tissue mallet, such as this one, can be treated nonoperatively. The patient’s sporting interest should not factor significantly in the decision making process. Should the patient have any degree of subluxation, which would be seen on the lateral radiograph of the finger, then the most appropriate recommendation would be to perform a closed reduction, realign the joint, and pin it. However, in this case where the lateral radiograph does not show any evidence of subluxation and there is no evidence of bony injury, such an injury can be treated effectively with a splint. There are numerous splints available for the treatment of soft tissue mallets. In the experience of this group of authors, a quick-setting, fiberglass cast application, which maintains the DIP joint at neutral and leaves the PIP joint free, is extremely effective in treating this condition. The patient and his family should be cautioned that irrespective of the duration of treatment and irrespective of the method of treatment, in most circumstances this injury heals with a slight dorsal bump and a slight droop with lack of the terminal few degrees of extension. On the day the patient comes to see you, he is accompanied by one of his colleagues who also sustained a similar injury but whose x-rays show that he has a bony avulsion of the distal phalanx base. The size of the fragment involves about 30% to 40% of the articular surface, and there is no evidence of any joint subluxation.

The most appropriate recommendation for this patient would be which of the following?

1. Open repair of the bony avulsion
2. Closed reduction and percutaneous pin fixation of the bony avulsion
3. Treatment with a splint
4. Open repair and trans-articular pinning

Discussion

The correct answer is (C). This patient has a bony avulsion. While some investigators believe that the size of the fragment is important in the decision- making about the need for internal fixation, there is no evidence to suggest that fragment size affects the long-term outcome. However, subluxation of the joint does affect long-term outcome as it promotes early degeneration. In this particular instance, the lateral radiograph does not show any evidence of subluxation. Therefore, although this patient has a bony mallet and the fragment appears to be 35% to 40% of the articular surface, this can also be treated nonoperatively. A similar cast, as applied to the other patient, is applied on this patient as well. Most bony mallets tend to heal in a more predictable fashion and over a shorter duration of time (4 weeks), whereas soft tissue mallets tend to require longer duration of splinting. It also appears that bony mallets tend to have a lesser droop and a smaller dorsal bump than soft tissue mallets. In both instances, the indications for internal fixation are the presence of subluxation of the joint. Patients who present early can have the subluxation reduced in the operating room, and the joint may be pinned, disregarding the size of the fragment and allowing the joint to heal in its anatomical position. However, should the subluxation not be reducible, a formal open reduction and joint reduction as well as internal fixation needs to be performed. Objectives: Did you learn...? Identify clinical presentation of Mallet finger? Treat Mallet finger? CASE 9 A 34-year-old female got into an altercation in a pub. During the course of the altercation, she struck a mirror sustaining a laceration to the dorsal aspect of her hand as shown in Figure 4–8. She presents to you now a few days out from the injury with difficulty in hand function. She is otherwise healthy, has no other medical problems, and has been in a splint to the fingertips.

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The most likely cause of her dysfunction is:

1. Splint-related stiffness affecting all the joints in the hand
2. Pain inhibition leading to loss of function in the hand
3. Extensor tendon lacerations of the middle and ring fingers
4. Reflex sympathetic dystrophy
5. None of the above

Discussion

The correct answer is (C). This patient has sustained a laceration across the dorsal aspect of the MP joint of the hand. When the hand is formed into a fist, the extensor tendons are immediately subcutaneous. It is therefore extremely common for any laceration in this area, which runs across the long axis of the extensor mechanism, to sever the extensor mechanism of the fingers partially if not completely. The appearance is fairly typical. In most circumstances, patients are unable to extend their fingers fully at the metacarpophalangeal joint. Should there be any doubt about the ability to extend the metacarpophalangeal joints, infiltration of local anesthetic in this area and an examination in the office can reveal the weakness of extension. The ability to maintain extension against resistance is also a good test, and patients who have partial injury will often times be unable to maintain extension against resistance, the so-called piano key sign.

You have made a clinical diagnosis of extensor tendon injury. The most appropriate form of management at this stage would be which of the following?

1. Short-arm cast with the metacarpophalangeal joints at neutral and the interphalangeal joints free
2. Short-arm cast to the fingertips with all joints at neutral
3. Exploration and open repair of affected structures
4. Dynamic splinting with early range of motion program

Discussion

The correct answer is (C). This patient has a clinical examination consistent with extensor tendon lacerations. It must be noted that weak extension is often times possible even if the laceration involves a substantial amount of the extensor tendon. Another reason to have weak extension is for the patient to be able to extend the digit through the juncturae. The juncturae attach to the extensor mechanism, and should there be a laceration proximal to the junctura, then the patient may still be able to demonstrate extension of the affected digit by using the extensor of the neighboring digit and pulling through the junctura. In this particular circumstance, the patient’s hand needs to be explored further, and the extensor mechanism needs to be repaired. The patient is taken to the operating room and the extensor mechanism of the middle and ring fingers are noted to be completely lacerated. After repair, the patient is called back to the office for a postoperative follow-up on the fifth day following surgery.

At this stage, the most appropriate form of postoperative rehabilitation and management would be which of the following?

1. Short-arm cast, MCP joints at neutral, and PIP joints free
2. Dynamic splinting with range of motion program
3. Short-arm splint with MCP joint at neutral, and PIP joints free
4. All of the above

Discussion

The correct answer is (D). While surgeon p