Monograph 19
Hand and Finger Trauma
By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997
Copied with permission from ACAPress
Background
Injuries of the Hand and Fingers
Weakness
Stiffness
Pain
Fusiform Effusion
Fractures and Dislocations
Finger Fractures
Finger Dislocations
Thumb Dislocations
Arthrokinematics
Basic Functional Anatomy of the Thumb and Fingers
The Thumb
The Fingers
Thumb and Finger Motion
Thumb Motion
Thumb Kinesiology and Strength
Finger Motion
Finger Kinesiology and Strength
Finger Biomechanics
Commentary
Contusions and Lacerations
Fistfighter's Knuckle
Karate Lump
Aneurysms of the Hand
Tests for Damaged Tendons
Finger and Thumb StrainsContractures
Dupuytren's Contracture
Volkmann's Ischemic Contracture
of the Hand
Finger Sprains
Metacarpophalangeal and Inter-
phalangeal Sprains
Boutonniere Deformity
Mallet (Baseball) Finger
Tenosynovitis
Tenosynovitis of the Extensor
Carpi Radialis
Suppurative Tenosynovitis
De Quervain's Disease
Trigger Finger
Thumb Sprains
Video Thumb
Bowler's Thumb
Skier's Thumb
Management
Articular Therapy
Subluxations and Simple Articular Displacements
Significant Features
General Management Direction
Adjustment Technics
Metacarpal Base Posterior Subluxation
Thumb Dislocations
Structural Fixations in the Hands
Posttraumatic Exercise
References and Bibliography
Syndrome: Finger/Hand Pain Primary Suspect Disorders Numbness Angina pectoris Pancoast's tumor Carpal tunnel syndrome Reflex sympathetic dystrophy Cervical IVD protrusion Scalenus anticus syndrome Cervical rib Spinal cord tumor Cervical spondylosis Stenosing tenosynovitis Diabetic neuropathy Subluxation complex Restricted shoulder motion Adhesive capsulitis Humeral dislocation Biceps tendinitis Humeral fracture Brachial neuritis Humeral subluxation Clavicular fracture Scalenus anticus syndrome Glenoid arthritis Subacromial bursitis Interossei atrophy Arthritis Shoulder-hand syndrome Diabetic neuropathy Stenosing tenosynovitis
Joint Motion Prime Movers Accessories Metacarpophalangeal flexion Flexor pollicis brevis Flexor pollicis longus
Abductor pollicis brevisInterphalangeal flexion Flexor pollicis longus Metacarpophalangeal extens. Extensor pollicis brevis Abductor pollicis longus
Extensor pollicis longusInterphalangeal extension Extensor pollicis longus Adduction Adductor pollicis Flexor pollicis brevis (deep) Abduction Abductor pollicis brevis
Abductor pollicis longusOpposition Opponens pollicis
Opponens digiti minimi
Thumb Kinesiology and StrengthExtension. Thumb extension is provided essentially by the extensor pollicis brevis (C7-C8) at the metacarpophalangeal joint and the extensor pollicis longus (C7-C8) at the interphalangeal joint. Test strength by stabilizing the patient's wrist and having the patient extend the thumb as far as possible. Apply increasing flexion resistance and record degree. The major muscles of the thumb are shown in Table 3.
Note: Spinal innervation varies somewhat in different people. The spinal nerves listed here are averages and may differ in a particular patient; thus, an allowance of a segment above and below those listed in most text tables should be considered.
Flexion. Thumb flexion is controlled by the medial (C8, ulnar) and lateral (C6-C7, median) flexor pollicis brevis at the metacarpophalangeal joint and by the flexor pollicis longus (C8-T1) at the interphalangeal joint. Strength is tested by having the patient touch the tip of the thumb firmly against the pad below the little finger. Note the power it takes to pull the patient's thumb from flexion.
Abduction. Thumb abduction is provided by the abductor pollicis longus (C6-C7, radial) and abductor pollicis brevis (C8-T1, median). Strength is tested by stabilizing the patient wrist, especially on the ulnar side. The patient fully abducts the thumb, and, at the end of motion, the examiner increasingly applies reverse pressure.
Adduction. Adduction of the thumb is controlled by the adductor pollicis (C8-T1, ulnar). Strength is tested by stabilizing the patient's wrist along the ulnar border and having the patient adduct the thumb against the examiner's increasing resistance.
Finger Motion. Gross movements of the fingers are regulated by the extrinsic muscles of the hand, while the intrinsics control the finer movements and tend to counterbalance the extrinsics. Finger extension is associated with finger spreading, and flexion tends to draw the fingers together. See Table 4. Finger motion involves flexion and extension at the metacarpophalangeal and interphalangeal joints. Abduction and adduction occur at the metacarpophalangeal joints. Active metacarpophalangeal motion is tested by stabilizing the patient's wrist and having him extend and flex with the digits straight. Active proximal interphalangeal motion is checked by stabilizing the metacarpophalangeal joints and having the patient extend and flex the proximal interphalangeal joints.
Active distal interphalangeal movement is judged by stabilizing the proximal interphalangeal joints and having the patient extend and flex the distal interphalangeal joints. Observe finger abduction and adduction by having the patient place the hand flat and spread the fingers apart and then tight. Individual joint-motion restriction should be noted when occurring in any direction. Also test passively if necessary.
Table 3. Major Muscles of the Thumb
Muscle Major Function Spinal Segment Abductor pollicis brevis Thumb metacarpophalangeal flexion, abduction C8-T1 Abductor pollicis longus Thumb abduction and metacarpophalangeal extension C6-C7 Adductor pollicis Thumb adduction C8-T1 Extensor pollicis brevis Thumb metacarpophalangeal extension C7-C8 Extensor pollicis longus Thumb metacarpophalangeal and interphalangeal extension C7-C8 Flexor pollicis brevis Thumb adduction, metacarpophalangeal flexion C8-T1 Flexor pollicis longus Thumb metacarpophalangeal and interphalangeal flexion, abduction C8-T1 Opponens digiti minimi Opposition C8-T1 Opponens pollicis Opposition C6-C7
Table 4. Finger Motion
Joint Motion Prime Movers Accessories Metacarpophalangeal flexion Interossei, dorsal Flexor digit. Profundus Interossei, volar Flexor digit. superfic. Lumbricales Flexor digiti minimi Proximal interphalangeal flexion Flexor digitorum superficialis Flexor digit. profundus Distal interphalangeal flexion Flexor digitorum profundus Extension Extensor digitorum Extensor digiti minimi Extensor indicis Lumbricales Interossei, dorsal and volar Abduction Interossei, dorsal Abductor digiti minimi Adduction Interossei, volar
Finger Kinesiology and Strength
During contraction of the flexor digiti group, for example, the tendons move proximally, and this exerts a pull on the attached phalanges. The degree of tendon excursion decreases distally with each joint from about 1-1/2 inches at the wrist to less than half an inch at the metacarpophalangeal joint, thus determining the movement of the joint involved. The major muscles of the fingers are shown in Table 5.
Table 5. Major Muscles of the Fingers
Muscle Major Function Spinal Segment Abductor digiti minimi Abduction, flexion C8-T1 Dorsal interossei Abduction, flex proximal, extend middle and distal phalanges C8-T1 Extensor digiti minimi Extension C6-C8 Extensor digitorum Extension C6-C8 Extensor indicis Extension C7-C8 Flexor digiti minimi Flex metacarpophalangeal joint C8-T1 Flexor digiti profundus Flex metacarpophalangeal, proximal, and distal interphalangeal joints C8-T1 Flexor digiti super-
ficialisFlex metacarpophalangeal and proximal interphalangeal joints C7-T1 Lumbricales Flex metacarpophalangeal joints, extend middle and distal phalanges C7-C8 Palmar interossei Adduction, flex proximal, extend middle and distal phalanges C8-T1
Flexion. Finger flexion is essentially controlled by the lateral (C7, median) and medial (C8, ulnar) lumbricals for the metacarpophalangeal joint, the flexor digiti superficialis (C7-T1) for the proximal interphalangeal joint, and the flexor digiti profundus (C8-T1) for the distal interphalangeal joint. To test flexion strength as a whole, the patient tightly flexes the fingers with the wrist pronated while the examiner stabilizes the patient's wrist with one hand and with the active supinated hand curls his fingertips under those of the patient's. The patient's fingers are then grasped in the palm, and increasing extension pressure is applied.
Extension. Primary finger extension is provided by the extensor digitorum (C6-C8), extensor indicis (C7-C8), and extensor digiti minimi (C8- T1). Strength is tested by stabilizing the wrist in the neutral position and having the patient extend the metacarpophalangeal joints while flexing the proximal interphalangeal joints. The examiner then places the active hand on the back of the patient's proximal phalanges and increasingly applies flexion pressure.
Abduction. Finger abduction is produced by the dorsal interossei (C8-T1) and the abductor digiti minimi (C8-T1). Strength is tested by having the patient extend and fan the fingers. The examiner, using his thumb and first finger, applies increasing pressure to force any two fingers together that are being measured.
Adduction. Adduction of the fingers is controlled by the palmar interossei (C8-T1). Strength is evaluated by having the patient extend the fingers, keeping them together. The examiner slips a sheet of paper between any two fingers being tested, has the patient apply maximum pressure, and then pulls the slip of paper and notes resistance.
Bilateral grip strength is commonly tested with a dynamometer and pinch strength by a pinch meter if objective records are necessary.
Finger Biomechanics
Finger motion is less difficult to appreciate when the proximal bone of the joint is stabilized while the distal bone moves about it. For example, the axis of flexion for an interphalangeal joint is considered to be at that point not moving in relation to either involved digit.Leverage. A digit's flexor tendon lies close to the axis when that finger is extended, but it moves further from the axis during flexion. This creates better mechanical advantage because of the longer moment arm produced. Each tendon exerts tension on the end of a lever whose vector extends from the joint axis perpendicular to the tendon.
Pulleys. Each tendon is held in a sling of fibrous tissue to create a series of pulleys parallel along the finger bones. If these pulleys were absent, the tendons would bowstring between the joints during flexion and fingertip control would be lost. Another important effect of these pulleys is that when the tendon changes direction across a pulley, there is an equal and opposite reaction force at the pulley that establishes a state of equilibrium; ie, the plus and minus factors total zero.
Viscoelastic Forces. Black/Dumbleton point out that there is a distinct relationship between finger joint position and the position of more proximal joints; ie, joint motion is the effect of involuntary viscoelastic forces in addition to normal active contraction. Active wrist flexion, for example, increases the viscoelastic forces on the posterior of the digit. The result is finger extension even without active contraction of the finger extensors. Likewise, active wrist extension affects finger flexion.
CLINICAL MANAGEMENT ELECTIVES OF DIGIT STRAIN/SPRAIN1. Stage of Acute Inflammation and Active Congestion
The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:
Disinfection of open skin (eg, scratches, abrasions, etc)
Cryotherapy
Cold packs
Cold immersions
Ice massage
Vapocoolant spray
Pressure bandage
Protection (padding)
Elevation
Indirect therapy (reflex therapy)
Auriculotherapy
Meridian therapy
Spondylotherapy
Pulsed ultrasound in water
Rest
Immobilization
Rigid appliance
Strap
Plaster cast
Indicated diet modification and nutritional supplementation.
2. Stage of Passive Congestion
The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:
Alternating warm and cool hydrotherapy
Pressure bandage
Protect lesion (padding)
Indirect therapy (reflex therapy)
Passive exercise of adjacent joints
Pulsed ultrasound in water
Cryokinetics (passive exercise)
Meridian therapy
Spondylotherapy
Rest
Immobilization
Rigid appliance
Strap
Plaster cast
Indicated diet modification and nutritional supplementation.
3. Stage of Consolidation and/or Formation of Fibrinous Coagulant
The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:
Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch related trigger points
Cryokinetics (active exercise)
Moderate active range-of-motion exercises
Meridian therapy
Gentle alternating stretching
Sinusoidal current
Ultrasound in water
Vibromassage
Spondylotherapy
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Semirigid appliance
Indicated diet modification and nutritional supplementation.
4. Stage of Fibroblastic Activity and Potential Fibrosis
At this stage, causes for pain should be corrected but some local tenderness likely exists. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:
Deep heat
Articular adjustment technics
Spondylotherapy
Local vigorous vibromassage
Spray-and-stretch related trigger points
Active range-of-motion exercises without weight bearing
Negative galvanism
Ultrasound in water
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Protective strap
Indicated diet modification and nutritional supplementation.
5. Stage of Reconditioning
Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonic with static resistance
Isotonic with varied resistance
Plyometric
Aerobic
Indicated diet modification and nutritional supplementation.
COMMENTARY
Contusions and Lacerations
The hand is designed for grasping, not for hitting. Hand cuts should be quickly cleaned and examined for deep injury. Use cold, compression, and elevation as necessary to reduce edema. Take care to avoid serious hand infection from careless management of small lacerations. The hand is particularly vulnerable to infection with venous and lymphatic extension.Palm Injuries. Palm damage tends to injure skin, vessels, tendons, and nerves. Palm bruises often occur over the metacarpal heads in the glove hand of the hockey goalie, baseball player, or handball enthusiast.
Injuries of the Dorsal Aspect of the Hand. Injuries to the dorsal aspect of the hand tend to damage skin, tendons, and infrequently bones. Highly painful compression injuries can severely damage all structures. Contusions of the dorsal aspect of the hand usually come from being stepped on when down. Cleats, sticks, and skate blades, obviously, increase the severity of the injury.
Fistfighter's Knuckle. 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.Karate Lump. It is not uncommon for karate enthusiasts to scarify their hands and feet by striking a straw-covered pliable post (makiwara) in several years of practice. The result can be extensive scar-tissue development over the injured part. This commonly occurs at the dorsal aspect of the 3rd and 4th metacarpophalangeal joints. Severe pain on flexion of the 3rd finger is typical. An entrapment syndrome may be produced as infiltrative scar tissue clamps the extensor tendon. In minor injuries, transient swelling and painful metacarpophalangeal joints develop. Occasionally, hand and wrist fractures will be related. Remarkably, a large number of hands that are continually abused by such a severe form of hand conditioning show no visible soft-tissue 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 common sites are at the hook of the hamate and at the base of the thenar eminence where branches of the radial and ulnar arteries are relatively unprotected.
Tests for Damaged TendonsFlexor Digitorum Profundus Test. This sign is based on the fact that flexor digitorum profundus tendons work only in unison. The examiner should stabilize the metacarpophalangeal and interphalangeal joints in extension and have the patient flex the finger being tested at the distal interphalangeal 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 the patient's fingers in extension except for the finger being tested. The patient then flexes the tested finger at the proximal interphalangeal joint. If the patient cannot do this, the sign is positive for a cut or absent tendon.
Extensor Digitorum Communis Test. The patient is asked to flex and then extend the involved finger. The inability to extend the finger indicates 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 distal phalanx. Inability to flex the phalanx suggests an injury to the tendon of the flexor 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 interphalangeal joint of any finger being tested against resistance. If the joint cannot be 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 contractures, the examiner lets the involved metacarpophalangeal joint flex slightly, relaxing intrinsics, and moves the proximal interphalangeal joint into flexion. Full flexion of the joint shows tight intrinsics; limited flexion indicates probable contracture of the interphalangeal joint capsule. This procedure is sometimes called the retinacular test.
Finger and Thumb Strains
The most common trigger point found in the hand is that of the adductor pollicis, and the most common area of referred trigger-point pain in the hand is found at the distal 2-4 metacarpal area.
ContracturesDupuytren's Contracture. Chronic contraction of palmar fascia (and/or sometimes the plantar fascia 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 permanent, painless distortion of the little finger in one or both hands. A hereditary 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 are usually associated.
This type of contracture is painless and usually begins on the ulnar side of the hand, especially involving the ring finger. The major symptoms are deformity, itching, and late painful nodules. The major complaint is that the contracted fingers interfere with hand function. If laceration, burn, and felon are excluded, the diagnosis is most likely shoulder-hand syndrome (reflex sympathetic dystrophy), rheumatoid arthritis, chronic alcoholism, diabetes mellitus, or epilepsy. A brachial plexus lesion is infrequently the origin. To distinguish between intrinsic muscle tightness and capsule contractures, the Bunnel-Littler test should be performed.
Management Considerations. Conservative procedures include stretching exercises within a warm bath, trigger point therapy, deep heat, 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 restoration of finger extension.
The Approach of R. V. Davis. Davis described a nonsurgical approach to managing early Dupuytren's contracture. He explains, after Turek, that the pathogenesis has three stages:
(1) proliferative;
(2) involutional; and
(3) residual.
Davis believes that the pathological events possibly amenable to nonsurgical reduction of this lesion is limited to the proliferative stage." Surgery is necessary beyond the proliferative stage because as the fascia undergoes fibrosis, it thickens and contracts and pulls the meniscule fasciculi connected to the skin causing dimpling. With this fascial thickening the circulation is occluded, resulting in atrophy of the integument. This circulatory impairment interferes with the healing process, whether surgical or nonsurgical in character." The objective is "...to reduce the density of the fibrous nodules, the fibrous band of the aponeurosis, and to achieve extensibility of the components of this soft-tissue complex, with the intention of disrupting the fibrous adhesions which have formed. This may be an intractable and frustrating process, even in the first stage."
Davis' treatment plan consists of:(1) Pulsed phonophoresis of trypsin, alpha chymotrypsin, and hyaluronidase to enhance proteolytic alteration of the fibrous components with 2-5% 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 iontophoresis.
(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 components should be maintained in a neutral position with the fingers extended. "Occasionally, each day, while maintaining the fingers in the neutral position, the extensors and flexors of the fingers should be lightly contracted voluntarily to avoid stasis edema and enhance the transfer of interstitial fluids. Proteolytic agent phonophoresis may be repeated dally during the healing process." Davis believes that this procedure may be more promising in the elderly and individuals in which surgical correction is not an option. If not successful, 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 pronation and flexion deformity of the hand, atrophy of the forearm muscles, degenerative neuritis, and muscular hypertonia, which usually follows trauma. The long flexors of the digits primarily exhibit the effects of inadequate nutrition. The contracture is the result of impairment or injury to a major artery or nerve (eg, radial). The tissues below the blockage are cool, cyanotic, painful, and swollen.
Supracondylar fracture of the humerus, elbow fracture/dislocation, or hematoma causing brachial artery contusion, rupture, or obstruction are frequent origins in the upper extremity. In many instances, muscle swelling or prolonged spasm within a fascia-encased compartment and ischemia-enhanced edema cause or contribute to the disorder. The resulting necrosis leads to fibrosis and contracture. Prolonged cast pressure or prolonged tourniquet applications may be a cause. The flexor compartment of the arm has difficulty in expanding to compensate for increased internal pressure.
Management Considerations. Once the cause has been determined and corrected, conservative rehabilitative procedures should be directed to the improvement of circulation and softening of the fibrotic tissues (eg, mobilization, deep heat, galvanism, ultrasound, massage).
Finger Sprains
Finger sprains with or without avulsed fragments are frequently treated in sports care and industrial clinics. In severe acute sprain, the ligament tears and allows the bone ends to subluxate and disrupt the integrity of the joint structure. Local pain, tenderness, swelling, and motion restriction are exhibited. A previously torn ligament may predispose a joint to recurring 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 severe, and recovery is slow until ligaments tighten sufficiently to inhibit recurring subluxation.
The interphalangeal joints are also easily sprained, torn, and dislocated. 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 pain, 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 10 days.
Boutonniere Deformity. 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 traumatic etiology, it is seen as a consequence of rheumatoid arthritis, psoriatic arthritis, and 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 digitorum tendon. 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 interphalangeal extension is very limited or lost. In such an injury, small bone fragments may occur at the distal interphalangeal joint's posterior aspect.
Both phalangeal fractures and extensor tendon abnormalities may produce mallet finger. Unexpectedly, few such injuries are caused by a baseball. Most 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 basketball, 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 splinted injured finger with its neighbor may be sufficient for stability. A common procedure is to treat as a severe sprain, and apply a molded splint to the extended finger for 5 weeks. Old injuries (eg, 4-5 weeks), however, do not respond well to splinting. There is usually no need for manipulation, but a slight "milking" action massage to disperse stagnant fluids is helpful before strapping. Inspect weekly, and re-tape as is necessary for a sufficient degree of healing to take place. It is the author's opinion that operative repair seldom gives better results.
TenosynovitisTenosynovitis of the Extensor Carpi Radialis. This disorder, most often seen in individual's involved in heavy labor, closely resembles de Quervain's disease in clinical features and therapy. Pain and tenderness are focal over the tendons of the wrist extensors (radial aspect).
Suppurative Tenosynovitis. If pus collects within the sheath of a palm tendon, four characteristic 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 infection.
(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 redness progressing upward suggest a spreading infection for which referral for 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 opening and causes pain on tendon motion. Thus, this is a first dorsal extensor compartment disorder of the wrist, essentially involving the extensor pollicis brevis and abductor pollicis longus where they cross over the styloid process of the radius. The major features are pain and tenderness at the compartment, possible radiation of the pain upward in the forearm and downward in the thumb that features tendon thickening and crepitus and is aggravated by both active and passive motions (especially forced thumb tendon stretching).
De Quervain's disease is a particular type of painful stenosing tenosynovitis near the styloid process of the radius due to narrowing of the tendon sheaths of the abductor pollicis longus and brevis and the extensor pollicis brevis. Persistent irritating movements produce chronic tendinitis of the thumb extensors as they pass through the narrow tunnel on the lateral wrist. The first signs are wrist pain on movement, styloid tenderness, and tendon thickening on the dorsum of the hand at the base of the thumb. Tendon crepitus during thumb motion may exist. Repetitive wrist and thumb exercise 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, bowling, racket sports, knitting, hedge clipping, and opening a car door are difficult. A dull ache may persist at rest.
Management. Associated spinal majors will likely be found at C6-T1 and the 1st rib. Release fixations found in the fingers, wrist, elbow, shoulder, and shoulder girdle. After relaxing the tissues and adjusting the subluxated-fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7-T4 for 1-2 minutes. Treat trigger points discovered, especially those found in the wrist flexors and extensors, subscapularis, infraspinatus, and upper trapezius and latissimus dorsi muscles. Supplemental nutrients B1, B6, C, niacin, rutin, and zinc are often recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors.
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, iontophoresis with hydrocortisone, alternating current for passive exercise, tendon friction massage of involved muscles (except in the elderly). Temporary TENS is often helpful in situations of intractable pain. After the acute stage has passed, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.
Trigger Finger. Trigger finger is most often seen in the thumb, but several fingers are sometimes affected. The phrase trigger finger refers to a chronic entrapment 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 swollen sheath tends to develop a pea-like mass distal to the thickening. Activity tends to improve finger function, while rest aggravates the condition. Simple surgery remedies the situation. Thus, referral should be considered if such conservative procedures as mobilization, rest during the inflammatory stage, moist heat, and ultrasound fail to effect an adequate response within several weeks. The condition is sometimes congenitally acquired by children, in which case it may spontaneously disappear.
Thumb Sprains
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. This can produce a complete rupture requiring surgery. The thumb can also be severely jammed, causing medial or lateral sprain, when hitting with the closed fist. Grade I and some Grade II sprains respond well to conservative management, but Grade III and frequently recurring injuries should usually be referred for surgical correction.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 the digital 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 enlargement of the 3rd and 2nd fingers are frequently seen. A tender mass may be palpated, or a bony callus formation may be evident on roentgenography. The primary symptoms are tenderness, pain, and paresthesia over the course of the nerve. Tinel's sign may be positive. Changing the grip on the ball or avoiding 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.
Management
The common procedure is to treat with standard acute sprain therapy, and 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 rubber ball during recuperation helps to strengthen grip and reduce posttraumatic contractures.
ARTICULAR THERAPYSubluxations and Simple Articular Displacements. All contact sports and heavy-labor occupations have a high incidence of metacarpal fracture, but severe displacement is not common. Many finger dislocations spontaneously reduce themselves or present as subluxations. Dislocation of the proximal interphalangeal joint usually entails severe injury of the collateral ligaments and is likely to heal with an unstable, swollen, stiff joint unless proper rehabilitative therapy is applied.
Significant Features. During initial evaluation, the length of a suspected fracture or dislocation is judged by comparing the involved finger with its counterpart on the uninjured hand. Joint integrity is assessed by palpating the joint's capsule and applying axial and leverage pressure to patient tolerance. Keep in mind that while incomplete and impacted fractures may be present, associated tendon, nerve, and vascular damage is quite rare except in lacerating or crush injuries.
Comparative x-ray views of the sound limb are frequently helpful. Depending on one's expertise, roentgenography may or may not be required to analyze possible complications prior to considered reduction of finger subluxations and uncomplicated dislocations.
Complicated dislocations in which there is considerable soft-tissue separation are rarely possible to treat effectively by closed methods. In these situations, the surrounding soft tissue is usually penetrated by bone that prevents complete reduction during adjustment. Open reduction is the only solution.
General Management Direction. Articular displacements are extremely painful; thus, special care must be taken to assure that one attempt at correction is sufficient. Prior traction cannot be used as in many other adjustments; the pain is too great. Prereduction radiographs should be taken to exclude avulsions and fractures.
Follow articular correction immediately with a finger splint strapped to an adjoining finger or apply a molded splint for 3-5 weeks. Postreduction radiographs should be taken to assure correction. Treat as a severe sprain, and apply a molded splint for 4-6 weeks. Note that the index finger's metacarpophalangeal joint is extremely resistant to closed reduction and often requires surgery.
Adjustment Technics. After ruling out fracture and complications requiring referral, correction of uncomplicated (simple) finger dislocations is simply made by stabilizing the patient's hand with one hand, grasping the involved digit distal to the lesion, and applying a quick traction force (pull) distally to allow repositioning.
For good control and to avoid slippage, an alternative technic consists of placing the patient's phalanx (that distal to the injured joint) high between your index and middle finger, then gently close your hand into a fist with your thumb over your index finger. Stabilize the patient's hand with your free hand.
Simple dislocations may also be reduced by slightly increasing the deformity and using leverage (and possibly traction) to slip the distal articulation into normal position. In metacarpophalangeal dislocations, hyperextend the phalanx and apply pressure and traction at its base to quickly slip it over the metacarpal head. This is often better procedure than straight axial traction. If the displacement is superior-medial or superior-lateral, the pull and pressure should be varied accordingly.
Metacarpal Base Posterior Subluxation. A metacarpal base subluxated posteriorly is related to wrist pain aggravated by wrist flexion, excessive wrist stress, wrist ganglion, and 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. More common causes, however, are chronic contractures and other soft-tissue shortening along the anterior surface of one or more metacarpals that tend to force the metacarpal base posterior relative to its carpal articulation. Thus, unless these shortened tissue are properly treated, the secondary subluxation will tend to resubluxate shortly after an adjustment because its cause remains.
Adjustment Technic. The doctor stands on the side of involvement of the seated or supine patient. Although not always necessary, it's best that the patient's pronated wrist be placed on a firm pillow. The patient's 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 around the involved finger for stability. With his other hand, the doctor applies a pisiform contact on top of the distal phalanx of his contact thumb. Moderate 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.
Thumb Dislocations
Malpositions of the thumb often occur between the 1st metacarpal and carpal joint, and they are often difficult to detect. Sometimes they occur between the 1st metacarpal and phalangeal joint. The reduction of simple dislocation and its general management are the same as for finger dislocations. Most thumb dislocations, however, are complex; thus, orthopedic referral is recommended.Structural Fixations in the Hands. Gillet reported that extraspinal fixations in the hands are second in frequency only to those found in the feet. It was his experience that these 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 joints. Gillet states that release of these fixations, for some unknown reason, appears to have an influence on upper midthoracic fixations, especially in the T4-T6 area.
Flexion, extension, abduction, and adduction mobility restrictions can often be found at the metacarpophalangeal joints and flexion-extension restrictions at the interphalangeal joints. Correction can be achieved simply by stabilizing the proximal bone and slowly moving the distal segment against the resistance, gradually attempting to increase the range of motion to patient tolerance.
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.
Posttraumatic Exercise
General grip strength (finger flexion) can be improved by squeezing a tennis ball. General extension strength is enhanced by attempting to open a clenched fist against the loose grip of the other hand.
REFERENCES AND BIBLIOGRAPHY:
Andrews RA, Harrelson GL: Physical Rehabilitation of the Injured Athlete. Philadelphia, W.B. Saunders, 1991, pp 72, 157-158.
Barham JN, Wooten EP: Structural Kinesiology. New York, Macmillan, 1973.
Basmajian JV: Recent Advances in the Functional Anatomy of the Upper Limb. American Journal of Physical Medicine, 48:165-177, 1969.
Black J, Dumbleton JH (eds): Clinical Biomechanics. New York, Churchill-Livingston, 1980.
Bowerman JW: Radiology and Injury in Sport. New York, Appleton- Century-Crofts, 1977.
Burns JR: Extremities: Adjusting and Evaluation. Published by author, 1984.
Cailliet R: Hand Pain and Impairment. Philadelphia, F.A. Davis, 1975, pp 1-14, 68-81, 101-115.
Cailliet R: Soft Tissue Pain and Disability. Philadelphia, F.A. Davis, 1980.
Chuinard RG: The Upper Extremity: Elbow, Forearm, Wrist and Hand. In D'Ambrosia RD: Musculoskeletal Disorders: Regional Examination and Differential Diagnosis. Philadelphia, J.B. Lippincott, 1977.
Davis RV: A Non-Surgical Approach to the Management of Dupuytren's Contracture. MPI Dynamic Chiropractic, July 31, 1992.
Frankel VH, Nordin M: Basic Biomechanics of the Skeletal System. Philadelphia, Lea & Febiger, 1980.
Garrick JG, Webb DR: Sports Injuries: Diagnosis and Management. Philadelphia, W.B. Saunders, 1990, pp 130-134.
Gillet H, Liekens M: Belgian Chiropractic Research Notes. Huntington Beach, CA, Motion Palpation Institute, 1981, pp 90-91.
Griffin JE, Karselis TC: Physical Agents for Pkysical Therapists, ed 2. Springfield, Illinois, Charles C. Thomas, 1982.
Hirata I Jr: The Doctor and the Athlete, ed 2. Philadelphia, J.B. Lippincott, 1974.
Hollingshead WH, Jenkins DB: Functional Anatomy of the Limbs and Back. Philadelphia, W.B. Saunders, 1981.
Kessler RM, Hertling D (eds): Management of Common Musculoskeletal Disorders. Philadelphia, Harper & Row, 1983.
MacConaill MA, Basmajian JV: Muscles and Movements: A Basis for Human Kinesiology. Baltimore, Williams & Wilkins, 1969.
Maitland GD: Peripheral Manipulation. Boston, Butterworths, 1976.
Mennell JMcM: Joint Pain. Boston, Little, Brown, 1964.
O'Donoghue DH: Treatment of Injuries to Athletes, ed 4. Philadelphia, W.B. Saunders, 1984, 286-312.
Schneider RC, Kennedy JC, Plant ML (eds): Sports Injuries: Mechanisms, Prevention, and Treatment. Baltimore, Williams & Wilkins, 1985, pp 747-763.
Schafer RC: Chiropractic Management of Extraspinal Articular Disorders. Arlington, Virginia, American Chiropractic Association, 1989, pp 168-169, 174-178.
Schafer RC: Chiropractic Management of Sports and Recreational Injuries, ed 2. Baltimore, Williams & Wilkins, 1986, pp 395-402.
Schafer RC: Clinical Biomechanics: Musculoskeletal Actions and Reactions, ed 2. Baltimore, Williams & Wilkins, 1987, pp 681-686.
Schafer RC: Clinical Chiropractic: The Management of Pain and Disability -?Upper Body Complaints. Huntington Beach, California, The Motion Palpation Institute, 1991, pp 191-195.
Schriber WA: A Manual of Electrotherapy, ed 4.. Philadelphia, Lea & Febigcr, 1975.
Schultz AL: The Shoulder, Arm, and Hand Syndrome. Stickney, SD, Argus, 1969.
Scott WN, Nisonson B, Nicholas JA (eds): Principles of Sports Medicine. Baltimore, Williams & Wilkins, 1984, pp 178-211.
Turek SL: Orthopaedics: Principles and Their Application, ed 3. Philadelphia, J.B. Lippincott, 1977.
Viegas SF: Atypical Causes of Hand Pain. American Family Practitioner, 35(1): 167-172.
Williams JGP, Sperryn PN (eds): Sports Medicine, ed 2. Baltimore, Williams & Wilkins, 1976.
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