Monograph 19 ~ HAND AND FINGER TRAUMA
 
   
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 Strains
Contractures
    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





The hand is the least protected and most active part of the upper extremity. Thus, it is easily injured. Aside from vulnerability to trauma, the hand often discloses important clues to remote and systemic disorders.



     BACKGROUND

Injuries of the Hand and Fingers

The priority concerns in diagnosis of ailments involving the hands are determining the cause of existing weakness, stiffness, pain, swelling, and deformity.

Weakness.   Differentiation must be made between trauma-related weakness and weakness associated with pathology. If the weakness exhibited is associated with pain, the radial nerve can be excluded because it lacks significant sensory fibers in the hand. Hand weakness progressing to paralysis with repetitive muscle contractions suggests myasthenia gravis. Chronic neuropathic hand weakness is often a part of the clinical picture of diabetes mellitus.

The absence of weakness in the hands is also significant when weakness exists elsewhere. Selective proximal weakness excluding the hands, forearms, and lower legs, for example, suggests cancer or an endocrine myopathy (eg, adrenal insufficiency, hyperthyroidism, hypothyroidism, or Cushing's syndrome).

Stiffness.   Elderly patients with advanced osteoarthritis report that initial morning stiffness becomes painful with daily activity. Patients with early rheumatoid arthritis or just suffering from hand myalgia will complain of hand and finger stiffness in the morning that eases with activity.

Pain.   The location of hand pain frequently points to the nerve involved if neuropathy is present. Note, however, that the cause may be at any point from the thumb to the cervical cord. The median nerve supplies the radial side of the palm and the thenar muscles. Pain radiating to the ulnar aspect of the hand and the ring and little fingers is characteristic of an ulnar nerve lesion. Differentiation aids in the diagnosis of painful syndromes of the hand are shown in Table 1.

Fusiform Effusion.   A palpable fusiform effusion at the proximal interphalangeal finger joints may be centered on the joint and symmetrical on both sides. Even if signs of osseous change are not evident in x-ray films, this fusiform effusion shows that a strong rheumatic diathesis exists.


Table 1. Hand/Finger Pain and Associated Symptoms

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




     FRACTURES AND DISLOCATIONS

Work injuries, home accidents, and sports account for a high incidence of metacarpal fractures, but severe displacements are not common. Fracture symptoms mimic severe sprain plus abnormal bone or joint contour.

Finger Fractures.   During examination, remember that crepitus is not always exhibited in finger fractures and fracture symptoms can mimic severe sprain plus abnormal bone or joint contour. A fracture of a proximal phalanx tends to displace anteriorly in an angular fashion because of lumbrical pull. A rotated phalanx, often noted by a nail's relationship with its neighbors, is an indication of fracture.

Fistfighter's Dislocation-Fracture.   A fracture of the 4th and/or 5th metacarpal, especially at the bone's neck, is often called a "fighter's" dislocation-fracture. The bone's head and neck are often pushed into the palm. This is most often seen in the bare-knuckled fighter or during riots rather than with the gloved boxer who commonly suffers a fracture at the proximal third of the 1st metacarpal.

Finger Dislocations.   Many finger dislocations will spontaneously reduce themselves. Dislocation of the proximal interphalangeal joint may entail severe injury of the collateral ligaments and is likely to heal with an unstable, swollen, stiff joint.

During on-field evaluation, bone length of a suspected fractured or dislocated digit can be judged by comparing it with the patient's uninjured hand. Check by applying axial and leverage pressure to patient tolerance. Keep in mind that incomplete and impacted fractures may be present, yet associated tendon, nerve, or vascular damage is infrequent.

Comparative x-ray views of the sound limb can be helpful. Depending on one's expertise, roentgenography may or may not be required to analyze possible complications prior to considered reduction.

Thumb Dislocations.   A fracture of a proximal thumb phalanx tends to displace anteriorly in an angular fashion because of lumbrical pull. A rotated phalanx, often noted by a nail's relationship with its neighbors, is an indication of fracture.



     ARTHROKINEMATICS

Basic Functional Anatomy of the Thumb and Fingers

The Thumb.   The metacarpal of the thumb conforms to the articular surface of the trapezium. This saddle joint allows a wide range of mobility in all directions so that the pad of the thumb can appose any finger pad. The two sesamoids of the flexor pollicis brevis ride on two eminences on the volar surface of the 1st metacarpal. These protect the joint between the thumb's 1st metacarpal and proximal phalanx.

The Fingers.   All reciprocally concave-convex metacarpophalangeal joints are freely movable with the exception of abduction and adduction. The convex metacarpal heads fit snugly against the shallow sockets of the proximal phalanges. The interphalangeal joints are true hinge joints that allow considerable flexion but only slight hyperextension. The carpal-metacarpal articulations in the fingers are fortified by individual complex ligamentous apparatus surrounding each joint in all directions. This tends to restrict carpometacarpal motion.

Finger motion is versatile because of the dynamic balance between muscles and tendons that creates an equilibrium of static and dynamic forces. This is an excellent example of viscoelastic forces that resist tendon-unit lengthening. The components involved are the fascia, tendon sheath, perimyseum, joint capsule, and joint inertia. If the viscoelastic forces on the anterior aspect exceed those on the posterior aspect and the extensors relax, for example, the digit flexes.


Thumb and Finger Motion

Thumb Motion.   The thumb is capable of metacarpophalangeal flexion and extension, and interphalangeal flexion and extension. Abduction and adduction occur at the carpometacarpal joint. See Table 2.

The examiner can observe active overall thumb flexion, extension, abduction and adduction by having the patient touch the tip of his thumb to the base of his little finger, to each fingertip, then extending the thumb as far as possible laterally. If joint restriction is noted, check both joints passively.


Table 2. Thumb Motion

Joint Motion Prime Movers Accessories
Metacarpophalangeal flexion Flexor pollicis brevis Flexor pollicis longus
Abductor pollicis brevis
Interphalangeal flexion Flexor pollicis longus  
Metacarpophalangeal extens. Extensor pollicis brevis Abductor pollicis longus
Extensor pollicis longus
Interphalangeal extension Extensor pollicis longus  
Adduction Adductor pollicis Flexor pollicis brevis (deep)
Abduction Abductor pollicis brevis
Abductor pollicis longus
 
Opposition Opponens pollicis
Opponens digiti minimi
 



Thumb Kinesiology and Strength

Extension.   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-
ficialis
Flex 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/SPRAIN

1. 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 Tendons

Flexor 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.

Contractures

Dupuytren'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.


Tenosynovitis

Tenosynovitis 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 Considerations.   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 THERAPY

Subluxations 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.


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