Elbow, Wrist, and Hand

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Elbow, Wrist, and Hand
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Patient Presentation

• A 10 year old patient fell off monkey bars and
  braced his fall with an outstretched arm
• He is grabbing his elbow close to him and appears
  in severe pain
• What do you do next?

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Highest on Differential List

• Posterior Dislocation
• Fracture including supracondylar fracture
• Soft Tissue Injury

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Check for deformity
INJURY EVALUATION
Check neuro- vascular status
Attempt to determine the mechanism
Determine need for x-rays
-Relocate? - Refer? - Radiograph?
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Radiography of the Elbow

• Trauma evaluation of the elbow should include
• A-P in full extension (if possible)
• 90 degree flexed lateral view
• both obliques
• an axial view with elbow flexed to 110 degrees
  and beam angled 45 degrees
• Special views include
• stress view performed supine with arm off table
  (gravity stress)
• radial head-capitellum view
• cubital tunnel view

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Dislocation of the Elbow

• Most often posterior due to hyperextension
  injury
• Posterior (and often lateral) displacement of the
  ulna and radius on the humerus
• Damage to the UCL, anterior capsule, and
  brachialis muscle
• Apply ice, splint, check neurovascular status
  refer for x-rays and treatment
• Immobilization is usually for a number of weeks
• Movement of the arm after immobilization must
  not be passive always active movement
• Complications include myositis ossificans, scar
  tissue formation, and ulnar nerve damage

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Supracondylar Fractures

• Injury occurs in children under age of 12
• May look like a dislocated elbow do not try to
  relocate an apparent dislocation without x-rays
• At time of injury arm is splinted and
  neurovascular status is checked (especially
  median)
• Usually there is rapid swelling which may lead
  to Volkmanns ischemic contracture
• Refer for immediate orthopedic consultation
• Fracture occurs with a fall on hand of
  outstretched arm or with severe valgus force or
  direct blow
• Pronation and supination are usually very
  painful x-ray for fracture, however, fat pad
  sign may be only indicator
• Sling or posterior splint for 3-4 weeks unless
  severely fragmented or displaced

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Volkmanns Ischemic Contracture
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Radial Head Fracture

• Mechanism
• Fracture occurs with
• fall on outstretched hand
• severe valgus force
• direct blow
• Evaluation
• Significant pain on pronation and supination
• X-ray to determine fracture (include
  radio-capitellum view), however, fat pad sign may
  be only indicator
• Treatment
• Sling or posterior splint for 3-4 weeks unless
  severely fragmented or displaced

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Nursemaids Elbow

• Mechanism
• Sudden jerking or swinging child (ages 2-4) by
  arms may cause damage or entrapment of the
  annular ligament
• Evaluation
• Significant pain on pronation and supination
• Palpation may reveal malpositioned radial head
• Treatment
• Reduction through flexion and rotation

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Patient Presentation

• A 20 year old patient is active in sports, in
  particular, baseball
• He has pain at his medial elbow made worse by
  throwing
• What do you do next?

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Static Stability of the Elbow

• Medial stability - anterior oblique UCL
• Ant. oblique tight in extension posterior -
  flexion
• Lateral stability - lateral ulnar collateral
  lig. (LUCL)
• Sectioning/rupture of LUCL causes a pivot shift
  of the humeroulnar joint
• The anconeus muscle is a major lateral
  stabilizer
• Medial stabilization also from pronator/flexor
  group lateral assistance from the extensor wad

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Ulnar Collateral Ligament Sprain

• Occurs with pitching, hitting forehand stroke in
  tennis, the training arm of batters, arm
  wrestling, and collegiate wrestling
• With throwing pain may be sudden, sharp, and
  often with a popping sound
• Pain is increased with valgus testing
• Chronic stress may lead to calcification of the
  UCL

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Medial Stretch Injury

• Damage to the ulnar nerve
• Strain of the flexor/pronator muscle group
• Sprain of the anterior oblique portion of the
  ulnar collateral ligament
• Strain and avulsion of the epicondyle
• Inflammation of the joint capsule medially

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Medial Epicondylitis

• Often referred to as Little League elbow occurs
  in 9-12 year olds
• In the adult, golfers elbow is the common
  diagnostic tag injury due to throwing club down
  at ball
• Swimmers elbow is another example improper
  pull-through mechanics with the backstroke

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Ulnar Nerve Problems

• Compression or irritation by fibrous cubital
  tunnel
• Muscular hypertrophy of the flexor carpi
  ulnaris
• Subluxation out of the groove

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Lateral Compression Injury

• Lateral compression due to a valgus force may
  lead to
• articular cartilage damage at the distal humerus
• osteocartilagenous lesion of the radial head
  which may lead to loose bodies
• If progressive occurring during growth phase,
  permanent damage is likely with some severe
  restrictions in movement
• Diagnosis made with radiographs (capitellum view)

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Little Leaguers Elbow

• Includes soft tissue and osseous injury
• Pt. presents with medial pain made worse by
  pitching, passive extension of the fingers/wrist,
  limitation of complete extension and occasionally
  a popping sound
• Radiographs may show accelerated growth,
  separation or fragmentation of the medial
  epiocondylar epiphysis
• Little League rules should be enforced and no
  curves or breaking pitches should be allowed in
  the 9-14 age group
• Fracture displaced more than 1 cm needs surgical
  repair

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Osteochondritis Dissecans
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Patient Presentation

• A 25 year old patient fell on his elbow
• Subsequently he has developed swelling at the
  olecranon
• During his workout, he felt a pop at the back of
  his elbow
• What do you do next?

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Posterior Compartment Pathology

• Triceps tendinitis at the olecranon
  insertion
• Impingement causing posteriomedial osteophytes
  on the olecranon
• Olecranon bursitis and avulsion fractures

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Orthopedic Testing of the Elbow

• Tinels - ulnar nerve
• Cozens/Mills and reverse - lateral and medial
  epicondylitis respectively
• Stability testing - valgus for ulnar
  collateral/varus for radial (performed with 25-30
  degrees of flexion)
• Valgus extension - valgus extension overload
  causing posteromedial impingement
• Repeated supination/pronation - for
  radiocapitellar chondromalacia

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Eccentric Exercise for the Elbow

• Stretch using a static approach 15-30 seconds
  repeat 3-5 xs
• Eccentric exercise performed with 3 sets of 10
• Slow sets first 2 days, intermediate next 2, and
  fast last 2
• Stretch statically as before exercise after each
  days session
• Ice for 5-10 minutes
• The third set of each day should cause some pain
  if not slightly increase weight
• If pain is felt during the first two sets reduce
  resistance or discontinue

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Patient Presentation

• A 33 year old assembly line worker is complaining
  of both pain and numbness from the forearm to the
  hand
• The symptoms are worse with work
• He also notices some weakness with specific
  movements
• What do you do next?

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Entrapment Syndromes

• Median
• Pronator Syndrome
• Carpal tunnel Syndrome
• Anterior Interosseous Syndrome (motor only)
• Ulnar
• Cubital Tunnel Syndrome
• Tunnel of Guyon Syndrome
• Radial
• Radial Tunnel Syndrome
• Posterior Interosseous Syndrome (motor only)

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Pronator Syndrome

• The median nerve may be entrapped at
• lacertus fibrosis
• pronator teres
• fibrous arch of flexor digitorum superficialis
• ligament of Struthers or enlarged bursa
• Symptoms include
• aching forearm pain worse with repetitive
  pronation or flexion
• sensory findings in radial 3 1/2 digits

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Pronator Syndrome

• Provocative maneuvers based on site of
  entrapment
• resisted forearm flexion - lacertus fibrosis or
  ligament of Struthers
• forearm pronation/wrist flexion - pronator teres
• middle finger flexion - flexor digitorum
  superficialis

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Anterior Interosseous Nerve (AIN) Syndrome

• AIN is motor only
• impinged or entrapped at
• the pronator teres
• the flexor digitorum superficialis
• Symptoms include pain in proximal forearm with no
  sensory findings
• Weakness of the FPL, pronator quadratus, and FDP
  of the 2nd 3rd digits leads to pulp-to-pulp
  sign

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Management of Median Nerve Problems

• Identify site of compression
• For carpal tunnel use of neutral, nocturnal
  splint, myofascial release, ultrasound, distal
  radioulnar or lunate adjusting, modifying work
  activity
• For pronator syndrome or anterior interosseous
  syndrome myofascial release, functional taping,
  work or recreational activity modification

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Cubital Tunnel Syndrome

• Entrapment of the ulnar nerve may occur at
• the arcuate ligament, or at the
• flexor carpi ulnaris
• Irritation may be due to tension with subluxation
  at the posterior condylar groove or with condylar
  osteophytes
• Aching pain at medial elbow with radiation some
  sensory findings in 4th and 5th digits motor
  findings are uncommon
• Provocative maneuvers
• subluxating the nerve or Tinels
• flexion of forearm for up to 3 minutes

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Ulnar Tunnel (Guyon) Syndrome

• Ulnar nerve may be compressed in tunnel formed by
  pisiform and hook of hamate
• Causes include
• trauma, ganglions, hook of hamate fractures,
  ulnar artery thrombosis
• Signs may be purely motor, purely sensory, or
  mixed
• Claw hand may occur ulnar lesions proximal to
  branches to FDP will not result in this deformity

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Radial Tunnel Syndrome

• Entrapment or compression of the radial nerve or
  its motor branch, the posterior interosseous
  nerve (PIN)
• Four potential entrapment sites and associated
  provocative maneuvers
• arcade of Frohse - forearm pronation with passive
  wrist flexion
• extensor carpi radialis brevis - resisted middle
  finger extension
• radial head - resisted elbow flexion and forearm
  supination

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Carpal Tunnel Syndrome

• Mechanical Causes
• Overuse
• RA/Tenosynovitis
• Lipoma
• Fractures/Dislocations
• Physiologic
• Diabetes
• Hypothyroidism
• Pregnancy

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Carpal Tunnel Syndrome

• Symptoms may include wrist or hand pain that may
  radiate to the forearm, elbow, and shoulder
• Numbness /paresthesias of the radial 3 1/2 digits
  sparing the thenar eminence nocturnal
  exacerbations
• Differentiate from or overlap with other median
  nerve entrapment sites and double-crush from
  cervical spine

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Carpal Tunnel Syndrome

• Testing includes
• physical examination
• Phalens (reverse Phalens)
• Tinels or compression
• Abductor policis brevis weakness
• objectifiable sensory loss over radial 3 1/2
  digits
• eventual thenar atrophy
• electrodiagnostic studies
• latency with NCV studies

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Carpal Tunnel Syndrome General

• 30-70 of patients respond to non-surgical
  management of CTS (some of whom continue to work
  with some discomfort) compared to 70 of patients
  who have full resolution of CTS with surgical
  management

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Evaluation Objectives

• Rule out other causes and confirm CTS through
  history and exam
• Determine possible work-related risks, and the
  risk for prolonged disability
• Refer patients with thenar atrophy

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• Determine if the patients pattern of involvement
  indicates median nerve involvement by evaluating
  whether the patients Katzs diagram indicates
  median nerve involvement or not
• Determine if there are other sites of entrapment
  other than the carpal tunnel (e.g. pronator,
  ligament of Struthers, etc.) and whether
  myofascial involvement is a cause or simulator of
  median nerve involvement

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CLASSIC
PROBABLE
UNLIKELY
The classic and probable patterns on a hand
symptom diagram have 64 percent sensitivity for
carpal tunnel syndrome. Only 9 percent of
patients with an unlikely pattern have carpal
tunnel syndrome
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TABLE 3.DIAGNOSTIC VALUE OF HISTORY AND PHYSICAL
EXAMINATION FINDINGS FOR CARPAL TUNNEL SYNDROME
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The flick sign predicts electrodiagnostic
abnormalities in 93 percent of cases and has a
false-positive rate of less than 5 percent
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• Determine if there is a cause other than carpal
  tunnel syndrome including trauma (fracture,
  instability, dissociation), systemic diseases
  (e.g. diabetes, rheumatoid conditions),
  pregnancy, or tumor
• Perform standard tests for thumb abduction and
  opposition strength, provocative tests (Tinels,
  Phalens, or compression test), and sensory
  testing and combine with history and Katz
  findings to determine if CTS is present
• Order or refer for EDT if the patient is
  non-responsive to 6-8 weeks of conservative
  management

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• Measure the patients functional involvement
  using a questionnaire such as the Carpal Tunnel
  Syndrome Questionnaire to establish baseline
  effects of condition and response to care.
• Evaluate work environment and determine the level
  of risk for CTS and for disability related to
  CTS. Consider a site inspection to determine
  possible work and worksite modifications.

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• Median nerve involvement evident on
  electrodiagnostic testing (EDT), specifically
  nerve conduction velocity (NCV) studies, strongly
  predicts those patients who have the best
  response to surgery, however, diagnostically
  there is inconsistent evidence for correlation to
  signs and symptoms for CTS.
• There is some question regarding the value of
  EDT if it does not change decision making in the
  management of CTS

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• Confirmation of median nerve involvement via EDT
  should be sought if a trial of non-surgical
  management is unsuccessful at reducing or
  eliminating symptoms and surgery is being
  considered
• The primary non-surgical approach is the use of a
  neutral wrist nocturnal splinting.

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Neutral Splinting for CTS
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• A multimodal approach coupled with splinting
  should be attempted including carpal bone
  mobilization, soft-tissue massage/nerve gliding,
  and exercise.
• If conservative management is unsuccessful, prior
  to surgical referral, consider work hardening or
  a multidisciplinary occupational rehabilitation
  program if conservative management is
  unsuccessful

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Management Directives

• Attempt a trial of conservative care to determine
  effectiveness
• Modify work environment if appropriate
• Obtain EDT for patients who do not respond and
  are considering surgery
• Refer for surgical consultation if conservative
  management is unsuccessful and EDT findings
  indicate median nerve involvement

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Weeks 1-2

• Attempt an initial trial of conservative care
  with the cornerstone being neutral wrist
  nocturnal splinting and worn as needed during the
  day. Consider a multimodal approach that includes
  mobilization, myofascial treatment, stretching,
  pulsed ultrasound, and exercise. Implement
  work-restrictions and modifications based on
  patient history and site inspection

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Weeks 3-6

• If successful at reducing symptoms, continue with
  an attempt at weaning the patient off of
  splinting. If unsuccessful at reducing symptoms,
  consider a different combination of splinting
  with the above-suggested list of options.

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Weeks 7-8

• If successful at reducing symptoms, continue with
  an attempt at weaning the patient off of
  splinting. If unsuccessful, and surgery is being
  considered, order EDT to determine median nerve
  involvement. If involvement is found, refer for
  surgical consult. If not, consider a
  work-hardening program or a multi-disciplinary
  occupational rehabilitation program for 1-2
  months.

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Greater than 2 months

• If work-hardening or multi-disciplinary
  rehabilitation is unsuccessful at reducing
  symptoms or the patient is unable to perform
  required work, refer for surgical consult

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EVALUATION OBJECTIVES FOR CARPAL TUNNEL SYNDROME
(CTS)
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CTS MANAGEMENT TIMELINE
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Patient Presentation

• A 22 year old patient fell off his skateboard and
  braced his fall with an outstretched arm
• He is grabbing his wrist close to him and appears
  to be in severe pain
• What do you do next?

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Wrist Radiographs

• Routine Series
• PA
• lateral
• radial oblique
• scaphoid axial projection
• Supplementary Views - Fracture/Instability
• PA in neutral, radial and ulnar deviation
• laterals in neutral, full radial and ulnar
  deviation
• bilateral AP views with fist actively clenched
• other views include carpal tunnel view, oblique,
  and 30 degree semisupinated view

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Scaphoid Fractures

• Proximal pole fractures result in 100 incidence
  of avascular necrosis 30 for distal fractures
• distal fractures 10 of total
• proximal fractures 20 of total
• waist fractures 70 of total
• Pain at anatomical snuffbox following a fall on
  an outstreched hand provocation test is to
  pronate and gently stress in ulnar plane
• Scaphoid radiographic series includes
• PA, lateral, right left obliques, PA with
  radial and ulnar deviation with fingers flexed
• Bone scan or CT is diagnostic

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Always Include an Oblique
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Scaphoid Fractures

• If initial films negative, immobilize for 2 weeks
  with follow-up films taken
• Distal fractures heal in 4-6 weeks with a short
  arm cast
• Fracture of the proximal 2/3rds is oblique to the
  long axis of wrist requiring a long arm cast with
  thumb spica for as long as 3-6 months

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Hook of Hamate Fracture

• Hook of hamate is impacted from a bat, golf club,
  or raquet or all on an outstretched hand
• Pain/tenderness at hamate decreased, painful
  grip test
• Carpal tunnel view or 20 degree supination view
  bone scan or CT often necessary
• 4th and 5th fingers in flexion and base of thumb
  in short arm cast for 10-12 weeks
• Non-union common

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Radiographic Evaluation of Lunate on Lateral View

• DISI - Dorsal Intercalated Segmental Instability
  is found with radial instability with rupture of
  scapholunate ligament lunate rotates dorsally
• PISI - Palmar (also called volar) Intercalated
  Segmental Instability found with rupture of the
  lunotriquetral ligament lunate rotates into
  palmar-flexion
• DISI pattern scapholunate angle gt 80 degrees or
  capitolunate angle gt 30 degrees
• PISI (or VISI) - scapholunate angle lt30 degrees

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Normal Alignment on Lateral
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DISI Instability
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DISI
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DISI
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VISI
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Scapholunate Dissociation

• Mechanism
• disruption of scapholunate interosseous and
  radioscaphoid ligaments due to a fall on an
  outstretched hand
• Evaluation
• wrist pain, decreased grip strength, catch-up
  click
• positive Watsons test
• PA radiograph reveals a Terry-Thomas sign 2-3
  mm space between scaphoid and lunate DISI
  pattern is visible
• Treatment
• Surgery

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Lunotriquetral Dissociation

• Mechanism
• fall on outstretched hand or similar compressive
  maneuver
• Evaluation
• painful clicking over ulnar aspect of wrist
• positive Ballotement test
• possible PISI pattern on lateral radiograph
• Treatment
• Immobilization for 1st or 2nd degree sprain
• Surgery may be necessary with more serious cases

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PISI
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Midcarpal Instability

• Mechanism
• Damage to the ligaments between the hamate and
  triquetrum occurs with a fall or blow to the
  medial side of the hand with hyper-pronation
• Evaluation
• positive popping/clicking with pain with active
  pronation coupled with ulnar deviation
• DISI pattern may be visible on x-ray
• Treatment
• Immobilization for 6 weeks in ineffective,
  several stabilizing surgeries are available

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Ulnar Variance
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Distal TFCC
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TFC Injury
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Distal Radio-Ulnar Injury

• Mechanism
• Usually a fall with wrist hyperextended and
  forearm hyperpronated injury may occur at
• Evaluation
• swelling and tenderness over distal articulation
• pain is increased with active or passive
  pronation
• ulna may be slightly more prominent
• radiographic findings are subtle
• Treatment
• ulna is reduced by dorsal pressure while
  supinating wrist long arm cast for 4-6 weeks

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Keinbocks Disease

• Avascular necrosis of the lunate
• Due to repetitive minor trauma possibly related
  to ulnar variance
• Lunate becomes more radiopaque as necrosis
  progresses
• If detected, cast immobilization for 8 weeks
• If unsuccessful, surgery may be necessary

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Rheumatoid Wrist
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Patient Presentation

• A 22 year old patient complains of wrist pain
  primarily on the dorsum of the wrist
• She is a classical pianist and has problems with
  practicing recently due to the pain
• What do you do next?

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Diagnosis of Tendon Involvement

• Localization of the involved tendon is based on
• insertion point tenderness or pain
• resisted movement accomplished by tendon or
  stretch into opposite pattern
• Other conditions must be differentiated such as
  fracture or ligament sprain before assuming
  tendon only problem

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DeQuervains Disease

• Disorder of the abductor policis longus and
  extensor policis brevis
• Is often an overuse syndrome due to repeated
  thumb extension/abduction
• Pain swelling over radial styloid is irritated
  by wrist ulnar deviation and thumb adduction with
  flexion (Finkelsteins test)
• Rest from inciting activity, myofascial and cross
  friction proximal to site of involvement

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Intersection Syndrome

• Inflammation of the tenosynovium of the radial
  wrist extensors where they cross under the APL
  and EPB 4-8 cm proximal to Listers tubercle
• May result from trauma or repeated
  flexion/extension
• Occurs in rowers, canoeists, and weight lifters
• Rest and modification of inciting activity
• Myofascial work proximal to site of involvement

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Treatment of Wrist Tendinitis

• Cross-friction massage proximal to insertion
  point for a period of 1-3 weeks every other day
• Cryotherapy and/or pulsed ultrasound
• Stretching using PNF hold-relax technique
• Adjust carpals
• Mild isometric contractions into direction of
  pain may help
• Avoid stretching tension that occurs with holding
  objects in hand such as a briefcase

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Patient Presentation

• A 16 year old female was playing rugby
• In a collision with another player she hurt her
  finger
• There is no deformity, however, she cannot move
  the finger without significant pain
• What do you do next?

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Quick Hand Evaluation

• Allens
• Two-point discrimination
• Sensory
• ulnar - volar tip of small finger
• radial - dorsum of thumb web
• median - volar tips of index long fingers
• Motor
• ulnar - cross long finger over dorsum of index
• median - point thumb towards ceiling palm up

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Finger Motor Function

• FDP - with MP PIP joints held in extension,
  flex DIP joint
• FDS - examiner holds all untested fingers in
  extension while patient flexes free finger
• EDC - with wrist extension, extend at MP IP
  joints
• FDL - thumb held in extension at MP ask patient
  to flex IP joint

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Boutonnieres Deformity(Central Slip Tear)

• Mechanism
• Hyperextension of MCP DIP with flexion of PIP
  resulting from a flexion injury of the PIP
  tearing the dorsally located central slip. The
  lateral bands (the hood) drops anteriorly holding
  the PIP flexed.
• Evaluation
• Point tenderness over dorsum of middle phalanx
  associated with generalized swelling of PIP the
  PIP cannot be fully extended.
• Treatment
• PIP splinted alone in extension to approximate
  central slip followed by exercises to extended
  PIP flex DIP.

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Boutonnere Deformity
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Pseudo-Boutonnieres Deformity

• Mechanism
• Extension injury of the DIP with damage to the
  volar plate.
• Evaluation
• Point tenderness at volar, middle phalanx
  associated with generalized swelling of PIP the
  PIP cannot be fully flexed or extended.
• Progressive calcification seen radiographically
  at vola plate in 3-6 months.
• Treatment
• PIP splinted alone in safety-pin splint

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PIP Extension Brace
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Jersey Finger

• Mechanism
• Avulsion of FDP when a player grabs another
  player
• Evaluation
• Unable to flex finger with FDP
• Tendon may be displaced as far as the palm
• X-ray to determine avulsion
• Treatment
• Surgical repair is necessary

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Mallet Finger

• Mechanism
• Avulsion of extensor tendon from DIP usually due
  to a blow to the finger (e.g. baseball finger).
• Evaluation
• A dropped DIP in acute cases swan neck in
  chronic
• Tenderness at dorsal DIP
• X-ray to determine avulsion
• Treatment
• DIP only splinted in extension for 6-8 weeks

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Mallet Finger
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Swan Neck Deformity
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MC Collateral Ligament Injury

• Mechanism
• Radial or ulnar stress to a flexed MCP joint may
  cause injury usually due to fall on ground or
  player contact
• Evaluation
• Pain and tenderness over MCP joint
• Pain elicited on flexion with radial ulnar
  deviation
• Stress test at 70 degs.
• X-ray may show an avulsed fragment at base of
  proximal phalanx
• Treatment
• Immobilization in flexion for 3 weeks buddy
  taping for 3 more

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PIP Collateral Ligament Injury

• Mechanism
• Very common finger pulled sideways and often
  subluxates and spontaneously reduces
• Evaluation
• Pain and tenderness over collateral ligament and
  volar plate
• Stress test only possible immediately after
  injury
• X-ray may show an avulsed fragment at volar plate
• Treatment
• Immobilization in flexion followed by buddy
  taping for if grade 1 2 grade 3 may need
  surgery

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Gamekeepers Thumb

• Mechanism
• Sprain of ulnar collateral ligament when player
  falls or strikes opponent with thumb abducted
• Evaluation
• Pain and tenderness over anteromedial aspect of
  MCP
• Stress test applied at 0 30 degs.
• Pain and weakness on pinch test
• X-ray may show an avulsed fragment at proximal
  phalanx stress x-rays may demonstrate
  instability
• Treatment
• Taping with cinch or sort-arm cast based on
  degree grade 3 needs surgery

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Boxers Fracture

• Mechanism
• Fracture of the neck of the fifth metacarpal
• Usually the result of heating an object with an
  uprotected wrist
• Evaluation
• Look for rotational deformity
• Percussion test on tip of finger painful.
• Pain and weakness on pinch test
• X-ray
• Treatment
• Angular deformity up to 40 degs. Acceptable
• With closed-reduction use thermoplastic gutter
  splinting or butterfly clamp

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Bennetts Fracture

• Mechanism
• Axial compression injury causing a
  trans-articular fracture of the first MCP joint
  with a triangular fragment of bone in place while
  shaft dislocates and held proximally by pull of
  APL
• Evaluation
• Significant pain and swelling at first metacarpal
• X-ray to determine avulsion and distinction from
  similar fractures
• Treatment
• Open reduction with fixation

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Bennetts Fracture
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Ganglions

• Mechanism
• Benign tumorous masses that may be intra- or
  extra-articular
• Thought to be due o congenital weakness or
  traumatic damage to ligaments or tendon
• Evaluation
• Pain and tenderness over palpable mass
• When deep, may not be palpable
• Most common locations are dorsally at
  scapholunate ligament and ventrally in FCR tendon
  or other flexors
• Treatment
• Rest and immobilization may help surgical
  excision may be necessary

127
Dupuytrens Contracture

• Nodular thickening of the fourth fifth finger
  flexors
• Eventually fingers flexed at the MCP PIP with
  DIP held in extension
• Management includes frequent stretching and
  possibly immobilization at night in a soft cast
• Eventually surgery may be necessary to release
  the fibrous tissue

128
Dupuytrens Contracture