This document discusses several types of hand injuries including Bennett's fracture, Rolando's fracture, and tendon injuries. Bennett's fracture is a fracture of the base of the first metacarpal bone that extends into the carpometacarpal joint, often accompanied by subluxation or dislocation. Rolando's fracture is an intra-articular fracture of the base of the first metacarpal bone that extends into the carpometacarpal joint. Tendon injuries can involve the flexor or extensor tendons and are classified based on the zone of injury. Treatment depends on the specific injury but may involve closed or open reduction, internal fixation, splinting, or surgery.

1. Injuries of the hand – Bennett’s
fracture disclocation , Rolando’s
fracture and Tendon injuries

2. Bennett’s Fracture
• Bennett's fracture is a fracture of the base of the first metacarpal bone which
extends into the carpometacarpal (CMC) joint.
• Intra-articular fracture
• most common type of fracture of the thumb,
• nearly always accompanied by some degree of subluxation or frank dislocation
of the carpometacarpal joint.

3. • The Bennett's fracture is named after Edward Hallaran Bennett .
• Bennett said his fracture "passed obliquely across the base of the bone,
detaching the greater part of the articular surface” , and "the separated
fragment was very large and the deformity that resulted there-from seemed
more a dorsal subluxation of the first metacarpal".

4. Mechanism of Injury
• an axial force directed against the partially flexed metacarpal.
• This type of compression along the metacarpal bone is often
sustained when a person punches a hard object, such as the
skull or tibia of an opponent, or a wall.
• It can also occur as a result of a fall onto the thumb.

5. • The proximal metacarpal fragment remains attached to the anterior oblique
ligament, which in turn is attached to the tubercle of the trapezium bone of the
CMC joint.
• This ligamentous attachment ensures that the proximal fragment remains in its
correct anatomical position.
• The distal fragment of the first metacarpal bone possesses the majority of the
articular surface of the first CMC joint.
• Unlike the proximal fracture fragment, strong ligaments and muscle tendons of
the hand tend to pull this fragment out of its correct anatomical position.

6. • Specifically:
• Tension from the abductor pollicus longus muscle (APL) subluxates the fragment in a dorsal,
radial, and proximal direction .
• Tension from the APL rotates the fragment into supination .
• Tension from the adductor pollicus muscle (ADP) displaces the metacarpal head into the palm
.

7. Clinical Evaluation
• Characteristic signs include –
• Pain,
• Swelling, and
• Ecchymosis around the base of the thumb and thenar eminence, and especially
over the CMC joint of the thumb .
• Instability of the CMC joint of the thumb, accompanied by pain and weakness of
the pinch grasp.

8. Radiographic Evaluation
•Xray – posteroanterior and
Lateral radiograph
•Traction xrays are advisable
• CT scan – rarely indicated in
case of doubt

9. Treatment
1.Conservative treatment
Indicated for undisplaced fractures.
2.Closed reduction and internal fixation
Indicated for reducible fractures.
3.Open reduction internal fixation (ORIF)
Indicated for fractures which are not reducible in a closed
manner.
• ORIF is also indicated in high-demand patients and those who
need immediate restoration of a full range of motion.
• However, ORIF is possible only if the anterior marginal fragment
is large enough for internal fixation (>20% of the articular
surface).

10. Closed reduction and POP application
• Reduction is performed by a combination of
1. longitudinal traction
2. pronation of the metacarpal
3. pressure at the thumb metacarpal base.
• Confirm correct restoration of the articular
surface using image intensification.

11. Closed reduction and internal fixation
• The most common are:
1. Transfixion of the base of the first metacarpal to the
trapezium
2. Transfixion of the thumb base
to the second metacarpal
3. Combination of both

12. • Wagner technique for closed pinning

14. Open Reduction and Internal Fixation

15. Reverse Bennett’s Fracture
• It’s a fracture-dislocation of the base of the 5th metacarpal
bone .
• pathologically and radiographically analogous to the
Bennett’s fracture of the thumb .
• It is quite unstable due to unopposed Extensor Carpi Ulnaris
force on the fracture fragment , which causes migration and
subluxation of the fragment .
• Frequently need K-wire stabilization to counteract the
strong force of ECU .

16. Pseudo bennett’s fracture
• A/K/A Epibasal fracture of the thumb .
• It’s a two-piece fracture of the proximal first
metacarpal bone usually result from longitudinal axial
loading .
• They are usually stable and depending on the degree
of displacement , and often do not require surgery .
• It is important to distinguish them from intra-articular
fractures , which are usually unstable and require
surgery .

17. Rolando’s Fracture
• Intra-articular fracture of the base of the first metacarpal bone which extends into the
carpometacarpal (CMC) joint.
• Differentiating feature from Bennett’s # - T- or Y-shaped fracture patterns can occur either in
the frontal or in the sagittal plane.
• Described by Rolando in 1910, this fracture is a 3-part intraarticular fracture of the base of the
thumb metacarpal.
• Today the term “Rolando’s fracture” is often misused to describe multifragmentary
intraarticular fractures of the thumb metacarpal base.

18. • Mechanism of Injury
• Clinical evaluation
• Radiographic evaluations
• Treatment
Same as Bennett’s Fracture

19. Xray

20. Closed Reduction and POP application
• As there is usually a flexion deformity,
• Reduction can be performed
with -Axial traction on the thumb
and simultaneous pressure over the
dorsal aspect of the basal diaphysis
near the fracture.

21. • Maintaining reduction
• During the application of the cast, it is
important to exert pressure over the dorsal
aspect of the first metacarpal diaphyseal
base, and from the palmar aspect over the
first metacarpal head.

22. • Pitfall: palmar pressure
• Avoid pressing from the palmar aspect
over the base of the proximal phalanx.
• This results in redisplacement of the
fracture and hyperextension of the MCP
joint.

23. Open Reduction and Internal Fixation
• Choice of approach
• For Y- or T-shaped patterns in the
frontal plane, a straight dorsal
approach is preferred.
• For a Y- or T-shaped fracture pattern in
the sagittal plane, the radiopalmar
approach is the preferred choice.

24. Open Reduction and Internal Fixation

25. Open Reduction and Internal Fixation

26. Open Reduction and Internal Fixation

27. Kirschner Wire Fixation
• Advantages...
• No cut.
• Less dissection of muscle.
• Less risk infection.
• Smaller procedure.
• Disadvantages...
• Plaster for 6 weeks.
• Must keep dry.
• Increased stiffness.
• Increased risk of late infection
along wire.

28. Open Reduction
• Advantages...
• Allows accurate alignment of joint
surface under direct vision.
• Gentle movements may be
started early if screw fixation is
noted to be strong at time of
surgery.
•Disadvantages...
• Exposure of the joint.
• Increased risk of injury to skin nerves ,
early infection.
• Need expertise in dissection

29. Complications
• Stiffness – MC
Stiffness of the 1st MCP joint , Wrist joint ,etc
• Post traumatic Arthritis
• Open Surgery related Complications

30. Tendon Injuries
• Flexor Tendon Injuries
• Extensor Tendon Injuries
• Tendon – “ Glistening structure between muscle and bone
which transmit force between muscle and bone “

31. Etiology
• Sharp object direct laceration (broken glass, kitchen
knives or table saws)
• Crush injury
• Motor vehicle accidents
• Avulsions
• Burns
• Animal or human bites
• Suicide attempts

32. Tendon Healing
• 2 forms:
–Intrinsic healing: occurs without direct blood flow to the tendon
–Extrinsic healing: occurs by proliferation of fibroblasts from the
peripheral epitendon; adhesions occur because of extrinsic healing
of the tendon and limit tendon gliding within fibrous synovial
sheaths

33. Phases of Tendon Healing
1.Inflammatory (0-5 days) : strength of the repair is reliant on
the strength of the suture itself
2.Fibroblastic (5-28 days) : or so-called collagen-producing phase
3.Remodelling (>28 days)

34. Timing of tendon repair
Primary: repair within 24 hours (contraindicated in case of high grade
condtamination i.e. human bites, infection)
Delayed Primary: 1-10 days when the wound can be still pulled open
without incision
Early Secondary: 2-4 weeks.
Late Secondary : after 4 weeks

35. Flexor Tendon Zones
1: flexor digitorum profundus distal to
insertion of flexor digitorum superficialis
2: insertion of flexor digitorum superficialis to
proximal edge of A1 pulley (“No Man’s Land”)
3: proximal edge of the A1 pulley to distal
edge of carpal tunnel
4: within the carpal tunnel
5: proximal to the carpal tunnel

36. ZONE 1: ZONE OF FDP AVULSION INJURIES
• Region b/w middle aspects of middle phalanx to finger tips
• Contains only one tendon-FDP
• Tendon laceration occurs close to its insertion
• Tendon to bone repair is required than tendon repair

37. Leddy and Packer Classi. Of Zone 1 Tendon
Injuries

38. ZONE II – NO MANS LAND
• From metacarpal head to middle phalanx
• Called so because initial attempts for tendon repair here produced poor results
• FDS and FDP within one sheath
• Adhesion formation risk is amplified at campers chiasma

39. ZONE III – DISTAL PALMAR CREASE
• B/w transverse carpal ligament and proximal margin of tendon sheath formation
• Lumbricals origin here prevents profundus tendons from over acting
• Delayed tendon repairs are succesfull even after several weeks of injury

40. ZONE IV – TRANSVERSE CARPAL LIGAMENT
• Lies deep to deep transverse ligament
• Tendon injuries are rare
ZONE V – PROXIMAL TO CARPAL TUNNEL
 Lies proximal to transverse carpal ligament

41. Signs and Symptoms
• Unable to bend one or more finger joints
• Pain when bending finger/s
• Open injury to hand (e.g., cut on palm side of hand, particularly in area where
skin folds as fingers bend)
• Mild swelling over joint closest to fingertip
• Tenderness along effected finger/s on palm side of hand

42. Complain of numbness
Preceeded by execissive bleed
Consider neurovascular insult!!

43. DETECTION
• History and physical
• Examination of wound
• Use of bedside ultrasonography in ER (more sensitive and specific than physical
examination)
• Wound exploration techniques or MRI.
• 3-view x-ray must be done (except most benign) to rule out foreign bodies or
bony injury.
• Radiographs to evaluate for possible fractures or dislocations (blunt trauma
cases)

44. Jersey Finger
• Avulsion injury of the flexor digitorum profundus tendon from
its insertion at the base of the DIP joint .
• It’s a Zone I flexor tendon injury .

45. • Jersey finger very frequently occurs in contact sports like football and
rugby.
• Catching of finger in a jersey and tearing a tendon while tackling
opponents in contact sports is the common cause of jersey finger.
• A jersey finger injury most frequently affects the ring finger of the
hand.

46. Mechanism of Injury
• Results from forceful hyperextension of DIP joint with FDP in
maximal contraction .
• The flexor digitorum superficialis remains intact and is not affected
in this type of injury.
• Tendon may rupture directly from its insertion into bone, or
• it may avulse bone fragment from base of distal phalanx; it may also
rupture at the musculotendinous junction .

49. MRI
• Disruption of flexor digitorum profundus (FDP) at volar base of distal phalanx ±
avulsion fragment.
• MRI also allows visualisation of the location of the end of tendons which will
affect the surgical classification and management of the patient .
ultrasound
 Simple and Cost-effective
 High sensitivity and specificity

51. Treatment
• Rest , Ice , Elevation
• Conservative for partial tear
• Splinting,
NSAID's,
Physical therapy

52. TESTS FOR FDP AND FDS

53. DICTUM
• Flexor tendon repair is not a surgical emergency.
• It is proved that equal or better results can be achieved by delayed
primary repair.
• Better to repair both FDP & FDS tendons rather than FDP alone
• Because the blood supply to the FDP tendon is jeopardized if the FDS
is not fixed (due to the vinculae anatomy)

54. Goals of Reconstruction
• Coaptation of tendons
• Anatomical repair
• Multiple strand repair to permit active range of motion rehabilitation
• Pully reconstruction to minimize bow-stringing
• Atraumatic surgical technique to minimize adhesions
• Strict adherence to rehabilitation protocol.

55. What we can provide ????
• Minimal dissection and handling
• Tendon apposition without gapping
• Early protected mobilization

56. Bunnell stitch Crisscross stitch
Mason-Allen stitch
Robertson and Al-Qattan
Interlock stitch
Core Suture Techniques

57. Kessler stitch Modified Kessler
Tajima modification
Of kessler stitch with
double loop at repair
site

58. Zone I Repair
• Wound extended proximally and distally
• Proximal tendon retrieved,core sutures are placed
• Keith needles used to pass the sutures around the distal phalanx exiting through
nail plate distally
• Remaining distal end of tendon sutured to the re-attached proximal portion

59. Direct repair:
if laceration is more than
1 cm from FDP insertion
Tendon advancement:
if the laceration is less
then 1 cm from insertion

60. Zone II Repair
• Repair both tendon lacerations – FDS , FDP
• Tendon sheath may be opened for exposure but A2 and A4 are
preserved as much as possible
• FDS is repaired first followed by FDP

61. Zone III Repair
• If both tendons are lacerated, both are repaired, end to end with
circumferential re-enforcing sutures
• May affect lumbricals in addition to flexor tendons
• Damaged lumbrical is either repaired or excised depending on severity
of injury and the location of the laceration

62. Zone IV Repair
• Lacerations of flexor tendons within the carpal canal are
typically associated with partial or complete laceration of
median nerve
• Here median nerves should be repaired first and the tendons
last

63. Zone V Repair
• In this area there may be concomitant ulnar nerve & artery damage as
well as radial artery & median nerve damage.
• Primary repair of the arteries is usually indicated
• If wound is contaminated, arteries are repaired and delayed repair of
tendons and nerves is planned

64. Brunner’s Incision

65. Tendon to Bone Attachment

66. One method of attaching tendon to bone. A, Small area of cortex is raised with osteotome. B, Hole
is drilled through bone with Kirschner wire in drill. C, Bunnell crisscross stitch is placed in end of
tendon, and wire suture is drawn through hole in bone. D, End of tendon is drawn against bone,
and suture is tied over button.

67. Fish-Mouth End-to-End Suture
(Pulvertaft) End-to-Side method tendon repair

68. Post Operative Protocol
• Active Extention-Rubber Band Flexion Method:
e.g. Kleinert , and Brooke-Army
• Immobilization
• Controlled Passive Motion Methods: e.g. Duran’s protocol
• Strickland: Early active ROM

69. • Combines dorsal extension block with rubber-band traction proximal to wrist
• Originally, included a nylon loop placed through the nail, and around the nail is placed a
rubber band
• This passively flexes fingers, & the patient actively extends within the limits of the splint
Active range of
motion
rehabilitation
Kleinert !!

70. Post-operative passive
exercises
Duran’s
At surgery, a dorsal extension-block
splint is applied with the wrist at 20-30°
of flexion, the MCP joints at 50-60° of
flexion, and the IP joints straight

72. MANCHESTER SHORT SPLINT
• Wrist
– Finishes at dorsal wrist crease
– Allows 45 degrees extension
• MCPJ
– 30 degrees flexion
• Exercises
– Commence 4th or 5th day
– Motion initiated at DIPJ

73. Complications
• Joint contracture
• Stiffness
• Adhesions
• Rupture
• Bowstringing
• Infection

74. Flexor Tendon reconstruction
• Flexor tendon reconstruction is a necessary
and important procedure for failed and
neglected tendon repairs.
• With improvements in flexor tendon repair
methods, the need for flexor tendon
reconstruction has substantially
diminished.

75. Tendon Grafting
• Indications :-
• 1. Failure of flexor tendon repair.
2. Injuries resulting in segmental tendon loss.
3. Delay in repair that obviates primary repair.
4. Patients in whom the surgeon believes delayed grafting is the better
treatment alternative for a zone 2 injury (e.g., segmental or extensive tendon
injury).
5. Occasionally, for delayed presentation of FDP avulsion injuries associated
with signifcant tendon retraction.

76. DONOR TENDONS FOR GRAFTING
• Palmaris Longus: Tendon of choice (fulfils requirement of length, diam
& availability)
• Plantaris Tendon: Equally satisfactory & advantage of being almost
twice as long, but is not accessible.
• Others: FDS, EDC

82. Summary
• Meticulous technique
– Minimal handling
– Appropriate suture configuration
– Minimal resection of tendon sheath
• Postoperative mobilization
• Supervision!

83. Extensor Tendon Zones
• The classification of extensor tendon injuries proposed by
Kleinert and Verdan ended at zone 8 (the forearm).
• Doyle added a ninth zone for the muscular area of the
extensor mechanism at the middle and proximal forearm.
• The classification is easy to recall if one remembers that the
joints are odd numbered; from distal to proximal, the DIP
joint is zone 1, PIP joint is zone 3, and so forth.
• The thumb IP joint is zone 1, and the MP joint is zone 3 .

84. Etiology
Sharp object direct laceration (broken glass, kitchen
knives or table saws)
Crush injury
Motor vehicle accidents
Avulsions
Burns
Animal or human bites
Suicide attempts

85. Signs and Symptoms
• Unable to straight (extend) one or more finger joints
• Pain while extending finger/s
• Open injury to hand (e.g., cut on dorsal side of hand )
• Mild swelling over joint closest to fingertip
• Tenderness along effected finger/s on dorsal side of hand

86. DETECTION
• History and physical
• Examination of wound
• Use of bedside ultrasonography in ER (more sensitive and specific than physical
examination)
• Wound exploration techniques or MRI.
• 3-view x-ray must be done (except most benign) to rule out foreign bodies or
bony injury.
• Radiographs to evaluate for possible fractures or dislocations (blunt trauma
cases)

87. Suturing techniques
• Doyle proposed the following techniques for extensor tendon repair:
Zone 1 (DIP joint): Running suture incorporating skin and tendon.
Zone 2 (middle phalanx): Running 5-0 stitch near cut edge of tendon,
completed with a “basket-weave” or “Chinese finger trap” type of cross-stitch
on the dorsal surface of the tendon .
Zones 3 through 5 in fingers, and zones 2 and 3 in thumb: Modifed Kessler
suture of 4-0 synthetic material in the thickest portion of the tendon. A 5-0
cross-stitch tied to itself at the beginning and end is run on the dorsal surface
of the tendon .

88. Mallet Finger
• Charac. by discontinuity of the terminal extensor tendon resulting in an extensor
lag at the DIP joint with or without compensatory hyperextension at the PIP joint
( swan neck deformity ) .
• It’s a zone 1 Extensor tendon Injury
• A/K/A Drop Finger or Baseball Finger
• Classically described as “soft tissue“ (tendon rupture) or “bony” (avulsed
fragment of bone)

89. Mechanism Of Injury
• Sudden forced flexion of the extended fingertip.
• This results in either:
• stretching or tearing of extensor tendon substance or
• avulsion of tendon insertion from the dorsum of distal phalanx, with or
without a fragment of bone.

91. Clinical Evaluation
• Relatively straightforward.
• Patients present with pain,swelling, deformity, and/or difficulty using the affected finger.
• Extensor lag at the DIP joint immediately after injury.
• Concurrent hyperextension of the PIP joint (ie, swan neck posture) may be noted with active
finger extension.

92. Radiographic Evaluation
• Posteroanterior, oblique, and lateral radiographs of the digit are recommended
to assess for bone injury and joint alignment.

93. Treatment options
• Rest , Ice and Elevation initially
• Non-surgical:
–Successful in most mallet injuries.
• Surgical:
–Treatment of either an acute or a chronic mallet finger
–Salvage of failed prior treatment

95. • Three different mallet finger splints
• A, Stack splint
• B, Perforated thermoplastic splint
• C, Aluminum foam splint

96. Surgical Management
• Type I Injuries
• Indications –
1.Volar subluxation of distal phalanx ,
2.>50% of articular surface involved
3.>2mm articular gap

97. Kirschner Wire Fixation
• To immobilize the DIP joint in extension, a transarticular K-wire is
driven longitudinally or obliquely across the DIP joint.
• Post-Operatively:
– K-wire is removed after 6-8 weeks.
– This is followed by 2-4 weeks of night time extension splinting.

98. Open Type II & III Injuries
• Typically managed by debridement and tendon suture .
• May require skin coverage procedures ,with or without tendon grafts .
• Open repair of the extensor tendon with a running 5-0 prolene suture
is performed .
• An oblique or axial Kirschner wire is placed across the DIP joint in full
extension .

99. Mallet Fracture Type IV
• Treatment alternatives:
• Observation with reassurance
• Extension splinting
• Closed and open reduction with internal fixation
• DIP joint arthrodesis.

100. • Indications for surgical intervention:
• Mallet fractures involving more than one third of articular surface
• Fractures with associated DIP joint subluxation
• Disadvantages of surgical treatment of mallet fractures:
–Technically demanding
–Higher complication rate than nonsurgical management

101. Surgical Management
• Techniques:
• Transarticular pinning of DIP joint ± fracture fragment fixation
• Tension band constructs
• Compression pinning
• Extension block pinning
• All of these techniques involve placement of at least one K-wire to
immobilize the DIP joint in extension.

102. Extension block pinning technique
• A, With the distal phalanx extended, a K-
wire is inserted proximal to the fractured
fragment.
• B, The fracture is reduced manually by
directing the exposed end of the K-wire
distally.
• C, The wire is drilled into the head of the
middle phalanx, and a second wire is passed
retrograde across the distal interphalangeal
joint.

103. Complications
• Complications associated with splinting:
• Most are transient.
• Most resolve with adjustment of the splint or after completion of
treatment.
• Complications include:
• Skin maceration and ulceration
• Tape allergy
• Transverse nail plate grooves
• Splint-related pain

104. • Complications associated with surgical treatment:
• Reported problems include:
• Infection
• Nail plate deformity
• Joint incongruity
• Hardware failure
• DIP joint prominence
• DIP joint deformity ( swan neck deformity )

105. Mallet Thumb
• Avulsion of the extensor pollicis longus (EPL) tendon at its
distal insertion (mallet thumb) is rare.
• A/K/A Goose neck deformity .
• Usually a late complication of colles’ fracture , RA .
• Although the recommended treatment for closed mallet
finger is conservative, some authors proposed operative
treatment for mallet thumb.

106. Zone I and II
repairs

107. Zone III repairs

108. Zone IV
repairs

109. Zone V
repairs

110. REHABILITATION
3 current treatment approaches to extensor tendon
rehabilitation are :-
Immobilization
Early controlled passive mobilization
Early active motion

111. Position of Immobilization for Extensor Tendon
Injury
• The finger should remain
parallel to forearm with wrist
in full extension
• PIP & DIP – Neutral

112. IMMOBILIZATION
• Keep the tendon in a shortened position through splinting or casting
• Tendons immobilized for 3 weeks
• In week 4, gentle active motion of the repaired tendon is introduced
• Rehabilitation depends on zone of injury

113. EARLY PASSIVE MOTION
• Extensors are held in extension by
dynamic, gentle rubber band
traction, and the patient is
allowed to actively flex the
fingers—passively moving
repaired extensor tendons

114. Reverse Kleinert splint

115. EARLY ACTIVE MOTION
•Early active short arc program (developed by Evans) allows tendon to actively
move 3 days after surgery
•Therapist must take care to ensure stress applied by early active motion does not
overpower strength of surgical repair
•Splinting program is complex and specific and requires a skilled occupational
therapist

116. Complications
• Extensor tendon injuries can cause:
• Finger deformity due to muscle imbalance
Boutonniere deformity , Swan neck deformity
Tendon adhesions: The tendon can attach itself to nearby bone and scar tissue.
Finger stiffness - scar tissue that forms may prevent full finger bending and
straightening even with the best treatment Surgery to free scar tissue can
sometimes be helpful in serious cases of motion loss
• Infection

117. THANK YOU……