Dr.MD.Monsur Rahman,PT MPT-Musculoskeletal Disorders Maharishi Markandeshwar Institute Of Physiotherapy And Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana - Ambala,133-207 (Haryana)

1. Crush Injuries of
Hand
MD.MONSUR RAHMAN
MPT-(ORTHO)

2. Hand Anatomy
Hand consist of 27 bones:
14 Phalangeal bones
5 Metacarpal bones
8 Carpal bones

3. Intrinsic muscles of the hand
1.(a)three muscles of thinner eminence
 Abductor pollicis brevis .
 Flexor pollicis brevis.
 Apponens pollicis brevis .
(b) one adductor of thumb
 Adductor pollicis
2. Four hypothenar muscles
 Palmaris brevis.
 Abductor digiti minimi.
 Flexor digiti minimi.
 Opponense digiti minimi.
3. Four lumbricals.
4. Four palmar interossei.
5. Four dorsal interossei.

5. Blood Supply(BS):
i. Hand and digits has dual
(BS) with contributions
from the radial and ulnar
arteries.
i. Proximal portions of the hand
(BS) come from the deep and
superficial arches on the
palmar and dorsal side.
ii. BS of the fingers is distributed
by the digital arteries that
arises from the superficial
palmer arch.

6. Introduction
• Common in all age groups.
• Hand is the most important functional unit of the upper limb.
(Motor or sensory)
• Stiffness of fingers

7. Classification
• Closed Injuries- Fractures
- Tendon Injuries
- Sprain
• Open Injuries - Crush Injuries
- Tendon Injuries
- Traumatic Amputations

8. CRUSH INJURIES
Compressive type of force to the tissues.
Most Common Causes:
-Machine Injuries In The Industries
-RTA
-Agricultural Injuries
-Fall of heavy objects in building
collapse, during earthquakes etc.

9.  Crush injuries result in:
 Damage to the overlying soft tissue envelope
 Laceration
 Fracture
 Bleeding
 Loss of vascular integrity
 The neurovascular structures and the bony ligamentous structures.

10. Danger signs in evaluation of crush
injuries
• Volar swelling, especially in the palm and digits
• Loss of active range of motion
• Pain on passive motion of the digits or hand
• Altered neurovascular status
• Increased swelling, even with elevation above heart level
• Profuse bleeding from an open crush injury.

11. Effects on the Tissues

12. Skin and Subcutaneous Tissue
Lacerations and contusions.
Foreign material --- embedded in the wounds.
Alternatively, the skin may look largely intact.

13. Muscles
Overstretching and tearing of the muscle bleeding and
swelling within the muscle itself.
A disruption of muscle-tendon connections may result in
loss of function.

14. Tendons
 The stretching forces may create small, partial tears.
During the healing process, scar tissue forms to heal such
tears and may cause the tendons to adhere to surrounding
tissues, resulting in loss of joint motion and hand function.

15. Nerves
Usually, nerves are not torn by a crush injury.
Conduction disrupted
It may take weeks to even months to determine whether the
loss of nerve activity is permanent.

16. Blood Vessels
Direct compression or shearing forces, which may injure
the inner layer
If the injured vessel is an artery --- Ischemia
If the injured vessels are veins--- restriction of venous
outflow

17. Bone and Joints
Joint capsules and surrounding ligaments may rupture
In children, the growth plates of the bones may be
disrupted.
Disruption of growth plates interferes with subsequent bone
growth, and the bone may not grow to its proper length.

18. The Anatomic Zones
• Five flexor zones:
zone 1
From the insertion of the profundus tendon at the distal phalanx to
just distal to the insertion of the FDS.

20. Flexor digitorum Profundus Tendon
Injury
• Disruption of the FDP tendon, also known as jersey finger
• In an athlete’s finger
- football or rugby.
• The injury causes forced extension of the DIP joint during
active flexion. (finger lies in slight extension relative to other
fingers in resting position)
• pain and swelling

23. Treatment
• Type I injuries (partial rupture of the tendon) can be treated without
surgery with rest, ice and elevation.
A finger splint is often used to hold the digit in place until healed.
• Type II (full tendon rupture) and
• Type III (rupture with bone chip attached)

24. TENODESIS
• Flexor tenodesis to prevent hyperextension & to stabilize the
distal joint
• Often, surgical pins are inserted into the injured digit to stabilize
the bone and tendon in their proper alignment.
• Securely re-attach the distal FDP tendon to the middle phalanx
with appropriate tension.

25. Collateral Ligament Injuries
• Forced ulnar or radial deviation at any of the IP joints can cause
partial or complete collateral ligament tears.
• The PIP joint usually is involved in collateral ligament injuries,
which are commonly classified as “jammed fingers.”
• pain located only at the affected ligament.

26. Treatment
• If the joints are stable and no large fracture fragments are present, the
injury can be treated with buddy taping (i.e., taping the injured finger,
above and below the joint, to an adjacent finger)
Am Fam Physician. 2006 Mar 1;73(5):810-816. News & Publications
Journals afp Vol. 73/No. 5(March 1, 2006)

27. Buddy Taping
(A) Self-adhesive wrap. (B) Velcro wrap.

28. Zone II
• Zone II is often referred to as "Bunnell's no man's land," the critical
area of pulleys between the insertion of the FDS and the distal
palmar crease.
• Both flexor tendons interweave in a complex manner, therefore even
minimum swelling can cause adhesions with pulleys & thereby
impair the free motion of the tendon.

30. Trigger Finger
• Trigger finger, or flexor tenosynovitis, is a condition in which the
tendons that flex the fingers become swollen and inflamed. This results
in pain at the base of one or more of the fingers
• Inability of FDS &FDP tendons to slide smoothly under the A1 pulley

32. TREATMENT
• Corticosteroids with local anesthetic into the flexor sheath.
TISSUE RELEASE
• A small (less than 2 cm) incision is made in the skin, and
the tight portion of the flexor tendon sheath is released.
• After the surgery, a sterile bandage is applied to the site of
surgery.
• This bandage is removed after a few days,
• And full use of the finger may then begin to prevent new
adhesions (scar).
(Full recovery is expected for surgery. By Jonathan Cluett, M.D., Journal About.com Guide
Updated March 29, 2007)

33. Zone-III
 Extends from the distal edge of the carpal ligament to the proximal
edge of the A1 pulley, which is the entrance of the tendon sheath.
 The distal palmar crease superficially marks the termination of zone
III and the beginning of zone II.

36. Dupuytren’s Contracture
• This condition is due to inflammation of involving the ulnar side of
the palmar aponeurosis. Localized thickening and shortening of the
palmar fascia.
• The fascia is thickened to form nodules and it contracts so that the
affected fingers are drawn into flexion.

38. Treatment
Subcutaneous Fasciotomy
Partial selective Fasciotomy
Complete Fasciotomy

39. Skin Graft Method
• A skin graft may be needed if the skin surface has contracted so
much that the finger cannot relax and the palm cannot be stretched
out flat.
• Surgeons graft skin from the wrist, elbow, or groin. The skin is
grafted into the area near the incision to give the finger extra
mobility for movement.

40. Zone IV
Includes the carpal tunnel and its contents (i.e., the 9 digital
flexors and the median nerve).

41. Carpal Tunnel Syndrome
• Cause of CTS - The tendons in the wrist swell and put compression
on the median nerve,
• Hand numbness, pain and tingling in the distribution of median
nerve.

43. Treatment
• During surgery, an incision is made in the palm.
• The roof of the carpal tunnel is divided to increase the size of the
carpal tunnel and decrease pressure on the median nerve.

44. Extensor Zones
• zone I - mallet finger
DIP jt. (finger) and IP jt. In thumb.
• zone II - middle phalanx (finger)
proximal phalanx (thumb)
• zone III - apex PIP joint (finger)
MCP jt. (thumb)
• zone IV- proximal phalanx (finger)
metacarpal (thumb)
• zone V - over apex MCP joint:
• zone VI - dorsum of hand
• Zone VII - dorsal retinaculum
• Zone VIII- distal forearm

46. Mallet Finger
• The trauma results in the avulsion
of the extensor tendon from the
point of attachment to the distal
phalanx

47. • A segment of the distal phalanx,
which comprises the distal
portion of DIP joint, may break
off along with the tendon.
• If not treated, mallet finger leaves
a deformity with the DIP in
permanent flexion.

48. Treatment
• Most mallet finger injuries can be closed-reduction and fixed by
percutaneous placement of K-wires.
• The longitudinal K-wire is blocking the DIP joint from flexion
to protect the repair.

49. A/P Radiographic view of
finger.
• The smaller oblique K-wire is
placed through the bone fragment,
fixing it to the distal fragment.

50. Swan Neck Deformity
• Finger with a hyper-extended PIP joint and a flexed DIP joint.
• The extensor tendon gets out of balance, which allows the DIP
joint to get pulled downward into flexion.

51. The Journal of hand surgery J Hand
Surg Am. 2010 Aug 13;: 20709465
Distraction arthrolysis using an external fixator followed by flexor
tenolysis- useful treatment for patient with pip joint extension
contracture and tendon adhesions after severe crush injury.

52. • On the day of attaching the external fixator, moderate
distraction was applied to the joint and the gap was widened
to approximately 2 mm.
• Pip joint was gradually widened for 10 days until a gap of
about 5 mm was attained.
• Passive range of motion was performed for about 1week until
swelling of the affected digit subsided. Then, flexor tenolysis
was performed.

53. Boutonniere Deformity
• Buttonhole deformity
• The middle finger joint is bent in a fixed position inward and the
outermost finger joint is bent excessively outward (away from the
palm)
• Most common causes are Rheumatoid Arthritis and trauma

54. Treatment
Gutter splinting will help stretch and straighten the PIP joint .
Best results occur when the PIP joint is limber, rather than
stuck in a bent position.

55. De Quervain’s Tenosynovitis
• Injury occurs because of inflammation around the tendon sheath of
the APL and EPB in the first dorsal compartment .
• Fibrous sheath (APL & EPB) tendon becomes fibrosed and thickened.
• Lateral aspect of lower end of the radius where the tendons lie in
shallow bony groove.

56. • A splint can be used - one that immobilizes the wrist, and also involves the
thumb.
• Corticosteroid injections into the tendon sheath. Surgical release may be
required in chronic cases.

57. Splint used for conservative treatment (left) & bandage used
following surgery (right).

58. SURGERY
• An incision is made over the first dorsal compartment and the dorsal
carpal ligament is cut to expose the tendons.
• The tendons APL and EPB are identified and motion is checked. The
wound is then closed and a compressive dressing with a plaster splint is
applied.

59. PHYSIOTHERAPY
• Visits will include heat treatments, soft tissue massage, and vigorous
stretching.
• Active and assisted active finger exercises may restore the hand
functions.
• Passive Stretching to correct the residual tightness of the soft tissues.

60. Prognosis
Crush injuries can be severe and devastating to the individual.
Long-term impairment and disability may occur, and disability is
sometimes permanent.

61. Thank You