A guide to hand injuries prepared by Dr Sanjib Kumar Das, MPT (Musculoskeletal), Fellow (PhD), NITIE (Ergonomics and Human Factors)

1. HAND INJURIES
Dr. Sanjib Kumar Das, Fellow (PhD) NITIE
Ergonomics and Human Factors

2. BENNETT'S FRACTURE-DISLOCATION
• It is an oblique intra-articular fracture of the base of the first
metacarpal with subluxation or dislocation of the metacarpal. It is
sustained as a result of a longitudinal force applied to the thumb.
TREATMENT
• Accurate reduction and restoration of the smooth joint surface is
important as incongruity of the articular surfaces would increase the
chances of developing osteoarthritis. The following methods of
treatment are used:
a) Closed reduction and percutaneous K-wire fixation under an image
intensifier, is a good technique. K-wire is used and incorporated in a
plaster cast.
b) Open reduction and internal fixation with a K-wire or a screw may
be necessary in some cases.

3. ROLANDO'S FRACTURE
• This is a complete articular, ‘T’ or ‘Y’ shaped
fracture of the first metacarpal.
TREATMENT
• Accurate reduction and fixation with ‘K1’ wires
and immobilization in a thumb spica for 3 weeks.

4. FRACTURES OF THE METACARPALS
• Fractures of the metacarpal shaft are common at all ages. The common causes
are:
(i) fall on the hand,
(ii) blow on the knuckles (as in boxing)
(iii) crushing of the hand under a heavy object.
• The fracture may be classified, according to the site, as follows:
a) Fracture through the base of the metacarpal, usually transverse and
undisplaced.
b) Fracture through the shaft – transverse or oblique. These fractures are
usually not much displaced because of the splinting effect of the interossei
muscles and adjacent metacarpals. When more than one metacarpal shafts
are fractured, this “auto-immobilisation” advantage is lost. Such fractures are
unstable and require operative treatment.
c) Fracture through the neck of the metacarpal – It commonly affects the neck
of the fifth metacarpal. The distal fragment is tilted forwards. It is usually
sustained when a closed fist hits against a hard object (Boxer's fracture).

5. TREATMENT
• Conservative treatment is sufficient in most cases. It consists
of immobilization of the hand in a light dorsal slab for 3
weeks.
• In cases with severe displacement or angulation, reduction is
necessary.
• This is achieved in most cases by closed reduction. Those
with multiple metacarpal fractures, internal fixation with K-
wires or mini plates may be required.

6. FRACTURES OF THE PHALANGES
• These are common fractures, generally sustained by fall of a
heavy object on the finger or crushing of fingers.
• The fractures can have various patterns and may be displaced or
undisplaced.
TREATMENT
a) Undisplaced fracture:
• Treatment is for the relief of pain.
• Splintage - to strap the injured finger to an adjacent finger for 2
weeks. After this, finger mobilization is started.

7. FRACTURES OF THE PHALANGES- TREATMENT
b) Displaced fracture:
• To reduce the fracture by manipulation and immobilized in a
aluminium splint.
• Active exercises must be started not later than 3 weeks after the
injury.
• If displacement cannot be controlled, open reduction and internal
fixation using K-wire, may be necessary.
MALLET FINGER (BASEBALL FINGER)
• The extensor tendon of the DIP joint is avulsed from its insertion at
the base of the distal phalanx.
• Clinically, distal phalanx is in slight flexion.
TREATMENT
• Immobilizing the DIP joint in hyperextension with the help of an
aluminium splint or plaster cast.

8. AMPUTATION OF FINGERS:PRINCIPLES OF TREATMENT
• Every effort should be made to save as much length of the thumb as
possible.
• Finger tip amputations if need reconstruction – full thickness skin be
covered the tip.
• In amputations at the level of the distal phalanx, replantation is not
possible.
• Replantation is not performed in the elderly persons, or in laborers
who do not need delicate functions of the hand. In such the finger is
amputated and the stump closed.
• Thumb reconstruction is possible using microsurgical technique by:
(i) Replantation
(ii) Pollicisation of the finger (one of the fingers is made into a thumb)
(iii) Transfer of a toe with its neurovascular bundle.

9. TENDON INJURIES OF THE HAND- DIAGNOSIS
• Flexor carpi radialis and flexor carpi ulnaris:
• Flexor digitorum:
• Testing for extensor tendons:

10. TENDON INJURIES OF THE HAND -TREATMENT
• Tendon injuries may be treated by the following methods:
a) Primary repair, end-to-end, if it is a clean cut injury. In
the finger if both flexor tendons are cut, only the profundus
tendon is repaired.
b) Delayed repair, reconstruction by tendon graft is
performed if it is a crushed tendon. The palmaris longus is
the most commonly used tendon for grafting.
c) Tendon transfer: If a tendon cannot be reconstructed, or
sometimes as a matter of choice, another dispensable tendon
can be transferred to its position, e.g., in rupture of the
extensor pollicis longus, the extensor indicis can be used.

11. TENDON INJURIES OF THE HAND
• The results of tendon repair are best in injuries at the
wrist, and are worst in those in the ‘danger area’ of the
hand i.e., between distal palmar crease and proximal
inter-phalangeal joint. The danger area is also known as
‘no man's land’.
• Extensor tendon repair has better prognosis than flexor
tendon repair.
• The main complication of tendon surgery is post-
operative adhesion of the tendon to the surrounding
tissues, thereby not allowing the tendon to glide
properly.

12. CRUSH INJURY TO THE HAND
CONSIDERATIONS FOR AMPUTATION
• The most demanding aspect of treatment of a crushed hand is the
assessment of the injury.
• The only indication for a primary amputation is an irreversible loss
of blood supply. Other factors are as follows:
a) Age of the patient: In children, amputation is indicated only when
the part is totally nonviable. However, in persons over 50 years of
age, amputation of one or two digits, except the thumb, may be
indicated when both digital nerves and flexor tendons are severed.
a) Cause of crushing: High speed, machine injuries produce more
crushing than those caused by fall of a heavy object onto the hand.
The causative factor also determines the extent of contamination,
and thereby chances of infection.

13. CRUSH INJURY TO THE HAND
c) Time since injury: In developing countries, often a patient
reaches the hospital after considerable delay, without proper first-
aid.
In such situations, there is increased risk of infection and poor
tissue viability, which may tilt the balance in favor of an
amputation.
d) Severity of crushing: A systematic examination of the hand,
with a viewpoint to evaluate the five tissue areas (skin, tendon,
nerve, bone and joint) helps in judging the severity of crushing.
When three or more of these require special procedures such as
grafting of skin, tendon suture, alignment of bone and joint,
amputation should be strongly considered.

14. CRUSH INJURY TO THE HAND
e) The part of the hand affected: Every effort should be made
to salvage as much of thumb and index finger as possible. One
should be hesitant in amputating a finger when other fingers are
also injured.
f) Other considerations: In some cases, the expected ultimate
function of the part may not be good enough to warrant the time
and effort required of the patient in not amputating the part.
For example, a person engaged in manual labor may be served
better by amputating a severely crushed finger, and putting him
back to work, than subjecting him to a series of operations only to
produce a ‘cosmetic’ finger.

15. PRINCIPLES OF TREATMENT
a) Assessment of the injury: It is done in two stages: (i)
soon after the patient is seen, and (ii) again prior to the
operation. Attention is first directed to the skin and then
to bones, tendons and nerves.
a) Treatment priorities: The first priority is thorough
cleaning and debridement of the wound. Next is
stabilization of fractures and dislocations, and after that
is wound closure with or without skin graft or skin flaps.
Nerves and tendons may be repaired in the primary
phase of the care, but this is of secondary importance.

16. PRINCIPLES OF TREATMENT
c) Individual tissue considerations: Skeletal stabilization is
performed if fracture or dislocation is unstable.
Primary repair of the extensor tendons, if ends can be visualized and
repair of the flexor tendons must not be attempted if extensive
dissection is required to find its ends.
Cut ends of the tendons are either tagged to each other or to the
surrounding tissues in order to prevent retraction.
Grafting can be carried out 3-6 weeks later. Digital nerves can be
repaired primarily in a clean wound or they can be repaired after 3-6
weeks.
d) Proper splintage : The ideal position of immobilization is with the
MP joints in 90° of flexion and IP joints in extension. In this position,
the collateral ligaments of these joints are kept. If possible, the finger
tips are left visible to evaluate circulation from time to time.

17. PRINCIPLES OF TREATMENT
e) Supportive care: The following supportive care is
required:
• Elevation of the hand for first 3-4 days to avoid edema.
• Finger movements to avoid edema and stiffness
• Antibiotics, prophylaxis against tetanus and gas gangrene
• Suitable analgesics
• Dressings as necessary
f) Rehabilitation: This consists of exercises, wax bath and
splintage. Once maximum benefit has been obtained by
physiotherapy, secondary operations may be considered for
further improvement in functions.

18. THANK YOU
Dr. Sanjib Kumar Das, Fellow (PhD) NITIE,
Ergonomics and Human Factors,
Asst. Prof., School of Physiotherapy,
P.P. Savani University, Surat, India
Mail: sanjib_bpt@yahoo.co.in
Contact No. :+91 8879485847
*Contents have been included from the book of Essential Orthopaedics, Maheshwari and Mhaskar, 5th Edition.