CHAPTER 4
Hand
Case Study 4.1: Acute Mallet Finger
Hardeep Singh and Craig M. Rodner
SETTING: ORTHOPEDIC URGENT CARE
Definition and Incidence
A mallet finger is an acute traumatic injury resulting from a hyperflexion injury to the distal portion of the finger, the distal interphalangeal (DIP) joint resulting in forced DIP flexion (Bendre, Hartigan, & Kalainov, 2005). This type of injury leads to disruption of the terminal extensor tendon.
Patient
The patient is a 22-year-old male who presents to the emergency department after having sustained an injury to his middle finger while playing football. He reported immediate pain and swelling distally in his middle finger and inability to extend his DIP joint. He was unable to return to playing football due to the deformity of his middle finger and pain. The team athletic trainer at the game saw him, and a foam splint was put in place. It was recommended that he follow up after the game at the urgent care clinic. He denies significant pain, but has a mild ache that he rates as 4 out of 10. He is concerned about the inability to extend his finger on his own.
Social History
This 22-year-old is in his final year of college, playing at a local Division 3 university. He is single, and lives on campus. He is not working at present.
Physical Assessment
Physical examination reveals a young man who presents with his father. He is in no acute distress, but does have mild discomfort. On inspection, he had swelling and deformity of his DIP joint, with the fingertip resting in flexion. He was unable to actively extend the DIP joint. His sensation is intact, and he has no other associated symptoms.
Diagnostic Evaluations
Radiographs of his hand revealed no fracture or joint subluxation. Given the clinical history and physical examination findings, the patient suffered an acute nonbony mallet finger injury. Disruption of the terminal extensor tendon leads to the DIP joint lag clinically.
Diagnosis
Mallet finger (disruption of the terminal extensor tendon).
Interventions
The patient is placed in an extension splint of the DIP joint with proximal interphalangeal (PIP) joint free for 6 weeks around the clock.
CLINICAL PEARLS
Immediate intervention with an extension splint or operative treatment of a bony avulsion is important in restoring function and decreasing pain (Kalainov, Hoepfner, Hartigan, Carroll, & Genuario, 2005). Figure 4.1 is an example of a bony mallet.
It is important for the nurse practitioner to realize that operative treatment is indicated in patients with a bony avulsion fracture that has significant articular surface involvement and a subluxed DIP joint.
Patient Education
Instruct the patient to keep the extension splint on at all times and to rest his affected hand. Importantly, teach the patient that this includes in the shower, and while changing the splint or tape. The consequence of this position must be emphasized to your patient for a good outcome. Ask the patient to return to clinic in 6 weeks to be reevaluated and to refrain from athletic activity to prevent further injury.
FIGURE 4.1 Radiographic example of a bony mallet.
Follow-Up Evaluation
He is seen back in the hand clinic in 6 weeks and the extension splint is removed. Physical therapy is recommended to help improve motion at the DIP joint.
REFERENCES
Bendre, A. A., Hartigan, B. J., & Kalainov, D. M. (2005). Mallet finger. Journal of the American Academy of Orthopaedic Surgeons, 13(5), 336–344.
Kalainov, D. M., Hoepfner, P. E., Hartigan, B. J., Carroll, C., & Genuario J. (2005). Nonsurgical treatment of closed mallet finger fractures. Journal of Hand Surgery, 30(3), 580–586.
Case Study 4.2: Acute Dislocation Interphalangeal Joint
Hardeep Singh and Craig M. Rodner
SETTING: ORTHOPEDIC URGENT CARE
Definition and Incidence
Dislocations of the DIP joint are typically the result of a traumatic injury to the PIP or DIP. The direction of these dislocations can be dorsal or volar, depending on the force exerted. Dorsal PIP dislocation is more common than volar dislocation and can lead to injury to the volar plate (Leggit & Meko, 2006).
Dorsal PIP fracture-dislocation—fracture is commonly located on the volar lip of the middle phalanx, with fractures involving more than 50% of the articular surface being unstable and requiring surgical treatment (Bindra & Foster, 2009). Volar PIP dislocation and fracture-dislocations are less common than dorsal dislocation, and these can lead to injury to the central slip resulting in a Boutonniere deformity.
Patient
A 20-year-old male presents with an obvious middle finger deformity after falling off his bike onto his hand. He is unable to extend or flex his middle finger at the PIP joint. He denies any numbness or tingling. He has pain that is 8 out of 10, and he is concerned over the appearance of his finger.
Social History
The patient is a 20-year-old college student. He is active socially, but does not participate in organized sports. He lives at school 2 hours away from his family.
Physical Assessment
Physical examination reveals a young man in no acute distress, but discomfort. He presents with his friend. On inspection, he has deformity of his middle finger PIP with inability to flex or extend his PIP joint. There are no soft-tissue abnormalities or open cuts, but there is a lot of dirt and mud on his hand, arms, and legs. With palpation, the middle finger is tender to palpation. There is no tenderness to palpation of his wrist, carpus, or metacarpals. He remains neurovascularly intact; sensation is full to the finger aforementioned and following the noted deformity.
Diagnostic Evaluations
Radiographs of his hand are obtained and the lateral x-rays reveal a dorsal PIP fracture dislocation, with a volar plate avulsion fracture of the medial phalanx (Figure 4.2).
Diagnosis
Dorsal PIP fracture dislocation.
Interventions
The patient undergoes a closed reduction of his PIP with longitudinal traction and is placed in a dorsal block splint. Immediate range of motion (ROM) is started and he is asked to follow up in 1 week, at which time follow-up x-rays are obtained (Figure 4.3).
Patient Education
It is important to explain the procedure of the closed reduction to the patient quickly, and to tell the patient that most of the discomfort he will experience is while the finger is, in fact, dislocated. While reducing the dislocation with longitudinal traction and reproduction of the mechanism of injury will cause brief discomfort, there is usually quite a reduction in the discomfort after it is completed.
FIGURE 4.2 Radiograph of the lateral view of the hand showing a dorsal proximal interphalangeal dislocation.
FIGURE 4.3 Post-reduction radiograph of the lateral view of the hand showing the reduced dorsal proximal interphalangeal dislocation, with joint congruity.
CLINICAL PEARLS
Dislocations can be simple or complex in nature. In a simple dislocation, the condyles are in contact; in a complex dislocation, the condyles are not in contact.
Urgent closed reduction and splinting are necessary for dislocations of the IP joints.
Follow-Up Evaluation
At the 1-week follow-up visit, the patient is encouraged to start with hand therapy (occupational therapy), to work on restoring normal motion and function.
REFERENCES
Bindra, R. R., & Foster, B. J. (2009). Management of proximal interphalangeal joint dislocations in athletes. Hand Clinics, 25(3), 423–435.
Leggit, J. C., & Meko, C. J. (2006). Acute finger injuries: Part II. Fractures, dislocations, and thumb injuries. American Family Physician, 73(5), 827–834.
