Hand Injuries

Tendon Injuries

7.1 Mallet Finger

Clin Sports Med 1998;17:449

Cause: Axial load against an actively extending finger.

Epidem:

Originally described in baseball, but can occur in any activity where the finger is subject to “jamming.”
Frequently missed initially with subsequent deformity and medicolegal consequences.

Pathophys:

Can result in a dorsal bony avulsion or a grade III (complete disruption) injury to the extensor digitorum tendon.

Sx:

Pain at the dorsal distal interphalangeal joint.

Si:

Inability to extend the isolated DIP.
Tenderness over the dorsal proximal aspect of the distal phalanx.

X-ray:

Bony avulsion from the dorsal proximal distal phalanx seen in approximately 20-30% of cases.

Rx:

Initially treated with PRICEMM (Protection, relative rest, ice, compression, elevation, medications, and modalities) and analgesia as needed.
No avulsion fracture: splint DIP fully extended for 6-8 w straight and an additional 6-8 w, if engaged in athletic activities.
Bony avulsion with <30% of joint space involved are frequently unstable and require surgical fixation. If stable, dorsal finger splint in full extension for 4 w.
Bony avulsion with >30% of joint space involved: refer for possible ORIF.
Permanent DIP extensor lag, if untreated. Watch for pressure necrosis from splint.

Return to Activity:

May return as soon as can be adequately splinted (as discussed above).

7.2 Jersey Finger (Football Finger)

Clin Sports Med 1998;17:449

Cause: Forced extension of the distal phalanx while actively flexing the DIP (eg, athlete grabbing onto a jersey).

Epidem: Common in football, rugby, martial arts or any sport where grabbing an opponent’s clothing can occur.

Pathophys:

Results in either a grade III tear or a bony avulsion fracture of the flexor digitorum profundus tendon.
An avulsion fracture of the volar lip of the distal phalanx limits retraction and enables repair by ORIF.
Pure tendon avulsions may retract to the PIP or palm.
If retracted to the palm, the blood supply via the vincula brevum and longum is compromised.

Sx: Pain and swelling at the DIP.

Si:

Unable to flex the isolated DIP with localized tenderness at the level of retraction of the avulsed segment.
The flexor digitorum profundus is examined by holding the PIP straight and asking the athlete to flex the DIP.
The superficialis is tested by holding the MCP straight and asking the athlete to flex the PIP.

X-ray: PA, lateral, and oblique views will document an avulsed fragment and may help localize the level of retraction.

Rx:

Initial treatment is PRICEMM and analgesics, as needed.
Refer for surgical repair within 3 w with retraction to PIP, within 1 w if retracted to the palm.

Return to Activity: 6-12 w following surgery, depending on chosen sport.

7.3 Traumatic Dislocation of the Extensor Hood (Boxer’s Knuckle)

Clin Sports Med 1998;17:449

Cause: Caused by direct blow to the flexed MCP or by flexion and ulnar deviation force across the MCP.

Epidem: Collision or contact sports.

Pathophys: Disruption of the sagittal fibers (usually radial) allowing the extensor tendon to sublux off the apex of the MCP into the valley between the MC heads.

Sx: Pain and swelling over the dorsum of the MCP.

Si:

MCP is tender dorsally with inability to actively extend the MCP joint from a flexed position.
After passive extension of the joint, the patient is able to maintain extension.

X-ray: Plain radiographs usually normal.

Rx:

Initially treated with PRICEMM, splinting, and analgesics as needed.
Splint the MCP in full extension with the PIP free for 4 w.
Active ROM exercises are begun at 4 w with the splint worn at all other times.
Splint is discontinued at 8 w.
Old injuries should be referred for possible surgical correction.

7.4 Central Slip Avulsion

Clin Sports Med 1998;17:449

Cause: Volar directed force on the middle phalanx against a semi-flexed finger attempting to extend.

Epidem: Contact and collision sports.

Pathophys: Disruption of the central slip of the extensor digitorum communis tendon over the PIP joint allowing for migration of the lateral bands volar to the axis of the joint (“Boutonniere” deformity).

Sx: Pain and swelling over the PIP joint.

Si:

The PIP is in 15-30° of flexion with point tenderness over the dorsal lip of the middle phalanx.
There is an inability to actively extend the PIP.

X-ray: May show an avulsion fracture at the dorsal base of the middle phalanx.

Rx:

Initially treated with PRICEMM as needed.
PIP is splinted in full extension for 4-5 w and further protected during sporting activity for an additional 6-8 w.
While splinted the DIP should be allowed to flex to help relocate the lateral bands back to their normal position.
If an avulsion fragment involves >1/3 of the joint, they should be referred for possible ORIF.

Return to Activity: 4-8 w depending on chosen activity.

7.5 Trigger Finger

Clin Sports Med 1998;17:449

Cause: Nonspecific flexor tenosynovitis from overdemand.

Epidem: Rowing, rock climbing, or any activity requiring repetitive finger flexion.

Pathophys: Most common in the flexor tendons of the thumb, middle, and long fingers.

Sx: Difficulty straightening involved finger (triggering), especially in AM, variable degree of pain.

Si: Variable amount of tenderness over flexor tendon sheath aggravated by active finger flexion or passive extension. Palpable nodule in flexor tendon sheath.

X-ray: Radiographs not indicated.

Rx:

Early or no triggering: splint finger at night.
Triggering: inject flexor tendon sheath through a mid-lateral approach over distal 1/3 of the proximal phalanx. Repeat in 6-8 w, if symptoms persist (max 2 injections and consider ortho referral). Splint at night.

Return to Activity: As symptoms allow.

Ligament Injuries

7.6 Collateral Ligament Tears

Clin Sports Med 1986;5:757

Cause: Result from valgus or varus stress to the PIP, DIP, or MCP.

Epidem: Collision and contact sports.

Pathophys: Causes partial or complete tears of the ulnar or radial collateral ligaments.

Sx: Pain and swelling at the involved joint.

Si: Laxity with valgus or varus stress. The joint may be stable or unstable with active flexion and extension.

X-ray: May show avulsion fracture from capsular insertion.

Rx:

Initially treated with PRICEMM, splinting, and analgesics as needed.
Stable with active ROM: buddy tape finger to finger adjacent to side of injury for 3 w.
Unstable with active ROM or obvious angulation: refer for possible surgical repair.

Return to Activity:

As symptoms allow, with protective splinting.

7.7 PIP Volar Plate Rupture (without Dislocation)

Clin Sports Med 1986;5:757

Cause: Hyperextension injury causing the distal portion of the volar plate to rupture from its attachment to the middle phalanx.

Epidem: Common in volleyball, football, or any sport where the finger is subject to hyperextension.

Pathophys: The loss of the volar stabilizing force of the PIP allows the extensor tendon to gradually pull the PIP into a hyperextension deformity (reverse Boutonniere).

Sx: Pain and swelling at the PIPJ.

Si:

The PIP is in varying degrees of hyperextension with maximal tenderness over the volar aspect of the PIP.
With active extension and flexion, the hyperextended PIP often “locks” in the extended position with an inability to initiate flexion.

X-ray: PA, lateral, and oblique may show an avulsion fragment at the base of the middle phalanx.

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