Hand Deformities,

Fractures, and palsy

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 NOTE
• The following subjects are NOT mentioned in
the guidelines
– Dupuytren contracture (slides 28-31)
– Hand fractures (32-45)
– Hand palsy (46-57)

• Sry, but I got the guidelines after finishing the

seminar 

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-Mallet deformity

-Trigger Finger

-Boutonniere Deformity

-Swan – Neck deformity

-Dupuytren contracture

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 Mallet Finger
• Aka: baseball finger
• Deformity in which the
fingertip is curled in and
cannot straighten itself
• Due to injury to
extensor digitorium
tendons at DIPJ

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5
 Mallet Finger/Causes
Forced flexion of the finger
when finger is extended:
. Sport Injury: Finger struck by
volleyball, basketball or
baseball when it is in
extension
. Other common mechanisms
of injury include forcefully
tucking in a bedspread or
slipcover or pushing off a
sock with extended fingers.

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 Mallet Finger/Presentation
• After DIPJ forced flexion: inability to actively extend the distal
joint, intact full passive extension
• Often injury is painless or nearly painless
• Dorsum of joint may be slightly tender and swollen

• Order X-ray to make sure there are no fractures

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 Despite active extension effort, the distal
interphalangeal joint of the index finger rests
in flexion, characteristic of a mallet finger

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This x-ray depicts a large, dorsal-lip avulsion
fracture from the distal phalanx, a bony
mallet injury.

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 Mallet Finger/Managment
• Mallet finger splint (6-
10 weeks)
• Surgery:
– In case of volar
sublaxation of distal
phalanx or avulsion
fracture
– K-wire (Kirschner wire)

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 Anteroposterior radiographic view of finger after 4
weeks. The longitudinal K-wire is blocking the distal
interphalangeal joint from flexion to protect the repair

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 Trigger Finger
• Trigger finger is the
popular name of
stenosing tenosynovitis,
a painful condition in
which a finger or thumb
locks when it is bent
(flexed) or straightened
(extended).

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 Trigger Tension
• Due to narrowing of the sheath that surrounds the tendon in
the affected finger, or a nodule forms on the tendon.

• Trigger finger is often an overuse injury because of repetitive

or frequent movement of the fingers (ex. hobbies as playing a
musical instrument or crocheting)

• Trigger finger may also result from trauma or accident

• It is called trigger finger because when the finger unlocks, it

pops back suddenly, as if releasing a trigger on a gun.

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 Trigger Tension
• Clinical Picture:
– Affected digits may become painful to straighten once
bent
– May make a soft crackling sound when moved.
– It props back suddenly when straightened
– Symptoms are usually worse in the morning and improve
during the day

• Treatment:
– local steroid injections and splinting (weeks to months)
– Surgery: cut the sheath that is restricting the tendon.

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Trigger Tension

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Introduction of the needle into
the tendon sheath at 45° to the
palm for injection treatment.

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 Boutonniere Deformity
• Aka: Buttonhole
Deformity
• Hyperflexion at the PIP
joint with
hyperextension at the
DIP
• Passive extension of the
PIP joint is easy.

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Boutonniere Deformity

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 Boutonniere Deformity
• Flexion deformity of the PIP
joint, due to interruption of
the central slip of the
extensor tendon:
Central Slip
– The lateral bands separate
– The head of the proximal
phalanx pops through the gap
like a finger through a button
hole
– The DIP joint is drawn into
hyperextension. Lateral Band

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 Boutonniere Deformity
• The 3 main etiologies:
– RA and other inflammatory arthritides (most often)
– mechanical trauma
– burns and infections

• An X-ray should be done to detect avulsion fractures

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 Boutonniere Deformity
• BD in patients with RA can be classified into 1 of the following 3
stages, which serve as a guide to the appropriate management:
– Stage I (mild) is the earliest stage and is the result of PIP joint synovitis
with mild extensor lag that still can be corrected passively. The
metacarpophalangeal (MP) joint usually is normal, and the DIP may or
may not be hyperextended.

– Stage II (moderate) is characterized by 30-40° of flexion contracture at

the PIP joint and hyperextension of the MP joint as a compensatory
mechanism. The finger has increased functional loss. Early passive
extension still is possible. With time, soft-tissue contractures develop,
and passive extension becomes restricted.

– Stage III (severe) begins when the PIP joint can no longer be extended
passively. Radiographs demonstrate destruction of the joint surfaces

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 Boutonniere Deformity
Treatment:
• Splinting 4 weeks minimal (6 weeks preferable):
– safety-pin splint (<40 degree)
– Dynamic spring splints (> 40)

• Surgery: When the deformity is the result of a dislocation of

the PIP joint
• Surgery carries a relatively high risk of FAILURE to achieve
completely normal functioning extension mechanism of the
finger.

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Bunnell Safety Pin Finger Dynamic spring
Splint extension splint

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 Swan-Neck deformity
• -the PIP joint is hyper
extended . DIP joint is
flexed.
• Cause:
– Volar plate becomes
weak -> hyperextension
of PIPJ -> flextion of DIFJ
• Due to injury or
inflammation (RA)

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Swan-Neck deformity

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 Swan-Neck deformity
• Swelling and pain due to inflammation from
injury or disease (RA)
• X-ray is done to evaluate the joints (RA) and look
for fractures.

• Treatment:
– A boutonnière deformity caused by an extensor
tendon injury can usually be corrected with a splint
(Murphy Ring Splints) that keeps the middle joint fully
extended for 6 weeks
– When splinting is ineffective, surgery may be needed.
MURPHY RING SPLINTS

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 Dupuytren contracture
• Pathologic condition of
the hand in which the
fascia of the palm are
shortened and
thickened
• Common in south
europe

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Dupuytren contracture

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 Dupuytren contracture
• Dupuytren's contracture is more common among people with
diabetes, alcoholism, or epilepsy
• The disorder affects both hands in 50% of people

• The disorder is occasionally associated with other disorders:

– Garrod's pads: thickening of fibrous tissue above the
knuckles
– Penile fibromatosis: shrinking of fascia inside the penis
that leads to deviated and painful erections
– Plantar fibromatosis: nodules on the soles of the feet

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 Dupuytren contracture
• Symptoms:
– The first symptom is usually a tender nodule in the palm
– Gradually, the fingers begin to curl.
– Eventually, the curling worsens, and the hand can become
arched (clawlike)

• Treatment:
– Surgery to correct contracted (clawed) fingers

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 Hand Fractures/Hx
• Hand trauma, industrial
• Hand dominance
• Hand injured
• Mechanism of injury:
– Clean/dirty environment
– Position of the hand
– Thermal, electric or chemical injury
– Wearing jewelry on finger, removed
• In assault:
– Hand open or fist clenched
– Lacerations (tendon injury)
– Contact with mouth, teeth
• Years since last tetanus immunization (esp. in lacerations and
abrasions)

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 Hand Fractures/ P/E
• Hand examination:
– Compare with uninjured
– Signs of inflammation, abrasions, erosions
– Abnormal position (esp. fingers): rotational
deformity
– Location of injury
– Capillary refill

• Neurology: radian, median and ulnar nerve

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With fingers flexed at the metacarpophalangeal
and proximal interphalangeal joints and
extended at the distal interphalangeal joints,
fingers should all point toward the scaphoid
bone

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 Examination of the patient's hand with the
fingers flexed may clearly reveal a rotational
deformity

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 Hand Fractures
• Imaging:
– X-ray: AP, lateral and oblique view
– MRI, CT, Bone scan seldom needed

• ED care:
– Pain management, reduction, splinting, referral
– Primary concern is preservation of function
– Except for distal phalanx fracture, all pts. Should be
referred to a hand surgeon
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 Boxer’s Fracture
• A break in one or more
metacarpal bones,
usually the fourth or the
fifth, caused by
punching a hard object.
Such a fracture is often
distal, angulated, and
impacted Fourth and fifth
• Finger shorten metacarpal fractures,
oblique view
posteriorly
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 Scaphoid Fracture
• Epidemiology
– common in young men;
not common in children
or in patients beyond
middle age
• Mechanism
– FOOSH resulting most
commonly in a
transverse fracture Scaphoid fracture in the middle third
through the waist or waist
(middle) of the scaphoid

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 Scaphoid Fracture
• Clinical Features:
– pain on wrist movement
– tenderness in scaphoid region (anatomical "snuff box")
– usually undisplaced
• Investigations:
– x-ray (AP/lat/scaphoid views with wrist exended and ulnar deviation)
– +/- bone scan and CT scan
• Note: a fracture may not be radiologically evident up to 2 weeks after
acute injury, so if a patient complains of wrist pain and has anatomical
snuff box tenderness but a negative x-ray, treat them as if they have a
scaphoid fracture and repeat x-ray 2 weeks later to rule out a fracture
• Treatment:
– Undisplaced: cast
– Displaced = open (or percutaneous) screw fixation

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 Colles’ and Smith Fracture
• Colles’ Fracture:
– Due to FOOSH
– > 40 yrs, female (esp. osteoperosis)
– Fx fragment: upward-dorsal angulation (fork-like
appearance)

• Smith Fracture:
– Aka: reverse Colles’ fracture
– Falling on the back of a flexed hand
– Fx fragment: volar (palmar) displacment
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Colles’ Fracture

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Smith Fracture

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 Both Bones Fracture
(Radius & Ulna)
• FOOSH, direct blow

• Internal fixation by
plates and screws

• Complications:
– Compartment syndrome
Anteroposterior radiograph of a
– malunion displaced, midshaft both-bone
forearm fracture in an adolescent
with a transitional growth plate

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 Ulnar nerve palsy
• This occurs due to
nerve compression at
the elbow (cubital
tunnel) or at the wrist
(Guyon's canal) (Ulnar
canal)
• Muscle weakness and
atrophy predominate
the clinical presentation

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 Ulnar nerve palsy/Causes
Cubital Tunnel Syndrome Guyon's Canal Syndrome
• Frequent bending of the elbow • A cyst within the canal.
• Leaning on the elbow, resting • Clotting of the ulnar artery.
it on an elbow,  rest during a • Fracture of the hamate bone.
long distance drive  or running • Arthritis of the wrist bones
machinery may cause
repetitive pressure and
irritation on the nerve.
• A direct hit on the cubital
tunnel may damage the ulnar
nerve

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 Ulnar nerve palsy/Causes
• Symptoms & signs:
– numbness and tingling in the ring and little finger and the sides and
back of the hand. At Guyon's Canal, sensory supply to the skin of the
back of the hand is spared.
– The hand may become weaker resulting in trouble opening bottles or
jars
– Clawing may occur in the ring and little fingers
–  Froment's test: by asking the patient to hold a piece of paper
between their thumb and index finger (hence checking adductor
pollicis). In a patient with Ulnar nerve palsy the interphalangeal joint
of the thumb will flex to compensate
• Treatment:
– Nonsurgical therapy: elbow or wrist splints to limit mobility in addition
to an anti-inflammatory drug such as ibuprofen.
– Surgical decompression maybe required in some cases

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Froment's test

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 Radial nerve palsy
• Aka:
– wrist drop
– Saturday night palsy

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• Causes
– Caused by excessive compression of the radial nerve
against a hard surface in individuals insensitized by the
intake of alcohol or sedatives
– Broken humerus
– lead poisoning 
– Stab wounds to the chest at or below the clavicle. Damage
the posterior cord of the brachial plexus

• Symptoms:
– Wrist drop
– Occasionally, the back of the hand may lose feeling

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Wrist Drop

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 Erb’s Palsy
• Aka:
– Waiter's tip deformity
– Erb-Duchenne Palsy

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 Erb’s Palsy
• Due to brachial plexus damage, by excessive lateral neck flexion
away from sholder:
– Forceps delivery
– Falling on the neck

• Leads to loss of the lateral rotators of the shoulder, arm flexors,

and hand extensor muscles.

• The position of the limb, under such conditions, is characteristic:

– the arm hangs by the side and is rotated medially;
– the forearm is extended and pronated.
– The hand is flexed
– The arm cannot be raised from the side; all power of flexion of the
elbow is lost, as is also supination of the forearm

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 Erb’s Palsy
• The three most common treatments from Erb's
Palsy are:
– Nerve transfers (usually from the opposite leg),
– Sub Scapularis releases
– and Latissimus Dorsi Tendon Transfers.

• Although range of motion is recovered in many

children under one year in age, individuals who
have not yet healed after this point will rarely
gain full function in their arm and may develop
arthritis
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