Bennett , rolando , tendon injuries

hand injuries

1. Injuries of the hand – Bennett’s fracture disclocation , Rolando’s fracture and Tendon injuries

2. Bennett’s Fracture Bennett's fracture is a fracture of the base of the first metacarpal bone which extends into the carpometacarpal (CMC) joint . I ntra-articular fracture most common type of fracture of the thumb, nearly always accompanied by some degree of subluxation or frank dislocation of the carpometacarpal joint .

3. The Bennett's fracture is named after Edward Hallaran Bennett . Bennett said his fracture "passed obliquely across the base of the bone, detaching the greater part of the articular surface ” , and "the separated fragment was very large and the deformity that resulted there-from seemed more a dorsal subluxation of the first metacarpal".

4. Mechanism of Injury an axial force directed against the partially flexed metacarpal . This type of compression along the metacarpal bone is often sustained when a person punches a hard object, such as the skull or tibia of an opponent, or a wall . It can also occur as a result of a fall onto the thumb .

5. T he proximal metacarpal fragment remains attached to the anterior oblique ligament, which in turn is attached to the tubercle of the trapezium bone of the CMC joint. This ligamentous attachment ensures that the proximal fragment remains in its correct anatomical position. The distal fragment of the first metacarpal bone possesses the majority of the articular surface of the first CMC joint. Unlike the proximal fracture fragment, strong ligaments and muscle tendons of the hand tend to pull this fragment out of its correct anatomical position.

6. Specifically: T ension from the abductor pollicus longus muscle (APL) subluxates the fragment in a dorsal, radial, and proximal direction . T ension from the APL rotates the fragment into supination . T ension from the adductor pollicus muscle (ADP) displaces the metacarpal head into the palm .

7. Clinical Evaluation Characteristic signs include – P ain , S welling , and E cchymosis around the base of the thumb and thenar eminence, and especially over the CMC joint of the thumb . I nstability of the CMC joint of the thumb, accompanied by pain and weakness of the pinch grasp.

8. Radiographic Evaluation Xray – posteroanterior and Lateral radiograph Traction xrays are advisable CT scan – rarely indicated in case of doubt

9. Treatment 1.Conservative treatment Indicated for undisplaced fractures. 2.Closed reduction and internal fixation Indicated for reducible fractures. 3.Open reduction internal fixation (ORIF) Indicated for fractures which are not reducible in a closed manner. ORIF is also indicated in high-demand patients and those who need immediate restoration of a full range of motion. However, ORIF is possible only if the anterior marginal fragment is large enough for internal fixation (>20% of the articular surface).

10. Closed reduction and POP application Reduction is performed by a combination of 1. longitudinal traction 2. pronation of the metacarpal 3. pressure at the thumb metacarpal base . Confirm correct restoration of the articular surface using image intensification.

11. Closed reduction and internal fixation The most common are: 1. Transfixion of the base of the first metacarpal to the trapezium 2. Transfixion of the thumb base to the second metacarpal 3. Combination of both

12. Wagner technique for closed pinning

13. Open Reduction and Internal Fixation

14. Reverse Bennett’s Fracture It’s a fracture-dislocation of the base of the 5 th metacarpal bone . pathologically and radiographically analogous to the Bennett’s fracture of the thumb . It is quite unstable due to unopposed Extensor Carpi Ulnaris force on the fracture fragment , which causes migration and subluxation of the fragment . Frequently need K-wire stabilization to counteract the strong force of ECU .

15. Pseudo bennett’s fracture A/K/A Epibasal fracture of the thumb . It’s a two-piece fracture of the proximal first metacarpal bone usually result from longitudinal axial loading . They are usually stable and depending on the degree of displacement , and often do not require surgery . It is important to distinguish them from intra- articular fractures , which are usually unstable and require surgery .

16. Rolando’s Fracture Intra- articular fracture of the base of the first metacarpal bone which extends into the carpometacarpal (CMC) joint . Differentiating feature from Bennett’s # - T- or Y-shaped fracture patterns can occur either in the frontal or in the sagittal plane . Described by Rolando in 1910, this fracture is a 3-part intraarticular fracture of the base of the thumb metacarpal . Today the term “Rolando’s fracture” is often misused to describe multifragmentary intraarticular fractures of the thumb metacarpal base.

17. Mechanism of Injury Clinical evaluation Radiographic evaluations Treatment Same as Bennett’s Fracture

18. Xray

19. Closed Reduction and POP application As there is usually a flexion deformity, Reduction can be performed with - Axial traction on the thumb and simultaneous pressure over the dorsal aspect of the basal diaphysis near the fracture .

20. Maintaining reduction During the application of the cast, it is important to exert pressure over the dorsal aspect of the first metacarpal diaphyseal base, and from the palmar aspect over the first metacarpal head.

21. Pitfall: palmar pressure Avoid pressing from the palmar aspect over the base of the proximal phalanx . This results in redisplacement of the fracture and hyperextension of the MCP joint.

22. Open Reduction and Internal Fixation Choice of approach For Y- or T-shaped patterns in the frontal plane, a straight dorsal approach is preferred. For a Y- or T-shaped fracture pattern in the sagittal plane, the radiopalmar approach is the preferred choice.

23. Open Reduction and Internal Fixation

24. Open Reduction and Internal Fixation

25. Open Reduction and Internal Fixation

26. Kirschner Wire Fixation Advantages... No cut. Less dissection of muscle. Less risk infection. Smaller procedure. Disadvantages... Plaster for 6 weeks. Must keep dry. Increased stiffness. Increased risk of late infection along wire.

27. Open Reduction Advantages... Allows accurate alignment of joint surface under direct vision. Gentle movements may be started early if screw fixation is noted to be strong at time of surgery. Disadvantages... Exposure of the joint. Increased risk of injury to skin nerves , early infection. Need expertise in dissection

28. Complications Stiffness – MC Stiffness of the 1 st MCP joint , Wrist joint ,etc Post traumatic Arthritis Open Surgery related Complications

29. Tendon Injuries Flexor Tendon Injuries Extensor Tendon Injuries Tendon – “ Glistening structure between muscle and bone which transmit force between muscle and bone “

30. Etiology Sharp object direct laceration (broken glass, kitchen knives or table saws) Crush injury Motor vehicle accidents Avulsions Burns Animal or human bites Suicide attempts

31. Tendon Healing 2 forms: Intrinsic healing : occurs without direct blood flow to the tendon Extrinsic healing : occurs by proliferation of fibroblasts from the peripheral epitendon ; adhesions occur because of extrinsic healing of the tendon and limit tendon gliding within fibrous synovial sheaths

32. Phases of Tendon Healing 1.Inflammatory (0-5 days) : strength of the repair is reliant on the strength of the suture itself 2.Fibroblastic (5-28 days) : or so-called collagen-producing phase 3.Remodelling (>28 days)

33. Timing of tendon repair Primary: repair within 24 hours (contraindicated in case of high grade condtamination i.e. human bites, infection) Delayed Primary: 1-10 days when the wound can be still pulled open without incision Early Secondary: 2-4 weeks. Late Secondary : after 4 weeks

34. Flexor Tendon Zones

35. ZONE 1: ZONE OF FDP AVULSION INJURIES Region b/w middle aspects of middle phalanx to finger tips Contains only one tendon-FDP Tendon laceration occurs close to its insertion Tendon to bone repair is required than tendon repair

36. Leddy and Packer Classi . Of Zone 1 Tendon Injuries

37. ZONE II – NO MANS LAND From metacarpal head to middle phalanx Called so because initial attempts for tendon repair here produced poor results FDS and FDP within one sheath Adhesion formation risk is amplified at campers chiasma

38. ZONE III – DISTAL PALMAR CREASE B/w transverse carpal ligament and proximal margin of tendon sheath formation Lumbricals origin here prevents profundus tendons from over acting Delayed tendon repairs are succesfull even after several weeks of injury

39. ZONE IV – TRANSVERSE CARPAL LIGAMENT Lies deep to deep transverse ligament Tendon injuries are rare ZONE V – PROXIMAL TO CARPAL TUNNEL Lies proximal to transverse carpal ligament

40. Signs and Symptoms Unable to bend one or more finger joints Pain when bending finger/s Open injury to hand (e.g., cut on palm side of hand, particularly in area where skin folds as fingers bend) Mild swelling over joint closest to fingertip Tenderness along effected finger/s on palm side of hand

41. Complain of numbness Preceeded by execissive bleed Consider neurovascular insult!!

42. DETECTION History and physical Examination of wound Use of bedside ultrasonography in ER (more sensitive and specific than physical examination) Wound exploration techniques or MRI. 3-view x-ray must be done (except most benign) to rule out foreign bodies or bony injury. Radiographs to evaluate for possible fractures or dislocations (blunt trauma cases)

43. Jersey Finger Avulsion injury of the flexor digitorum profundus tendon from its insertion at the base of the DIP joint . It’s a Zone I flexor tendon injury .

44. Jersey finger very frequently occurs in contact sports like football and rugby . Catching of finger in a jersey and tearing a tendon while tackling opponents in contact sports is the common cause of jersey finger. A jersey finger injury most frequently affects the ring finger of the hand .

45. Mechanism of Injury Results from forceful hyperextension of DIP joint with FDP in maximal contraction . The flexor digitorum superficialis remains intact and is not affected in this type of injury. Tendon may rupture directly from its insertion into bone, or it may avulse bone fragment from base of distal phalanx; it may also rupture at the musculotendinous junction .

46. MRI Disruption of flexor digitorum profundus (FDP) at volar base of distal phalanx ± avulsion fragment.  MRI also allows visualisation of the location of the end of tendons which will affect the surgical classification and management of the patient . ultrasound Simple and Cost-effective High sensitivity and specificity

47. Treatment Rest , Ice , Elevation Conservative for partial tear Splinting, NSAID's, Physical therapy

48. TESTS FOR FDP AND FDS

49. DICTUM Flexor tendon repair is not a surgical emergency. It is proved that equal or better results can be achieved by delayed primary repair. Better to repair both FDP & FDS tendons rather than FDP alone Because the blood supply to the FDP tendon is jeopardized if the FDS is not fixed (due to the vinculae anatomy)

50. Goals of Reconstruction Coaptation of tendons Anatomical repair Multiple strand repair to permit active range of motion rehabilitation Pully reconstruction to minimize bow-stringing Atraumatic surgical technique to minimize adhesions Strict adherence to rehabilitation protocol.

51. What we can provide ???? Minimal dissection and handling Tendon apposition without gapping Early protected mobilization

52. Bunnell stitch Crisscross stitch Mason-Allen stitch Robertson and Al- Qattan Interlock stitch Core Suture Techniques

53. Kessler stitch Modified Kessler Tajima modification Of kessler stitch with double loop at repair site

54. Zone I Repair Wound extended proximally and distally Proximal tendon retrieved,core sutures are placed Keith needles used to pass the sutures around the distal phalanx exiting through nail plate distally Remaining distal end of tendon sutured to the re-attached proximal portion

55. Direct repair : if laceration is more than 1 cm from FDP insertion Tendon advancement : if the laceration is less then 1 cm from insertion

56. Zone II Repair Repair both tendon lacerations – FDS , FDP Tendon sheath may be opened for exposure but A2 and A4 are preserved as much as possible FDS is repaired first followed by FDP

57. Zone III Repair If both tendons are lacerated, both are repaired, end to end with circumferential re-enforcing sutures May affect lumbricals in addition to flexor tendons Damaged lumbrical is either repaired or excised depending on severity of injury and the location of the laceration

58. Zone IV Repair Lacerations of flexor tendons within the carpal canal are typically associated with partial or complete laceration of median nerve Here median nerves should be repaired first and the tendons last

59. Zone V Repair In this area there may be concomitant ulnar nerve & artery damage as well as radial artery & median nerve damage. Primary repair of the arteries is usually indicated If wound is contaminated, arteries are repaired and delayed repair of tendons and nerves is planned

60. Brunner’s Incision

61. Tendon to Bone Attachment

62. One method of attaching tendon to bone. A, Small area of cortex is raised with osteotome. B, Hole is drilled through bone with Kirschner wire in drill. C, Bunnell crisscross stitch is placed in end of tendon, and wire suture is drawn through hole in bone. D, End of tendon is drawn against bone, and suture is tied over button.

63. Fish-Mouth End-to-End Suture ( Pulvertaft ) End-to-Side method tendon repair

64. Post Operative Protocol Active Extention -Rubber Band Flexion Method: e.g. Kleinert , and Brooke-Army Immobilization Controlled Passive Motion Methods: e.g. Duran ’s protocol Strickland : Early active ROM

65. Combines dorsal extension block with rubber-band traction proximal to wrist Originally, included a nylon loop placed through the nail, and around the nail is placed a rubber band This passively flexes fingers, & the patient actively extends within the limits of the splint Active range of motion rehabilitation Kleinert !!

66. Post-operative passive exercises Duran’s At surgery, a dorsal extension-block splint is applied with the wrist at 20-30° of flexion, the MCP joints at 50-60° of flexion, and the IP joints straight

67. MANCHESTER SHORT SPLINT Wrist Finishes at dorsal wrist crease Allows 45 degrees extension MCPJ 30 degrees flexion Exercises Commence 4 th or 5 th day Motion initiated at DIPJ

68. Complications Joint contracture Stiffness Adhesions Rupture Bowstringing Infection

69. Flexor Tendon reconstruction Flexor tendon reconstruction is a necessary and important procedure for failed and neglected tendon repairs. With improvements in flexor tendon repair methods, the need for flexor tendon reconstruction has substantially diminished. 

70. Tendon Grafting Indications :- 1. Failure of flexor tendon repair. 2. Injuries resulting in segmental tendon loss. 3. Delay in repair that obviates primary repair.   4. Patients in whom the surgeon believes delayed grafting is the better treatment alternative for a zone 2 injury (e.g., segmental or extensive tendon injury). 5. Occasionally, for delayed presentation of FDP avulsion injuries associated with signifcant tendon retraction.

71. DONOR TENDONS FOR GRAFTING Palmaris Longus : Tendon of choice (fulfils requirement of length, diam & availability ) Plantaris Tendon: Equally satisfactory & advantage of being almost twice as long, but is not accessible . Others: FDS, EDC

72. Summary Meticulous technique Minimal handling Appropriate suture configuration Minimal resection of tendon sheath Postoperative mobilization Supervision!

73. Extensor Tendon Zones The classification of extensor tendon injuries proposed by Kleinert and Verdan ended at zone 8 (the forearm).  Doyle added a ninth zone for the muscular area of the extensor mechanism at the middle and proximal forearm. The classification is easy to recall if one remembers that the joints  are odd numbered; from distal to proximal, the DIP joint is zone 1, PIP joint is zone 3, and so forth.  The thumb IP joint is zone 1, and the MP joint is zone 3 .

74. Etiology Sharp object direct laceration (broken glass, kitchen knives or table saws) Crush injury Motor vehicle accidents Avulsions Burns Animal or human bites Suicide attempts

75. Signs and Symptoms Unable to straight (extend) one or more finger joints Pain while extending finger/s Open injury to hand (e.g., cut on dorsal side of hand ) Mild swelling over joint closest to fingertip Tenderness along effected finger/s on dorsal side of hand

76. DETECTION History and physical Examination of wound Use of bedside ultrasonography in ER (more sensitive and specific than physical examination) Wound exploration techniques or MRI. 3-view x-ray must be done (except most benign) to rule out foreign bodies or bony injury. Radiographs to evaluate for possible fractures or dislocations (blunt trauma cases)

77. Suturing techniques Doyle proposed the following techniques for extensor tendon repair: Zone 1 (DIP joint):  Running suture incorporating skin and tendon. Zone 2 (middle phalanx):  Running 5-0 stitch near cut edge of tendon, completed with a “basket-weave” or “Chinese finger trap” type of cross-stitch on the dorsal surface of the tendon . Zones  3  through 5 in fingers, and zones 2 and 3 in thumb: Modifed Kessler suture of 4-0 synthetic material in the thickest portion of the tendon. A 5-0 cross-stitch tied to itself at the beginning and end is run on the dorsal surface of the tendon .

78. Mallet Finger C harac . by discontinuity of the terminal extensor tendon resulting in an extensor lag at the DIP joint with or without compensatory hyperextension at the PIP joint ( swan neck deformity ) . It’s a zone 1 Extensor tendon Injury A/K/A Drop Finger or Baseball Finger Classically described as “ soft tissue “ (tendon rupture) or “ bony ” (avulsed fragment of bone)

79. Mechanism Of Injury Sudden forced flexion of the extended fingertip . This results in either: stretching or tearing of extensor tendon substance or avulsion of tendon insertion from the dorsum of distal phalanx, with or without a fragment of bone.

80. Clinical Evaluation R elatively straightforward. Patients present with pain,swelling , deformity, and/or difficulty using the affected finger . E xtensor lag at the DIP joint immediately after injury. Concurrent hyperextension of the PIP joint ( ie , swan neck posture) may be noted with active finger extension.

81. Radiographic Evaluation Posteroanterior , oblique, and lateral radiographs of the digit are recommended to assess for bone injury and joint alignment.

82. Treatment options Rest , Ice and Elevation initially Non-surgical: Successful in most mallet injuries. Surgical: Treatment of either an acute or a chronic mallet finger Salvage of failed prior treatment

83. Three different mallet finger splints A , Stack splint B , Perforated thermoplastic splint C , Aluminum foam splint

84. Surgical Management Type I Injuries Indications – 1.Volar subluxation of distal phalanx , 2.>50% of articular surface involved 3.>2mm articular gap

85. Kirschner Wire Fixation To immobilize the DIP joint in extension, a transarticular K-wire is driven longitudinally or obliquely across the DIP joint. Post-Operatively : K-wire is removed after 6-8 weeks. This is followed by 2-4 weeks of night time extension splinting.

86. Open Type II & III Injuries T ypically managed by debridement and tendon suture . M ay require skin coverage procedures ,with or without tendon grafts . Open repair of the extensor tendon with a running 5-0 prolene suture is performed . An oblique or axial Kirschner wire is placed across the DIP joint in full extension .

87. Mallet Fracture Type IV Treatment alternatives: Observation with reassurance Extension splinting Closed and open reduction with internal fixation DIP joint arthrodesis .

88. Indications for surgical intervention: Mallet fractures involving more than one third of articular surface Fractures with associated DIP joint subluxation Disadvantages of surgical treatment of mallet fractures: Technically demanding Higher complication rate than nonsurgical management

89. Surgical Management Techniques: Transarticular pinning of DIP joint ± fracture fragment fixation Tension band constructs Compression pinning Extension block pinning All of these techniques involve placement of at least one K-wire to immobilize the DIP joint in extension.

90. Extension block pinning technique A, With the distal phalanx extended, a K-wire is inserted proximal to the fractured fragment. B, The fracture is reduced manually by directing the exposed end of the K-wire distally. C, The wire is drilled into the head of the middle phalanx, and a second wire is passed retrograde across the distal interphalangeal joint.

91. Complications Complications associated with splinting: Most are transient. Most resolve with adjustment of the splint or after completion of treatment. Complications include: Skin maceration and ulceration Tape allergy Transverse nail plate grooves Splint-related pain

92. Complications associated with surgical treatment: Reported problems include: Infection Nail plate deformity Joint incongruity Hardware failure DIP joint prominence DIP joint deformity ( swan neck deformity )

93. Mallet Thumb A vulsion of the extensor pollicis longus (EPL) tendon at its distal insertion (mallet thumb) is rare. A/K/A Goose neck deformity . Usually a late complication of colles ’ fracture , RA . Although the recommended treatment for closed mallet finger is conservative, some authors proposed operative treatment for mallet thumb.

94. Zone I and II repairs

95. Zone III repairs

96. Zone IV repairs

97. Zone V repairs

98. Rehabilitation 3 current treatment approaches to extensor tendon rehabilitation are :- Immobilization Early controlled passive mobilization Early active motion

99. Position of Immobilization for Extensor Tendon Injury The finger should remain parallel to forearm with wrist in full extension PIP & DIP – Neutral

100. IMMOBILIZATION Keep the tendon in a shortened position through splinting or casting Tendons immobilized for 3 weeks In week 4, gentle active motion of the repaired tendon is introduced Rehabilitation depends on zone of injury

101. EARLY PASSIVE MOTION Extensors are held in extension by dynamic, gentle rubber band traction, and the patient is allowed to actively flex the fingers—passively moving repaired extensor tendons

102. Reverse Kleinert splint

103. EARLY ACTIVE MOTION Early active short arc program (developed by Evans) allows tendon to actively move 3 days after surgery Therapist must take care to ensure stress applied by early active motion does not overpower strength of surgical repair Splinting program is complex and specific and requires a skilled occupational therapist

104. Complications Extensor tendon injuries can cause:  Finger deformity  due to muscle imbalance Boutonniere deformity , Swan neck deformity   Tendon adhesions : The tendon can attach itself to nearby bone and scar tissue.    Finger stiffness  - scar tissue that forms may prevent full finger bending and straightening even with the best treatment Surgery to free scar tissue can sometimes be helpful in serious cases of motion loss Infection

105. THANK YOU……