Crush injuries of hand

Dr.MD.Monsur Rahman,PT
MPT-Musculoskeletal Disorders
Maharishi Markandeshwar Institute Of Physiotherapy And Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana - Ambala,133-207 (Haryana)

1. Crush Injuries of Hand MD.MONSUR RAHMAN MPT-( ORTHO )

2. Hand Anatomy Hand consist of 27 bones: 14 Phalangeal bones 5 Metacarpal bones 8 Carpal bones

3. Intrinsic muscles of the hand 1.(a)three muscles of thinner eminence Abductor pollicis brevis . Flexor pollicis brevis. Apponens pollicis brevis . (b) one adductor of thumb Adductor pollicis 2. Four hypothenar muscles Palmaris brevis. Abductor digiti minimi. Flexor digiti minimi. Opponense digiti minimi. 3. Four lumbricals. 4. Four palmar interossei. 5. Four dorsal interossei .

4. Blood Supply(BS ): Hand and digits has dual (BS) with contributions from the radial and ulnar arteries . Proximal portions of the hand (BS) come from the deep and superficial arches on the palmar and dorsal side . BS of the fingers is distributed by the digital arteries that arises from the superficial palmer arch.

5. Introduction Common in all age groups. Hand is the most important functional unit of the upper limb. (Motor or sensory) Stiffness of fingers

6. Classification Closed Injuries- Fractures - Tendon Injuries - Sprain Open Injuries - Crush Injuries - Tendon Injuries - Traumatic Amputations

7. CRUSH INJURIES Compressive type of force to the tissues. Most Common Causes: - Machine Injuries In The Industries -RTA - Agricultural Injuries -Fall of heavy objects in building collapse, during earthquakes etc.

8. Crush injuries result in: Damage to the overlying soft tissue envelope Laceration Fracture Bleeding Loss of vascular integrity The neurovascular structures and the bony ligamentous structures.

9. Danger signs in evaluation of crush injuries Volar swelling, especially in the palm and digits Loss of active range of motion Pain on passive motion of the digits or hand Altered neurovascular status Increased swelling, even with elevation above heart level Profuse bleeding from an open crush injury.

10. Effects on the Tissues

11. Skin and Subcutaneous Tissue Lacerations and contusions . Foreign material --- embedded in the wounds . Alternatively, the skin may look largely intact .

12. Muscles Overstretching and tearing of the muscle bleeding and swelling within the muscle itself. A disruption of muscle-tendon connections may result in loss of function.

13. Tendons The stretching forces may create small, partial tears . During the healing process , scar tissue forms to heal such tears and may cause the tendons to adhere to surrounding tissues, resulting in loss of joint motion and hand function.

14. Nerves Usually, nerves are not torn by a crush injury. Conduction disrupted It may take weeks to even months to determine whether the loss of nerve activity is permanent.

15. Blood Vessels Direct compression or shearing forces, which may injure the inner layer If the injured vessel is an artery --- Ischemia If the injured vessels are veins--- restriction of venous outflow

16. Bone and Joints Joint capsules and surrounding ligaments may rupture In children, the growth plates of the bones may be disrupted. Disruption of growth plates interferes with subsequent bone growth, and the bone may not grow to its proper length.

17. The Anatomic Zones Five flexor zones: zone 1 F rom the insertion of the profundus tendon at the distal phalanx to just distal to the insertion of the FDS.

18. Flexor d igitorum Profundus Tendon Injury Disruption of the FDP tendon, also known as jersey finger In an athlete’s finger - football or rugby. The injury causes forced extension of the DIP joint during active flexion. (finger lies in slight extension relative to other fingers in resting position)  pain and swelling

19. Treatment Type I injuries (partial rupture of the tendon) can be treated without surgery with rest, ice and elevation. A finger splint is often used to hold the digit in place until healed. Type II (full tendon rupture) and Type III (rupture with bone chip attached)

20. TENODESIS Flexor tenodesis to prevent hyperextension & to stabilize the distal joint Often, surgical pins are inserted into the injured digit to stabilize the bone and tendon in their proper alignment. Securely re-attach the distal FDP tendon to the middle phalanx with appropriate tension.

21. Collateral Ligament Injuries Forced ulnar or radial deviation at any of the IP joints can cause partial or complete collateral ligament tears. The PIP joint usually is involved in collateral ligament injuries, which are commonly classified as “jammed fingers.” pain located only at the affected ligament.

22. Treatment If the joints are stable and no large fracture fragments are present, the injury can be treated with buddy taping (i.e., taping the injured finger, above and below the joint, to an adjacent finger) Am Fam Physician.  2006 Mar 1;73(5):810-816. News & Publications Journals afp Vol. 73/No. 5(March 1, 2006)

23. Buddy Taping (A) Self-adhesive wrap. (B) Velcro wrap.

24. Zone II Zone II is often referred to as "Bunnell's no man's land," the critical area of pulleys between the insertion of the FDS and the distal palmar crease. Both flexor tendons interweave in a complex manner, therefore even minimum swelling can cause adhesions with pulleys & thereby impair the free motion of the tendon.

25. Trigger Finger Trigger finger, or flexor tenosynovitis , is a condition in which the tendons that flex the fingers become swollen and inflamed. This results in pain at the base of one or more of the fingers Inability of FDS &FDP tendons to slide smoothly under the A1 pulley

26. TREATMENT Corticosteroids with local anesthetic into the flexor sheath. TISSUE RELEASE A small (less than 2 cm) incision is made in the skin, and the tight portion of the flexor tendon sheath is released. After the surgery, a sterile bandage is applied to the site of surgery. This bandage is removed after a few days, And full use of the finger may then begin to prevent new adhesions (scar). (Full recovery is expected for surgery. By Jonathan Cluett , M.D. , Journal About.com Guide Updated March 29, 2007)

27. Zone-III Extends from the distal edge of the carpal ligament to the proximal edge of the A1 pulley, which is the entrance of the tendon sheath. The distal palmar crease superficially marks the termination of zone III and the beginning of zone II.

28. Dupuytren’s Contracture This condition is due to inflammation of involving the ulnar side of the palmar aponeurosis. Localized thickening and shortening of the palmar fascia. The fascia is thickened to form nodules and it contracts so that the affected fingers are drawn into flexion.

29. Treatment Subcutaneous Fasciotomy Partial selective Fasciotomy Complete Fasciotomy

30. Skin Graft Method A skin graft may be needed if the skin surface has contracted so much that the finger cannot relax and the palm cannot be stretched out flat. Surgeons graft skin from the wrist, elbow, or groin. The skin is grafted into the area near the incision to give the finger extra mobility for movement.

31. Zone IV Includes the carpal tunnel and its contents (i.e., the 9 digital flexors and the median nerve).

32. Carpal Tunnel Syndrome Cause of CTS - The tendons in the wrist swell and put compression on the median nerve , Hand numbness, pain and tingling in the distribution of median nerve.

33. Treatment During surgery, an incision is made in the palm. The roof of the carpal tunnel is divided to increase the size of the carpal tunnel and decrease pressure on the median nerve.

34. Extensor Zones zone I - mallet finger DIP jt. (finger) and IP jt. In thumb.       zone II - middle phalanx (finger) proximal phalanx (thumb)   zone III - apex PIP joint (finger) MCP jt. (thumb) zone IV- proximal phalanx (finger) metacarpal (thumb)     zone V - over apex MCP joint:               zone VI - dorsum of hand Zone VII - dorsal retinaculum Zone VIII- distal forearm            

35. Mallet Finger The trauma results in the avulsion of the extensor tendon from the point of attachment to the distal phalanx

36. A segment of the distal phalanx, which comprises the distal portion of DIP joint, may break off along with the tendon. If not treated, mallet finger leaves a deformity with the DIP in permanent flexion.

37. Treatment Most mallet finger injuries can be closed-reduction and fixed by percutaneous placement of K-wires. The longitudinal K-wire is blocking the DIP joint from flexion to protect the repair.

38. A/P R adiographic view of finger. The smaller oblique K-wire is placed through the bone fragment, fixing it to the distal fragment.

39. Swan Neck Deformity Finger with a hyper-extended PIP joint and a flexed DIP joint. The extensor tendon gets out of balance, which allows the DIP joint to get pulled downward into flexion.

40. The Journal of hand surgery J Hand Surg Am. 2010 Aug 13;:   20709465  Distraction arthrolysis using an external fixator followed by flexor tenolysis - useful treatment for patient with pip joint extension contracture and tendon adhesions after severe crush injury.

41. On the day of attaching the external fixator, moderate distraction was applied to the joint and the gap was widened to approximately 2 mm. Pip joint was gradually widened for 10 days until a gap of about 5 mm was attained. Passive range of motion was performed for about 1week until swelling of the affected digit subsided. Then, flexor tenolysis was performed.

42. Boutonniere Deformity Buttonhole deformity The middle finger joint is bent in a fixed position inward and the outermost finger joint is bent excessively outward (away from the palm) Most common causes are Rheumatoid Arthritis and trauma

43. Treatment Gutter splinting will help stretch and straighten the PIP joint . Best results occur when the PIP joint is limber, rather than stuck in a bent position.

44. De Quervain’s Tenosynovitis Injury occurs because of inflammation around the tendon sheath of the APL and EPB in the first dorsal compartment . Fibrous sheath (APL & EPB) tendon becomes fibrosed and thickened. Lateral aspect of lower end of the radius where the tendons lie in shallow bony groove.

45. A splint can be used - one that immobilizes the wrist, and also involves the thumb. Corticosteroid injections into the tendon sheath. Surgical release may be required in chronic cases.

46. Splint used for conservative treatment (left) & bandage used following surgery (right).

47. SURGERY An incision is made over the first dorsal compartment and the dorsal carpal ligament is cut to expose the tendons. The tendons APL and EPB are identified and motion is checked. The wound is then closed and a compressive dressing with a plaster splint is applied.

48. PHYSIOTHERAPY Visits will include heat treatments, soft tissue massage, and vigorous stretching. Active and assisted active finger exercises may restore the hand functions. Passive Stretching to correct the residual tightness of the soft tissues.

49. Prognosis Crush injuries can be severe and devastating to the individual. Long-term impairment and disability may occur, and disability is sometimes permanent.

50. Thank You