Injuries & Fractures

The hand is one of the most flexible and useful parts of our body. Because of overuse in various activities, the hands are more prone to injuries, such as sprains and strains, fractures and dislocations, lacerations and amputations while operating machinery, bracing against a fall and sports-related injuries.

Fractures

A fracture is a break in the bone, which occurs when force greater than the bearable limit is applied against a bone. The most common symptoms of any fracture include severe pain, swelling, bruising or bleeding, deformity, discoloration of the skin and limited mobility of the hand.

Finger fracture

Fingers are fine structures of the human body that assist in daily routine activities through coordinated movements. Any abnormality affecting the fingers can have a huge impact on the quality of life. A finger fracture is not a minor injury, and if left untreated can lead to stiffness, pain, disruption of the alignment of the whole hand and interference with specialized functions such as grasping or manipulating objects. Finger fractures commonly occur during sports activities, when you break a fall or while operating machinery.

Diagnosis

The diagnosis of a hand or finger fracture is based on history, physical examinations and X-ray imaging to determine the type and severity of the fracture. X-rays are the most widely used diagnostic tools for the evaluation of fractures.

Treatment

The objective of early fracture management is to control bleeding, provide pain relief, prevent ischemic injury (bone death) and remove sources of infection such as foreign bodies and dead tissues. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after the fracture heals. To achieve this, maintenance of fracture reduction with immobilization technique is done by either non-operative or surgical methods.

Non-operative Therapy

The bones can be realigned by manipulating them into place. Following this, splints, casts or braces made up of fiberglass or plaster of Paris material are used to immobilize the bones until they heal. The cast is worn for 3 to 6 weeks.

Surgical Therapy

During surgery, the fracture site is adequately exposed, the bones realigned and reduction of the fracture is done internally using wires, plates and screws and intramedullary nails.

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of the cast or brace so that the bone becomes solid enough to bear stress. Rehabilitation program involves exercises and gradual increase in activity levels to strengthen the muscles and improve range of motion.

Tendons are the bands of fibrous connective tissue that connect muscles to bone. Tendons aid in movement of the fingers, hand and all other body parts.

There are two types of tendons present in the hand- extensor tendons and flexor tendons. Extensor tendons present on top of the hand help with straightening the fingers. Whereas, flexor tendons that lie on the palm side of the hand help in bending the fingers. The flexor tendons are smooth, flexible, thick tissue strands which bend the fingers.

Deep cuts on the under surface of the wrist, hand, or fingers can cut and injure the tendon and make it unable to bend one or more joints in a finger. When a tendon is cut, it acts like a rubber band, where the cut ends are pulled away from each other.

Flexor tendon tears may be partial or complete. If tendons are completely cut through, the finger joints cannot bend on their own at all.

Causes

Any cut or laceration to the arm, hand, or fingers can cause a flexor tendon injury. Other possible causes include:

• Damage to the tendon from -a sports injury, often associated with football, rugby, and wrestling
• Stretching of the tendon where the tendon is pulled off the bone
• Jersey finger: When a player finger catches on another player’s jersey or clothing
• Rheumatoid arthritis
• Adventurous activities such as rock climbing

Symptoms

Inform your doctor if you have any of the following symptoms:

• Recent cut to hand or fingers
• Pain
• Swelling
• Loss of ability to bend the finger
• Numbness (loss of sensation)

Diagnosis

Make sure to see a doctor when you sustain a finger injury that is affecting the flexion and extension of your fingers.

First Aid: Apply ice immediately to the injured finger. Wrap a sterile cloth or bandage around the injury and keep your finger elevated above your heart level to reduce bleeding if present. A tetanus injection may need to be administered if not current.

Your doctor will review your symptoms and medical history. A physical examination will be done, which includes a complete examination of both hands. During the exam, you will be asked to bend and straighten your fingers. Your fingers will also be checked for sensation, blood flow, and strength. An X-ray may be ordered to check for any damage to the surrounding bone.

Treatment

A ruptured tendon cannot heal without surgery because the cut ends usually pull away after an injury.

There are many options to repair a cut tendon; the type of repair depends on the type of cut. The aim of the procedure is to restore normal function of the joints and surrounding tissues following a tendon laceration.

The flexor tendon repair is usually an outpatient procedure and can be performed under local or general anesthesia. The surgeon makes an incision on the skin over the injured tendon. The damaged ends of the tendon are brought together with sutures to achieve a secure repair. If the tendon injury is severe, a graft may be required. A graft is a piece of tendon that is derived from other parts of the body such as a foot or toe. After the repositioning of the tendon, the incisions are closed with sutures and a dressing pad is placed over the surgical site. Your surgeon will place your hand in a protective splint to restrict movements.

Depending on the injury, you will be advised to start hand therapy for a few weeks following surgery. This is to improve the movement of the finger. Follow your surgeon’s specific instructions for a successful recovery.

Possible complications of surgery include pain, bleeding, infection, stiffness, rupture of the repair, and damage to the surrounding nerves or blood vessels. A second surgery may be needed to release any excess scar tissue that interferes with finger movement.

Mallet finger is a condition where the end of the finger is bent and does not straighten. It occurs when the extensor tendon on the back of the finger is damaged.  The finger joint is a hinge-joint that allows bending and straightening of the fingers. Each finger is composed of 3 phalanges bones, joined by 2 interphalangeal joints (IP joints). The joint near the base of the finger is called the proximal IP joint or PIP joint, and the joint near the tip of the finger is called the distal IP joint or DIP joint.

Mallet finger occurs from sports activities causing a “jammed” finger or from excessive stress on the finger such as with a crushing injury.  The injury causes either rupture of the extensor tendon without a bone fracture or rupture with a small or large bone fracture.

Generally, mallet finger can be treated non-surgically using specially designed splints that immobilize the finger and promote natural healing. In cases of fracture, complete bone healing may take 6-8 weeks, followed by physical therapy for strengthening. In severe cases that don’t respond to conservative treatment, surgery is recommended.

If left untreated, mallet finger can develop into a finger joint deformity referred to as a swan neck deformity.

Causes

Mallet finger occurs due to sports activities (such as baseball) or other activities that cause a direct and forceful impact on the fingers. 

Signs and Symptoms

The main symptoms of mallet finger are drooping of the finger at the distal joint, pain and swelling around the area and limited range of motion at the joint.

Diagnosis

The diagnosis of mallet finger involves a physical examination and obtaining an X-ray of the injured finger. In some cases, other imaging techniques such as MRI scan may be recommended.

Treatment

Mallet finger can be treated non-surgically by applying a specially designed splint for 6-8 weeks. Immobilizing the finger with a splint helps promote natural healing of the torn tendon or bones. 

For patients who require use of their fingers to perform occupational tasks, internal splints can be used; this involves surgical placement of metal pins in the affected bones. The pins can be removed after 6 weeks of healing.

Patients who fail to achieve adequate relief are recommended for surgery which involves repairing the torn tendon. If the mallet finger involves a fracture of the bone fragment, then it can be stabilized and fixed using pins and a special K-wire. 

Post-operative care

After mallet finger surgery, the patient is recommended for physical therapy or occupational therapy for flexibility and strengthening exercises.

Risks and complications

The common risks and complications associated with mallet finger surgery, include:

• Avascular necrosis (bone death from lack of blood supply)
• Infection
• Stiffness
• Nail-bed damage
• Chronic tenderness

Injuries that involve tearing or stretching of the ligaments of your fingers are termed as sprains. Sprains in the fingers are most often caused from a fall when you extend your arms to reduce the impact of the fall, or from overuse or repetitive activity of the thumb such as with texting.

Some of the symptoms of finger sprains include:

• Reduction in your ability to grasp items
• Pain immediately after the injury
• Swelling and bruising of the fingers
• Redness and tenderness

Finger sprains are diagnosed with the help of a physical examination of the hand to check for any abnormalities by moving your fingers in different positions. Your doctor may also suggest imaging tests such as X-rays to find the exact location of the injury.

Finger sprains can be treated with the help of applying ice packs and immobilizing your finger to allow it to heal. You may also be given pain medications to reduce discomfort. Once your fingers heal, you will be advised to perform strengthening exercises to strengthen your fingers. Surgical treatment is very rare and may be required only in complex cases where the ligament is completely torn.

A break or a crack in the bones of the thumb is known as a thumb fracture. Thumb fractures can occur from a direct blow, a fall, and muscle contractions or twisting during sports such as football, hockey, skiing and wrestling. Fractures may occur anywhere on the thumb, but a fracture at the base of the thumb, near the wrist, is considered the most serious. A fractured thumb is associated with severe pain, tenderness and swelling at the fracture site, little or no thumb movement, deformed appearance or coldness or numbness in the thumb.

A diagnosis of a fracture in the thumb is done by reviewing your medical history and performing a detailed examination of your thumb. X-rays are usually ordered to confirm the diagnosis.

Treatment involves the use of splints or casts to immobilize the bones until they heal. Surgery is usually considered if nonsurgical treatment fails to provide relief. External fixation is a surgery that fixes pins above and below the fracture site to treat the fracture from the outside. These pins are held in place by an external fixation device. Internal fixation involves the implantation of wires, pins, screws and plates from the inside to maintain the bones in proper position while they heal.

Finger dislocation is a condition in which the bone of your finger has moved away from its normal position. Dislocation can be caused from jamming or overextending the finger during sports activities, or during a fall with an outstretched hand.

The symptoms of a dislocated finger include:

• Pain and difficulty in moving your finger
• Finger appears to be crooked and swollen
• A feeling of numbness or tingling
• A break in the skin

Your doctor can diagnose a dislocated finger by a physical examination of your hand. Imaging tests like X-rays will be used to confirm the diagnosis of dislocation.

Initially, you will be advised to remove any jewelry on the finger. You will be instructed to apply an ice pack and keep your hand in an elevated position to reduce swelling. Your doctor will realign your dislocated finger usually under local anesthesia and apply a splint or buddy tape it to the next finger for support.  Your doctor may prescribe pain medications to reduce pain and swelling.