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INJURIES AND
DISEASES OF HAND
AND WRIST
Su-Yang Hwa
Department of Orthopaedics
Tri-Service General Hospital
National Defense Medical Center
Contents
Anatomy and Physical Examination of the Hand
Phalangeal Fractures and Dislocations
Fractures and Dislocations Involving the Metacarpal
bone
4. Fractures and Dislocations of the Thumb
5. Thumb Reconstruction
6. Distal Radius Fractures
7. Distal Radio-ulnar Joint and Triangular Fibrocartilage Complex
8. Scaphoid Fractures and Nonunions
9. Kienbock disease
10. Carpal Bone Fractures Excluding the Scaphoid
11. Carpal Instability including Dislocations
1.
2.
3.
Anatomy and Physical
Examination of the Hand
Fig. Terminology for describing forearm, hand, and digital motion. (From Seiler JG III. Essentials of
hand surgery, Lippincott Williams & Wilkins, Philadelphia, PA, 2002, with permission)
Fig. The biconcave surfaces of the
thumb carpometacarpal joint allow thumb
rotation, flexion/extension, and
abduction/ adduction. MCI, Thumb
metacarpal; Tz, trapezium. (From
Trumble TE, editor: Principle of hand
surgery and therapy. Philadelphia, 2000,
WB Saunders Company.)
Fig. Hand dressing: “safe” position of fingers. (From Seiler JG III. Essentials of hand surgery,
Lippincott Williams & Wilkins, Philadelphia, PA, 2002, with permission)
Fig. Surface anatomy if the palm. (From Trumble TE, editor: Principle of hand surgery
and therapy. Philadelphia, 2000, WB Saunders Company.)
Felon, pulp infection
(pain, flexion deformity,
swelling, warm , pus
formation)
Fig. Drainage of a felon using a mid-lateral incision. Complete division of the vertical septae
should be performed. (From Seiler JG III. Essentials of hand surgery, Lippincott Williams &
Wilkins, Philadelphia, PA, 2002, with permission)
Fig. Anatomy of the palmar plate if the proximal interphalangeal joint. (From
Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000,
WB Saunders Company.)
Fig. Palmar extraarticular wrist ligaments. C, Capitate; H, Hamate; L, Lunate; P, Pisiform; R,
Radius; S, Scaphiod; Tp, Trapezoid; Tz, Trapezium; U, Ulna. (From Trumble TE, editor:
Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)
Fig. Diagrammatic representation of the extraarticular dorsal wrist ligaments. C, Capitate; H,
Hamate; L, Lunate; P, Pisiform; R, Radius; S, Scaphoid; Tp, Trapezoid; Tz, Trapezium; U, Ulna.
(From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB
Saunders Company.)
Fig. Schematic representation of the Guyon’s
canal add its contents. FCU, Flexor carpi
ulnaris. (Courtesy of Jason R. Izzi, D.M.D.)
Guyon canal
Fig. The six dorsal compartments of the extensor tendons. APL, Abductor pollicis longus; ECRB,
extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris;
EDC, extensor digitorum communis; EDM, extensor digiti minimi; EIP, extensor indicis proprius;
EPB, extensor pollicis brevis; EPL, extensor pollicis longus; MC, metacarpal. (From Trumble TE,
editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders Company.)
De Quervian’s disease (stenosing of first
extensor retinaculum (APL. EPB tendons )
Fig. Clinical photograph of
the Finkelstein’s test.
Fig. The flexor tendon sheath is composed of annular pulleys and crucuate pulleys. (From
Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB Saunders
Company.)
Fig. Sagittal bands of the extensor
mechanism provide for extension of the
metacarpophalangeal joint. FDP, Flexor
digitorum profundus; FDS, flexor digitorum
superficialis. (From Trumble TE, editor:
Principle of hand surgery and therapy.
Philadelphia, 2000, WB Saunders Company.)
Fig. The transverse band of the
extensor mechanism provides for
flexion of the
metacarpophalangeal joint.
(From Trumble TE, editor:
Principle of hand surgery and
therapy. Philadelphia, 2000, WB
Saunders Company.)
Fig. Four dorsal interossei provide abduction and three volar interossei provide
adduction of the fingers. (From Trumble TE, editor: Principle of hand surgery and
therapy. Philadelphia, 2000, WB Saunders Company.)
Intrinsinc minus
Intrinsinc plus
Fig. The lumbrical muscles function to the flex the metacapophalangeal joint and extend
the proximal interphalangeal joint. (From Trumble TE, editor: Principle of hand surgery and
therapy. Philadelphia, 2000, WB Saunders Company.)
Fig. The muscles of the
thenar eminence include the
abductor pollicis brevis (APB),
flexor pollicis brevis (FPB),
opponens, and adductor
pollicis. FCR, Flexor carpi
radialis; FCU, flexor carpi
ulnaris; FDS, flexor digitorum
superficialis; FPL, flexor
pollicis longus. (From
Trumble TE, editor: Principle
of hand surgery and therapy.
Philadelphia, 2000, WB
Saunders Company.)
Fig. Sensory patterns of the median ulnar and radial nerves for the palm (left view) and dorsum
(right view) of the hand. (From Trumble TE, editor: Principle of hand surgery and therapy.
Philadelphia, 2000, WB Saunders Company.)
Fig. Anatomy of the dorsal sensory nerves of the hand on the palm (left view) and dorsum (right
view). (From Trumble TE, editor: Principle of hand surgery and therapy. Philadelphia, 2000, WB
Saunders Company.)
Fig. Positive Froment’s sign with thumb
interphalangeal joint flexion to compensate
for paralysis of abductor pollicis muscle
indicates a low ulnar nerve palsy. EPL, Flexor
pollicis longus. (From Trumble TE, editor:
Principle of hand surgery and therapy.
Philadelphia, 2000, WB Saunders Company.)
Fig. The Allen test to evaluate patency of
the radial and ulnar arteries. (From
Trumble TE, editor: Principle of hand
surgery and therapy. Philadelphia, 2000,
WB Saunders Company.)
Fig. A: When the digit is flexed, the deformity is quite apparent. B: Active finger
flexion generates malrotation of ring finger with digital overlapping. (From Seiler JG III.
Essentials of hand surgery, Lippincott Williams & Wilkins, Philadelphia, PA, 2002,
with permission)
Fig. Rupture of ulnar collateral ligament of
the metacarpophalangeal joint of the
thumb. (From Seiler JG III. Essentials of
hand surgery, Lippincott Williams & Wilkins,
Philadelphia, PA, 2002, with permission)
Fig. A: Mechanism. Due to the extensor apparatus lesion, the
digital phalanx flexes by effect of the flexor profundus tendon.
The proximal stump of the distal conjoined extensor tendon
retracts in a proximal direction and consequently the lateral
bands are slack initially and later contract and displace dorsally.
Due to the concentration of the extension forces over the
middle phalanx, the PIP joint is progressively set in
hyperextension. B: Various splints (dorsal padded aluminum
splint, volar padded aluminum splint, concave aluminum splint).
Dorsal padded aluminum splint allows adjustable fixation of the
DIP joint. (From Peimer CA. Surgery of the hand and upper
extremity. New York: McGraw-Hill, 1996, with permission.)
Fig. Hand dressing: “safe” position of fingers. (From Seiler JG III.
Essentials of hand surgery, Lippincott Williams & Wilkins, Philadelphia,
PA, 2002, with permission)
Fig. Zones of flexor tendon injury.
Zone II: “no man’s land.”
Fig. Retinacular pulley system. A, Annual
pulley, with flexor digitorum superficialis
omitted. B and C, demonstration of function
of annual pulleys and tendon bowstringing
with absent A-2 and A-4.
Stage I Kienböck’s
disease.
Fig. Schematic drawing of the
arterial supply of the palmar
aspect of the carpus. Circulation
of the wrist is obtained through the
radial, ulnar, and anterior
interosseous arteries and the
deep palmar arch: 1, palmar
radiocarpal arch: 2, palmar branch
of anterior interosseous artery; 3,
palmar intercarpal arch; 4, deep
palmar arch; and 5, recurrent
artery. (From Bucholz RW,
Heckman, JD, Court-Brown C, et
al., eds. Rockwood and Green’s
Fractures in Adults, 6th ed.
Philadelphia: Lippincott Williams &
Wilkins, 2006.)
Fig. Schematic drawing of carpal
instability. (A) Normal longitudinal
alignment of the carpal bones with
the scaphoid axis at a 47-degree
angle to the axes of the capitate,
lunate, and radius. (B) A volar
intercalated segmental instability
(VISI) deformity is usually
associated with disruption of the
lunatotriquetral ligament. (C) A
dorsal intercalated segmental
instability (DISI) deformity is
associated with scapholunate
ligament disruption or a displaced
scaphoid fracture. (From Bucholz
RW, Heckman JD, Court-Brown C,
et al., eds. Rockwood and Green’s
Fractures in Adults, 6th ed.
Baltimore: Lippincott Williams &
Wilkins, 2005.)
Fig. Vulnerable zones of the carpus. (A) A lesser arch injury follows a curved path
through the radial styloid, midcarpal joint, and the lunatotriquetral space. A greater arc
injury passes through the scaphoid, capitate, and triquetrum. (B) Lesser and greater
arc injuries can be considered as three stages of the perilunate fracture or ligament
instabilities. (From Johnson RP. The acutely injured wrist and its residuals. Clin Orthop
1980;149:33-44.)
Fig. Left: The collateral ligaments of the
metacarpophalangeal joints are relaxed in
extension, permitting lateral motion, but they
become taut when the joint is fully flexed. This
occurs because of the unique shape of the
metacarpal head, which acts as a cam. Right:
The distance from the pivot point of the
metacarpal to the phalanx in extension is less
than the distance in flexion, so the collateral
ligament is tight when the joint is flexed. (From
Rockwood CA Jr, Green DP, Bucholz RW,
Heckman JD, eds. Rockwood and Green’s
Fractures in Adults, 4th ed, vol. 1. Philadelphia:
Lippincott-Raven, 1996:659.)
Fig. Redcution of metacarpal fractures
can be accomplished by using the digit
to control the distal fragment, but the
proximal interphalangeal joint should
be extended rather than flexed. (From
Bucholz RW, Heckman, JD, CourtBrown C, et al., eds. Rockwood and
Green’s Fractures in Adults, 6th ed.
Philadelphia: Lippincott Williams &
Wilkins, 2006.)
Fig. Displacement if Bennett
fractures is driven primarily
by the abductor pollicis
longus and the adductor
pollicis resulting in flexion,
supination, and proximal
migration. (From Bucholz RW,
Heckman, JD, Court-Brown C,
et al., eds. Rockwood and
Green’s Fractures in Adults,
6th ed. Philadelphia:
Lippincott Williams & Wilkins,
2006.)
Fig. Top: A lateral view,
showing the prolonged insertin
of the superficialis tendon into
the middle phalanx. Center: A
fracture through the neck of the
middle phalanx is likely to have
a volar angulation because the
proximal fragment is flexed by
the strong pull of the
superficialis. Bottom: A fracture
through the base of the middle
phalnx is more likely to have a
dorsal angulation because of
the extension force of the
central slip on the proximal
fragment and a flexion force on
the distal fragment by the
superficialis. (From Rockwood
CA Jr, Green DP, Bucholz RW,
Heckman JD, eds. Rockwood
and Green’s Fractures in Adults,
4th ed, vol. 1. Philadelphia:
Lippincott-Raven, 1996:627.)
Fig. Simple metacrpophalangeal joint
dislocations are spontaneusly
reducible and usually present in an
extended posture with the articular
surface of P1 sitting on the dorsum of
the metacarpal head. Complex
dislocations have bayonet apposition
with volar plate interposition that
prevents reduction. (From Bucholz
RW, Heckman, JD, Court-Brown C, et
al., eds. Rockwood and Green’s
Fractures in Adults, 6th ed.
Philadelphia: Lippincott Williams &
Wilkins, 2006.)
Fig. The Stener lesion: The adductor
aponeurosis proximal edge function as
a shelf that blocks the distal
phalangeal insertion of the ruptured
ulnar collateral ligament of the thumb
metacarpophalangeal joint from
returning to its natural location for
healing after it comes to lie on top of
the aponeurosis. (From Bucholz RW,
Heckman, JD, Court-Brown C, et al.,
eds. Rockwood and Green’s Fractures
in Adults, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2006.)
Fig. Galeazzi fracture in a 40-year-old male.
Fig. Intraarticular distal radius fractures.
(Reproduced by permission from Melone
CP Jr: Open treatment for displaced
articular fractures of the distal radius. Clin
Orthop 1986; 202:103.)
Fig. Distal radius fracture treated
with external and internal fixation.
A
B
Fig. A. PA
view of
perlinate
dislocation.
B. Lateral
view of
perilunate
dislication.
Fig. Unstable transverse fracture
of metacarpal shat.
Fig. Forces causing unstable proximal phalanx fracture. [Reproduced and modified with
permission from the American Society for Surgery of the Hand (ASSH): Fracture of the hand.
In ASSH 1996 Regional Review Course Syllabus. Englewood, CO: 1996;9-6.]
Fig. Salter type IV fracture of
proximal phalanx.
Fig. Complex dorsal dislocation MP joint with interposition Volar plate.
[Reproduced and modified with permission from the American Society for
Surgery of the Hand (ASSH): Articular fractures and joint injuries. In ASSH 1996
Regional Review Course Syllabus. Englewood, CO: 1996;9-14.]
Fig. Stener lesions (interposition of adductor aponeurosis). [Reproduced and modified
with permission from the American Society for Surgery of the Hand (ASSH): Articulr
fractures and joint injuries. In ASSH 1996 Regional Review Course Syllabus. Englewood,
CO: 1996;9-16.]