Injuries of your hand
Your finger, hand, wrist, and elbow have a vital function in your everyday activities. So it is no surprise when you have an injury to one of them it causes a major disruption to your life. There are many different types of injuries:
Sprain
Thumb Sprains
What are thumb sprains?
A sprain is an injury to a ligament. Ligaments are the connective tissues that connect bones to bones across a joint.
How do thumb sprains occur?
These types of injuries are common in sports and falls. The thumb is jammed into another player, the ground, or the ball. The thumb may be bent in an extreme position, causing a sprain. The thumb will usually swell and may show bruising. It is usually very painful to move.
What are the most common types of thumb sprains?
The most common ligament to be injured in the thumb is the ulnar collateral ligament. Injury to this ligament is sometimes called “skier’s thumb” because it is a common skiing injury. It occurs when the skier falls and the pole acts as a fulcrum in the hand to bend the thumb in an extreme position. This ligament may also be injured by jamming the thumb on the ground when falling or by jamming the thumb on a ball or other player. The radial collateral ligament may also be injured. It is much less commonly injured than the ulnar collateral ligament.
How are thumb sprains treated?
X-rays are usually taken to make sure the bones of the thumb and hand are not fractured. We will then examine the thumb to determine whether the ligament is torn. If the ligament is partially torn, it is usually treated in a cast or splint. Radial collateral ligament injuries are frequently treated this way as well. The end of a completely torn ulnar collateral ligament often gets trapped behind a tendon. Complete ulnar collateral ligament tears are most commonly treated with surgery to repair the ligament. Sometimes the remaining ligament tissue is of poor quality and the ligament must be reconstructed.
Chronic Injuries
The term “chronic” refers to an old injury of greater than several weeks duration. In this case, the joint may be unstable with symptoms of pain, especially with pinching. The joint may feel loose and strength may be decreased. These injuries may be treated by reconstruction of the ligament, or joint fusion if arthritis is present.
Associated Injuries
On occasion, fractures may occur along with thumb sprains. These may require additional surgery with repair using metal pins, screws, or plates. Cartilage damage may occur as well which does not show up on x-ray. This occasionally results in long-term pain and eventual arthritis. Some patients may benefit from cortisone injections or eventual surgery.
© American Society for Surgery of the Hand
Wrist Sprains
What is a sprain?
A sprain is an injury to a ligament. Ligaments are the connective tissues that connect and stabilize one bone to another bone; they could be thought of as very strong tape that holds the bones together at a joint. The degree of ligament injury may vary over a wide range of severity. Sprains are generally classified into three types: Grade I – stable injury to a ligament; Grade II – partial tearing/stretching; and Grade III – complete tear of the ligament, either within the mid-portion of the ligament, or as an avulsion (“pulling away”) from its attachment into bone. A sprain may upset the normal coordinated movements of the wrist bones resulting in persistent stiffness, pain, swelling, and possible instability.
How do wrist sprains occur?
A sprain of one or multiple wrist ligaments occurs when there is excessive loading or force transmitted across the wrist. These frequently occur as the result of a fall forwards or backwards onto an outstretched hand. Force may be applied in other ways, such as with a violent twisting injury (torsion). Often, these injuries are associated with sports and other outdoor activities such as biking, skiing, or snowboarding.
What are the most common types of wrist sprains?
There are many ligaments which stabilize the wrist joint. One of the most common ligament injuries involves the scapho-lunate ligament, the ligament which links the scaphoid and lunate bones.
How are wrist sprains diagnosed?
The diagnosis of a wrist sprain includes a careful patient history (how the injury occurred), a clinical examination, and diagnostic testing. The patient typically presents with complaints of wrist pain and stiffness, and loss of strength is also common. Examination of the wrist will allow us to pinpoint tenderness and thus localize the site of injury, and also assess wrist stability. Usually X-rays are obtained to evaluate for potential fractures and for signs of ligament insufficiency. While ligaments themselves are not seen on X-rays, the consequence of a ligament injury may be appreciated indirectly based on abnormal alignment of the wrist bones. Additional diagnostic testing may be required, such as an MRI or an MRI-arthrogram, which involves an injection of contrast into the wrist to enhance the sensitivity of the MRI. Wrist arthroscopy is a very precise, direct way to examine the wrist ligaments. It is a surgical procedure in which a small scope and specialized instruments are placed into various parts of the wrist joint via several small (approximately 3mm) incisions. However, the risks and benefits of the surgery must be considered relative to the severity of the wrist injury.
How are wrist sprains treated?
The goals of treating a wrist ligament injury are to:
- provide pain relief
- minimize potential stiffness or loss of motion
- restore wrist joint stability
- reduce the risk of long-term consequences of an untreated wrist ligament injury (arthritis, pain, instability)
The treatment of a wrist sprain is guided by the severity of the injury. Similar to a sprained ankle, milder ligament sprains of the wrist may be treated with protected activity, supportive splinting or casting, strategies to minimize inflammation and discomfort, and gradual return to activity. Evaluation will help grade the severity of the injury, identify associated injuries, and determine the need for more specific diagnostic testing.
For less severe wrist sprains, the ligaments usually heal well – occasionally, the injury and healing response may cause stiffness and we may recommend stretching and motion exercises to minimize the potential for longer term loss of wrist mobility.
In the case of a ligament tear, treatment may or may not involve surgery; treatment depends on the specific ligament injury and individual patient needs and considerations. For certain injuries, wrist arthroscopy may be recommended to evaluate the wrist and to possibly trim loose or inflamed flaps from the injured ligament. If the findings are more severe, we may need to proceed with an open ligament repair or reconstruction. The ligaments themselves are not always very substantial, and so repairs may need to be augmented with additional tissue such as the joint capsule or various tendon grafts, especially if the injury is not being treated acutely. There is much research underway searching for better methods to treat these serious injuries. They include stronger and more precise ligament reconstructions using either local tissues (tendons) or distant tissues (ligaments from the hand or foot). Pins or screws are often used to help stabilize the repairs as well.
Chronic wrist sprains
Unrecognized or untreated ligament injuries may result in wrist instability which leads to progressive cartilage degeneration (arthritis) in the wrist joint. This arthritic change may result in pain, stiffness, and swelling; these symptoms may be intermittent and vary in their severity. A common pattern is seen with scapho-lunate ligament tears that alter the normal wrist joint mechanics. The unlinked scaphoid rotates away from the lunate. As a result of the abnormal rotation of the scaphoid, its joint surface no longer makes contact with the radius bone properly. Instead of broad contact along the entire joint surface, there is “edge on edge” contact of the joint, wearing it down in a predictable progressive pattern of arthritis. This form of arthritis is known as scapho-lunate advanced collapse, or “SLAC” wrist, which progresses to involve a greater amount of the wrist over time, thereby limiting treatment options. A good analogy is that of placing two spoons into a drawer; normally they are placed flush with one another, with the greatest surface area of contact. However, if the spoons are rotated slightly, they match up “edge on edge” and no longer have a good, broad surface area where they touch each other.
In the presence of a chronic wrist ligament injury and associated arthritis, mild / intermittent symptoms may be treated with splinting, activity modifications, and analgesics, such as anti-inflammatory medications. Persistent symptoms or a symptom flare may be treated with a steroid injection.
Should these conservative measures fail, surgery may be considered in order to remove the offending, arthritic joint surfaces, such as with a proximal row carpectomy (remove the arthritic first row of wrist bones, which includes the scaphoid), or scaphoidectomy and partial wrist fusion (remove the arthritic scaphoid bone and fuse four small wrist bones together for stability). In the case of more widespread wrist arthritis, wrist arthroplasty (joint replacement) or total wrist fusion may be performed.
© American Society for Surgery of the Hand
Laceration/ Tendon injury
Flexor Tendon Injuries
Flexor tendons in the hand and forearm:
The muscles that bend (flex) the fingers are called flexor muscles. These flexor muscles move the fingers through cord-like extensions called tendons, which connect the muscles to bone. The flexor muscles start at the elbow and forearm regions, turn into tendons just past the middle of the forearm, and attach to the bones of the fingers. In the finger, the tendons pass through fibrous rings called pulleys, which guide the tendons and keep them close to the bones, enabling the tendons to move the joints much more effectively.
Deep cuts on the palm side of the wrist, hand, or fingers can injure the flexor tendons and nearby nerves and blood vessels. The injury may appear simple on the outside, but is actually much more complex on the inside. When a tendon is cut, it acts like a rubber band, and its cut ends pull away from each other. A tendon that has not been cut completely through may still allow the fingers to bend, but can cause pain or catching, and may eventually tear all the way through. When tendons are cut completely through, the finger joints cannot bend on their own.
How are flexor tendon injuries treated?
Tendon Healing Tendons are made of living cells. If the cut ends of the tendon can be brought back together, healing begins through the cells that are inside of the tendon as well as the tissue outside of the tendon. Because the cut ends of a tendon usually separate after an injury, a cut tendon can not heal without surgery.
We will advise you on how soon surgery is needed after a flexor tendon is cut. There are many ways to repair a cut tendon, and certain types of cuts need a specific type of repair. In the finger, it is important to preserve certain pulleys, and there is very little space between the tendon and pulley in which to perform a repair. Nearby nerves and blood vessels may need to be repaired as well. After surgery, and depending on the type of cut, the injured area can either be protected from movement or started on a very specific limited-movement program for several weeks. We may prescribe hand therapy for you after surgery. If unprotected finger motion begins too soon, the tendon repair is likely to pull apart. After four-to-six weeks, the fingers are allowed to move slowly and without resistance. Healing takes place during the first three months after the repair.
In most cases, full and normal movement of the injured area does not return after surgery. If it is hard to bend the finger using its own muscle power, it could mean that the repaired tendon has pulled apart or is bogged down in scar tissue. Scarring of the tendon repair is a normal part of the healing process. But in some cases, the scarring can make bending and straightening of the finger very difficult. Depending on the injury, we may prescribe therapy to loosen up the scar tissue and prevent it from interfering with the finger’s movement. If therapy fails to improve motion, surgery to release scar tissue around the tendon may be required.
Hand Therapy After Surgery
If a program of controlled, limited motion is selected as therapy for the first several weeks after surgery, it is important to work closely with a hand therapist and your surgeon to understand the therapy and follow set guidelines. The tendon repair might pull apart if your hand is used too soon or if therapy guidelines are not followed. In addition to regaining motion of the finger after a tendon injury, therapy will be helpful in softening scars and building grip strength.
© American Society for Surgery of the Hand
Extensor Tendon Injuries
What is an Extensor Tendon?
Extensor tendons, located on the back of the hand and fingers, allow you to straighten your fingers and thumb. These tendons are attached to muscles in the forearm. As the tendons continue into the fingers, they become flat and thin. In the fingers, smaller tendons from small muscles in the hand join these tendons. It is these small-muscle tendons that allow delicate finger motions and coordination.
How are Extensor Tendons Injured?
Extensor tendons are just under the skin, directly on the bone, on the back of the hands and fingers. Because of their location, even a minor cut can easily injure them. Jamming a finger may cause these thin tendons to rip apart from their attachment to the bone. After this type of injury, you may have a hard time straightening one or more joints. Treatment is necessary to return use to the tendon and finger.
How are Extensor Tendon Injuries Treated?
Cuts that split the tendon may need stitches, but tears caused by jamming injuries are usually treated with splints. Splints stop the healing ends of the tendons from pulling apart and should be worn at all times until the tendon is fully healed. We will apply the splint in the correct place and give you directions on how long to wear it. Sometimes a pin is placed through the bone across the joint as an internal splint in addition to the external splint.
What are the Common Extensor Tendon Injuries?
Mallet finger refers to the droop of the end joint where an extensor tendon has been cut or separated from the bone. Sometimes a piece of bone is pulled off with the tendon, but the result is the same: a fingertip that cannot actively straighten. Whether the tendon injury is caused by a cut or jammed finger, splinting is necessary. Often the cut tendon requires stitches. A splint is used to keep the fingertip straight until the tendon is healed. The size of the splint and length of time you will have to wear it is determined by the type and location of your injury. The splint should remain in place constantly during this time. The tendon may take four to eight weeks, or longer in some patients, to heal completely. Removing the splint early may result in drooping of the fingertip, which may then require additional splinting. Your physician will instruct you to remove the splint at the proper time. Sometimes there is a mild permanent droop, despite proper splint wear.
Boutonniere deformity describes the bent-down (flexed) position of the middle joint of the finger from a cut or tear of the extensor tendon at the middle joint. Treatment involves splinting the middle joint in a straight position until the injured tendon is fully healed. Sometimes, stitches are necessary when the tendon has been cut and even if the tendon is torn. If the injury is not treated, or if the splint is not worn properly, the finger can quickly become even more bent and finally stiffen in this position. Be sure to follow our instructions and wear your splint for a minimum of four to eight weeks. We will tell you when you may stop wearing the splint.
Lacerations or cuts on the back of the hand that go through the extensor tendons cause difficulty in straightening the finger at the large joint where the fingers join the hand. Stitching the tendon ends together is the usual way of treating these injuries, followed by splinting to protect the repair. The splint for a tendon injury in this area may include the wrist and part of the finger. Dynamic splinting, which is a splint with slings that allows some finger motion, may be used for injuries of this kind. The dynamic splint allows early movement and protects the healing tendon.
What Can I Expect as a Result of my Extensor Tendon Injury?
Extensor tendon injuries may form scar that causes the tendon to adhere to nearby bone and scar tissue, limiting the movement of the tendon. The scar tissue that forms may prevent full finger bending and straightening even with the best of treatment. Many factors can affect the seriousness of the injury, including fracture, infection, medical illnesses, and individual differences. To improve motion, hand therapy may be necessary. Surgery to free scar tissue may sometimes by helpful in serious cases of motion loss. We will explain the risks and benefits of the various treatments of extensor tendon injuries.
© American Society for Surgery of the Hand
Laceration/Nerve injury
What are nerves?
Nerves are the “telephone wiring” system that carries messages from the brain to the rest of the body. A nerve is like a telephone cable wrapped in insulation. An outer layer of tissue forms a cover to protect the nerve, just like the insulation surrounding a telephone cable. A nerve contains millions of individual fibers grouped in bundles within the “insulated cable.” Nerves serve as the “wires” of the body that carry information to and from the brain. Motor nerves carry messages from the brain to muscles to make the body move. Sensory nerves carry messages to the brain from different parts of the body to signal pain, pressure, and temperature. While the individual axon (nerve fiber) carries only one type of message, either motor or sensory, most nerves in the body are made up of both.
What happens when a nerve is injured?
Nerves are fragile and can be damaged by pressure, stretching, or cutting. Pressure or stretching injuries can cause the fibers carrying the information to break and stop the nerve from working, without disrupting the insulating cover. When a nerve is cut, both the nerve and the insulation are broken. Injury to a nerve can stop the transmission of signals to and from the brain, preventing muscles from working and causing loss of feeling in the area supplied by that nerve.
When nerve fibers are broken, the end of the fiber farthest from the brain dies, while the insulation stays intact, leaving empty tubes which used to carry the nerve fibers. The end that is closest to the brain does not die, and after some time may begin to heal. If the insulation was not cut, the nerve fibers may grow down the empty tubes until reaching a muscle or sensory receptor. If both the nerve and insulation have been cut and the nerve is not fixed, the growing nerve fibers may grow into a ball at the end of the cut, forming a nerve scar called a ‘neuroma’. A neuroma can be painful and cause an electrical feeling when touched.
How is it treated?
To fix a cut nerve, the insulation around both ends of the nerve is sewn together. A nerve in a finger is only as thick as a piece of thin spaghetti, so the stitches have to be very tiny and thin. The repair may need to be protected with a splint for the first 3 weeks to protect it from stretching apart since it is so delicate. The goal in fixing the nerve is to repair the outer cover so that nerve fibers can grow down the empty tubes to the muscles and sensory receptors and work again. The surgeon tries to line up the ends of the nerve repair so that the fibers and empty tubes match up with each other as best as possible, but with millions of fibers in the nerve, not all of the original connections are likely to be re-established. If a wound is dirty or crushed, your physician may wait to fix the nerve until the skin has healed. If there is a gap between the ends of the nerve, we may need to take a piece of nerve (nerve graft) from another part of the body to fix the injured nerve. This may cause permanent loss of feeling in the area where the nerve graft was taken. Smaller gaps can sometimes be bridged with “conduits” made from a vein or special cylinder.
Once the nerve cover is fixed, the nerve fibers generally begin to start growing across the repair site after three or four weeks. The nerve fibers then usually grow down the empty nerve tubes up to one inch every month, depending on the patient’s age and other factors. This means that with an injury to a nerve in the arm 11 or 12 inches above the fingertips, it may take as long as a year before feeling returns to the fingertips. The feeling of pins and needles in the fingertips is common during the recovery process. While this can be uncomfortable, it usually passes and is a sign of recovery.
What is my role in recovery and what kind of results can I expect?
The patient should be aware of several things while waiting for the nerve to heal. Your doctor may recommend therapy to keep joints flexible. If the joints become stiff, they will not work even after muscles begin to work again. When a sensory nerve has been injured, the patient must be extra careful not to burn or cut their fingers since there is no feeling in the affected area. After the nerve has recovered, the brain gets “lazy,” and a procedure called sensory re-education may be needed to improve feeling to the hand or finger. We will recommend the appropriate therapy based on the nature of your injury.
Factors that may affect results after nerve repair include age, the type of wound and nerve, and location of the injury. While nerve injuries may create lasting problems for the patient, care by a physician and proper therapy help return to more normal use.
© American Society for Surgery of the Hand
Fracture
Hand and Finger Fractures
What are fractures?
The hand is made up of many bones that form its supporting framework. This frame acts as a point of attachment for the muscles that make the wrist and fingers move. A fracture occurs when enough force is applied to a bone to break it. When this happens, there is pain, swelling, and decreased use of the injured part. Many people think that a fracture is different from a break, but they are the same. Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to displace or shift. Some fractures occur in the shaft (main body) of the bone, others break the joint surface. Comminuted fractures (bone is shattered into many pieces) usually occur from a high energy force and are often unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin. There is some risk of infection with compound fractures.
How does a fracture affect the hand?
Fractures often take place in the hand. A fracture may cause pain, stiffness, and loss of movement. Some fractures will cause an obvious deformity, such as a crooked finger, but many fractures do not. Because of the close relationship of bones to ligaments and tendons, the hand may be stiff and weak after the fracture heals.
Fractures that injure joint surfaces may lead to early arthritis in those joints.
How are hand fractures treated?
Medical evaluation and x-rays are usually needed so we can tell if there is a fracture and to help determine the treatment. Depending upon the type of fracture, we may recommend one of several treatment methods.
A splint or cast may be used to treat a fracture that is not displaced, or to protect a fracture that has been set. Some displaced fractures may need to be set and then held in place with wires or pins without making an incision. This is called closed reduction and internal fixation.
Other fractures may need surgery to set the bone (open reduction). Once the bone fragments are set, they are held together with pins, plates, or screws. Fractures that disrupt the joint surface (articular fractures) usually need to be set more precisely to restore the joint surface as smooth as possible. On occasion, bone may be missing or be so severely crushed that it cannot be repaired. In such cases, a bone graft may be necessary. In this procedure, bone is taken from another part of the body to help provide more stability. Sometimes bone graft substitutes may be used instead of taking bone from another part of the body.
Fractures that have been set may be held in place by an “external fixator,” a set of metal bars outside the body attached to pins which are placed in the bone above and below the fracture site, in effect keeping it in traction until the bone heals.
Once the fracture has enough stability, motion exercises may be started to try to avoid stiffness. We can determine when the fracture is sufficiently stable.
What types of results can I expect from surgery for hand fractures?
Perfect alignment of the bone on x-ray is not always necessary to get good function. A bony lump may appear at the fracture site as the bone heals and is known as a “fracture callus.” This functions as a “spot weld.” This is a normal healing process and the lump usually gets smaller over time. Problems with fracture healing include stiffness, shift in position, infection, slow healing, or complete failure to heal. Smoking has been shown to slow fracture healing. Fractures in children occasionally affect future growth of that bone. You can lessen the chances of complication by carefully following our advice during the healing process and before returning to work or sports activities. A hand therapy program with splints and exercises may be recommended by your physician to speed and improve the recovery process.
© American Society for Surgery of the Hand
Wrist Fractures
What is a wrist fracture?
The wrist is made up of eight small bones and the two forearm bones, the radius and ulna. The bones come together to form multiple large and small joints. At each joint, the ends of the bones are lined with a very smooth covering (cartilage). The bones are held together by ligaments. The shape and design of these joints allow the wrist to bend and straighten, move side-to-side, and rotate, as in twisting the palm up or down.
A fracture may occur in any of these bones when enough force is applied to the wrist, such as when falling down onto an outstretched hand. Severe injuries may occur from a more forceful injury, such as a car accident or a fall off a roof or ladder. Osteoporosis, a common condition in which the bone becomes thinner and more brittle, may make one more susceptible to getting a wrist fracture with a simple fall.
The most commonly broken bone of the wrist is the radius. Many people think that a fracture is different from a break, but they are the same. When the wrist bone is broken, there is pain, swelling, and decreased use of the hand and wrist. Often the wrist appears crooked and deformed. Fractures of the small wrist bones, such as the scaphoid, are unlikely to appear deformed.
Fractures may be simple with 1 or 2 large bone pieces that are well aligned and stable. Other fractures are unstable, which implies that the bone fragments tend to displace or shift, which may cause the wrist to appear crooked. Some fractures break the normally smooth, ball bearing-like joint surface; others will be near the joint but leave the joint surface intact. Sometimes the bone is shattered into many pieces, which usually makes it unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin. There is a higher risk of infection with compound (open) fractures. The alignment of the bones once healed may affect the wrist’s function. If the bones heal in a significantly altered position, there may be permanent limitations in motion with an increased risk of arthritis and pain.
How are they evaluated?
Examination and x-rays are needed so that we can tell if there is a fracture and assess the position of the bones, in order to help determine the treatment. Occasionally a CT scan may be helpful to get better detail of the fracture fragments. In addition to the bone, ligaments (the structures that hold the bones together), tendons, muscles, and nerves may be injured as well when the wrist is broken. These injuries may need to be treated in addition to the fracture. Whenever the bone protrudes through the skin, it is important to receive immediate care to minimize the risk of bony infection. When numbness in the fingers is present, it implies that the nerves have been injured.
How are they treated?
Treatment is dependent on many factors. Patient factors such as age, activity level, hobbies, occupation, hand dominance, prior injuries or wrist arthritis, and other medical problems are very important when considering treatment. Remember, it might only be your wrist, but we all need our hands to perform daily activities. Local factors relate to the bone quality (density – osteoporosis), while others relate to the fracture itself. Certain fractures are simple and in good position with the bone and joints well aligned, whereas others are fragmented into multiple pieces and may be badly displaced. Some fractures are stable and will stay in place, whereas others are unstable and might shift during treatment. It is very important to see a physician with an in-depth understanding of these factors in order to get optimal treatment and outcome.
A splint or cast may be used to treat a fracture that is not displaced, or to protect a fracture that has been set. Usually a cast is worn for several weeks depending on each patient’s fracture and ability to heal the broken bone.
Other fractures may need surgery to properly set the bone and/or to stabilize it. Fractures may be stabilized with pins, screws, plates, rods, or external fixation. Plates and screws that can be placed through an incision on the bottom or top of the wrist are often used to hold the bone fragments in place and may allow early use of the hand and wrist. These implants are buried inside the wrist and usually do not require removal. External fixation is a method in which a frame outside the body is attached to pins which have been placed in the bone above and below the fracture site, in effect keeping it in traction until the bone heals. Sometimes arthroscopy is used in the evaluation and treatment of wrist fractures.
On occasion, bone may be missing or may be so severely crushed that there is a gap in the bone once it has been re-aligned. In such cases, a bone graft may be necessary. In this procedure, bone is taken from another part of the body, or bone bank or bone graft substitutes are used, to help fill the defect.
While the wrist fracture is healing, it is very important to keep the fingers and shoulder flexible, provided that there are no other injuries that would require that they be immobilized. Once the wrist has enough stability, motion exercises may be started for the wrist itself. Hand therapy is often used to help recover flexibility, strength, and function.
What kind of results can I expect?
Recovery time varies considerably, depending on the severity of the injury, associated injuries, and other factors as noted previously. It is not unusual for maximal recovery from a wrist fracture to take several months. Some patients may have residual stiffness or aching. If the surface of the joint was badly injured, arthritis may develop. On occasion, additional treatment or reconstructive surgery may be needed.
© American Society for Surgery of the Hand
Scaphoid Fractures
What are scaphoid fractures?
The scaphoid bone is one of the eight small bones that make up the “carpal bones” of the wrist. There are two rows of bones, one closer to the forearm (proximal row) and the other closer to the hand (distal row). The scaphoid bone is unique in that it links the two rows together. This puts it at extra risk for injury, which accounts for it being the most commonly fractured carpal bone.
How do scaphoid fractures occur?
Fractures of the scaphoid occur most commonly from a fall on the outstretched hand. Usually it hurts at first, but the pain may improve quickly, over the course of days or weeks. Bruising is rare, and there is usually no visible deformity and only minimal swelling. Since there is no deformity, many people with this injury mistakenly assume that they have just sprained their wrist, leading to a delay in seeking evaluation. It is common for people who have fractured this bone to not become aware of it until months or years after the event.
Diagnosis of scaphoid fractures Scaphoid fractures are most commonly diagnosed by x-rays of the wrist. However, when the fracture is not displaced, x-rays taken early (first week) may appear negative. A non-displaced scaphoid fracture could thus be incorrectly diagnosed as a “sprain.” Therefore a patient who has significant tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist, or “snuffbox”) should be suspected of having a scaphoid fracture and be splinted. An X-ray a couple of weeks later may then more clearly reveal the fracture. In questionable cases, MRI scan, CT scan, or bone scan may be used to help diagnose an acute scaphoid fracture. CT scan and/or MRI are also used to assess fracture displacement and configuration. Until a definitive diagnosis is made, the patient should remain splinted to prevent movement of a possible fracture.
Treatment of scaphoid fractures
If the fracture is non-displaced, it can be treated by immobilization in a cast that usually covers the forearm, hand, and thumb, and sometimes includes the elbow for the first phase of immobilization. Healing time in a cast can range from 6- 10 weeks and even longer. This is because the blood supply to the bone is variable and can be disrupted by the fracture, impairing bony healing. Part of the bone might even die after fracture due to loss of its blood supply, particularly in the proximal third of the bone, the part closest to the forearm. If the fracture is in this zone, or if it is at all displaced, surgery is more likely to be recommended. With surgery, a screw or pins are inserted to stabilize the fracture, sometimes with a bone graft to help heal the bone. Surgery to place a screw may also be recommended in non-displaced cases to avoid prolonged casting.
Complications of scaphoid fractures - Non-union: If a scaphoid fracture goes unrecognized, it often will not heal. Sometimes, even with treatment, it may not heal because of poor blood supply. Over time, the abnormal motion and collapse of the bone fragments may lead to mal-alignment within the wrist and subsequent arthritis. If caught before arthritis has developed, surgery may be performed to try to get the scaphoid to heal.
Avascular necrosis: A portion of the scaphoid may die because of lack of blood supply, leading to collapse of the bone and later arthritis. Fractures in the proximal one third of the bone, the part closest to the forearm, are more vulnerable to this complication. Again, if arthritis has not developed, surgery to try to stabilize the fracture and restore circulation to the bone may be attempted.
Post-traumatic arthritis: If arthritis has already developed, salvage-type procedures may be considered, such as removal of degenerated bone or partial or complete fusion of the wrist joint.
© American Society for Surgery of the Hand
Fingertip injury
What gets injured in a fingertip injury?
Injured components may include skin, bone, nail, nailbed, tendon, and the pulp, the padded area of the fingertip. The skin on the palm side of our fingertips is specialized in that it has many more nerve endings than most other parts of our body. These nerve endings enable the fine sensation we have in our fingertips, and they can also be damaged. When this specialized skin is injured, exact replacement may be difficult.
How do they occur?
Fingertip injuries are one of the more common injuries in the hand. The fingertips are exposed in many of our activities. They can be crushed, such as by a closing door, a hammer, or a heavy object dropped onto the finger. They can be cut with a knife or power tool, such as a saw, sander, lawnmower, or snowblower.
How are they evaluated?
It is important to know how the injury occurred, and about any medical problems, as these can factor into deciding about treatment. Examination reveals the extent of tissue injury and its size. Sensation and circulation of the tip are assessed. Mobility of the tip is also checked, as injuries can occur to the tendons that bend or straighten the fingertip. X-rays are often needed to see if the bone has been injured.
How are they treated?
Severe crush or avulsion injuries can completely remove some or all of the tissue at the fingertip. If just skin is removed and the defect is less than a centimeter in diameter, it is often possible to treat these injuries with simple dressing changes. If there is a little bit of bone exposed at the tip, it can sometimes be trimmed back slightly and treated with dressings, too. For larger skin defects, skin grafting is occasionally recommended. Smaller grafts can be obtained from the little finger side of the hand. Larger grafts may be harvested from the forearm or groin. If the nailbed is injured, it is repaired.
When patients lose more than skin and have exposed bone, the injury may need to be covered with a flap of skin that has some soft tissue with it for padding. Small wounds on the tip of the finger may be covered with a flap from the injured finger. Larger wounds, such as those that result in substantial loss of the pulp, require a flap that is elevated from an adjacent finger or other source. The flap remains attached to its original site so that it has blood supply while it is stitched to the finger wound. A skin graft is used to cover the donor site defect. After a few weeks the flap has sufficient blood supply coming from the injured finger as it heals into its new location, and can be divided from its origin and fully set into the wound.
Fractures of the bone in the tip of the finger are common. Very small fractures of the end or tuft of the bone usually do not affect the strength of the bone. Repair of the soft tissue, such as the nail bed, usually re-aligns and stabilizes these bone fragments. Fractures closer to the joint may require a splint or even a temporary metal pin(s) to hold the bone fragments in proper position. If the damage is too severe, amputation of the fingertip may be necessary.
What can I expect?
Fingertip sensitivity is common and may last for many months. Sometimes the feeling in the fingertip is limited. The contour may have some distortion, and the quality and texture of the skin may be different than the very specialized skin that normally covers the fingertip. There also may be some deformity at the donor site of a graft or flap. Stiffness can be a concern, especially if a flap is needed.
What is involved with nail bed injuries?
Injuries to the nail are often associated with damage to other structures that are in the same location. These include fractures of the bone (distal phalanx), and/or cuts of the nailbed, fingertip skin (pulp), tendons that straighten or bend the fingertip, and nerve endings.
What causes nail bed injuries?
Many result from crush injuries after getting the fingertip caught in a door. Any type of pinching, crushing, or sharp cut to the fingertip may result in injury to the nail bed.
Presentation of nail bed injuries
Simple crushes of the fingertip may result in a very painful collection of blood (hematoma) under the nail. More severe injuries can result in cracking of the nail into pieces, or tearing off of pieces of the nail and/or fingertip, and possible injuries to the adjacent structures.
Diagnosis of nail bed injuries
An accurate history of the cause of the injury should be obtained. X-rays are recommended to look for associated fractures that may require treatment. The full extent of the injury may not be evident until adequate anesthesia (usually local) is given and the nail is examined with magnification. Other medical conditions that may affect healing should be discussed with us.
Treatment of nail bed injuries
Restoring the normal anatomy of the nail and surrounding structures is the goal of treatment. Simple hematomas are drained by making a small hole in the nail in order to relieve the pressure and provide pain relief. Straightforward cuts are repaired to put the parts back where they belong.
Repairing the nail bed to which the fragments of bone are attached usually restores alignment of many fractures of the fingertip. Larger fragments of bone may need to be pinned or require splinting to heal the fracture. Missing areas of nail bed can be grafted from the same finger or from other digits. Tendon injury may require splinting or pinning. Local flaps of skin may be used to replace missing skin, or the open area of skin may be allowed to just heal on its own, or covered with a skin graft.
Prognosis
The final appearance and function of the nail and surrounding structures depends on the ability to restore the normal anatomy. If the injury is sharp and can be repaired, a normal nail is likely. If there is more severe crushing of the nail bed, then there is a greater likelihood of nail bed scarring and subsequent deformity of the nail. If the germinal matrix (crescent-shaped zone at the base of the nail bed from which the nail grows) is injured, there will likely be a deformity of the nail as it grows. The function of the fingertip also depends on the extent of injury to structures other than the nail. It normally takes 3-6 months for the nail to grow from the cuticle to the tip of the finger.
Surgical Reconstruction
Loss of part or all of the nail bed can be reconstructed with grafts from other digits. Grafts may be taken from the nail bed of a toe to prevent further injury or deformity of the fingers. The most common graft is a split-thickness graft to reconstruct missing nail bed.
© American Society for Surgery of the Hand
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