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Bennett’s #
Small medial fragment of bone which may tilt, but maintains its relationship with
the trapezium, the vertical # line involves the trapezometacarpal joint; most important
is the proximal and lateral subluxation of the thumb MC.
Treatment is reduction by applying traction to thumb, abducting it and applying
pressure to the lateral aspect of the base under GA or Bier block.
Bennett’s #
Maintaining reduction can be troublesome. Cast should be carefully moulded.
Check x-rays are taken to confirm reduction. Arm should be elevated in the sling.
Weekly x-rays should be taken. If cast appears loose at any stage or # is slipping, a
new cast should be applied. Plaster cast should be maintained for 6 weeks.
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Bennett’s #
Alternative methods are AO small fragment screw fixation, IM K-wire, K-wire
fixation of thumb to index and middle MC or use of 2 K-wires to stabilize the 1st MC.
# of base of 1st MC
Greenstick # of this type are common in children. Angulation is usually slight to
moderate and should be accepted, gross angulation should be manipulated.
In this types there is no subluxation.
Plaster fixation for about 5 weeks is desirable.
Gamekeeper’s thumb
Caused by forcible abduction of thumb leading to rupture of ulnar collateral
ligament. If unrecognized or untreated, there is progressive MP subluxation,
interference with grasp and disability.
Extend the MP joint fully and apply stress to UCL by abducting PP, repeat with
thumb flexed at MP joint and see for laxity.
If in doubt stress X-rays should be taken. Look for avulsion # on x-ray, if # is there
note its position (Marked displacement, rotation so that its articular surface is pointing
distally are indications of surgery.
Gamekeeper’s thumb
Mild laxity or minimally displaced #, fixation in scaphoid type cast for 6 weeks.
Gross laxity (complete tear) or rotated #, surgical repair of torn ligament or
repositioning of # and cast for 6 weeks.
Long standing lesions with marked symptoms, MP joint fusion.
# of PP of thumb
Severely angled # reduced by traction and local pressure and held with a dorsal or
volar slab to which is added a girder extension. Minimally angled fracture or splinter
# protected by local slab.
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Injuries of 5th MC
Types:
Types: # of the neck, spiral # of shaft usually UN displaced, transverse # of shaft
often angulated, # of the base and # of the head.
# of the neck : Caused by banging a clenched fist as in fight, angulation and
impaction are common. When angulation is slight, it is accepted and # supported for
3-4 weeks with dorsal slab with finger extension and garter strapping of ring and little
finger.
Injuries of 5th MC
If angulation is gross, reduction is achieved by flexing MP joint and applying
pressure to head via PP using thumb while the fingers apply counter pressure to the
shaft. Reduction should be checked and maintained while slab is applied
Spiral #, transverse # of shaft with mild to moderate angulation or displacement and
# of base may be treated adequately by application of a Colles’s plaster for 3-4 weeks
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Injuries of 5th MC
Marked angulation of shaft # treated by traction and local pressure prior to POP.
Displaced # may be similarly reduced but soft tissue interposition requires open
reduction. In those cases reduction is maintained by PC or IM k-wire.
# of head of 5th MC are treated by garter strapping and early mobilization. If
symptoms are marked a dorsal slab may be applied for initial 1-2 weeks.
Injuries of 5th MC
Dislocation of the base of 5th MC is usually easily reduced with traction, but may
need K-wire stabilization.
Injuries to index, middle & ring MC
Commonest is spiral # of shaft, but # involving base and neck are frequent. Un
displaced # may be supported by a Colles’s type slab but watch for swelling which
can be severe especially in multiple #.
Displaced # are managed as mentioned in 5th MC by reduction either closed or open
F/B k-wire either IM or trans fixation kept for 3 weeks F/B plaster fixation for further
2 weeks.
# of PP and MP
Un displaced simple # of shaft, base, neck, intercondylar region or epiphyseal
injuries seldom present any problem. Garter strapping for 3-4 weeks may give
adequate support but if symptoms are marked this may be supplemented by use of
volar or dorsal slab with finger extension.
There is tendency for angulation sue to intrinsic muscle pull and if more than 15º it
should be corrected by gentle traction using thumb as a fulcrum. These # are stable in
flexion and affected finger is required to be fixed initially in this position.
IM k-wires are used in case of open and multiple #.
# of PP and MP
Care is taken to keep uninjured fingers free and exercised. Rigid fixation should be
discarded as soon as possible.
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Mallet finger
Caused by forcible flexion of finger from the extended position. Distal slip of EDP
tears from its attachment to the base of DP or avulses a fragment of bone. Patient is
unable to extend the distal IP joint fully; drooping of the DP may be slight or severe.
In late cases there is hyperextension of PIP joint. If more than 1/3rd of articular surface
is detached subluxation of the DIP joint may occur.
Mallet finger
In last case ORIF using K-wires is done and kept for 4 weeks.
Otherwise hold the DIP in extension for 6 weeks using Abuna splint or mallet
splint.
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If deformity recurs, immediate surgery is not advised as disability may be slight,
spontaneous fibrotic healing may occur after 6 months.
Results of tendon suture are uncertain
IP fusion gives the best overall results.
# dislocation
It is important that joint surface is correctly relocated and mobilization started as
early as possible.
ORIF is usually required with an IM k-wire which is removed after 2-3 weeks and
mobilization started using garter strapping for the first week or more until the #
becomes more stable.
Tenosynovitis
Direct trauma to or excessive use of a tendon and its synovial sheath causes
synovial inflammation. The synovial surface becomes dry and covered with fibrin.
Movement of a tendon produces clinically detectable crepitations. Inflammation is
greatest at the MT junction. Clinically pain is experienced over course of muscle and
tendon and is accentuated by active or passive movement. Tenderness and crepitations
detected.
Mild cases treated by rest, cool packs and gentle exercise to prevent adhesions.
Severe cases may be splinted temporarily.
Trigger finger
Fusiform swelling of sublimis tendon at its bifurcation as it passes through
thickened and constricted sheath over the MC Head.
On movement the sudden escape of the nodule from the narrowed canal is
accompanied by an audible snap. Later on disproportion becomes too great to permit
passage and finger becomes locked usually in flexion.
Conservative treatment includes local injections of corticosteroids, rest by splinting
finger in extension and avoidance of direct pressure on the nodule.
Surgery if needed is done. The thickened sheath over MC head is incised.