Soft Tissue Injuries of the Finger and Thumb

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Elsevier Science

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Review

. 2018 Aug;39(4):397-410.

doi: 10.1053/j.sult.2018.04.001.

Epub 2018 Apr 16.

Juliann Giese 
¹
, Christopher Cerniglia 
²

Affiliations

Affiliations

• ¹ Department of Radiology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA.
• ² Department of Radiology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA. Electronic address: [email protected].

• PMID:

  30070232

• DOI:

  10. 1053/j.sult.2018.04.001

Review

Juliann Giese et al.

Semin Ultrasound CT MR.

2018 Aug.

. 2018 Aug;39(4):397-410.

doi: 10.1053/j.sult.2018.04.001.

Epub 2018 Apr 16.

Authors

Juliann Giese 
¹
, Christopher Cerniglia 
²

Affiliations

• ¹ Department of Radiology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA.
• ² Department of Radiology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA. Electronic address: [email protected].

• PMID:

  30070232

• DOI:

  10.1053/j.sult.2018.04.001

Abstract

Soft tissue digital injury of the hand is a common presenting complaint in the emergency setting. Although initial work-up requires physical examination and radiographs, many of these entities may be radiographically occult and solely appreciated on ultrasound (US) or magnetic resonance imaging (MRI). If undiagnosed, these conditions may lead to sequela of untreated disease including early osteoarthritis, pain, permanent deformity, and immobility. Soft tissue finger injuries that may not be readily apparent without the use of MRI or US are discussed. The key imaging features of radiolucent foreign bodies in addition to tendon, collateral ligament, sagittal band, and pulley injuries on MRI and US are discussed.

Copyright © 2018 Elsevier Inc. All rights reserved.

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Soft Tissue Injuries of the Hand

Mallet Finger (Zones I and II)

Clinical presentation

Zone I and Zone II extensor tendon injuries may result in a mallet deformity, due to loss of continuity of the conjoined lateral bands at the DIP joint.
The history is usually a direct blow that forcibly flexes an extended finger. However, the trauma may also be minor, or even forgotten. If left untreated, apart from being painful, the digit becomes hooked and may eventually develop a swan-neck deformity due to compensatory hyperextension at the PIP joint.
Open injuries should be referred to a hand surgeon for primary repair.

Clinical management

Radiographs

Closed mallet finger injuries are usually treated conservatively.

Mallet finger deformity may be due to bone or soft-tissue injury and radiographs are needed to confirm this.

Referral criteria

Criteria for referral include:

• The absence of full passive extension (indicating possible bony or soft-tissue entrapment requiring surgical intervention)
• Joint subluxation or an avulsion fracture of more than one-third of the articular surface

There is evidence [16-17] to suggest that even the latter injury may be treated non-operatively with good patient satisfaction, although studies with longer follow-up are required to assess the effects of resultant DIPJ arthritis on treatment outcome.

Splinting

Conservative treatment entails continuous splinting of the DIPJ in neutral or slight hyperextension for at least six weeks.

There is insufficient evidence [18, 19] to recommend any particular splint; all achieve similar outcomes, patient compliance being the key to a successful outcome.

Learning Bite

A well-fitting splint for a mallet finger is vital to ensure compliance and avoid skin breakdown, the main complication of conservative treatment. The PIPJ must be left free to allow mobilisation and prevent stiffness.

Rupture or Division of the Central Slip

Clinical presentation

Zone III injuries may involve rupture or division of the central slip (as in the image) and if unrecognised can result in the boutonnire deformity – characterised by flexion at the PIPJ and hyperextension at the DIPJ and caused by the unopposed action of FDS and volar displacement of the lateral bands. Direct visualisation in an open laceration is the easiest way to confirm and treat this injury. A simple suture followed by six weeks splintage of the PIP joint in extension is usually satisfactory.

Closed rupture of the central slip over the PIPJ is easily missed. The history may be of axial loading or forced flexion with the PIPJ in extension, or after a volar dislocation of the PIPJ. Clinically, presentations may be variable – patients may present with an acute boutonniere deformity, with an unreduced volar dislocation or, most commonly, with a painful, swollen PIPJ.

Clinical management

Examination

Examination should look specifically for maximal localised tenderness over the dorsal aspect of the PIPJ, at the insertion of the central slip. Bruising may be noticed in the area.

Active extension at the PIPJ does not exclude a rupture as, in the acute setting, full extension may still be achieved by the lateral bands.

Elson’s test

Various clinical, non-invasive tests have been described for early diagnosis of closed central slip rupture including the test described by Elson [20].

Elson’s test is performed with the PIP joint of the injured finger flexed 90 over the edge of a table. The patient then tries to extend the PIP joint of the injured finger against resistance. The absence of extension force at the PIP joint and fixed extension at the DIP joint are signs of complete rupture of the central slip.

However, the test will not demonstrate a partial rupture, and may be limited by pain and the patient’s cooperation.

See here for a video demonstration.

Boutonnire deformity

X-ray may show an avulsion fracture, and sometimes gives the first clue to a developing boutonnire deformity.

Treatment

If a central slip rupture is known or strongly suspected, the PIPJ should be splinted in a static extension splint, leaving the DIPJ free.

Further follow-up in a hand clinic is required. The swollen, painful PIPJ with full active extension should be followed up in an ED clinic at 2-3 days for senior clinician re-assessment for possible central slip injury.

Lacerations (Zone IV)

Zone IV tendon injuries over the proximal phalanx are usually due to lacerations.

The ED management should include a wound exploration under local anaesthetic cover.

Confirmed tendon injuries need referral to a hand surgeon for tendon repair, splinting and follow-up.

Open Zone V Injuries

Clinical presentation

Open zone V injuries overlie the MCPJ. Open injuries in this area must be suspected to be a human bite until proven otherwise [3]. Indeed such injuries are called ‘fight bites’, and in addition to tendon injury, joint involvement and septic arthritis are likely.

Due to the broad sagittal band and extensor tendon interconnections, the ruptured tendon does not retract and extensor lag is usually mild. The position of the joint at the time of injury must be remembered as the tendon laceration may be proximal to the skin wound.

Clinical management

ED management of open zone V injuries may include a wound exploration to establish the depth of the wound and any tendon or joint involvement. Alternatively, these injuries may be referred urgently to a hand surgery unit.
It is recommended that all zone V wounds require surgical exploration and any joint involvement needs thorough debridement and washout. Admission for hand elevation and IV antibiotics is also required. Zone V tendon injuries from a human bite should undergo delayed repair when the risk of infection and septic arthritis are minimised [2].

Closed Zone V Injuries

Clinical presentation

Closed zone V injuries in this area may also present as a subluxation or dislocation of the extensor hood. The tendon usually subluxes in an ulnar direction, due to a tearing of the sagittal fibres on the radial side, with the middle (long) finger being the most commonly affected [21].

The injury is of forced flexion or extension at the MCPJ, with immediate pain and a persistent loss of extension of the affected finger. There may be a painful popping sensation over the dorsum of the hand with attempts at movement. Active extension of the MCPJ is weak or absent. However, once passively corrected, with the tendon having relocated centrally, the patient will be able to maintain extension actively.

Clinical management

Hand surgeon referral is required as both surgical repair and conservative management with splintage are possible.

Zone VI Injuries

Zone VI injuries frequently involve tendon damage due to their superficial site over the dorsum of the hand. When assessing extension, care is advised because, if the laceration is proximal to the junctura tendinae, the patient may be able to extend the involved MCPJ despite a ruptured tendon. Weak extensor forces are transmitted to the junctura from adjacent extensor tendons.

ED management may include a wound exploration to identify any tendon injury. Confirmed tendon injuries require surgical repair for which hand surgery referral is required.

Zone VII and VIII Injuries

Zone VII and Zone VIII injuries involve the wrist and forearm, with possible damage to the extensor retinaculum.

Open injuries to these areas require surgical exploration and should be referred to a hand surgeon.

High Pressure Injection Injury

This seemingly innocuous injury is often underestimated and underrecognized. The injury is characterized by a small puncture wound and injection of liquid (lubricants, oils, solvents etc) into the hand using high pressure guns (2000 to 12000 psi). The wounds are small, but the underlying damage is usually extensive. The injected substance leads to extensive tissue damage (local necrosis and oedema). As a result, this may lead to compartment syndrome of the affected limb. Due to their potential morbidity, injection injuries are characterized as “the most urgent of all emergencies of the hand”

These patients would require immediate referral to the Hand Surgeons for debridement. ED management includes intravenous antibiotics and tetanus prophylaxis.

Causes and treatment of inflammation of the tissues of the fingers and feet

Contents

• 1 Panarithiasis: causes, symptoms, types and methods of treatment of inflammation of the fingers and feet
  • 1. 1 Panarithiasis: causes and methods of treatment
    • 1.1.1 Causes of inflammation

    9 0005 1.1 .2 Symptoms of panarithiasis

    • 1.1.3 How to treat panarithiasis
  • 1.2 Understanding panarithiasis
    • 1.2.1 What is panarithiasis?
  • 1.3 Causes of panarithiasis
  • 1.4 Symptoms and signs of panarithiasis
  • 1.5 Diagnosis of panarithiasis
    • 1.5.1 Main symptoms and signs
    • 1.5.2 Additional diagnostic tests
    • 1.5.3 When to see a doctor

    9 0015

    • 1.6 Treatment of panarithiasis at home
      • 1.6.1 Use warm compresses
      • 1.6.2 Use topical antiseptics
      • 1.6.3 Use anti-inflammatory drugs
      • 1.6.4 Maintain wound hygiene
      • 1.6.5 Keep calm
      • 1.6.6 Causes of panarithiasis and preventive measures
    • 1.7 Modern approaches to the treatment of panarithiasis
    • 1.8 Prevention of panarithiasis
      90 005 1.8.1 Hygiene measures
      • 1. 8.2 Medical examination
      • 1.8 .3 Proper nutrition
      • 1.8.4 Proper footwear
      • 1.8.5 Timely treatment of other diseases
    • 1.9 Possible complications of panarithiasis
      • 1.9.1 Sepsis
      • 1.9.2 Abscesses
      • 1.9.3 Traumatic arthritis
    • 1.10 Preventing the spread of infection in panarithiasis
      • 1.10.1 Maintain hand hygiene 900 10
      • 1.10.2 Avoid contact with other people
      • 1.10.3 Do not squeeze out ulcers
      • 1.10.4 Take preventive measures
      • 1.10.5 Take care of shoes and clothes
    • 1.11 When should I see a doctor in case of panarithiasis?
    • 1.12 Conclusions
    • 1.13 Related videos:
    • 1.14 Q&A:
      • • 1.14.0.1 What is panarithiasis?
        • 1.14.0.2 What causes panarithiasis?
        • 1.14.0.3 What are the symptoms of panarithiasis?
        • 1.14.0.4 How to treat panarithiasis in the early stages?
        • 1. 14.0.5 What to do if panarithiasis has become chronic?
        • 1.14.0.6 How can panarithiasis be prevented?

  Find out about the causes and treatment of panarithiasis, inflammation of the tissues of the fingers and feet. Manage the disease correctly and in a timely manner to avoid complications and maintain health. A detailed description of the symptoms and methods of therapy on the site.

  Panarithiasis is an inflammatory disease that occurs at the site of injury or contact with infected material on the toes or feet. It can be caused by a small cut, abrasion, or splinter. If left untreated, panarithiasis can lead to serious health problems, including sepsis and loss of fingers.

  Panarithiasis symptoms may include pain, redness, swelling, purulent mucus or fluid. Although at the initial stage of the disease, treatment at home is possible, if the condition worsens, it is recommended to consult a doctor or a medical institution for qualified medical care and treatment.

  Panarithiasis: Causes and Treatments

  Causes of Inflammation

  Panarithiasis is an inflammatory process that can occur on the finger or foot. The main cause of panarithiasis is the introduction of infection into a wound or cut on the skin, whether it is an injury or a runny nose. In addition, the risk of inflammation increases with improper care of the skin on the hands and feet or in the absence of protective equipment during work operations.

  Symptoms of panarithiasis

  Initial symptoms of panarithiasis can vary, but most often patients complain of pain, swelling and redness in the affected finger or foot. In the progressive state of panarithiasis, one may notice the appearance of pustules, an increase in temperature at the site of inflammation, and even general weakness and a disturbing fever.

  Treatments for panarithiasis

  Panarithiasis is usually treated with antibiotics, which are selected individually depending on the type of infection. Also, the course of treatment may include the use of anti-inflammatory ointments and liquids. At home, you can apply various compresses and treat sore spots on the fingers or feet. If the treatment of panarithiasis does not help or the situation worsens, you should definitely consult a doctor and undergo additional studies to determine possible causes.

  Understanding panarithiasis

  What is panarithiasis?

  Panarithiasis is a health problem that causes inflammation of the tissues on the fingers or toes. Inflammation can be caused by infection or injury, and can lead to pain, discomfort, and other problems.

  In addition, there are various types of panarithiasis, including superficial and deep panarithiasis. Superficial fenugreek affects the skin and soft tissues on the surface of the finger, while deep fenugreek affects the bones and joints inside the finger.

  It is important to remember: if inflammation of the tissues on the arms or legs occurs, you should immediately consult a doctor for correct and timely treatment.

  Causes of panarithiasis

  Panarithiasis (inflammation of the tissues of the fingers and feet) can occur for various reasons. Violations of personal hygiene and infection of wounds upon contact with a contaminated surface is one of the most common causes of the development of panarithiasis.

  Also, the cause of the disease can be mechanical damage to tissues, for example, when hitting or cutting a finger. Incorrectly selected shoes or frequent rubbing of the heel against shoes also contributes to the inflammatory process.

  Immunodeficiencies (including HIV infection), circulatory disorders and the presence of other chronic diseases can cause disruption of the tissue regeneration process and contribute to panarithiasis.

  • Violation of personal hygiene is one of the main causes of panarithiasis
  • Mechanical impact of on tissues, for example, hitting or cutting a finger

  foot

  • Immunodeficiencies , circulatory disorders and other chronic diseases – the cause of impaired tissue regeneration and the occurrence of panarithiasis

  Symptoms and signs of panarithiasis

  Panarithiasis is an extremely unpleasant and painful inflammatory disease of the tissues of the fingers and feet, which can lead to serious complications m and even the loss of a finger. One of the main symptoms of panarithiasis is severe pain in the affected area, which may be accompanied by redness, swelling, swelling and fever. Often, pain occurs as a result of a minor injury, such as a strong blow or damage to the nail.

  At an early stage of development, panarithiasis can be manifested by weakness, headache and appetite disorders. In the future, an abscess with purulent contents may form, the opening of which can lead to even more pain and infection of the hands or feet. In some cases, sepsis may develop, which is a dangerous condition and requires immediate medical attention.

  1. Severe pain in the affected area
  2. Redness, swelling and swelling
  3. Fever
  4. Weakness and headache
  5. Formation of an abscess with purulent contents

  Diagnosis of panarithiasis

  Main symptoms and signs

  nye symptoms and signs. First of all, patients complain of acute pain when pressing on the affected area, as well as swelling, redness and elevated skin temperature. When an abscess is formed on the finger, a bubble often appears filled with purulent fluid, as well as areas of necrosis.

  Additional diagnostic methods

  Additional diagnostic methods are required to accurately diagnose and determine the severity of panarithiasis. This may include bacteriological examination of purulent fluid and tissues, which reveals the causative agent of infection. An ultrasound, X-ray, or MRI may also be required to rule out complications and infiltrates. In some cases, a general blood test may be prescribed, which allows you to assess the general state of health and identify possible disorders in the body.

  When to see a doctor

  When the first signs of panarithiasis appear, you should consult a surgeon or traumatologist. Self-treatment can lead to serious complications and the development of purulent-septic processes. The doctor will conduct an examination and prescribe the necessary diagnostic measures, after which further treatment will be determined depending on the severity of the disease.

  Home treatment for panarithiasis

  Use warm compresses

  Warm compresses can help treat fenugreek by reducing pain and improving circulation in the finger or foot. To do this, heat the tissue material in warm water, and then apply it to the sore spot for 15-20 minutes several times a day.

  Use topical antiseptics

  Topical antiseptics such as iodine and hydrogen peroxide can help prevent infection and speed up healing. They can be applied to the affected area with a cotton swab.

  Use anti-inflammatory drugs

  Anti-inflammatory drugs such as paracetamol can help reduce pain and inflammation, and some may be available without a prescription. However, you should consult your doctor before using any medication.

  Wound Hygiene

  It is important to remember to keep the wound clean and dry at all times to prevent infection. If a purulent wound has arisen, a visit to a doctor is required for treatment and drainage.

  Rest

  It is important to rest your toe or foot without stressing it and providing room for recovery. In the case of acute or recurrent panarithiasis, specialist advice may be required.

  Causes of panarithiasis and preventive measures

  Panarithiasis can occur due to various causes, including damage to the skin of the finger or foot, poor hygiene, and the presence of disorders in the immune system. To avoid panarithiasis, you should maintain hygiene of the skin of the hands and feet, take care of the health of the immune system, and immediately treat any skin lesions.

  Modern approaches to the treatment of panarithiasis

  Currently, there are several methods of treating panarithiasis, which depend on the degree and form of the disease.

  Another effective treatment is surgery. It is carried out with the development of complications, such as abscesses or abscesses. The doctor drains and removes infected tissue. The operation allows you to avoid re-inflammation in the future.

  In addition, physiotherapy and medications may be prescribed to reduce pain and speed up the healing process.

  • Conclusion: Modern approaches to the treatment of panarithiasis involve the use of an integrated approach, including the use of antibiotics, surgery (if necessary), physiotherapy and local therapy to accelerate healing.

  Prevention of panarithiasis

  Hygiene measures

  The main way to prevent panarithiasis is to observe hygiene measures. It is necessary to wash hands and feet regularly, especially after contact with dirt, dust, chemicals. Protective gloves must be worn when handling water or solutions.

  Medical examination

  When the first symptoms of panarithiasis appear, a doctor should be consulted. An early appointment for a consultation will prevent the development of the disease and avoid the need for surgery.

  Proper nutrition

  Regular consumption of foods rich in vitamins and minerals helps to maintain a healthy immune system and strengthen the body’s defenses.

  The right shoes

  Wear shoes that fit and fit you. Poor-quality or uncomfortable shoes can lead to mechanical damage to the skin and nails, which can lead to the development of panarithiasis.

  Timely treatment of other diseases

  Concomitant diseases (especially metabolic disorders, injuries, diseases of the circulatory system) can cause the development of panarithiasis. Therefore, they need to be detected and treated promptly.

  • Conclusion: Prevention of panarithiasis is simple measures that include hygiene, proper nutrition, choosing the right shoes and timely access to a doctor. To prevent the development of the disease, it is necessary to monitor your health and carry out regular preventive measures.

  Possible complications of panarithiasis

  Sepsis

  Panarithiasis is not a serious disease, but some cases can lead to serious complications. If the inflammation spreads to the skin and deep tissues, then sepsis can develop – a dangerous condition that occurs when blood is infected with bacteria.

  Abscesses

  If an attempt to treat panarithiasis fails, an abscess may form – a cavity containing pus. On the fingers and feet, an abscess can cause a feeling of heaviness and pain. A large abscess requires medical intervention.

  Traumatic arthritis

  Left untreated for a long time and if panarithiasis recurs, the infection can impair the function of the joints in the fingers and toes, causing traumatic arthritis. It leads to constant pain, decreased joint mobility and permanent limitation of movement.

  • There are several ways to prevent panarithiasis, including keeping your home and workplace clean, protecting your hands and feet from injury, and practicing sports safety.
  • If you have symptoms of panarithiasis, seek medical attention to prevent possible complications.

  Preventing the spread of infection in panarithiasis

  Maintain hand hygiene

  Maintaining hand hygiene is key to preventing the spread of infection in panarithiasis. Wash your hands regularly with soap and water, especially after contact with possible sources of infection such as dirty surfaces or the ground.

  Avoid contact with other people

  If you have panarithiasis, it is important to avoid contact with other people so as not to transmit the infection. If contact is necessary, use gloves or other personal protective equipment.

  Do not pop pustules

  If you notice an abscess on your toe or foot, do not try to pop it yourself. This can lead to aggravation of inflammation and the spread of infection. Consult your doctor for proper treatment.

  Take preventive measures

  Take preventive measures to strengthen the body’s immune system. This may include proper nutrition, exercise, regular sleep, and other health measures.

  Look after your shoes and clothes

  Take care of your shoes and clothes, especially if you are in public places where bacteria can be high. If necessary, use disinfectants for shoes and clothing.

  Panarithiasis Prevention Comparison Chart Prevention Method Benefits Disadvantages

  90 329

  Hand Hygiene	Simple and effective way to prevent transmission	May require regular handwashing, which is not always convenient
  Avoidance of contact with other people	Reduces the risk transmission to others	May be uncomfortable in some situations
  Non-squeezing pustules	Prevents aggravation of inflammation and spread of infection	Requires a visit to a doctor for proper treatment
  Carrying out preventive measures	Helps strengthen the immune system and reduce the likelihood of infection	May require additional effort and expense
  Take care of shoes and clothes	Improves environmental hygiene and reduces transmission of infection	May be uncomfortable for some people

  When should I see a doctor for panarithiasis?

  Panaritias can become a serious problem if not treated promptly. If you start treatment as soon as you notice the first symptoms, then there is every chance to avoid any complications. However, there are certain cases when you need to see a doctor immediately.

  • Localized panarithiasis : if the tissue inflammation is limited to a few fingers and is only on the surface of the skin, you can try to treat it at home. However, if the inflammation spreads to other areas or if other symptoms occur (such as pustules), you should immediately consult a doctor.
  • Widespread panarithiasis : if the inflammation spreads to several fingers and is located in deep tissue layers, you should immediately consult a doctor. This can become a serious problem if not treated promptly.
  • Intolerable pains : if the pains become severe and intermittent, this may indicate that there is a serious inflammation. In this case, immediately consult a doctor to get qualified medical assistance.

  Remember that it is better to be overweight than underweight. If there is doubt or uncertainty about the diagnosis, it is always best to consult a doctor for advice.

  Conclusions

  The study of panarithiasis showed that this type of inflammatory process most often occurs at the site of injury or damage to the skin on the fingers and feet. Also, the risk of developing panarithiasis increases in the presence of herniated intervertebral discs and other diseases accompanied by impaired blood circulation in the tissues.

  If you have the first signs of panarithiasis, you should contact a specialist for diagnosis and treatment. Delay can lead to the development of complications such as phlegmon and sepsis.

  Treatment of panarithiasis should be comprehensive and include antibiotics, treatment of wounds and physiotherapy. The infected toe or foot should be kept in an elevated position and exercised regularly to stimulate blood circulation and improve lymphatic drainage.

  • It is important to diagnose panarithiasis early and start treatment immediately.
  • Treatment should be comprehensive and include antibiotics, wound dressing and physical therapy.
  • Keep the infected finger or foot in an elevated position and do exercises to stimulate circulation and lymphatic drainage.

  In general, panarithiasis is a serious disease that must be treated as soon as the first symptoms appear. Compliance with first aid measures and full compliance with the recommendations of the doctor allows you to successfully avoid the development of complications in the future.

  Related videos:

  Q&A:

  What is panarithiasis?

  Panaritias is an inflammatory disease that occurs on the skin of the fingers and toes, as well as their paranasal tissues. Usually, panaritias causes pain, as well as terrible pain and swelling, which makes it difficult to use the fingers normally.

  What causes can lead to panarithiasis?

  Panarithiasis can occur due to various factors, such as infection or bacteria in the wounds on the fingers, impaired blood circulation, poorly manicured nails and finger injuries.

  What are the symptoms of panarithiasis?

  Among the symptoms that can be seen with panarithiasis are redness and swelling of the skin around the nail and pain when touching or pressing on the infected area. Suppuration and discharge of pus from the wound, fever and discomfort when moving are also possible.

  How to treat panarithiasis in the early stages?

  If you suspect that you have panarithiasis, you should contact your doctor as soon as possible. In the early stages of the disease, it can be treated with antibiotics and careful wound care to prevent more serious complications.

  What to do if panaritias has become chronic?

  If panarithiasis has become chronic, treatment will be difficult. The doctor may prescribe drugs to increase immunity, as well as removing part of the nail plate to provide better access to the wound and improve its healing. In some cases, surgery may be required.

  How can panarithiasis be prevented?

  One of the main ways to prevent panarithiasis is good hand and foot care. Nails and hands should be kept clean and protective gloves should be worn when handling sharp objects. If you have had an injury or wound on your fingers, you must urgently see a doctor and operate on the wound to avoid infection and the appearance of panarithiasis.

  Tendon injury | Center for Endosurgical Technologies

  The choice of tendon reconstruction method is made taking into account the time elapsed since the injury, the prevalence of cicatricial changes along the course of the tendons, and the condition of the skin at the operation site. The tendon suture is indicated if it is possible to connect the damaged tendon end-to-end, in the normal state of the soft tissues in the area of ​​operation. There is a primary tendon suture performed within 10-12 days after the injury in the absence of signs of infection in the wound area and its incised nature, and a delayed suture, which is applied from 12 days to 6 weeks after the injury under less favorable conditions (torn-bruised wounds). In many cases, later suturing is not possible due to muscle retraction and significant diastasis between the ends of the tendon. All types of tendon sutures can be divided into two main groups – removable and submersible.

  Removable sutures, introduced in 1944 by Bunnell S., are used to fix the tendon to the bone and in areas where early movement is not so necessary. The suture thread is removed after the tendon is sufficiently firmly fused with the tissues at the point of fixation. The dip sutures remain in the tissues, carrying the mechanical load. In some cases, additional sutures are used to provide a better alignment of the ends of the tendons. In chronic cases, as well as with a primary defect, tendon plasty (tendoplasty) is indicated. The source of the tendon autograft is tendons, the taking of which does not cause significant functional and cosmetic disorders, for example, the tendon of the long palmar muscle, superficial flexor fingers, long extensor toes, plantar muscle.

  Finger flexor tendon injuries

  Anatomy.

  Flexion of fingers 2-5 is carried out by two long tendons – superficial, attached to the base of the middle phalanx and deep, attached to the base of the distal phalanx. Flexion of 1 finger is carried out due to the tendon of the long flexor of 1 finger. The flexor tendons are located in narrow, complex in shape, bone-fibrous canals that change their shape depending on the position of the finger

  Changes in the shape of the bone-fibrous canals of 2-5 fingers when they are bent

  In places of greatest friction between the palmar wall of the canals and the surface of the tendons, the latter are surrounded by a synovial membrane that forms the sheaths. The tendons of the deep flexors of the fingers are connected by means of the worm-like muscles with the extensor tendon apparatus.

  Diagnostics.

  In case of damage to the tendon of the deep flexor of the finger with a fixed middle phalanx, flexion of the nail is impossible, with combined damage to both tendons, flexion of the middle phalanx is also impossible.

  Diagnosis of flexor tendon injuries (1, 3 – deep, 2, 4 – both)

  Flexion of the main phalanx is possible due to contraction of the interosseous and vermiform muscles.

  Treatment.

  There are five zones of the hand, within which anatomical features affect the technique and results of the primary tendon suture.

  Zones of the hand

  In zone 1, only the deep flexor tendon passes in the bone-fibrous canal, so its damage is always isolated. The tendon has a small range of motion, the central end is often held by mesotenon and can be easily removed without significant expansion of the damaged area. All these factors determine the good result of the imposition of the primary tendon suture. The most commonly used transosseous tendon suture is removed. Dip welds may be used.

  Over the course of zone 2, the tendons of the superficial and deep finger flexors cross over, the tendons are tightly adjacent to each other, and have a large range of motion. The results of the tendon suture are often unsatisfactory due to cicatricial adhesions between the sliding surfaces. This zone was called the critical or “no man’s zone”.

  Due to the narrowness of the bone-fibrous canals, it is not always possible to suture both tendons; in some cases, it is necessary to excise the tendon of the superficial flexor of the finger and suture only the tendon of the deep flexor. In most cases, this avoids contractures of the fingers and does not significantly affect the function of flexion.

  In zone 3, the flexor tendons of neighboring fingers are separated by neurovascular bundles and worm-like muscles. Therefore, tendon injuries in this area are often accompanied by damage to these structures. After the suture of the tendon, the suture of the digital nerves is necessary.

  Within zone 4, the flexor tendons are located in the carpal tunnel along with the median nerve, which is located superficially. Tendon injuries in this area are quite rare and are almost always associated with damage to the median nerve. The operation involves the dissection of the transverse ligament of the wrist, the suture of the tendons of the deep flexors of the fingers, the tendons of the superficial flexors are excised.

  During the 5th zone synovial sheaths end, the tendons of neighboring fingers pass close to each other and, when the hand is clenched into a fist, they move together. Therefore, cicatricial fusion of tendons with each other practically does not affect the volume of flexion of the fingers. The results of the tendon suture in this area are usually good.

  Postoperative management.

  The finger is immobilized with a dorsal plaster splint for 3 weeks. From the second week after the edema subsides and the pain syndrome in the wound decreases, passive flexion of the finger is performed. After removing the plaster splint, active movements begin.

  Injuries of the extensor tendons of the fingers

  Anatomy.

  In the formation of the extensor apparatus, the tendon of the common extensor of the finger and the tendons of the interosseous and vermiform muscles, connected by many lateral ligaments, form a tendon-aponeurotic stretching

  Extensors of fingers and hands.

  It must be remembered that the index finger and little finger, in addition to the common one, also have their own extensor tendon. The middle bundles of the extensor tendon of the fingers are attached to the base of the middle phalanx, unbending it, and the lateral bundles are connected to the tendons of the small muscles of the hand, attached to the base of the nail phalanx and perform the function of extending the latter. The extensor aponeurosis at the level of the metacarpophalangeal and proximal interphalangeal joints forms a fibrocartilaginous disc similar to the patella. The function of the small muscles of the hand depends on the stabilization of the main phalanx by the extensor of the finger. When the main phalanx is bent, they act as flexors, and when extended, together with the extensor of the fingers, they become extensors of the distal and middle phalanges.

  Thus, the perfect extensor-flexion function of the finger can be said only with the integrity of all anatomical structures. The presence of such a complex interconnectedness of the elements to some extent favors the spontaneous healing of partial injuries of the extensor apparatus. In addition, the presence of lateral ligaments of the extensor surface of the finger prevents the tendon from contracting when injured.

  Diagnostics.

  The characteristic position that the finger takes depending on the level of damage allows a quick diagnosis.

  Diagnosis of damage to the

  extensor tendons at the level of the distal phalanx, the finger assumes a flexion position in the distal interphalangeal joint. This deformity is called the mallet finger. In most cases of fresh injuries, conservative treatment is effective. To do this, the finger must be fixed in a position overextended at the distal interphalangeal joint using a special splint. The amount of hyperextension depends on the level of mobility of the patient’s joints and should not cause discomfort. The remaining joints of the finger and hand must be left free. The term of immobilization leaves 6-8 weeks. However, the use of tires requires constant monitoring of the position of the finger, the state of the elements of the splint, as well as the patient’s understanding of the task facing him, therefore, in some cases, transarticular fixation of the nail phalanx with a wire is possible for the same period. Surgical treatment is indicated when the tendon is torn from its attachment site with a significant bone fragment. In this case, a transosseous suture of the extensor tendon is performed with fixation of the bone fragment.

  When the extensor tendons are damaged at the level of the middle phalanx, the triangular ligament is simultaneously damaged, and the lateral tendon bundles diverge in the palmar direction. Thus, they do not unbend, but bend the middle phalanx. In this case, the head of the main phalanx moves forward through a gap in the extensor apparatus, like a button passing through a loop. The finger assumes a position bent at the proximal interphalangeal joint and overbent at the distal interphalangeal joint. This deformation is called “boutonniere”. With this type of injury, surgical treatment is necessary – stitching together the damaged elements, followed by immobilization for 6-8 weeks.

  Treatment of injuries at the level of the proximal phalanx, metacarpophalangeal joints, metacarpus and wrist only surgically – primary suture of the tendon, followed by immobilization of the hand in the extension position in the radiocarpal and metacarpophalangeal joints and slight flexion in the interphalangeal joints for a period of 4 weeks, followed by movement development .

  Damage to the nerves of the hand

  The innervation of the hand is provided by three main nerves – median, ulnar and radial. In most cases, the main sensory nerve of the hand is the median, and the main motor nerve is the ulnar, which innervates the muscles of the little finger elevation, interosseous, 3 and 4 worm-like muscles and the adductor thumb muscle. Of great clinical importance is the motor branch of the median nerve, which departs from its lateral cutaneous branch immediately after exiting the carpal tunnel. This branch innervates the short flexor of the 1st finger, as well as the short abductor and opposing muscles of Many. the muscles of the hand have a double innervation, which retains, to one degree or another, the function of these muscles when one of the nerve trunks is damaged. The superficial branch of the radial nerve is the least significant, providing sensation on the dorsum of the hand. If both digital nerves are damaged due to loss of sensitivity, the patient cannot use his fingers, their atrophy occurs.

  Diagnosis of nerve damage should be made before surgery, as this is not possible after anesthesia.

  The suturing of the nerves of the hand requires the use of microsurgical techniques and adequate suture material (suture 6\0-8\0). In the case of fresh injuries, the soft and bone tissues are treated first, after which the suture of the nerve is started

  Epineural suture of the nerve

  The limb is fixed in a position that ensures the least tension of the suture line for 3-4 weeks.