[An unusual case: fracture of the handle of the malleus due to finger manipulation]. / Ein ungewöhnlicher Fall: Fraktur des Hammergriffs durch Fingermanipulation.

An isolated fracture of the handle of the malleus is a rare entity in otorhinolaryngology and manifests clinically as acute-onset unilateral hearing loss. Several factors may cause this injury, including acute barotraumatic pressure changes or traumatic events. Various therapeutic approaches such as tympanoplasty, autologous graft, or application of bone cement are discussed. We report the case of a 46-year-old female patient who developed acute hearing loss in her left ear after finger manipulation. Clinical evaluation revealed axial displacement of the handle of the malleus and audiometry indicated conductive hearing loss. After otoscopy, audiometry, and computed tomography, tympanoscopy was indicated due to suspicion of ossicular chain disruption. Intraoperatively, an isolated fracture of the handle of malleus was found, which was treated with glass ionomer cement. Following postoperative examination, there was progressive improvement in the acoustic transmission component, such that a normal hearing threshold was observed 4 months postoperatively. This case report underlines the importance of precise diagnosis and individualized treatment for rare middle ear injuries.

[Finger injuries in athletes]. / Lésions des doigts chez le sportif.

Hand injuries in sportives are becoming increasingly common, accounting for approximately 25% of all sports-related injuries. The recent growing popularity for sports such as climbing, which even became an Olympic discipline in 2022, is increasing hand and finger injuries in the active population. Some sports are more prone to typical hand and finger injuries. These injuries need to be treated quickly and correctly, to enable the athlete to receive optimal treatment followed by appropriate rehabilitation, in order to return to his or her sport in the best possible conditions. We have chosen to highlight five of these specific pathologies to help general practitioners and sports physicians to make an accurate diagnosis and manage or refer these injuries as best as possible.

Les pathologies de la main chez le sportif sont de plus en plus courantes, représentant 25 % de toutes les blessures sportives. L'engouement récent pour des sports tels que l'escalade, devenue même discipline olympique depuis 2022, accroît les blessures à la main et aux doigts dans la population active. Certains sports exposent davantage à des blessures typiques de la main et des doigts. La prise en charge de ces lésions doit se faire rapidement et correctement afin de permettre à l'athlète un traitement optimal suivi d'une rééducation adaptée et un retour au sport dans les meilleures conditions. Nous avons choisi de mettre en lumière cinq de ces pathologies spécifiques afin d'aider les médecins généralistes et du sport à poser un diagnostic précis et prendre en charge ou orienter correctement ces blessures.

[Nail and fingertip injuries: a practical guide for general practitioners]. / Traumatismes de l'ongle et de l'extrémité digitale : guide pratique pour le médecin de premier recours.

Nail and fingertip injuries account for approximately 15 to 24% of hand injuries and are particularly frequent among young and active patients. Despite their prevalence they are often overlooked and considered as cosmetology. However, the nail unit involves complex anatomical structures that help to improve the sensitivity and fine motor skills of the fingers and protect the distal phalanx. If not treated correctly, these injuries can generate significant functional impairments. This article aims to present the most frequently encountered traumas, their anatomical and physiological involvement, and their management in the standard practice of the general practitioner.

Les traumatismes unguéaux et de l'extrémité des doigts représentent 15 à 24 % des lésions de la main et sont particulièrement fréquents chez les jeunes patients actifs. Malgré leur prévalence, ils sont souvent négligés et considérés comme de la cosmétologie. Or l'ongle et la partie distale du doigt comportent des structures anatomiques complexes qui participent à améliorer la sensibilité, la motricité fine et à protéger les phalanges distales. Les traumatismes de ces structures, s'ils ne sont pas pris en charge correctement, peuvent engendrer des séquelles fonctionnelles importantes. Cet article a pour but de présenter les traumatismes les plus fréquemment rencontrés, leur implication anatomique et physiologique ainsi que leur prise en charge dans la pratique courante de médecine de premier recours.

Common Finger Fractures and Dislocations.

Finger fractures and dislocations are commonly seen in the primary care setting. Patients typically present with a deformity, swelling, and bruising with loss of function. Anteroposterior, lateral, and oblique radiography should be performed to identify fractures and distinguish uncomplicated injuries from those requiring referral. Uncomplicated distal phalanx fractures, caused by a crush injury to the end of the finger, require splinting of the distal interphalangeal joint for four to six weeks. Uncomplicated dorsal avulsion fractures (mallet finger) of the distal interphalangeal joint, caused by forced flexion against resistance, require strict splint immobilization for eight weeks. Flexor digitorum profundus fractures are caused by forceful extension of the distal interphalangeal joint when in a flexed position, resulting in an avulsion fracture at the volar base of the distal phalanx, and usually require surgery. Uncomplicated middle and proximal phalanx fractures, typically caused by a direct blow, can be treated with buddy splinting if there is minimal angulation (less than 10 degrees); however, larger angulations, displacement, and malrotation often require reduction or surgery. Dorsal proximal interphalangeal joint dislocations require reduction and buddy splinting in slight flexion with an extension-block splint. Volar proximal interphalangeal joint dislocations require reduction and splinting in full extension for four to six weeks. Distal interphalangeal joint dislocations require reduction and splinting in full extension (for volar dislocations) or 15 to 30 degrees of flexion (for dorsal dislocations) for two to three weeks. Dorsal metacarpophalangeal joint dislocations are managed with reduction and splitting, but referral to an orthopedic specialist is required if the dislocation is not easily reduced. Volar metacarpophalangeal dislocations are rare and warrant referral.

Primary Periphyseal Stress Injuries of the Fingers in Adolescent Climbers: A Critical Review.

ABSTRACT: The worldwide rise in popularity of climbing and development of climbing as a competitive sport is reflected by its debut at the 2021 Summer Olympic Games in Tokyo. Digital primary periphyseal stress injuries in adolescent climbers may pose a significant risk to long-term skeletal health. The aim of this article is to critically review research on the diagnosis and management of primary periphyseal stress injuries of the fingers in adolescent climbers. We adopted a systematic approach to searching for relevant literature. Articles were identified after searches of the following electronic databases: Discover, Academic Search Complete, PubMed, Embase, SPORTDiscus, and ScienceDirect. Conclusive evidence suggests digital primary periphyseal stress injuries are a consequence of repetitive microtrauma. Pain reported by adolescent climbers on the dorsal aspect of the proximal interphalangeal joint should be investigated promptly to avoid serious negative consequences. Clinicians should be aware of the efficacy of imaging techniques to inform a clinical diagnosis. A conservative management approach is preferred but in rare cases surgical intervention may be necessary. A diagnostic and therapeutic algorithm for digital primary periphyseal stress injuries is presented.

Delayed Presentation of a Flexor Digitorum Profundus Avulsion Injury: A Case Report.

Avulsion of the flexor digitorum profundus (FDP) tendon is a relatively common injury in athletes. Also known as "jersey finger," it can also occur in nonathletes, and is often not initially diagnosed. Early diagnosis and repair are essential to regaining optimum return of function. We report a case of a 37-year-old woman who was seen six weeks following an undiagnosed FDP avulsion injury. Due to finger stiffness and the delayed diagnosis, she was treated with occupational therapy to maximize finger range of motion. The anatomy, classification, diagnosis, and treatment options for FDP avulsion injuries are discussed. The goal of this paper is to increase awareness for this injury, resulting in early diagnosis and prompt treatment.

Proximal Interphalangeal Hyperextension Injuries in Children: The Development of a Clinical Decision Guide.

OBJECTIVE: To develop a clinical decision guide for the diagnosis and treatment of hyperextension injuries of long fingers. STUDY DESIGN: Consecutive patients age <16 years (n = 300) with an acute proximal interphalangeal (PIP) joint hyperextension injury were included. High-risk and low-risk measures for severe injury were established with a standardized clinical examination and anteroposterior and lateral radiographs of the injured finger. Four clinical variables were assessed: location of pain; swelling and bruising, stability, and mobility. Pathological radiographic findings were compiled, and the risk of late complications was analyzed. The predictive value of the clinical examination in the identification of low-risk injuries was assessed. RESULTS: The majority (67%) of children consulting for a hyperextension finger trauma did not have a fracture. No child with a low-risk clinical examination had a subsequent high-risk diagnosis (eg, relevant intra-articular fracture, dislocation). Among 64 clinical high-risk diagnoses only 12 significant fractures were found. CONCLUSION: Treatment decisions after PIP hyperextension injuries can be based on a clinical examination using a standardized evaluation protocol. Application of the clinical decision guide presented here has a sensitivity of 100% to rule out a significant injury. Present results showed that the majority of radiographs currently performed are avoidable. Once the decision rule is validated, its clinical application will improve patient care, reduce waiting times in emergency departments, avoid unnecessary radiation exposure, and possibly reduce costs.

Olympic competition climbing: the beginning of a new era-a narrative review.

Climbing as a competition sport has become increasingly popular in recent years, particularly the sub-discipline of bouldering. The sport will debut in the Tokyo Summer Olympic Games. National and international competitions have three disciplines: lead (climbing with rope protection), bouldering (climbing at lower heights with mattress floor protection) and speed (maximum speed climbing on a standardised route in 1-on-1 mode). There is also a 'combined mode' of all three disciplines (combined) which forms the Olympic competition format; all competition formats are held on artificial walls. Existing literature describes a predominantly low injury frequency and severity in elite climbing. In comparison to climbing on real rock, artificial climbing walls have recently been associated with higher injury rates. Finger injuries such as tenosynovitis, pulley lesions and growth plate injuries are the most common injuries. As finger injuries are sport-specific, medical supervision of climbing athletes requires specific medical knowledge for diagnosis and treatment. There is so far little evidence on effective injury prevention measures in top athletes, and antidoping measures, in general, requiring further work in this field. An improved data situation regarding high-performance climbing athletes is crucial to ensure that the sport continues to be largely safe and injury-free and to prevent doping cases as extensively as possible.

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

BACKGROUND: Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. METHODS: Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. RESULTS: Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. CONCLUSIONS: Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Finger Flexor Pulley Injuries in Rock Climbers.

Finger flexor pulley system injuries are the most common overuse injury in rock climbers. These injuries occur rarely outside of rock climbing, owing to the sport's unique biomechanical demands on the finger. As rock climbing continues to grow and earn recognition as a mainstream sport, an understanding of how to diagnose and treat these injuries also has become important. Our purpose is to describe current concepts in anatomy, biomechanics, clinical evaluation, imaging, prevention, and treatment strategies relating to finger flexor pulley system injuries. Our literature search was performed on PubMed with MeSH terms and keywords as subject headings to meet the objectives of this review. The "crimp grip" used in rock climbing is the mechanism for these injuries. The A2, A3, and A4 pulleys are at the highest risk of injury, especially when loaded eccentrically. Physical examination may reveal clinical "bowstringing," defined as the volar displacement of the flexor tendons from the phalanges; however, imaging is required for characterization of the underlying injury. Ultrasound is highly sensitive and specific for diagnosis and is recommended as the initial imaging technique of choice. Magnetic resonance imaging is recommended as an additional imaging study if ultrasound is inconclusive. Properly warming up increases the amount of physiologic bowstringing and is thought to prevent injury from occurring. Pulley injuries may be classified as grade I through IV. Conservative treatment, including immobilization, the H-tape method, and the use of a protective pulley splint, is recommended for grade I to III injuries. Surgical repair is reserved for grade IV injuries that are not amenable to conservative treatment.

[Extensor tendon injuries at the level of the proximal interphalangeal joint]. / Strecksehnenverletzungen in Höhe des Mittelgelenks.

Closed and open injuries of the extensor mechanism at the proximal interphalangeal (PIP) joint can involve the central slip, the lateral slips or both. They are classified as zone III injuries. All open injuries on the dorsal side of the PIP joint should raise suspicion of an extensor tendon injury that is frequently overlooked. The operative strategy consists of wound revision with extensor tendon suture or refixation of the central slip. Acute closed central slip injuries are clinically diagnosed (Elson test) after ruling out bony injuries to the joint. Nondisplaced avulsions of the central slip insertion or lacerations can be treated nonoperatively by splinting. For displaced avulsions and complex injuries the treatment is surgical. In overlooked injuries a typical deformity (buttonhole/Boutonnière deformity) develops within 1-2 weeks that is characterized by an extension lag of the PIP joint and hyperextension at the distal interphalangeal joint. In early cases, when passive extension is still complete (mobile buttonhole deformity) the central slip can be immediately reconstructed. In fixed deformities complete passive extension of the PIP joint has to be restored before surgery by hand therapeutic measures or PIP joint release. Depending on the pattern of the injury and the resulting defects, a number of reconstructive techniques have been established that are summarized in this article. The functional results can be limited by tendon adhesions, imbalance within the reconstructed extensor apparatus and stiff joints that can all restrict the range of motion. Therefore, active rehabilitation protocols are mandatory for optimal results.

[Extensor tendon injuries of fingers in the region of the metacarpophalangeal joint (zone V)]. / Strecksehnenverletzungen der Finger im Bereich der Grundgelenke (Zone V).

Due to the exposed situation of the extension side of the metacarpophalangeal joint when the fingers are bent, injuries in this region are not uncommon. The extensor apparatus lies directly below the skin and the various parts can be easily injured. Due to the complex anatomical structure, the different clinical appearances and the various forms of treatment, injuries of the extensor tendons in the region of the metacarpophalangeal joint must be examined in a very differentiated manner. The not uncommonly occurring deviation phenomenon makes all injuries in zone V suspicious and special attention must be paid to them. The alarming multitude of revision surgeries with tenolysis, arthrolysis and restoration of the balance of extensor tendons or centering show that these operations are much more demanding than the way they are appreciated in the literature and by many surgeons (beginner's operation). The article presents the surgical treatment with suture techniques and reconstruction possibilities as well as the aftercare, in addition to the special anatomy and diagnostics.

The Utility of Diagnostic Tests for Digital Nerve Injury.

PURPOSE: The purpose of this study was to present the sensitivity and specificity of 6 clinical tests for the diagnosis of digital nerve injury. The clinical tests are as follows: light touch, pinprick, static and dynamic 2-point discrimination (D2PD), Semmes-Weinstein monofilament, and wrinkle test. METHODS: We reviewed the charts of all the patients who were admitted to our department with hand lacerations and/or suspicions of digital nerve injury that were examined before surgery with the 6-sensation test, comparing the results to the surgical findings. RESULTS: The study included 70 patients with 85 injured nerves overall. Of the 85 nerves, 51 were found with full cut, 9 with partial cut, and 25 with no cut. Only 2 variables were significantly associated with the study outcome: D2PD > 4 (P = 0.0141, odds ratio = 3.9, 95% confidence interval = 1.3-11.8, sensitivity = 80.7%, specificity = 48%) and wrinkle test (P = 0.0098, odds ratio = 4.0, 95% confidence interval = 1.4-11.6, sensitivity = 69.5%, specificity = 62.5%).Multivariable logistic regression included these variables and revealed the predictive probability for a nerve injury to be 92% if both risk factors exist and 43% if none of these risk factors exist. If one risk factor exists, the predictive probability for a cut is still very high (75%). CONCLUSIONS: The combination of positive wrinkle test and D2PD > 4 gave a predictive probability for a nerve injury as 92% in the cases in our study and should be considered in the evaluation of patients with hand lacerations and suspicions of digital nerve injury.

Closed Digital Artery Injury in Children: A Case Report and Review of the Literature.

Closed digital artery injury is a very rare phenomenon, even more so in children, with only 5 cases reported in the literature. We report a case of closed digital arterial interruption in a child after crush injury to the left hand. We further discuss possible etiologies and describe adequate management as found in the pertinent literature. Digital arterial injury should be suspected even in closed hand trauma because a delay in recognition may lead to devastating consequences.

[Treatment of acute injuries of the hand]. / Tipps und Tricks in der Behandlung offener Handverletzungen in der Notfallpraxis.

Treatment of acute injuries of the hand Abstract. Injuries to the hand are a common presentation in primary care units. When accurately assessed, many open injuries may be handled in the emergency department without referral to a hand surgery specialist. We would like to give some recommendations on how to treat the most frequent injuries like lesions to the nail and nailbed, fingertip amputation as well as burns, infections and bites. But first, we highlight the different methods of local anesthesia and discuss the use of a tourniquet or vasoconstriction with adrenalin - WALANT - instead.

A Test for the Clinical Evaluation of the Flexor Digitorum Superficialis of the Fifth Finger.

Physical examination is essential in diagnosing tendinous lesions. This is particularly true of the flexor digitorum superficialis of the little finger (FDS5), which is functionally absent in approximately 30% of the population. The objective of our study was to determine the diagnostic value of 3 clinical tests commonly used to assess the function of this tendon. METHODS: Patients with wounds of the FDS5 were included in this study. Under local or regional anesthesia, 3 described clinical tests were performed to assess the function of the FDS5: (i) the classic test; (ii) Stein's modified test, and (iii) Mecott's modified test. We determined sensitivity, specificity, and predictive values of all such tests. The integrity of the tendon was assessed surgically. Correlation among blinded observers was also established. RESULTS: A total of 28 subjects with a mean age of 28 years (ranging from 5 to 56) participated in this study. The classic test obtained a sensitivity of 100% and a specificity of 72%; Stein's test resulted in a sensitivity of 83% and a specificity of 95%, whereas Mecott's test reached a sensitivity of 100% and a specificity of 95%. CONCLUSIONS: Among the 3 tests described and used in our study, Mecott's modified test proved to be more sensitive and specific than the other two; therefore, we consider this to be the test that should be used in determining the integrity of the FDS5.

A New Surgical Method to Reconstruct the Fingertip.

BACKGROUND: In our previous study, we used cross finger fascial flap combined with split-thickness toe nail bed graft to reconstruct large area defect of the nail bed with distal phalanx exposure. Fingertip avulsions are common injuries to the upper extremity and cause a great deal of distress for patients. Replantation, amputation and flap coverage are considered. However, all these methods have their limitations. METHODS: Five patients with fingertip avulsions were enrolled. We used the methods mentioned above combined with the reversed pedicled island flap to covered the defects of both the dorsal and volar sides and reconstruct the fingertip. RESULTS: All the 5 patients were followed for at least 3 months. The blood supply of the flaps and nail bed is good. All the patients were satisfied with their new fingertips. CONCLUSIONS: The method we introduced in this study is proved to be an effective surgical method for fingertip avulsions.

Distal Finger Reconstruction by Bilateral Lateral Hallux Osteo-onychocutaneous Free Flap.

OBJECTIVE: In this report, we present our experience on the use of bilateral lateral hallux osteo-onychocutaneous free flaps for reconstruction of distal finger and the aesthetic and functional results of this technique in a series of cases. PATIENTS AND METHODS: From February 2005 to May 2015, 7 patients underwent finger reconstruction distal to the distal interphalangeal joint using the bilateral lateral hallux osteo-onychocutaneous free flaps. The mean age was 29.3 years (range, 24-33 years). The lateral hallux osteo-onychocutaneous flaps were harvested from bilateral donor sites. The size of each flap was designed based on the size of half distal finger defect. The lateral hallux osteo-onychocutaneous free flaps from both donor sites were combined to reconstruct the distal finger. More than 50% of hallux nail was preserved in each of donor sites, which was covered with a local flap. RESULTS: All flaps used for reconstruction survived without complications after surgery. The average length of follow-up was 93.4 months (range, 16-163 months). All reconstructed distal fingers showed good aesthetic appearance, except one that underwent a secondary debulking procedure. The average total active motion of the finger was 215.7 degrees (range, 200-230 degrees). Neither pain nor numbness sensation in the reconstructed fingers was complained by the patients. The donor site morbidity was minimal. All patients had pain-free and good function outcome in both feet. CONCLUSIONS: The use of the bilateral lateral hallux osteo-onychocutaneous free flaps may provide an option for distal finger reconstruction with satisfactory function and anesthetic outcomes with minimal hallux donor site morbidity.

Anatomical and Clinical Comparison of Small Free Flaps for Repairing Finger Skin Defects.

The reconstruction of finger defects requires improved functional outcomes and acceptable esthetic outcomes, and small free flaps present a good alternative technique for repairing finger skin defects. From January 2006 to December 2018, we investigated the number and diameter of proximal digital artery perforators, medial plantar artery perforators, and peroneal proper plantar digital arteries of the hallux by dissection and then transplanted free digital arterial perforator flaps, free medial plantar flaps, and free peroneal flaps from the hallux to repair small finger skin defects. The number (SD) of perforators from the medial plantar artery was approximately 2.2 (0.5), and these perforators measured 0.53 (0.20) mm in diameter. The diameter (SD) of the first metatarsal dorsal artery was approximately 1.16 (0.30) mm. A total of 25 patients were included in this study. The transplantation times (SD) for free digital arterial perforator flaps, free medial plantar flaps, and free peroneal flaps from the hallux were 3.5 (0.5) hours, 3.2 (0.7) hours, and 2.0 (0.4) hours, respectively. The follow-up period ranged from 8 to 15 months. All flaps survived and were appropriately shaped. The donor site was either covered with a free flap or directly sutured. Among these 3 types of small flaps, the free peroneal flap from the hallux can be recommended for clinical use because of the large diameter of the contributing vessels, the short operative time, the ease of access, and the improved appearance of the donor site.

A Comparative Study of Finger Pulp Reconstruction Using Free Distal Ulnar Artery Perforator Flaps and Reverse Dorsal Homodigital Island Flaps.

PURPOSE: This study aimed to compare and analyze the outcomes of finger reconstruction using free distal ulnar artery perforator (FDUAP) and reverse dorsal homodigital island (RDHI) flaps. METHODS: The study included 27 patients with finger pulp defects that were reconstructed using FDUAP or RDHI flaps. Standardized assessment of outcomes included objective sensory recovery, duration of operation, range of motion in the repaired fingers, pain at the reconstructed finger pulps and donor sites, and recovery time before returning to work. Subjective assessment of outcomes included the cold intolerance, aesthetic appearance, and functional recovery. RESULTS: All flaps in the series showed complete survival. The average surgical time for the RDHI flaps was significantly smaller than that for the FDUAP flaps. Sensory recovery was significantly better with FDUAP flaps than with RAHI flaps. No significant differences were detected between the 2 procedures regarding range of motion, cold intolerance, or pain of the injured finger pulps and donor sites. The outcomes of aesthetic result and functional recovery satisfied all patients. Optimal cosmetic satisfaction was obtained in the FDUAP flap group. CONCLUSIONS: Although both types of flaps offer a satisfactory approach for finger reconstruction with small-to-medium defects, FDUAP flaps are more suitable for such operations because of the better sensory reconstruction and aesthetic results.