Diagnosis and treatment of flexor tendon injuries of the hand: what the radiologist needs to know.

This article reviews the diagnosis and treatment of flexor tendon injuries of the hand highlighting flexor tendon anatomy, important pre-operative imaging findings, surgical options, and post-operative complications. Imaging plays a key role in guiding treatment of these difficult to manage injuries. Thus, it is important for radiologists to have a sound understanding of factors important in treatment decision-making. In the pre-operative setting, accurately identifying the location of the torn proximal tendon stump in subacute and chronic injuries helps dictate whether the patient is a candidate for a primary flexor tendon repair or may require a tendon reconstruction to restore function. In the post-operative setting, the status of the repair and presence of surrounding adhesions help dictate if and when the patient will require subsequent surgery and whether that surgery will be a tenolysis, revision repair, reconstruction, or fusion.

Quick and safe: why a k-wire-extension-block-fixation of a bony mallet finger is the favoured treatment.

INTRODUCTION: Mallet fingers are the most common tendon injuries of the hand. Bony avulsion distal finger extensor tendon ruptures causing a mallet finger require special attention and management. In this monocentral study, we analyzed the clinical and individual outcomes succeeding minimal invasive k-wire extension block treatment of bony mallet fingers. MATERIALS AND METHODS: In a retrospective study, we sent a self-designed template and a QUICK-DASH score questionnaire to all patients, who were treated because of a bony mallet finger between 2009 and 2022 and fulfilled the inclusion criteria. A total of 244 requests were sent out. 72 (29.5%) patients participated in the study. Forty-five men and twenty-seven women were included. RESULTS: 98.7% (n = 75) of the cases were successfully treated. Patients were highly satisfied with the treatment (median 8.0; SD ± 2.9; range 1.0-10.0). Based on the QUICK-DASH score, all patients showed no difficulties in daily life. The extent of avulsion did not influence the outcome. CONCLUSION: We conclude that the minimally invasive treatment of a bony mallet finger should be offered to every patient, because it is safe, fast, and reliable. Thus, we propose to perform extension-block pinning independently of the articular area.

Phalangeal Fractures and Fingertip Injuries.

A comprehensive analysis of the assessment, diagnosis, and management of phalangeal fractures and fingertip injuries should emphasize the importance of achieving the right balance between undertreatment and overtreatment. Phalangeal injuries are complex, requiring an in-depth understanding of hand anatomy, fracture patterns, and treatment options to optimize patient outcomes. A thorough examination of proximal and middle phalangeal fractures and fingertip injuries, including those to the nail bed and distal phalanx, is important. A systematic approach to addressing the most prevalent injuries in this category should be implemented while highlighting the need for patient-specific approaches to treatment and a multidisciplinary perspective to ensure the best possible outcomes for patients.

Proximal Interphalangeal Joint Fractures.

Multiple fracture patterns can occur around the proximal interphalangeal joint and require surgeons to have a thorough understanding of the anatomy, clinical and radiographic examination, common fracture patterns, surgical and nonsurgical treatment options, and potential complications. Proximal phalangeal condylar fractures are typically managed surgically, because even nondisplaced fractures have a propensity for displacement. Middle phalangeal base fractures most commonly present as a volar lip fracture with or without dorsal subluxation or dislocation. Treatment options include extension block splinting or pinning, transarticular pinning, open reduction and internal fixation, external fixation, volar plate arthroplasty, and hemihamate arthroplasty. Less common fractures include dorsal lip fractures with or without volar subluxation or dislocation (the central slip fracture), lateral plateau impaction or avulsion injuries, and pilon fractures. The main goals in the management of middle phalangeal base fractures are to restore articular congruency and initial early range of motion, which are more important than obtaining an anatomic reduction.

[Sport Injuries to Wrist and Fingers].

INTRODUCTION: About one fifth of all sports accidents involve the hand. Many injuries can be diagnosed and treated easily. However, some of them such as fractures of the scaphoid or the hamate of the hamulus are difficult to detect with conventional radiographs and are often missed without a CT scan. Ligament injuries such as the skier's thumb must be recognized and treated properly, often surgically. There are also sport-specific injuries, such as the closed rupture of a flexor tendon pulley in climbers, which otherwise occur rarely and are little known. These topics, pitfalls and tricks will be discussed.

Direct fixation of fracture fragment with modified double Kirschner wires for the treatment of old bony mallet finger.

BACKGROUND: The management of old bony mallet fingers is complicated. The purpose of this study was to describe direct fixation of fracture fragment with modified double Kirschner wires (K-wires) for treatment of old bony mallet finger, and to evaluate the functional outcomes during long-term follow-up. METHODS: Forty-nine patients with old bony mallet finger were enrolled and underwent surgical treatment from August 2014 to January 2021 in our hospital. Patients were divided into two groups according to whether they had undergone triple K-wires fixation or modified double K-wires with a dorsal brace fixation. The operation time, mean number of intraoperative fluoroscopy, bone union time, functional recovery and incidence of complications were monitored. RESULTS: Neither QuickDASH nor visual analogue scale measurement found statistically significant difference between the two groups (P > 0.05). However, the patients that underwent fixation with double K-wires and a dorsal brace required a shorter operation time and fewer intraoperative fluoroscopy, and exhibited a significantly greater mean final active range of the distal interphalangeal joint flexion, compared to those treated with triple K-wires (P < 0.01). CONCLUSION: Direct fixation of fracture fragment with modified double K-wires was an easy and feasible procedure which could achieve anatomical reduction and stable fixation of the dorsal fracture block of old bony mallet finger with relatively few complications.

Stress Fractures of the Distal Phalanx in Skeletally Immature Sport Climbers.

Stress fractures in the distal phalanx of skeletally immature patients are rare and previously unreported clinical occurrences. We report on 2 adolescent sport climbers with such fractures of the dorsal metaphysis of the distal phalanx at the point where parts of the extensor tendon insert. A conservative treatment approach alone was sufficient in healing this fracture type in both patients after 12 wk. Clinicians should be informed of the existence of this rare clinical phenomenon and counsel patients that a conservative treatment approach may result in complete healing without the need for an invasive procedure.

Palmar Shift of the Proximal Interphalangeal Joint in Different Grip Positions as a Potential Risk Factor for Periphyseal Injuries in Adolescent Climbers.

INTRODUCTION: The aim of this study was to evaluate different grip positions as a contributing factor for primary periphyseal stress injuries of the finger phalanges in climbing. METHODS: Ultrasound imaging of the proximal interphalangeal joint was performed on 37 asymptomatic adolescent climbers. Longitudinal images were obtained of middle and ring fingers of both hands in different grip positions (open, half-open, and crimp), unloaded and loaded. The translation between the dorsal head of the proximal phalanx and the shaft of the middle phalanx was measured in an unloaded and loaded situation for all grip positions. The resulting difference was determined as the palmar shift. RESULTS: The mean age of the study population was 13 y. Results showed a palmar shift of 0.57 mm in a loaded crimp grip position compared to 0.13 mm in an open position and 0.20 mm in a half-open grip position. With a P value of <0.001, this shift was significantly higher in a crimp grip position compared to open or half-open grip positions. CONCLUSIONS: This leads to an increase in joint incongruity and much higher peak forces on the dorsal aspect of the epiphyseal-physeal-metaphyseal complex, which is particularly vulnerable during the adolescent growth spurt. Thus, climbing and training behavior should be adapted accordingly during this phase by avoiding the crimp grip position until epiphyseal fusion.

Jersey finger type IV: a case report.

Avulsion of the flexor digitorum profundus, usually known as jersey or rugby finger, is a rare condition that can only be treated surgically. It is mostly reported in sports injuries, in which the diagnosis is easily made. It is less frequent in household accidents, but should not be ignored because good results are time-dependent. Type IV jersey finger is the combination a fracture of the volar base of the distal phalanx and avulsion of the flexor digitorum profundus. This is a rare variety, and the surgical approach has not been discussed in detail. We introduce here a case report describing the clinical aspect, diagnostic approach, surgical technique and results at 6 months.

Posttraumatic Osteoarthritis of the Distal Interphalangeal Joint: A Follow-Up Study of 12 Years After Nonsurgical Treatment of Mallet Finger Fractures.

PURPOSE: In treatment of mallet finger fractures (MFFs), the aim is to minimize residual extension lag, reduce subluxation, and restore congruency of the distal interphalangeal (DIP) joint. Failure to do so may increase the risk of secondary osteoarthritis (OA). However, long-term follow-up studies focusing on OA of the DIP joint after an MFF are scarce. The purpose of this study was to assess OA, functional outcomes, and patient-reported outcome measures (PROMs) after an MFF. METHODS: A cohort study was performed with 52 patients who sustained an MFF at a mean of 12.1 years (range, 9.9-15.5 years) previously and who were treated nonsurgically. A healthy contralateral DIP joint was used as the control. Outcomes were radiographic OA, using the Kellgren and Lawrence and Osteoarthritis Research Society International classifications, range of motion, pinch strength, and PROMs (Patient-Rated Wrist Hand Evaluation, Quick Disabilities of the Arm, Shoulder, and Hand, Michigan Hand Outcome Questionnaire, 12-item Short Form Health Survey). Radiographic OA was correlated with PROMs and functional outcomes. RESULTS: At follow-up, there was an increase in OA in 41% to 44% of the MFFs. Of all the MFFs, 23% to 25% showed a higher degree of OA than the healthy control DIP joint. Range of motion (mean difference ranging from -6° to -14°) and Michigan Hand Outcome Questionnaire score (median difference, -1.3) were decreased after MFFs but not to a clinically relevant extent. Radiographic OA was weakly to moderately correlated with functional outcomes and PROMs. CONCLUSIONS: Radiological OA after an MFF is similar to the natural degenerative process in the DIP joint and is accompanied by a decrease in range of motion of the DIP joint, which does not clinically affect PROMs. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Closed Traumatic Zone 2 Flexor Tendon Injury of the Long Finger - A Case Report.

Closed rupture of the flexor digitorum profundus (FDP) tendon causes loss of flexion at the distal interphalangeal joint. Following trauma, these are known to present as avulsion fractures (Jersey finger) commonly in ring fingers. Traumatic tendon ruptures at the other flexor zones are seldom noted and are often missed. In this report, we present a rare case of closed traumatic tendon rupture of the long finger FDP at zone 2. Though it was missed initially, was confirmed with Magnetic Resonance Imaging and underwent successful reconstruction using an ipsilateral palmaris longus graft. Level of Evidence: Level V (Therapeutic).

Open Reduction and Internal Fixation of Dorsal Fracture-Dislocation of the Proximal Interphalangeal Joint Using a Plate: A Series of 37 Patients.

Background: Open reduction and internal fixation with a plate is one of the alternative treatments for fracture-dislocation of the proximal interphalangeal (PIP) joint. However, it does not always lead to satisfactory results. The aim of this cohort study is to describe the surgical procedure and discuss the factors affecting the treatment results. Methods: We retrospectively reviewed 37 cases of consecutive unstable dorsal fracture-dislocation of the PIP joint treated using a mini-plate. The volar fragments were sandwiched with a plate and dorsal cortex, and screws were used as subchondral support. The average rate of articular involvement was 55.5%. Five patients had concomitant injuries. The mean age of the patients was 40.6 years. Mean time between injury and operation was 11.1 days. The average postoperative follow-up duration was 11 months. Active ranges of motion, % total active motion (TAM) were evaluated postoperatively. The patients were divided into two groups according from Strickland score and Gaine score. Fisher's exact test, Mann-Whitney U test and a logistic regression analysis were used to evaluate the factors affecting the results. Results: The average active flexion, flexion contracture at the PIP joint, and % TAM were 86.3°, 10.5° and 80.6%, respectively. Group I included 24 patients who had both excellent and good scores. Group II included 13 patients who had neither excellent nor good scores. When the groups were compared, there was no significant relationship between the type of fracture-dislocation and the extent of articular involvement. There were significant associations between outcomes and patient age, period from injury to surgical intervention and presence of concomitant injuries. Conclusions: We concluded that meticulous surgical technique leads to satisfactory results. However, factors, including the patient's age, time from injury to surgery and the presence of concomitant injuries needing adjacent joint immobilisation, contribute to unsatisfactory outcomes. Level of Evidence: Level IV (Therapeutic).

MRI anatomy and injuries of the fingers.

Magnetic resonance imaging (MRI) diagnosis of underlying finger pathology can be intimidating due to the presence of unique anatomy. The small size of the fingers and the unique orientation of the thumb compared to the fingers also introduce unique demands on the MRI system and the technologists performing the study. This article will review the anatomy pertinent to injuries at the fingers, provide protocol guidance, and discuss pathology encountered at the fingers. Although much of the encountered pathology in the fingers overlaps with adults, unique pathology to children will be highlighted when applicable.

[Open metacarpophalangeal dislocation]. / La luxation métacarpo- phalangienne ouverte.

Open metacarpophalangeal dislocation Abstract. Dislocation of a finger is a pathology often encountered in emergency centers. The following case example provides a reminder of its management and the situations in which the patient should be referred to the specialist.

Résumé. La luxation d'un doigt est une pathologie souvent rencontrée dans les centres d'urgence. L'exemple du cas suivant permet un rappel sur sa prise en charge et les situations dans lesquelles le patient doit être référé au spécialiste.

Does Inclination of the Toe Proximal Phalangeal Head Affect the Outcomes of Vascularized Joint Transfers? Retrospective Study of 22 Joint Transfers.

BACKGROUND: Different shapes of the proximal phalangeal head of toe proximal interphalangeal joints (e.g., oval and circular) are observed in vascularized joint transfers. The difference in shape implies the varying degrees of inclination of the articular surfaces between toes. This study investigated the impact of articular inclination on outcomes after toe joint transfers for finger proximal interphalangeal joint reconstruction. METHODS: Twenty-one patients who underwent vascularized joint transfer from May of 2009 to May of 2018 were included. Their mean age was 33.4 years and mean follow-up period was 28.9 months. All patients had a type I central slip according to the Te classification. Articular surface inclination was measured on lateral radiographic views. RESULTS: Passive range of motion of the toe proximal interphalangeal joint before vascularized joint transfer was 71.1 ± 9.6 degrees. The functional range of motion of the reconstructed proximal interphalangeal joint was 60.0 ± 17.0 degrees. The extensor lag after the joint transfer was 9.4 ± 19.6 degrees. The articular inclination of the toe joint was 71.9 ± 9.7 degrees. A Pearson correlation analysis of all variables, including age, preoperative range of motion of the toe joint, postoperative range of motion of the reconstructed joint, articular inclination of the toe joint, and extensor lag of the reconstructed joint with toe articular inclination, was performed. There was no significant correlation between articular inclination of the toe joint and extensor lag of the reconstructed joint ( p = 0.226). CONCLUSION: The articular surface inclination of the toe did not affect the functional range of motion after joint transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Floating phalanx; simultaneous double dislocation of the interphalangeal joint in a finger: A case report and literature review.

Isolated proximal and distal interphalangeal joint (DIPJ) dislocations are widely seen as a result of sporting injuries and major trauma. The combination of dorsal dislocation of the DIPJ in the same finger concomitant to traumatic dorsal dislocation of the proximal interphalangeal joint (PIPJ) is a rarely seen injury. The case is, here, presented of a 65-year-old female patient with proximal and DIPJ dislocation of the right-hand ring finger accompanied by volar and dorsal plate injuries in the proximal and distal joints. With this case, it was aimed to introduce a new term of 'floating phalanx' into medical literature. The treatment was applied to the patient of closed reduction under peripheral block and the application of an aluminium finger splint in semiflexion. In a 24-month follow-up period, the 4th finger of the patient was observed to be stable and has pain-free range of movement. This case is an uncommon case of volar and dorsal plate avulsion fractures with PIPJ and DIPJ dorsal dislocation treated successfully with closed reduction and conservative treat-ment with excellent functional results.

Extension Block Pinning Vs Single Kirshner Wiring To Treat Bony Mallet Finger. A Retrospective Study.

BACKGROUND AND AIM: Bony Mallet Finger or Mallet Fracture is a common injury of the hand, which follows a forced flexion of the extended distal interphalangeal joint, that leads to a bony avulsion of the distal phalanx. Depending on fracture extension and dislocation, those lesions can either be treated conservatively or surgically. Several surgical options have been described in the literature. The aim of this study is to compare retrospectively two percutaneous pinning techniques: the extension block technique according to Ishiguro vs an original single Kirshner wiring (Umbrella technique). METHODS: Between January 1998 and December 2019, among all patients treated surgically for a Mallet Fracture with either the Ishiguro' and the Umbrella technique, 98 have been included in this study. All patients have been assessed one year after surgery using the Crawford method. RESULTS: With both techniques better results have been achieved in younger patients and for those treated early. The umbrella technique seems to have better results in patients with fracture classified as 2b or 2c (Wehbe and Schneider classification), whereas the Ishiguro technique seems more appropriate for patients with a 1b fracture. Complication rate and typology vary depending on the used technique. CONCLUSIONS: The Ishiguro' and the Umbrella technique both lead to good results for the treatment of surgical Mallet Fractures. The choice of the best type of pinning should mainly depend on fracture extension and time elapsed from trauma.