Thumb Sprains

Thumb Sprains 

 

What are thumb sprains?

A sprain is an injury to a ligament. Ligaments are the connective tissues that connect bones to bones across a joint. The most common thumb sprain involves the collateral ligaments of the Metacarpophalangeal (MCP) joint.

 

How do thumb sprains occur?

These types of injuries are common in sports and falls on to an outstretched hand. The thumb is jammed into another player, the ground, or the ball. The thumb may be bent in an extreme position, causing a sprain. The thumb will usually swell and may show bruising. It is usually very painful to move.

 

What are the most common types of thumb sprains?

The most common ligament to be injured in the thumb is the ulnar collateral ligament (see Figure 1). Injury to this ligament is sometimes called “skier’s thumb” because it is a common skiing injury. It occurs when the skier falls and the pole acts as a fulcrum in the hand to bend the thumb in an extreme position. This ligament may also be injured by jamming the thumb on the ground when falling or by jamming the thumb on a ball or other player. The radial collateral ligament  may also be injured. The radial ligament is much less commonly injured than the ulnar collateral ligament (see Figure 1). For many years an injury to the ulnar collateral ligament of the thumb MCP joint has also been called "gamekeepers thumb" after the chronic injury to that ligament suffered by a gamekeeper  reportedly this phrase has been attributed to

 

What are some signs that this injury may have occurred?

 

Characteristic signs include pain, swelling, and bruising around the thumb , and especially over the MCP joint of the thumb. The patient will often manifest a weakened ability to grasp objects or perform such tasks as tying shoes and tearing a piece of paper. Other complaints include intense pain experienced upon catching the thumb on an object, such as when reaching into a pants pocket.

 

How are thumb sprains treated?

X-rays are usually taken to make sure the bones of the thumb and hand are not fractured. Sometimes "stress" X-rays are also used. Your doctor will then examine the thumb to determine whether the ligament is torn. If the ligament is partially torn, it is usually treated in a cast or splint. Radial collateral ligament injuries are frequently treated this way as well. The end of a completely torn ulnar collateral ligament often gets trapped behind a tendon. This "trapping" of the ligament in the edge of the aponeurosis is known as a Stener Lesion.  Complete ulnar collateral ligament tears are most commonly treated with surgery to repair the ligament. The presence or absence of a Stener Lesion is at times used to determine whether surgery is needed but typically complete lesions or ligament tears require surgery.  Sometimes the remaining ligament tissue is of poor quality and the ligament must be reconstructed with a tendon or ligament graft. A partial strain that does not require referral can be treated with either a thumb spica cast or a gamekeeper's thumb splint for four to six weeks. Active range of motion exercise is started at three to four weeks, with gradual return to full activity.

 

Chronic Injuries

The term “chronic” refers to an old injury of greater than one or two months duration. In this case, the joint may be unstable with symptoms of pain, especially with pinching. The joint may feel loose and strength may be decreased. These injuries may be treated by reconstruction of the ligament, or joint fusion if arthritis is present. Untreated tears can cause disabling instability of the hand, since the ulnar collateral ligament stabilizes the first MCP joint when the thumb is adducted against the index and middle fingers when gripping objects. Reconstruction typically involves taking a small piece of tendon tissue from the wrist to be placed into the thumb joint.

 

Associated Injuries

On occasion, fractures may occur along with thumb sprains. These may require additional surgery with repair using metal pins, screws, or plates. Cartilage damage may occur as well which does not show up on x-ray. This occasionally results in long-term pain and eventual arthritis. Some patients may benefit from cortisone injections or eventual surgery.

 

What happens and what should I expect after surgery?

 

A cast is placed on your thumb, wrist and forearm for approximately 4 weeks.  Your thumb tip and your fingers are left free.  After the cast is removed, the pin that holds your joint in place is typically removed in the office. You then go to hand therapy and are fitted for a removable splint that is very similar in size and shape to your cast. However you can remove this splint for exercises and range of motion.  At first you will remove the splint under the supervision of the therapist. As you progress you will be instructed by the therapist to remove the splint in controlled situations for exercise and use.  It still takes another month at least before you can use your hand without limits or splinting.  Some take longer, others go faster, but overall you have to consider it to be a 2 -3 month process.

Failure to wear a cast, and then a splint and deciding not to go to therapy can limit or compromise your result.  In general some loss of motion of the thumb occurs but the goal is to have a stable thumb joint for activity.

Bite Wounds of the HAND

Animal and Human Bites of the Hand
Bites are extremely common and can cause significant pain and other problems, especially when associated with an infection. Early recognition of warning signs and appropriate treatment are key in minimizing potential problems from the bite.

When an animal bites, bacteria from its mouth can contaminate the wound. These bacteria may grow within the wound and cause an infection. The consequences of infection range from mild discomfort to life-threatening complications.

Many factors may contribute to the infection, including the type and location of the wound, pre-existing health conditions in the bitten person that impair immunity, such as diabetes, HIV, etc., the extent of delay before treatment, the presence of a foreign body in the wound, and the animal causing the bite.

Animal Bites
There are as many as three million animal bites in the United States each year. Dogs are responsible for most animal bites in this country (up nullto 90%), with cat bites accounting for about 5% of such injuries. Other biting animals include rodents (at least 2%), rabbits, ferrets, farm animals, monkeys, and reptiles.

Animal bites to the hand most frequently occur on the fingers of the dominant hand of children between the ages of 5 and 14. Women are bitten more frequently by cats, and men by dogs. Infections occur more frequently in cat bites because cats have extremely sharp, pointed teeth that can cause deep puncture wounds. The skin usually flaps over the bite, thereby sealing off the puncture wound, precluding open drainage and allowing an infection to develop (see Figure 1).

The major concern of all bite wounds is subsequent infection. In the United States, about 1% of dog bites and 6% of cat bites require hospitalization. With swift and proper care, the prognosis is usually very good for recovery from these injuries.

Rabies is an extremely rare but fatal infection which may result from an animal bite. In the United States, unlike the rest of the world, wild animals such as bats, skunks, raccoons, and foxes spread more than 90% of rabies infection. Report animal bites to your public health department. They may ask your assistance in locating the animal so that it can be confined and observed for symptoms of rabies.

Human Bites
Human bite wounds contain very high concentrations of bacteria so the risk of infection is high. These infections can progress quickly and result in substantial complications, so early treatment is necessary (see Figure 2). Often, human bites occur when a person’s fist is driven into another’s mouth, such as during a fistfight. After the skin is broken, bacteria are seeded into the soft tissue and the ‘knuckle’ joint, which if left untreated often results in deep infection in the joint which may ultimately destroy the joint. These problems can be effectively treated by early diagnosis, intravenous antibiotics, and surgery to drain the infection out of the joint and wash it out.

Symptoms of Concern with Animal Bites to the HandIf the bite results in swelling, redness, warmth, continued pain beyond 24 hours, pus draining from the bite wound, red streaks extending up the arm or forearm, swollen lymph nodes (“glands”) around the elbow or in the armpit, loss of mobility, loss of sensation in the hand or fingertip, fever, malaise, night sweats, or rigors, emergency treatment should be sought either in your physician’s office or the emergency room.

Treatment of animal bitesYour doctor will examine the wound and ask about contributing factors to the injury. A complete history of the bite, including the type of animal and its status (general health, rabies vaccine, behavior), the time and location of the event, circumstances of the bite, whereabouts of the animal, and pre-hospital treatment will be reviewed.

It is crucial to update your tetanus status if you have not had a booster shot within the past ten years.

X-rays may be used to identify any damage to the bones and joints or tooth fragments that may have broken off. If an infected bite to the hand goes untreated for too long, x-rays may reveal evidence of osteomyelitis, or the spread of infection to the bone.

Animal bites to the hand require meticulous cleansing. Your doctor or other medical personnel will wash the wound and might trim away any devitalized (dead) tissue, damaged skin, blood clots, or other particles that could be a source of infection. It is important to look for signs of lymphangitis, indicated by the presence of red streaks on the forearm. Your doctor will feel the inner side of the elbow for evidence of enlarged lymph nodes. When the wound is infected, a culture is obtained to identify the type of bacteria that is causing the infection and thus help determine the antibiotic that is most effective for treatment.

The use of antibiotics for animal bites depends on the particular circumstances of the injury, patient health and sensitivity to various medications, and the appearance of the wound. Some bites require the use of IV antibiotics, while others may be treated with oral medication. The presence of an underlying fracture usually dictates inpatient antibiotic treatment. If you are diagnosed as having an infection of a flexor tendon sheath or a joint, you will need hand surgery, which will need to be performed as soon as possible.

Figure 1 Finger infection from cat bite

Figure 2. Wound Infection of thumb after human bite

Follow-up care is crucial in the case of animal bite wounds, to ensure that infection is diminishing or has not developed, and to restore the hand as much as possible to its former condition.

Carpal Boss

Clinical Characteristics

The dorsal wrist ganglion is most often confused with the carpal boss, so named by the French physician Foille.  The carpal boss is an osteoarthritic spur that develops at the base of the second and/or third carpometacarpal joints. (figure 1) A firm, bony, nonmobile, tender mass is visible and palpable at the base of the carpometacarpal joints, especially when the wrist is volar flexed.

Figure 1.

Radiologically, the mass is best visualized with the hand in 30 to 40 degrees supination and  

 20 to 30 degrees ulnar deviation ("carpal boss view")( figure 2).

Figure 2

The boss is more common in women (2:1), in the right hand (2:1), and between the third and fourth decades.  The mass may be asymptomatic, but the patient may complain of considerable pain and aching.  A small ganglion is associated with  the carpal boss in 30 percent of cases, adding to its confusion with the more common dorsal wrist ganglion. 

Injection to the ganglion or to the cmc joint may  be used to reduce pain and irritation.  This may be combined with splinting and anti inflammatory medication and avoidance of trauma to the back of the hand\

If symptoms persist at times surgery may be offered. (figure 2) Surgery may involve the removal of the prominent bone, the excision of an associated ganglion or cyst and at times involves tenosynovectomy or tenolysis of adjacent affected tendons.  

What occurs during surgery may depend upon the preoperative findings as well as the surgical intra operative findings

The most common complication is the persistence of a mass because of excision of the ganglion alone or inadequate excision of the osteophytes.  Pain will persist unless all abnormal abutting surfaces have been excised.  Dorsal wrist ganglions can present over the carpometacarpal joints and must be distinguished from the carpal boss with its own associated ganglion.  Avoidance of injury to branches of the radial and ulnar sensory nerves is again stressed.            

Arthritis of the Thumb and Wrist

What Is It?
In a normal joint, cartilage covers the end of the bones and serves as a shock absorber to allow smooth, pain-free movement. In osteoarthritis (OA, also called degenerative arthritis) the cartilage layer wears out, resulting in direct contact between the bones and producing pain and deformity. In the hand, one of the most common joints to develop OA is the base of the thumb. The thumb basal joint, also called the carpometacarpal (CMC) joint, is a specialized saddle-shaped joint that is formed by a small bone of the wrist (trapezium) and the first bone of the thumb (metacarpal).The saddle shaped joint allows the thumb its wide range of motions, including up, down, across the palm, and the ability to pinch (see Figure 1 below).

Figure 1.

Figure 2

Who Gets It?OA at the base of the thumb at the level of the wrist is more commonly seen in women over the age of 40.The exact cause is unknown, but genetics, previous injuries such as fractures or dislocations, and generalized joint laxity may predispose towards development of this type of arthritis.

What Are the Symptoms and Signs?The most common symptom is pain at the base of the thumb at the level of the wrist. The pain can be aggravated by activities that require pinch, such as opening jars, turning door knobs or keys, and writing. Also pain can progress to at rest and at night. In more severe cases, progressive destruction and mal-alignment of the joint occurs, and a bump develops at the base of the thumb, which occurs as the metacarpal moves out of the saddle joint. This shift in the joint can cause limited motion and weakness, making pinch difficult (see Figure 2).  The next joint above the CMC may compensate by loosening, causing it to bend further back (hyperextend).

How is the Diagnosis Made?

Figure 3

The diagnosis is made by history and physical evaluation. Pressure and movement such as twisting will produce pain at the joint.  A grinding sensation may also be present at the joint . Often a physician will perform a test called of all things, The Grind Test, to determine if loading the joint will cause pain.  Palpation or putting pressure on the joint  in selected areas is also used to diagnose this problem.  X-rays are used to confirm the diagnosis, although symptom severity often does not correlate with the x-ray findings. Often special X-ray views of the thumb and the wrist: including good images of the thumb and  trapezial views of the wrist are needed to fully delineate the arthritis.(see figure 3)

Figure 4. Base of the Thumb Metacarpal
sequential wear patterns arthritic stage (1)

The X-ray stage of the arthritis at the base of the thumb metacarpal has been shown to correlate with cartilage thickness and smoothness. ( see figure 4) Often in stage one it is very difficult to detect any xray changes despite changes to the articular cartilage. In stage II early joint spurs form at the edges of the joint.  These are typically less than 2mm in size. In stage III there is joint space narrowing as well as small joint spurs ans fragments.  Finally in stage IV arthritis  there is a narrow to often obliterated joint space and large bone spurs  know as osteophytes and changes to the subchondral bone ( bone just below the cartilage) often referred to as subchondral cysts and sclerosis or "whitening" of the bone on a standard xray image.


What are the Treatment Options?
Less severe thumb arthritis will usually respond to non-surgical care. Arthritis medication, splinting and  cortisone injections may help alleviate pain. A hand therapist might provide a variety of rigid and non-rigid splints which can be used while sleeping or during activities. However a rigid splint may irritate the skin if there are prominent bone spurs and can cause increase pain if too much immobilization occurs.
Recently topical medications such as a prescription anti-inflammatory  gel have had some success.
Patients with advanced disease or who fail non-surgical treatment may be candidates for surgical reconstruction.  A variety of surgical techniques are available that can successfully reduce or eliminate pain.  Surgical procedures vary and may include a combination of removal of arthritic bone and joint reconstruction , joint fusion, bone realignment, capsulodesis, tendon transfers, ligament reconstruction, release of contractures and even arthroscopy in very rare select cases. A consultation with your hand surgeon can help decide the best option for you.


Additional references

(1) Sequential Wear Patterns of the Articular Cartilage of the Thumb Carpometacarpal Joint in Osteoarthritis

Osteoarthritis of the Thumb Carpometacarpal Joint in Women and Occupational Risk Factors: A Case–Control Study

Diagnostic Value of Clinical Grind Test for Carpometacarpal Osteoarthritis of the Thumb

Thumb Carpometacarpal Osteoarthritis: Arthrodesis Compared with Ligament Reconstruction and Tendon Interposition

portions: © 2006 American Society for Surgery of the Hand and Modified/Addended by handctr for more see www.handctr.com

Facebook and THE HAND CENTER

The Hand Center of Western Massachusetts has updated its facebook site to include pages concerning Dupuytren's disease, arthritis, endoscopic carpal tunnel release and other interesting Hand related topics

Patient Choice Award 2010

Dr. Wint has been awarded a 2010 Patient Choice Award from www.vitals.com
This is the third year in a row that such an award has been given to him.

Golf Injuries to the Hand, Wrist or Elbow

The Hand Center of Western Massachusetts
Soon the snow will be gone and many in Western Massachusetts and Northern Connecticut will turn in their shovels and snowblowers for golf clubs. Golf can be especially hard on the hands, wrists and elbows. Make sure you are fit for this golf season.

Golf Injuries to the Hand, Wrist or Elbow

For most golfers, the hand and/or wrist is the third most common body region injured, after the back and elbow. The wrist is injured 3 times more frequently than the hand. In golf, the action of the wrist is important for the “snap” of the shot in long shots, and the precision “feel” in short shots.

SNOW BLOWER SAFETY TIPS... O. C. D. STICK

Snow Blower Safety O.C.D.  STICK

As the first big snowfall comes to the Northeast for 2011, we are reminded all too often of the devastating effecets of a snowblower injury to the hand. It is important to keep a few snowblower safety tips in mind.

If you remember anything SNOWBLOWER SAFETY ....OCD STICK

(off clutch delay..use a stick)

If a snow blower jams, turn it off, disengage the clutch, delay, wait until the machine has less torque as there may be still some "spin" left in the impeller. Finally use a stick or broom handle to clear the snow. Never use hands, fingers or feet. It is often the impeller that spins very quickly in the outflow chute that causes injury as the advancing finger dosnt know that this it at the bottom of the chute.

Heavy wet snow, greater than 6 inches and in conditions greater than 28 degrees F are associated with a greater frequency of injury. The most common injury is to the middle finger in a male  with an average age of  44 years.

PLEASE BE CAREFUL..OCD STICK ( off clutch delay stick)

Put a stick on your snow blower, an old broom handle or a hockey stick tied to the hand works well. ( remember to watch out for flying debris ..your eyes.. as well)

Recommendations for safe use of a jammed snow blower snow blowers include :

1. If the snow blower jams, immediately turn it off..OFF

2. Disengage the clutch...CLUTCH

3. Wait 10 seconds after shutting of to allow Impeller Blades to stop rotating..DELAY

4. Always use a stick or broom handle to clear impacted snow. The stick most be strong enough to avoid breakage or eye injures can result from flying fragments..STICK

5. Never put your hand near chute or around blades

6. Keep all shields in place. Do not remove safety devices on machine

7. Keep hands and feet away from moving parts

8. Keep a clear head, concentrate and ...

Do not drink alcoholic beverages before using a snow blower

As physicians dedicated to the care of the Hand and Upper extremity we want to inform the public concerning the perils and pitfalls of improper snow blower use. Physicians, nurses, allied health professionals and therapists who deal with these injuries live in fear of the first heavy wet snow of the season. Invariably injuries are seen despite general knowledge that these injuries occur. These safety tips cannot guarantee against injury but hopefully if you are reading these or even better spreading these... it is one more step towards preventing these types of injuries.

News organizations and weather services can help.

Conditions that are associated with a higher incidence of injuries, hay wet snow exceeding 6 inches of accumulation and temperatures above 28 degrees Fahrenheit offer good opportunities to provide warning for the public. We need your help to reduce the incidence of these preventable injuries.

www.handctr.com

http://www.youtube.com/watch?v=mZxAHx95-oM

DUPUYTREN'S DISEASE: Surgery, needle aponeurotomy or xiaflex?

Dupuytren's Disease 

What is Dupuytren's disease?
Dupuytren’s disease is an abnormal thickening of the tissue just beneath the skin known as fascia. This thickening occurs in the palm and can extend into the fingers (see Figure 1). Firm cords and lumps may develop that can cause the fingers to bend into the palm (see Figure 2), in which case it is described as Dupuytren’s contracture. Although the skin may become involved in the process, the deeper structures—such as the tendons—are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).

What causes Dupuytren's disease? The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.
What are the symptoms and signs of Dupuytren's disease?

Symptoms of Dupuytren’s disease usually include lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Thick cords may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. These cords cause bending or contractures of the fingers. In many cases, both hands are affected, although the degree of involvement may vary.

The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop (see Figure 3). As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets.  Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

What are the treatment options for Dupuytren's disease?
In mild cases especially if hand function is not affected, only observation is needed.
 For more severe cases various  techniques are available in order to straighten the finger(s). Your treating surgeon will discuss the method most appropriate for your condition based upon the stage of the disease and the joints involved. The goal of any treatment is to improve finger position and thereby hand function. Despite  treatment the disease process may recur. Before treatment, your doctor should discuss realistic goals and results.
Types of treatment may include Needle Aponeurotomy, Partial or Complete Fasciectomy, and limited release as well as on Collagenase injections or cortisone injection in a nodule.  The rationale behind each treatment depends upon the treating physician and the patient.
Surgical Fasciectomy  (Partial or Complete) uses open incisions and the cords and nodules are removed
Open Aponeurotomy or Fasciotomy uses small incisions an the cords are released
Needle Aponeurotomy  (NA) or Percutaneous Aponeurotomy (PA) or Percutanoeous Needle Fasciotomy (PNF) or Incisional Fasciotomy or Open Fasciotomy
Needle aponeurotomy uses a small gauge needle or a microblade as a cutting device to sever the abnormal cords of tissue in the palm and digits which cause the fingers to flex down.  The tissue is not removed it is essentially perforated or cut in multiple places along the palm  to release the contracture (see figure 3) Incisional or Open fasciotomy is done in some instances.
Collagenase Injection (Xiaflex)
Collagenase is an enzyme that digest collagen a structural protein in tissues.  Xiafllex is a collagenase derived  from the bacteria Clostridium Histolyticum.  Xiaflex is a mixture of several types of collagenase, titrated to achieve digestion of  tissue or cords that are present in the hands  of those who have Dupuytren's disease. (Figure 4)
Corticosteroid Injection (cortisone shot)
When a steroid or cortisone injection  is given to the palm, in a nodule or small cord  it will often soften the cord. There are studies that state that this may limit progression of the disease While there have been no large scale prospective double blinded studies or dose dependent sudies many surgeons now will attempt to inject a nodule or soft cord that is not ready for surgery in an attempt to treat it.

IMPORTANT considerations:

1. The presence of a lump in the palm does not mean that surgery  or treatment is required or that the disease will progress.
2. Correction of finger position is best accomplished with milder contractures and contractures that affect the base of the finger. Complete correction sometimes can not be attained, especially of the middle and end joints in the finger. no matter what method is used.
3. Skin grafts are sometimes required to cover open areas in the fingers if the skin is deficient during open fasciectomy or open removal of cord tissue..
4. The nerves that provide feeling to the fingertips are often intertwined with the cords and may be affected by any treatment
5. Splinting and hand therapy are often required after surgery  or other treatment procedures in order to maximize and maintain the improvement in finger position and function.
6. All treatments for Dupuytren's may involve the risk of tendon, nerve, joint, skin: injury, infection, and stiffness. as well other conditions that may negatively affect the result.

 
Figure 1: Dupuytrens disease may present as a small lump, pit, or thickened cord in the palm of the hand
 
Figure 2: In advanced cases, a cord may extend into the finger and bend it into the palm

Figure 3: In Needle Aponeurotomy , a cord may be released without the need for  standard  incisions.

Figure 4: , Xiaflex is a collagenase, a drug that is injected into a cord  to dissolve a small segment of that cord, to treat the contracture.
These pictures are before and one day after injection  (just after manipulation). Xiaflex  treatment requires that a manipulation take place the next day

*Based on Phase I clinical trials, collagenase injections work better for metacarpophalangeal (MP) joint contractures than for proximal interphalangeal (PIP) joint contractures, and for lower severity contractures than for higher severity contractures.

*Ideally, patients for collagenase injection should have a well-defined, palpable cord, ideally one that is strung away from the flexor tendon system. The worst patient is probably someone who has a small finger IP contracture that’s more than 50 degrees and has been there for 5 or 10 years. Collagenase can only affect the cord itself; it won’t be able to act on the secondary tissues that have changed. *(source; http://www.aaos.org/news/aaosnow/oct10/clinical2.asp)

More information, references and documents

Dupuytren's Bibliography
Collagenase and Needle Aponeurotomy for Dupuyten's Disease ; a 2010 Article discussing reported date 

Dupuytren's Update NA and Xiaflex 

Dupuytrens   (.PDF)   from ASSH

New treatments for Dupuytren contracture from AAOS

XIAFLEX® CORD II Study Published in The Journal of Hand Surgery

Xiaflex injection photos from AAOS (PDF)

portions © 2009 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee
taken modified from ASSH and other sources including AAOS by www.handctr.com

HALLOWEEN PUMPKIN CARVING SAFETY TIPS (part 2)

Halloween Safety Tips That Are No Trick:  Orthopaedic Surgeons offer Halloween Injury Prevention Tips

Every Halloween, kids across the country parade
 neighborhoods in search of the most glorious prize:
candy.   The build-up for Halloween is almost as exciting as the day itself with pre-Halloween festivities like pumpkin-picking, pumpkin carving and selecting the perfect costume for the big day.  And though the holiday calls for fun, the American Academy of Orthopaedic Surgeons (AAOS) stresses the importance of taking proper precautions to avoid injuries this Halloween.

HALLOWEEN INJURY STATISTICS: A nine-year study examined holiday-related pediatric emergency room visits between 1997 and 2006.  Results of this study show Halloween among the top three holidays producing the most ER visits:

• Finger/hand injuries accounted for the greatest proportion of injuries on Halloween (17.6 percent).
• Of the finger/hand injuries sustained on Halloween, 33.3 percent were lacerations and 20.1 percent were fractures.
• Children ages 10-14 sustained the greatest proportion of injuries (30.3 percent).

Source:  D’Ippolito A, Collins CL, Comstock RD. Epidemiology of pediatric holiday-related injuries presenting to US emergency departments. Pediatrics. 2010 May;125(5):931-7.

for more information :   http://handctr.blogspot.com/2010/10/hand-surgeons-warn-of-pumpkin-carving.html

Hand Surgeons Warn of Pumpkin Carving Dangers

Hand Surgeons Warn of Pumpkin Carving Dangers




Hand Surgeons Warn of Pumpkin Carving Dangers


Use caution during the Halloween season, and take steps to prevent hand injuries when carving.

“Every Halloween season we see four or five patients—both adults and children—who come into our office with severe injuries to their hands and fingers,” says Jeffrey Wint, MD, an ASSH member from The Hand Center of Western Massachusetts, Springfield, MA. “Treatment can often run three to four months from the time of surgery through rehabilitation.”

To prevent hand injuries, the ASSH suggests the following safety tips

Carve at a Clean, Dry, Well-lit Area

Wash and thoroughly dry all of the tools that you will use to carve the pumpkin: carving tools, knife, cutting surface, and your hands. Any moisture on your tools, hands, or table can cause slipping that can lead to injuries.

Always Have Adult Supervision

“All too often we see adolescent patients with injuries because adults feel the kids are responsible enough to be left on their own,” says Wint. “Even though the carving may be going great, it only takes a second for an injury to occur.”

Leave the Carving to Adults

Never let children do the carving. Wint suggests letting kids draw a pattern on the pumpkin and have them be responsible for cleaning out the inside pulp and seeds. When the adults do start cutting, they should always cut away from themselves and cut in small, controlled strokes.

Sharper is not Better

“A sharper knife is not necessarily better because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it,” says Wint. “An injury can occur if your hand is in the wrong place when the knife finally dislodges from the thick skin of the pumpkin. Injuries are also sustained when the knife slips and comes out the other side of the pumpkin where your hand may be holding it steady.”

Use a Pumpkin Carving Kit

Special pumpkin carving kits are available in stores and include small serrated pumpkin saws that work better because they are less likely to get stuck in the thick pumpkin tissue. “If they do get jammed and then wedged free, they are not sharp enough to cause a deep, penetrating cut,” says Wint.

Help for a pumpkin carving injury

Should you cut your finger or hand, bleeding from minor cuts will often stop on their own by applying direct pressure to the wound with a clean cloth. If continuous pressure does not slow or stop the bleeding after 15 minutes, an emergency room visit may be required.

Copyright © American Society for Surgery of the Hand 2009.

modified altered and changed by www.handctr.com from assh.org

see also http://www.handctr.com/Jeffrey%20C%20Wint.htm

http://www.assh.org/Public/Safety/Pages/PumpkinCarvingSafety.aspx

Mallet finger (baseball finger)

MALLET FINGER (BASEBALL FINGER)

A mallet finger occurs when the extensor tendon at the tip of a finger ruptures. The rupture of this tendon can involve the tendon alone, be associated with a small bone fragment or fracture or can be associated with a fracture that requires significant care.

The force applied to the finger can come from something as simple as tucking in a bed sheet or can come from a direct blow to the end of a finger. Mallet finger has also been known as baseball finger.

Mallet finger.

A mallet finger often begins with pain at the distal joint of the finger.  At times there is an immediate loss of motion while at other times the finger seems to stay straight for a while and only later starts to lose its ability to be extended actively at the tip.  At times there is an injuries are typically closed in that the skin and nail is intact but at times there is an injury to the skin or nail bed as well. In severe cases the injury is associated with an open injury to the joint or bone, a so called open or compound fracture.

In adults the injury can involve the joint surface.  In children it can involves the growth plate or physis.

The diagnosis is often made based upon the type of injury and the appearance of the finger.  The fingertip will droop down and there is a loss of active motion.  Often the finger can be passively pushed up to straighten it but the independent active motion to extend the digit at the tip has been lost

X-rays are often taken to further delineate the injury and see how much if any bone, joint or

Types of splints used to treat mallet finger. A, Dorsal aluminum splint. B, Commercial splint.

Reproduced with permission from Culver JE Jr: Office management of athletic injuries of the hand and wrist. Instr Course Lect 1989;38:473-482.

 growth plate is involved

Treatment depends largely upon the extent the soft tissue and underlying boney injury.

Tendon rupture without bone injury

Most of these mallet finger injuries can be treated with splinting.  The splint can be applied in a variety of ways depending upon the injury.  Typically the split is left in place full time for six to eight weeks with a time for part time splinting after that depending upon what daily activity is done by the patient with a typical part time period of 3 – 4 weeks.  In some situations pinning of the joint is used rather than a splint

Tendon rupture with a small bone fragment

These injuries typically are treated like non-boney injuries

Tendon rupture with a large bone fragment involving the joint.

 These injuries may respond to splinting and splinting is often used however a small bump may always be present a t the joint.  At times if the doctor feels that that the bone fragment is large enough and the joint may be unstable surgery may be offered.  During surgery pins or small screws may be used and the joint itself may be pinned to prevent motion during the healing process.

  

Above: X-rays showing fracture at the insertion of the extensor tendon. In the first image on the left the fragment is displaced.  This will heal with a bump but will be able to be treated with a splint.  IN the image on the right the joint has subluxed.  This will  need to have surgical repair.

In adults with severe open injury more immediate surgery may also be offered

Children

In children the doctor needs to differentiate between these injuries that require reduction or realignment of the bone without surgery and those who may have a portion of the nail bed significantly torn or retained within the fracture site or growth plate.  Often children will not have a tendon injury but a fracture through the physis which appears to be a mallet injury.  X-rays often will reveal this.

 

Mallet deformity from a fracture across the growth plate in a child is different than the adult fracture or tendon avulsion

Late or Delayed Treatment in adults

Delayed treatment of mallet finger deformity may consist of splinting initially and at times surgical methods are offered to correct chronic deformities and other associated joint and tendon problems that may accompany the chronic situation

Results

Most mallet fingers heal well, although often there is a slight loss of full extension. The slight extension loss typically has no effect on hand of finger function, but if left untreated it can cause other issues to occur in the finger due to tendon imbalance. While treatment of a closed mallet finger is not an acute emergency, the improper, partial or untreated injury can lead to further problems such as a swan neck deformity.

 Swan neck deformity from tendon imbalance and laxity at the proximal joint.