Central Slip Injuries Research Articles

581 Documentation of Peripheral Sensory Function Assessment in Hand Trauma at a Regional Referral Unit

Abstract Aim This audit aimed to assess the quality of documentation of sensory function assessment in hand trauma patients treated at a regional referral unit. The audit was based on The British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) “Peripheral Nerve Injury” national guideline, last updated in December 2021. Method The scope included all hand trauma referrals received between the 1st and 10th of March 2022. Initial case screening excluded missed appointments, telephone consultations, missing hand assessment sheets and reviews of old injuries. Following that, patients with diagnoses of pulp injury, amputation, closed central slip injury, mallet injury, phalanx infection, old injuries, and removal of metalwork, which were not relevant to the audited guideline, were excluded. All remaining records were analysed for any description of sensory assessment and description of the sensation level using a 1-10 scale. Additionally, cases of volar lacerations were checked for documentation of two-point discrimination (2PD). Results The search yielded 97 patient records. Following the initial screening, 10 cases were excluded. 56 out of 87 remaining cases had diagnoses relevant to the audit. 24 cases were classified as volar injuries. 73% of hand assessment sheets contained any description of peripheral sensory assessment (41/56). 1-10 assessment was documented on 23% of records (13/56). 17% of volar injury records contained 2PD examination documentation (4/24). Conclusions Documentation of sensory assessment in hand trauma, especially two-point discrimination in volar lacerations, requires improvement. One possibility to improve the adoption of 2PD evaluation would be an introduction of a cheap and widely available assessment device.

Successful Boutonniere Reconstruction With Wide-Awake Local Anesthesia No Tourniquet

In this retrospective study, we evaluated the results of central slip reconstruction with a modified Snow's technique under wide-awake local anesthesia no tourniquet. Between 2016 and 2019, 13 patients with boutonniere deformity were operated. All of the patients had boutonniere deformity with a passively correctable proximal interphalangeal joint. In 7 patients, temporary proximal interphalangeal joint transfixation with a K-wire to secure the repair was preferred. For the rest of the patients, postoperative follow-up was done with an orthosis. All patients were referred to a hand therapist for postoperative rehabilitation. The mean interval between the injury time and the surgery was 55.7 days. After the surgery, the average proximal interphalangeal joint flexion was 104.8° and the loss of proximal interphalangeal joint extension was 6.15°. The average distal interphalangeal flexion was 65.3°. Seven cases had excellent results, 4 patients had good results, and 2 patients had fair results. Our study demonstrated that with a modified Snow technique, encouraging results can be achieved for neglected central slip injuries in which primary repair is impossible. Surgery under wide-awake local anesthesia no tourniquet enables the surgeon to check the stability of the repair, and early active motion with relative motion flexion orthoses can be started with confidence. Therapeutic IV.

Experimental Evaluation of the Elson Test Efficiency Following Central Slip Injury

PurposeThe purpose of this article is to explore the amount of work, quantitated by flexion and extension cycles, that is needed to obtain a positive Elson test following a central slip injury. MethodsThirteen frozen cadaveric fingers from individuals with an average age of 79.6 years were used. Testing was performed by imposing sinusoidal displacement of the 2 tendons, with loads ranging from 30 N to 2 N at 1 Hz. Following transection to the central slip, each finger was cycled 1,000 times using the same protocol adopted for the control. Following 100, 200, 300, and 1,000 cycles, we measured the extension angles of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints from the flexed position and the distance between landmarks of the extensor apparatus and simulated an Elson test. ResultsIn both the fingers, the range of motion of the metacarpophalangeal and distal interphalangeal joints measured in the controls remained unchanged, whereas the range of motion of the proximal interphalangeal joint was significantly reduced immediately after central slip transection. Combining both ring and middle fingers, for a displacement of 5 mm, the force measured in the control (1.05 ± 0.69 N) increased to the value of 2.36 ± 0.97 N at the 1,000th cycle. Although the middle finger has shown a significant difference in force at 100 cycles following central slip transection, 200 cycles were needed to observe a difference on the ring finger. ConclusionsIn controlled conditions, there is a variation in resistance to flexion of the distal interphalangeal joint. However, the amplitude of the forces is so small that they are likely imperceptible clinically. Delayed testing should be considered to increase the sensitivity of the test or in patients experiencing pain. Type of study/level of evidenceDiagnostic V.

Volar dislocation of the proximal interphalangeal joint

The author reports a volar dislocation of the right-hand ring finger's proximal interphalangeal joint in 65-year-old women presented two days after the injury. Apparent shortening, rotation and ulnar deviation of the finger are the classical clinical findings. Radiographs are essential in differentiating between the variants of volar dislocation. Type 1 dislocation presents as irreducible dislocation because of the entangled proximal phalanx in the buttonhole and always associated with the same side collateral ligament injuries. Type 2 dislocation is reducible because of the central slip rupture and a resultant boutonniere deformity. The author reported a case with a complex spectrum of injury, causing the volar dislocation of the proximal interphalangeal joint with the proximal migration of the middle phalanx and radial displacement. This was because of the same side collateral ligament rupture and central slip avulsion. Central slip reconstruction and radial collateral ligament repair produced a stable, painless joint and a full range of movement at the final follow-up. V • Type 2 Volar dislocation of the proximal interphalangeal joint is rare. • It is reducible and has central slip injury with boutonniere deformity. • Central slip reconstruction and collateral ligament repair produce stable 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 zoneIII 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 atypical deformity (buttonhole/Boutonnière deformity) develops within 1-2weeks 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, anumber 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.

Boutonniere Deformity: A Review of Considerations before Treatment and Current Treatment Options

Central slip injury is a common occurrence in hand trauma. When the base of the middle phalanx, which is the contact part of the central tendon, is weakened or damaged, extension lag or restriction would be found in the proximal interphalangeal (PIP) joint and the distal interphalangeal joint becomes hyperextended, presenting buttonhole or boutonniere deformation. Buttonhole deformation has limited cases that a hand surgeon can experience, and there is still no clear guideline for treatment, so treatment tends to depend on the knowledge and experience of the treating doctor. In this review, the factors to be considered in determining the treatment of boutonniere deformity are discussed, and nonsurgical or surgical treatment is considered. Treatment of the PIP joint in boutonniere deformity is a difficult task. Understanding the cause of the deformity, the time point and the stage of deformity, the relationship to the biomechanical changes in adjacent joints, the patient’s functional limitations, and the condition of the joint will improve treatment decisions and outcomes. Based on these considerations, an appropriate treatment should be chosen among nonsurgical or surgical treatments. Various surgical options were introduced but none of method guarantee the optimal outcome. Sufficient understanding of deformity and sufficient consultation and cooperation with the patient regarding the treatment process, outcome, and rehabilitation are necessary.

Salter-Harris type II fracture of the middle phalanx with concomitant central slip injury in an 11 years old: a case report

<p>An 11-year-old male sustained an irreducible, completely displaced epiphyseal fracture of the proximal interphalangeal joint (PIPJ) of the middle finger with an associated central slip injury. Central slip injuries occurring in conjunction with Salter-Harris type II middle phalanx fracture are rare entities, with no previously documented case. Our patient underwent open reduction, internal fixation through crossed-pins to achieve reduction and fixation. He was then splinted in extension for six weeks to allow healing of the central slip injury. At 1-year follow-up, the patient had full range-of-motion with no clinical indication of physeal disruption or growth arrest of the repaired digit. We demonstrate a case in which ephiphyseal fractures of the proximal interphalangeal joint with a concomitant central slip injury can safely be treated with open reduction internal fixation combined with a period of immobilization. We characterize a surgical method of reduction and fixation with splinted immobilization and describe lessons learned from this previously unreported case.</p>

Central slip extensor tendon injuries: a systematic review of treatments.

This systematic review describes and compares outcomes of operative and non-operative management of central slip extensor tendon injuries. A PRISMA-compliant methodology identified 3785 studies. Of these, 29 underwent full text review. No randomized controlled trials were identified. Nine studies evaluated treatment modalities specific to cohorts with acute central slip injuries in adults. A range of operative and non-operative elements of management was identified although no studies directly compared the two. Where aspects of rehabilitation were studied, this was always after surgery. The evidence base regarding treatment of central slip injury is limited and the roles of different treatment strategies for open as well as closed injuries are not well-supported by evidence.

Therapeutic management of closed central slip injuries: Outcome of a service evaluation

Introduction Closed central slip injuries can be difficult to manage and there is a lack of published research to support evidence-based clinical decision making in practice. This article presents the results of a service review in a busy trauma hospital hand therapy department. Method Following a literature review and retrospective review of outcomes, new clinical guidelines for central slip injuries were developed. These were implemented with 22 patients referred to hand therapy for conservative management of closed central slip injuries during a one-year period. Results The majority of patients (72%) had either an excellent or good outcome using the Strickland-Glogovac outcome measure and an average total active motion of 90% compared to their unaffected hand. Conclusions The outcomes following implementation of new treatment guidelines following the service review are in line with the small amount of published data currently available. They provide detailed guidelines for the conservative management of closed central slip injuries in a busy out-patient setting.

Reconstruction of Traumatic Central Slip Injuries: Technique Using a Slip of Flexor Digitorum Superficialis.

Multiple reconstruction techniques have been described for correction of boutonniere deformities including direct repair, central slip reconstruction, lateral band reconstruction, transverse retinacular ligament reconstruction, staged reconstruction, and extensor tenotomy. Each technique has been reported to have variable results with complications including capsular contracture, loss of proximal interphalangeal flexion, and residual deformity. We describe a surgical technique for central slip reconstruction using a slip of the flexor digitorum superficialis tendon through a bone tunnel.

Sports Injury-Related Fingers and Thumb Deformity Due to Tendon or Ligament Rupture.

Background:Hand injuries are very common in sports, such as skiing and ball sports. One of the major reasons causing hand and finger deformity is due to ligament and tendon injury. The aim of this study was to investigate if the high-resolution 3T magnetic resonance imaging (MRI) can demonstrate the complex anatomy of the fingers and thumb, especially the tendons and ligaments, and provide the accurate diagnosis of clinically important fingers and thumbs deformity due to ligamentous and tendinous injuries during sport activities.Methods:Sixteen fresh un-embalmed cadaveric hands were harvested from eight cadavers. A total of 20 healthy volunteers' hands and 44 patients with fingers or thumb deformity due to sports-related injuries were included in this study. All subjects had MR examination with T1-weighted images and proton density-weighted imaging with fat suppression (PD FS) in axial, coronal, and sagittal plane, respectively. Subsequently, all 16 cadaveric hands were sliced into 2-mm thick slab with a band saw (six in coronal plane, six in sagittal plane, and four in axial plane). The correlation of anatomic sections and the MRI characteristics of tendons of fingers and the ulnar collateral ligament (UCL) at the metacarpal phalangeal joint (MCPJ) of thumb between 20 healthy volunteers and 44 patients (confirmed by surgery) were analyzed.Results:The normal ligaments and tendons in 16 cadaveric hands and 20 volunteers' hands showed uniform low-signal intensity on all the sequences of the MRI. Among 44 patients with tendinous and ligamentous injuries in the fingers or thumb, 12 cases with UCL injury at MCPJ of the thumb (Stener lesion = 8 and non-Stener lesion = 4), 6 cases with the central slip injury, 12 cases with terminal tendon injury, and 14 cases with flexor digitorum profundus injury. The ligaments and tendons disruption manifested as increased signal intensity and poor definition, discontinuity, and heterogeneous signal intensity of the involved ligaments and tendons.Conclusions:Sports injury-related fingers and thumb deformity are relatively common. MRI is an accurate method for evaluation of the anatomy and pathologic conditions of the fingers and thumb. It is a useful tool for accurate diagnosis of the sports-related ligaments and tendons injuries in hand.

The modified mallet splint for closed central slip injuries

The modified mallet splint for closed central slip injuries

Don’t slip up! A modified technique for assessing central slip injuries

Don’t slip up! A modified technique for assessing central slip injuries

Boutonniere Deformity

A 30-year-old man presents to the office 6 weeks after a softball jammed the right, dominant index finger. He was referred to the hand clinic with a 35° extensor lag of the proximal interphalangeal (PIP) joint (boutonniere deformity) that is passively correctable. •Discuss the results of nonsurgical treatment of central slip injuries with respect to timing of intervention. •Describe the Matev rebalancing technique for lateral band reconstruction and the various iterations. •State the location of the Dolphin extensor tenotomy to treat Boutonniere deformity. •Summarize the role of the transverse retinacular ligaments in the established Boutonniere deformity. •Discuss the complications of Boutonniere surgery. Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month’s test, visit http://www.assh.org/professionals/jhs. •Discuss the results of nonsurgical treatment of central slip injuries with respect to timing of intervention. •Describe the Matev rebalancing technique for lateral band reconstruction and the various iterations. •State the location of the Dolphin extensor tenotomy to treat Boutonniere deformity. •Summarize the role of the transverse retinacular ligaments in the established Boutonniere deformity. •Discuss the complications of Boutonniere surgery. Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month’s test, visit http://www.assh.org/professionals/jhs. JournaL CME QuestionsJournal of Hand SurgeryVol. 36Issue 1Preview Full-Text PDF

Early Active Short Arc Motion for the Closed Central Slip Injury

Early Active Short Arc Motion for the Closed Central Slip Injury

The modified Elson's test in open central slip injury

Lacerations across the dorsum of the finger at the level of the proximal interphalangeal joint (PIPJ) may involve the underlying central slip of the extensor mechanism. This injury, if untreated, will lead to the development of a boutonierre deformity, characterised by flexion of the PIPJ and extension of the distal interphalangeal joint (DIPJ). The injury may be overlooked initially as the finger will retain some active extension and the boutonierre deformity subsequently develops over the following days and weeks. In the normal finger, the extensor tendon inserts into the base of the middle phalanx via the central slip and to the base of the distal phalanx via the lateral bands. If the normal finger is fixed in flexion

The results of treatment for isolated zone 3 extensor tendon injuries

We evaluated late-term results of surgical repair and physical rehabilitation of isolated zone 3 extensor tendon injuries. Sixteen patients (13 males, 3 females; mean age 28 years; range 11 to 57 years) underwent surgical repair for isolated simple central slip injuries of zone 3 extensor tendon. Injuries involved the second, third, fourth, and fifth fingers in seven, three, two, and four patients, respectively. Primary tendon repair was performed in 14 patients. Two patients were treated after one week and two months following primary injury, respectively. Tendons were repaired by modified Kessler and epitendinous sutures in four patients, and by locking running suture in 12 patients. Following surgical repair, three patients underwent K-wire fixation in extension for two weeks, while 13 patients received the short arc motion protocol. The patients were assessed with respect to proximal interphalangeal (PIP) joint motion and extension loss. Functional results were assessed using the Strickland formula. The mean follow-up was 58 months (range 8 to 120 months). Full range of motion of the PIP joint was achieved in 15 patients (93.8%). The mean PIP joint motion was 98 degrees. One patient (6.3%) had an extension loss of 10 degrees in the range of motion of the PIP joint. There were no losses in the range of motion in three patients treated with K-wire fixation. The mean of the Strickland formula was 94.8% (range 74% to 100%), showing an excellent result in 15 patients (98.3%) and a good result in one patient (6.3%). All the patients returned to their pre-injury work status. None had buttonhole deformity or soft tissue complication. A proper suture technique combined with the short arc motion protocol provides good results in the treatment of isolated zone 3 extensor tendon injuries.

Ultrasound visualization of central slip injuries of the finger extensor mechanism

Purpose To evaluate the ability of ultrasound to detect a central tear of the finger extensor tendon mechanism. Methods Twelve fresh-frozen and thawed cadaver fingers were used. All fingers had a midradial incision with exposure of the extensor mechanism over the proximal interphalangeal joint. Six fingers had a sharp transection of the central slip. The other 6 fingers were used as sham dissection controls. All fingers had the exposure closed by suture and then were examined by a musculoskeletal ultrasonographer. Results All 12 fingers were identified correctly as either sham controls with intact central slips or as injury models that had a transected central slip. Thus there was a sensitivity of 100% a specificity of 100%, and a positive predictive value of 1.000, which were statistically significant. Conclusions Diagnostic ultrasound is a very accurate noninvasive study that can identify central slip injuries in the extensor mechanism of the finger. We recommend that clinically suspected cases of boutonniere injury be scanned by high-frequency ultrasound to confirm the diagnosis and allow either early initiation of splinting or eliminate the need for prolonged splinting required for this injury.

A PROSPECTIVE REVIEW OF OPEN CENTRAL SLIP LACERATION REPAIR AND REHABILITATION

A prospective review was carried out to evaluate the outcome of surgically repaired open central slip (zone III) injuries which were treated with 3 weeks of proximal interphalangeal joint immobilization within a cylinder splint and then with 3 weeks of controlled mobilization within a Capener coil splint. Thirty-one fingers in 27 patients were assessed by the same independent therapist. All fingers achieved an excellent or good recovery with a mean proximal interphalangeal joint flexion of 94° (range 70–110°) and a mean distal interphalangeal joint flexion of 57° (range 30–81°). Extension deficits of the proximal interphalangeal joint were noted in five fingers (mean 6°, range 3–15°). The results show that a combination of immobilization and controlled mobilization is an effective rehabilitation regime for surgically repaired open central slip injuries.

Diagnosis of closed central slip injuries: A cadaveric analysis of non-invasive tests

Four non-invasive tests for central slip integrity were analysed using 20 fresh frozen cadaver fingers. A pre-boutonnière deformity was simulated by dividing the central slip. A passively correctable boutonnière was simulated by dividing the central slip, triangular ligament and oblique fibres of the extensor expansion. The test described by Boyes, which evaluates distal interphalangeal joint flexion, was found not to be reliable for the diagnosis of either injury. The test described by Elson, which evaluates distal interphalangeal joint rigidity while actively extending the flexed proximal interphalangeal joint, was the only manoeuvre which was able to discern central slip integrity in both simulated injuries. The central slip tenodesis test and testing resistance of active proximal interphalangeal joint extension should be performed with the proximal interphalangeal joint in flexion to weaken the effectiveness of the lateral bands.