Thumb Injuries Research Articles

Closed Mallet Thumb Injury: A Review of the Literature and Case Study of the Use of Magnetic Resonance Imaging in Deciding Treatment

At present, the literature dedicated to closed mallet thumb injury offers conflicting evidence between conservative and operative approaches. Although conservative treatment is often successful, retraction of the extensor pollicis tendon may lead to improper reattachment and continued deformity. This discussion and case report serve to highlight the use of magnetic resonance imaging as an adjunct in selecting the proper treatment strategy for this injury at initial presentation.

Advances in Extensor Tendon Diagnosis and Therapy

After studying this article, the participant should be able to: 1. Identify clinical situations in which hand sonography can result in the detection of partial extensor tendon tears. 2. Identify the limitations of magnetic resonance imaging in diagnosing extensor tendon tears. 3. Understand the various postoperative therapeutic protocols for extensor tendon repair. 4. Choose the appropriate surgical repair and postoperative therapeutic protocol for a specific extensor tendon injury. 5. Identify the social and economic variables that may influence the availability and efficacy of the various postoperative therapeutic protocols. This article describes how the application of radiographic imaging facilitates the earlier detection and differentiation of extensor tendon injuries. Furthermore, it defines the best surgical procedure and postoperative therapy for a specific injury. A literature review was performed of extensor tendon injury articles published since 1989. High-resolution sonography was more accurate than physical examination and magnetic resonance imaging in detecting extensor tendon injuries. Traditional postoperative static splinting was equivalent to early motion protocols for all uncomplicated thumb injuries and zone 1 to 3 injuries of the second through fifth digits. The only definable benefit of early motion therapy compared with static splinting was a quicker return to final function for proximal zones of injury in the second through fifth digits. The results of early active and passive motion, measured at 6 months, were comparable to those from static splinting. A higher rupture rate for early active motion and greater cost for early active and passive motion were noted compared with static splinting. High-resolution sonography allows identification of difficult to diagnose partial and complete extensor tendon injuries. Static splinting should remain the postoperative standard of care for extensor tendon injuries to the thumb and distal zones of injury for digits 2 through 5. The best therapy protocol for proximal zones of injury should be individualized based on social and economic variables.

Advances in Extensor Tendon Diagnosis and Therapy

After studying this article, the participant should be able to: 1. Identify clinical situations in which hand sonography can result in the detection of partial extensor tendon tears. 2. Identify the limitations of magnetic resonance imaging in diagnosing extensor tendon tears. 3. Understand the various postoperative therapeutic protocols for extensor tendon repair. 4. Choose the appropriate surgical repair and postoperative therapeutic protocol for a specific extensor tendon injury. 5. Identify the social and economic variables that may influence the availability and efficacy of the various postoperative therapeutic protocols. This article describes how the application of radiographic imaging facilitates the earlier detection and differentiation of extensor tendon injuries. Furthermore, it defines the best surgical procedure and postoperative therapy for a specific injury. A literature review was performed of extensor tendon injury articles published since 1989. High-resolution sonography was more accurate than physical examination and magnetic resonance imaging in detecting extensor tendon injuries. Traditional postoperative static splinting was equivalent to early motion protocols for all uncomplicated thumb injuries and zone 1 to 3 injuries of the second through fifth digits. The only definable benefit of early motion therapy compared with static splinting was a quicker return to final function for proximal zones of injury in the second through fifth digits. The results of early active and passive motion, measured at 6 months, were comparable to those from static splinting. A higher rupture rate for early active motion and greater cost for early active and passive motion were noted compared with static splinting. High-resolution sonography allows identification of difficult to diagnose partial and complete extensor tendon injuries. Static splinting should remain the postoperative standard of care for extensor tendon injuries to the thumb and distal zones of injury for digits 2 through 5. The best therapy protocol for proximal zones of injury should be individualized based on social and economic variables.

Mallet Thumb Injury in a Collegiate Football Player

Mallet Thumb Injury in a Collegiate Football Player

‘Sag sign’—A simple radiological sign for detecting injury to the thumb ulnar collateral ligament

Aim: To describe a new radiological sign after rupture of the thumb ulnar collateral ligament. Introduction: Rupture of the thumb ulnar collateral ligament is a commonly missed injury, with delayed diagnosis leading to considerable morbidity. Stress radiographs and MRI scans have been used to diagnose chronic (gamekeepers thumb) or acute (skiers thumb) injuries to this ligament. The former often causes discomfort and the latter are often not readily available. We describe a new radiological sign seen on the lateral radiographs of the thumb, which has previously not been described in the literature. The ‘sag sign’ is volar subluxation of the proximal phalanx in relation to the metacarpal at the metacarpal phalangeal joint Method: Between 2001–2006, radiographs of nineteen patients who had undergone repair of thumb ulnar collateral ligaments were retrospectively reviewed. There were 12 male and 7 female patients with an average age of 44. These were compared to a control group of normal thumb radiographs. The ‘sag sign’ was present on all the lateral radiographs of thumbs with ulnar collateral ligament tears. Once the ligament was repaired, the metacarpophalangeal joint alignment returned to normal. The sign was validated by senior house officers and registrars in orthopaedics training. Conclusion: The sag sign is a reliable indicator of an underlying injury to the thumb ulnar collateral ligament. Many studies have looked at the radiological diagnosis of this commonly missed injury. Stress radiography and ultrasound require straining an injured thumb which can extend the lesion and cause discomfort. MRI and MR arthrography are both sensitive and specific, but are costly and time consuming. Our sign is evident on plain film, is easily available, and does not require additional apparatus.

Epidemiology of alpine skiing injuries in lowlanders

During one alpine skiing season injuries were registered prospectively among 951 Danish alpine skiers. The injury incidence was 19.4 injuries per 1000 skiing days, or 3.4 injuries per 1000 skiing hours. The incidence of injuries treated by a doctor was 5.9 injuries per 1000 skiing days, which is 2–5 times higher than previously reported. Lower extremity doctor-treated injuries comprised 65% of the total and upper extremity doctor-treated injuries 25% - a distribution seen 25 years ago in alpine skiing countries. Only 18% of the thumb injuries were seen by a doctor. Neither age, preholiday training, self-rated skiing ability, ski school attendance during the week nor the use of rented versus owned equipment significantly influenced the risk of injury.

One‐stage reconstruction of complicated thumb injury with combination of microsurgical transplantations

Complicated thumb loss of the hand still remains a great challenge to hand and microsurgeons. In this article, we report our technique and outcomes in 10 cases using one-stage microsurgical procedures. In each case, three tissue transplants in combination with a sequential vascular anastomoses was performed, i.e. the second toe for the thumb, the extensor digitorum brevis for thenar opponent muscle, and the anterolateral thigh flap for the first web space, and adjacent soft tissue defects. All the transplants survived eventually. After an average of 6 years follow-up, the results were very inspiring. Combined tissue transfer can hasten patient recovery and improve functional outcomes. However, this method needs meticulous technique and great experience in microsurgery.

Wheelchair-Related Thumb Injury of Multifactorial Etiology: A Case Report

Pooyania S, Kirby RL, Smith C. Wheelchair-related thumb injury of multifactorial etiology: a case report. A 56-year-old man presented with bilateral transtibial amputations secondary to peripheral vascular disease and diabetes. While using a hospital-owned wheelchair to descend a 27-m–long, 5.6° slope in an underground tunnel connecting the rehabilitation center to a neighboring acute care facility, the patient had difficulty slowing the wheelchair to negotiate a turn. After sustaining burns on the palmar aspects of the thumbs due to friction against the metal handrims, he shifted his thumbs onto the treaded tires. This pulled his right thumb between the wheel lock and the tire of the wheelchair. The resulting laceration and small chip fracture of the dorsal aspect of the thumb metacarpal required immobilization. This injury might have been prevented if the ramp had not violated accessibility guidelines, if the handrims and wheel locks had been different, if brakes had been available, if the patient had been wearing gloves, and/or if the patient had used appropriate procedures for descending long, steep inclines. This case has several implications for the wheelchair-delivery system.

Antebrahijalni reverzni ostrvski rezanj na peteljci AIP za rekonstrukciju defekta na palcu

Fasciocutaneous lobe on AIP ( a. interossea posterior) is characterized by thin skin, good texture and satisfactory pedicle lenght, which enables the repair of numerous hand defects. It can be either loose or reversed on the pedicle. We present here 2 neglected cases of thumb injury in which there was a need to compensate the full thickness of the skin. We believe that thumb defects can be repaired with both functionally and esthetically good effects using AIP lobe.

A modified thumb spica splint for thumb injuries in the ED

There are a significant number of hand and upper extremity injuries treated in US emergency departments (EDs) each year. Many of these involve the thumb and wrist. These injuries encompass the range from fractures, strains, and sprains to more specific injuries such as gamekeeper thumb and de Quervain tenosynovitis. These injuries often require diagnosis, splinting, and referral to a hand or orthopedic surgeon. The splint described in this article is presently being used for patients with de Quervain tenosynovitis, but it may have more widespread application in emergency medicine. It is a safe and simple splint that is underused in EDs for splinting thumb injuries.

Clinical experiences and dosage pattern in subcutaneous single-injection digital block technique

100 patients with injuries to their fingers were treated using the subcutaneous digital block as described by Low et al.. Different dosages ranging from 2 to 3 millilitres of a local anesthetic were required to obtain appropriate anesthesia according to the location of injury. 108 finger injuries were treated, 18 thumb injuries, 90 finger injuries. The anesthetic was administered using a 0.55 x 25 mm needle and injected strictly subcutaneously into the flexor crease at the base of the finger or thumb. Injuries to the palmar aspect of the fingers were anesthetized using 2 ml of a local anesthetic (1% Lidocain), whereas 3 ml were needed for sufficient pain relief in case of injury to the dorsal aspect of the fingers. Injury to the thumb required a higher dosage (3 ml subcutaneously), and only offered sufficient pain relief for palmar injuries. In the case of dorsal injuries, we found that this technique was not sufficient in providing pain relief. Additionally, we performed a deep local nerve block (Oberst), if the patient still felt discomfort or pain. The severity or type of injury did not play a role according to our findings. The subcutaneous finger block as described by Low et al., therefore, is the method of choice treating injuries to the fingers and to the palmar aspect of the thumb, since it offers a decrease in the amount of anesthetic required and increases patient comfort.

Thumb amputations from team roping.

Thumb injuries during team roping have elements of both avulsion and crush, resulting in a poor prognosis for replantation success. To review 19 cases of thumb amputation from team roping at our institution since 1983. Retrospective cohort study. Cases were included in the study only if a microvascular repair of artery and vein was needed for the thumb to survive. Vein grafts were used to span the damaged vessel segment. Of the 19 thumb amputation cases, 15 attempts were made to replant the thumb. In the remaining four cases, patients had bone shortening and primary closure. The force of injury was calculated based on mechanism. Of the 15 attempts at replantation, only 5 (33%) were successful, despite meticulous technique. One patient subsequently had an emergency toe-to-thumb transfer after an unsuccessful replant, and the remaining nine underwent amputation. Nine of the 10 patients with failed replants had poor flow intraoperatively. In the group of patients younger than 15, the success was 3 of 5 (60%) and in the group 15 years or older the success was 2 of 10 attempts (20%.) Follow-up was available in 13 of the 15 cases of replanted thumbs. All patients were subjectively satisfied with their results, and all patients with successful replants and seven patients with no thumb returned to rodeo. Biomechanical analysis showed a huge amount of force and pressure, several times larger than that of ring avulsion injury, results when a steer pulls on the thumb.

Traumatic thumb injury management using mobilization with movement

Traumatic thumb injury management using mobilization with movement

Upper limb in injuries in dry ski slope skiing--a continuing problem.

The aim of this study was to assess how common injuries to the upper limbs are from dry ski slope skiing, to document the pattern of injury to the upper limbs from dry ski slope skiing and to discuss preventative measures. Skier's experience was also determined. The study was carried out on 174 patients attending the accident and emergency department over a period of 3 years who had sustained injuries from dry ski slope skiing. Prospective registration was used to collect the data. Sixty-seven per cent of the patients had received instructions prior to skiing. Upper limb injuries outnumbered lower limb injuries by a ratio of 7.9 to 1. Thumb injuries outnumbered other injuries in the upper limb. The mechanism of injury was due to a fall in 94.2% of patients. It is concluded that the lattice network on dry ski slopes significantly contributes to the platform of injuries to the upper limbs, and ways in which the lattice network may be improved are recommended.

Telemark skiing injuries: characteristics and risk factors

To determine the types of injuries associated with telemark skiing and the effects of ability level, equipment, and terrain. A survey was mailed to a sample of North American telemark skiers. Completed surveys were returned by 548 telemarkers (response rate = 74.5%). The mean age was 42.7 (+/- 9.3) years, and 69% were male. A total of 439 injury events resulted in 494 body injuries, reported by 285 skiers (52%). Lower-extremity injuries (n = 231) were more frequent than upper-extremity injuries (n = 187). Knee injuries were most common with 128 cases, followed by 80 thumb, 66 shoulder, and 44 ankle injuries. Surgery was required in 39 cases. Skiers suffering thumb injuries with sequela lasting greater than 3 months were 10.1 times less likely to have sought medical attention than skiers with other long-term injuries (p < 0.001). Injuries occurred more often at lift-served ski areas (74.2%) than in the backcountry (25.8% [p < 0.001, OR = 2.09]). There was no association between boot type and overall knee or ankle injury, but risk of severe ankle injury was increased in leather boots compared to plastic (OR = 8.0, CI = 1.05, 60.59). Release bindings were used by 27.9% of all skiers but were in use in only 18.7% of injury events, suggesting that release plates have a protective effect against injury (OR = 0.59, p < 0.001). In 66 of 82 injuries (80.5%) sustained while using release bindings, the bindings did not release. The knee, thumb, shoulder, and ankle are most frequently injured telemark skiing. Injuries are more likely to occur at lift-served areas than in the backcountry. Thumb injuries are often ignored and may result in long-term sequela. Ankle injuries appear more severe in leather boots. Release bindings appear protective against injury, but they often do not release.

Snowboarding Injuries

Injury patterns in snowboarding brief differ from those in Alpine skiing. Snowboarders tend to have fewer knee and thumb injuries than skiers but more upper-extremity trauma, fractures in general, and ankle injuries. Of particular concern in snowboarding is fracture of the lateral process of the talus (LPT), which masquerades as an inversion ankle sprain, is often missed, and can lead to significant disability. Signs are typically similar to those of inversion sprains, but pain on palpation of the lateral process can be helpful in diagnosis. Standard radiographs often do not show the fracture, so CT or lateral tomography may be required. The most minor, nondis-placed LPT injuries may heal with casting and rehab, but more severe fractures typically require surgery.

Long-term outcome of neurovascular palmar advancement flaps for distal thumb injuries

SUMMARY.Thirteen neurovascular palmar flaps for thumb tip coverage were reviewed: six O’Brien and seven Moberg flaps with a mean follow-up of 81 months. Both techniques were found to be safe and effective in preserving pulp sensibility, with a mean 2PD of 5 mm and a Semmes–Weinstein identical to the contralateral side in nine cases. The interphalangeal joint regained a normal range of motion, and did not seem to be affected by the perioperative flexion. The main residual complaints were persistent cold intolerance (present in all cases and severe in three), pulp instability (present in six and severe in two), and nail deformity. This last problem was more related to the injury. Despite these drawbacks, O’Brien and Moberg flaps remain the first choice for coverage of 1–2 cm pulp defects of the thumb.

FINGER RECONSTRUCTION WITH VOLAR ADVANCEMENT FLAP USING V-Y CLOSURE

A variety of flaps have been reported for the reconstruction of finger tip injuries. The volar advancement flap was first intoduced in 1964. Recently, this technique was combined with V-Y closure and has been applied in the treatment of thumb tip injuries. We treated seven thumb-tip injuries and five finger-tip injuries using the volar advancement flap with V-Y closure. The flaps were advanced an average of 14 mm (range: 10 to 18 mm). All flaps survived completely. The static two-point discrimination in the flaps ranged from 5 to 8 mm (average 6.3 mm). One of the advantages of this procedure is the single-stage reconstruction of the pulp defect with preservation of sensation. In addition, skin graft coverage of the donor site is not required. The result was excellent with less postoperative complications in thumb-tip injury cases. In finger-tip injury cases, however, several postoperative complications occurred such as the PIP joint contracture, cold intolerance of the dorsum of finger tip, and claw-nail deformity. Accordingly, the indication for this flap should be limited to the thumb injury case.

Hand-Based Thumb Spica Casting

A hand-based thumb spica cast can be used to protect the metacarpophalangeal (MCP) and interphalangeal (IP) joints of the thumb after uncomplicated ulnar collateral ligament (UCL) sprains and certain other thumb injuries. The cast allows continued participation in many activities, letting the patient grip an implement and move the wrist joint but immobilizing the thumb joints.

NEUROVASCULAR PEDICLE AND ADVANCEMENT FLAPS FOR PALMAR THUMB DEFECTS

Thumb injuries are potentially devastating for overall hand function. The aim of surgical reconstruction is to preserve length, restore normal sensibility, and provide an aesthetic, rounded thumb profile. The level and type of thumb injury are most important factors in determining the treatment options for thumb reconstruction. The technical expertise and decision-making skills of the surgeon are of equal significance. With correct management, the majority of patients with these injuries regain excellent functional results.