Injuries & Tears

The wrist is more prone to injuries /problems that may include sprains and strains as well as fractures can occur with lifting and carrying heavy objects, wrist injury while operating machinery, bracing against a fall, or sports-related injuries.

Some of the common wrist injuries include:

Sprains and strains: Sprains and strains are the two most common types of injuries affecting the wrist. A sprain refers to an injury to a ligament and a strain refers to a muscle injury. Sprains and strains occur due to excessive force applied during a stretching, twisting, or thrusting action. Most sprains and strains will repair themselves with adequate rest, ice application, compression, and elevation. Surgery is occasionally required to repair the damage.

Ligamentous injuries: Ligaments are tissues that connect bones to other bones. They are made up of several fibres and one or all of the fibres may be involved. Complete ligament injury occurs when all the fibres are torn. Ligament injuries may cause pain and swelling and limit the movement of wrist joints. Ligament injuries are effectively treated with splinting and taping with restriction of movement of injured structures.

Fractures: A fracture is a break in the bone that occurs when more force than the bearable limit is applied against a bone. Crushing injuries to the hand or wrist, occurring due to high degree of force or pressure, may also cause fractures. A fracture may cause severe pain, swelling, bruising or bleeding, discolouration of the skin and limit the mobility of the limb. Fracture of the wrist bones can be treated by using a cast or splint while the bone heals. Sometimes, surgery may be needed where the plates, pins or screws may be placed to keep the stable.

Repetitive trauma syndrome: Repetitive stress injury occurs as a result of repeated similar movements for longer periods of time. This often causes pressure on the joints, resulting in inflammation, pain and decreased function in the extremity. The condition is more likely to develop with repetitive, rapid, forceful and prolonged movements of the wrist, or vibration or frequent pushing, pulling or carrying heavy objects. Carpal tunnel syndrome is the most common of these syndromes.

Carpal tunnel syndrome: Carpal tunnel syndrome is a condition characterised by numbness or pain in the thumb and first two fingers, and occurs when the median nerve is compressed at the wrist. Carpal tunnel syndrome is often a common complaint in individuals who use their hands for prolonged period of time in a particular occupation. Immobilisation of the affected part for a certain period may help heal the condition. Medications, physical therapy and surgery may also be recommended. Often, splinting for a shorter period of time can treat the condition.

Any problem that causes pain, swelling, discoloration, numbness or a tingling sensation, or abnormal positioning of the wrist that persists for more than two or three days should be evaluated by your doctor to establish the cause and obtain the best treatment as early as possible.

Tendons are bands of fibrous connective tissue that connect muscles to bone. Tendons aid in the movement of the fingers, hand and all other body parts.

There are two types of tendons present in the hand: the extensor tendons and flexor tendons. Extensor tendons present on the top of the hand help with straightening the fingers. Whereas, flexor tendons that lie on the palm side of the hand help in bending the fingers. The flexor tendons are smooth, flexible, thick tissue strands that bend the fingers.

Deep cuts on the under surface of the wrist, hand or fingers can cut and injure the tendon and make it unable to bend one or more joints in a finger. When a tendon is cut, it acts like a rubber band, where the cut ends are pulled away from each other.

Flexor tendon tears may be partial or complete. If tendons are completely cut through, the finger joints cannot bend on their own at all.

Causes

Any cut or laceration to the arm, hand, or fingers can cause a flexor tendon injury. Other possible causes include:

• Damage to the tendon from a sports injury, often associated with football, rugby and wrestling
• Stretching of the tendon, where the tendon is pulled off the bone
• Jersey finger: When a player's finger catches on another player’s jersey or clothing
• Rheumatoid arthritis
• Adventurous activities such as rock climbing

Symptoms

Inform your doctor if you have any of the following symptoms:

• Recent cut on hand or fingers
• Pain
• Swelling
• Loss of ability to bend the finger
• Numbness (loss of sensation)

Diagnosis

Make sure to see a doctor when you sustain a finger injury that is affecting the flexion and extension of your fingers.

First aid: Apply ice immediately on the injured finger. Wrap a sterile cloth or bandage around the injury and keep your finger elevated above your heart level to reduce bleeding if present. A tetanus injection may need to be administered if not current.

Your doctor will review your symptoms and medical history. A physical examination will be done, which includes a complete examination of both hands. During the exam, you will be asked to bend and straighten your fingers. Your fingers will also be checked for sensation, blood flow and strength. An X-ray may be ordered to check for any damage to the surrounding bone.

Treatment

A ruptured tendon cannot heal without surgery because the cut ends usually pull away after an injury.

There are many options to repair a cut tendon; the type of repair depends on the type of cut. The aim of the procedure is to restore normal function of the joints and surrounding tissues following a tendon laceration.

The flexor tendon repair is usually an outpatient procedure and can be performed under local or general anaesthesia. The surgeon makes an incision on the skin over the injured tendon. The damaged ends of the tendon are brought together with sutures to achieve a secure repair. If the tendon injury is severe, a graft may be required. A graft is a piece of tendon that is derived from other parts of the body such as a foot or toe. After the repositioning of the tendon, the incisions are closed with sutures and a dressing pad is placed over the surgical site. Your surgeon will place your hand in a protective splint to restrict movements.

Depending on the injury, you will be advised to start hand therapy for a few weeks following surgery. This is to improve the movement of the finger. Follow your surgeon’s specific instructions for a successful recovery.

Possible complications of surgery include pain, bleeding, infection, stiffness, rupture of the repair, and damage to the surrounding nerves or blood vessels. A second surgery may be needed to release any excess scar tissue that interferes with finger movement.

The hand is one of the most flexible and useful parts of our body. Because of overuse in various activities, the hands are more prone to injuries, such as sprains and strains, fractures and dislocations, lacerations and amputations while operating machinery, bracing against a fall and sports-related injuries.

Fractures

A fracture is a break in the bone, which occurs when force greater than the bearable limit is applied against a bone. The most common symptoms of any fracture include severe pain, swelling, bruising or bleeding, deformity, discolouration of the skin and limited mobility of the hand.

Finger fracture

Fingers are fine structures of the human body that assist in daily routine activities through coordinated movements. Any abnormality affecting the fingers can have a huge impact on the quality of life. A finger fracture is not a minor injury, and if left untreated can lead to stiffness, pain, disruption of the alignment of the whole hand and interference with specialised functions such as grasping or manipulating objects. Finger fractures commonly occur during sports activities, when you break a fall or while operating machinery.

Diagnosis

The diagnosis of a hand or finger fracture is based on history, physical examinations and X-ray imaging to determine the type and severity of the fracture. X-rays are the most widely used diagnostic tools for the evaluation of fractures.

Treatment

The objective of early fracture management is to control bleeding, provide pain relief, prevent ischemic injury (bone death) and remove sources of infection such as foreign bodies and dead tissues. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after the fracture heals. To achieve this, maintenance of fracture reduction with immobilisation technique is done by either non-operative or surgical methods.

Non-operative Therapy

The bones can be realigned by manipulating them into place. Following this, splints, casts or braces made up of fibreglass or plaster of Paris material are used to immobilise the bones until they heal. The cast is worn for 3 to 6 weeks.

Surgical Therapy

During surgery, the fracture site is adequately exposed, the bones realigned, and reduction of the fracture is done internally using wires, plates and screws and intramedullary nails.

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of the cast or brace so that the bone becomes solid enough to bear stress. Rehabilitation program involves exercises and gradual increase in activity levels to strengthen the muscles and improve range of motion.

Injuries to the fingertip can involve crushing, tearing or amputation (cutting-off) of the tips of the fingers, which can occur at home, work or during play. Fingertip injuries can occur during every-day activities while using a knife, a lawnmower or snow blower, or when we jam our hands/fingers in the door. They are the most common injuries that occur to the hand. The tips of the longer fingers are more prone to such injuries. The skin, soft tissue, bone, nail and/or nail-bed can become damaged.

First aid

First aid can be administered immediately after the injury, before visiting a doctor. You should clean the injured part, elevate it and apply ice to reduce the bleeding and swelling. Cover the fingertip with a sterile dressing and immobilise it with the help of a splint. For a fingertip that has been amputated, you should clean the amputated part with saline and wrap it in gauze. The injured part can be inserted in a watertight bag and the bag can be placed on ice. Avoid putting the amputated part directly in ice as it can damage it further.

Diagnosis

At the doctor’s office, your doctor will ask you how the injury happened and consider your medical history. The wound will be examined for missing tissue, exposed bone and nail injury. Your doctor will clean the wound to remove contaminants and dead tissue, and will inject an anaesthetic to relieve pain in the affected finger. X-rays may be ordered to confirm a fracture.

Treatment

The fingertips have a rich nerve supply and are very sensitive. If not treated immediately and efficiently, the injury can lead to permanent deformity and can disrupt the complex functioning of the hand. The aim of treatment is to alleviate pain and preserve sensation and normal functioning of the hand and fingers.

Your doctor may pierce the finger to relieve pressure if blood builds up under the nail. You may be given antibiotics or a tetanus shot to prevent infection. Treatment of fingertip injuries depends on the extent of injury and the angle of cut.

Tissue injury without exposed bone

A small wound may close on its own. Your doctor may cover it with a dressing and recommend a splint for protection while the wound heals. You may be instructed to soak the finger in warm water and an antiseptic solution.

Large and open fingertip wounds that do not have any skin remaining to cover the wound may require surgery. Surgery involves covering the injury with a skin graft taken from your palm (donor site) and suturing both the openings.

Exposed bone injury

A large injury with exposed bone may not have enough tissue to cover the wound and would require surgery. Surgical techniques include:

• Reconstructive flap surgery: This surgery is performed to cover the wound with new skin, fat and blood vessels. Skin flap or soft tissues can be taken from the injured or healthy finger, or palm of the same hand. The flap can also be taken from the skin next to the wound and pulled over the injured finger to cover it while it is still connected to the donor site. This provides a healthy blood supply to the injured tissue. Once the wound is covered with the skin graft, it is allowed to heal.
• Replantation: If a large part of the fingertip is cut-off, your surgeon may reattach the amputated part to the wound site.

Fingertip injuries in children

The surgeon will clean and prepare your child’s amputated fingertip and reattach it. Even in case of injury with bone exposure, the reattached fingertip should continue to grow normally. This is especially possible in children below 2 years of age.

Physical therapy

Exercise may be suggested for improving the strength and movement of your hands. Your doctor or physical therapist may suggest additional therapies, such as electric stimulation of the nerves, heat and massage therapy, traction, splinting, and special wrappings to control swelling and promote healing.

Introduction

A nail is the hard covering at the end of the dorsal side of your fingers and toes. The nail is composed of a nail plate, nail matrix (a tissue that protects the nail) and nail bed. The nail plate is a hard, translucent part of the nail composed of a protein called keratin. The nailbed is the skin that is present below the nail plate. Nail bed injuries are very commonly associated with hand injuries or fingertip injuries.

Causes

Generally, nailbed injuries are caused during road accidents, crush injuries (while handling tools), cutting (while handling machinery) and when the fingers get jammed between doors.

Symptoms

The symptoms of a nailbed injury are based on the type of injury. A minor injury will be characterised with swelling and pain. Moderate level of injury may cause clotting of blood associated with deeper pain. Severe injuries can result in cutting of the nail, tearing and rupturing of adjacent structures, and even fracture of bones under the nail.

Diagnosis

The presentation of nailbed injuries is obvious and does not require diagnostic tests most of the time. Your doctor might recommend X-ray if the nail bed injury is severe and has led to the fracture of a bone. Blood tests are not usually recommended unless necessary (if you are diabetic).

Treatment

The goal of treatment is to restore the normal anatomy of the nail and the surrounding structures. A simple blood clot that appears as red or purple in colour will fade away gradually. Pain killers and antibiotics may be advised to alleviate the pain and prevent infection. In case of severe injuries, such as a nail cut and broken bones, surgery may be recommended. Restoring the finger alignment with the help of splinting and using nailbed grafts to replace the injured portion of the nail can heal the damage effectively.

Prevention

Nailbed injuries are mostly accidental. Care should be taken to avoid injury by handling things safely. Some of the precautions that can be taken to avoid the complications of nail bed injuries are:

• Do not pull off or cut the nail after injury
• Apply pressure to stop bleeding
• Wash the area carefully and wrap the wound with a clean cloth
• Get a tetanus immunisation

The forearm consists of two bones, the radius and ulna. The radius is the larger of the two forearm bones, and the region towards the wrist is called the distal end. Fractures in this end are most common.

The distal radius can be broken in various ways, but generally occurs around 1 inch from the distal end of the wrist. The most commonly occurring distal radius fracture is the Colle’s fracture, which leads to an upward tilting of the broken radius bone. Other types of distal radius fractures include:

• Intra-articular fracture: Fracture extending into the wrist joint
• Extra-articular fracture: Fracture not extending into the wrist joint
• Open fracture: Fractured bone, that breaks through the skin
• Comminuted fracture: Bone fractured into more than two pieces

Causes

Falling onto an outstretched arm is the most common way to fracture the distal radius. Other causes include:

• Minor falls with the presence of osteoporosis (fragile bones)
• Major trauma to the wrist during a vehicular accident

Symptoms

The symptoms occurring with distal radius fractures include bruising, swelling, immediate pain and tenderness, and limited mobility. The broken wrist may also appear deformed.

Diagnosis

Your doctor will diagnose distal radius fractures by ordering an X-ray of the wrist to detect broken or displaced bone. Your doctor can also view the number of pieces the bone is broken into from the X-ray images. Sometimes, a computer tomography (CT) scan may be required to get a detailed view of the fractured fragments.

Treatment

You can protect your wrist with a splint and apply an ice pack while keeping the wrist elevated until the doctor examines it. The choice of treatment will depend on your age, level of activity, nature of fracture and your surgeon’s preference.

Nonsurgical treatment

If the bone is aligned properly even after the fracture, a plaster cast may be enough to allow it to heal on its own. In case the broken bones are misaligned, realignment of the broken fragments may be required. For this, your doctor may perform closed reduction, which involves moving the broken bone pieces into place and straightening the bone without opening the skin. After alignment of bones, your doctor will place a splint or cast on your arm. The splint may be used initially for a few days till the swelling subsides, after which a cast may be added. The cast may be changed after a few weeks as it loosens with the reduction in swelling.

The healing process will be monitored with regular X-rays. After the cast is removed, the doctor may recommend physical therapy to help improve the function and motion of your injured wrist.

Surgical treatment

Surgical therapy is recommended for fractures that are completely displaced and cannot be corrected with a cast. Open reduction technique involves directly accessing and aligning the broken bones through an incision. After alignment, the bones can be secured together in the correct position with the use of any of the following or a combination of these techniques:

• Cast
• Plate and screws
• Metal pins (titanium or stainless steel)
• External fixation (outside the skin stabilising frame to hold the bones in its aligned position until it heals)

Open fractures: Surgery is recommended for all open fractures within a few hours after the wrist injury. The bone and exposed soft tissues are thoroughly cleaned, antibiotics are administered to prevent infection, and internal fixation methods are used to hold the broken bones in correct position. For badly damaged soft tissues, a temporary external fixator may be placed. The internal fixation screws or plates may be placed after several days in a separate procedure.

A laceration is a tear or ragged opening in the skin usually caused by an injury or trauma. A laceration may be either a partial laceration or a complete laceration. Tendons connect muscles to bones and allow coordinated movement of the joints. A deep cut or laceration on the palm side of the hand can damage the flexor tendons that control movement in your hand. Since the nerves of the hands are located very close to the tendons, a laceration may damage them as well, causing numbness in your fingers.

Causes

Tendon and nerve lacerations may be caused by blunt trauma such as a sudden blow or a fall or by sharp objects such as a knife or broken glass.

Symptoms

The symptoms of a tendon laceration include pain, tenderness, and inability to bend the joints of your finger. Lacerated nerves often cause pain and numbness in your fingers.

Diagnosis

The diagnosis of tendon and nerve lacerations is made on the basis of your history and physical examination. An X-ray may be taken to rule out any fractures. If the nerves are lacerated your doctor may order an electromyography (EMG) or nerve conduction velocity (NCV), an electrical conduction test to determine the extent of damage to the nerve. Sometimes, an MRI Neurography or CT scan may also be recommended.

Treatment

The treatment for tendon laceration includes cleansing the wound, removal of dead tissue and dressing or splinting the wound to prevent infection. If required, pain medications or antibiotics may be prescribed to reduce pain and inflammation, and prevent infection. Physical therapy is usually prescribed to regain range of motion, strength and function.

If a tendon is completely lacerated, surgery to sew the ends of the tendon back together may be necessary. After surgery, a dressing or splint is applied to protect the repair.

Loose bodies are small loose fragments of cartilage or a bone that float around the joint. The loose bodies can cause pain, swelling, locking and catching of the joint. Loose bodies occur if there is bleeding within the joint, death of tissues lining the joints associated with tuberculosis, osteoarthritis and rheumatoid arthritis. Other causes include fractures, trauma, bone and cartilage inflammation and benign tumours of the synovial membrane.

Loose bodies are commonly found in individuals who participate in sports since they are more susceptible to fractures and other sports injuries.

Often, X-ray helps in diagnosing loose bodies. However, small loose bodies that contain little fragments of bone or no bone may not be visible on an X-ray. In such cases, other diagnostic tests such as CT scan or arthrography, MRI scan and ultrasound may be performed to locate the loose body. For small loose bodies, your doctor may prescribe anti-inflammatory medications to relieve pain and swelling. However, any loose body that is causing the symptoms are removed.

The loose bodies are removed by an arthroscopic procedure. Surgery is performed depending on the location and the size of the loose bodies.

• A suction tip is used to withdraw the loose body or is held with a small needle and grasped with a surgical instrument called a grasper.
• If loose bodies are present in the joint space, a special instrument, called mechanical burr or a resector is used to break the loose bodies. The broken pieces will be easily degraded by the body by means of a mechanism called enzyme degradation.
• Large loose bodies caused by fractures, inflammation of bone and cartilage (osteocartilaginous loose bodies) are reduced and fixed into position using screws or pins.
• If the loose body is caused by benign tumours of the synovial membrane, a procedure called partial synovectomy may be done. It involves removal of part of the synovium.
• Arthrotomy is a surgical procedure that employs an open technique, in which incisions are made into the joint and the loose body is removed.

Following surgery, rehabilitation program may be needed to control pain and restore function and strength to the involved joint.

A mallet finger is a condition where the end of the finger is bent and does not straighten. It occurs when the extensor tendon on the back of the finger is damaged. The finger joint is a hinge-joint that allows bending and straightening of the fingers. Each finger is composed of 3 phalanges bones, joined by 2 interphalangeal joints (IP joints). The joint near the base of the finger is called the proximal IP joint or PIP joint, and the joint near the tip of the finger is called the distal IP joint or DIP joint.

Mallet finger occurs from sports activities, causing a “jammed” finger or from excessive stress on the finger such as with a crushing injury. The injury causes either rupture of the extensor tendon without a bone fracture, or rupture with a small or large bone fracture.

Generally, a mallet finger can be treated non-surgically using specially designed splints that immobilise the finger and promote natural healing. In cases of fracture, complete bone healing may take 6-8 weeks, followed by physical therapy for strengthening. In severe cases that don’t respond to conservative treatment, surgery is recommended.

If left untreated, a mallet finger can develop into a finger joint deformity referred to as a swan neck deformity.

Causes

Mallet finger occurs due to sports activities (such as baseball) or other activities that cause a direct and forceful impact on the fingers.

Signs and Symptoms

The main symptoms of a mallet finger are drooping of the finger at the distal joint, pain and swelling around the area, and limited range of motion at the joint.

Diagnosis

The diagnosis of mallet finger involves a physical examination and obtaining an X-ray of the injured finger. In some cases, other imaging techniques such as MRI scan may be recommended.

Treatment

A mallet finger can be treated non-surgically by applying a specially designed splint for 6-8 weeks. Immobilising the finger with a splint helps promote natural healing of the torn tendon or bones.

For patients who require the use of their fingers to perform occupational tasks, internal splints can be used; this involves surgical placement of metal pins in the affected bones. The pins can be removed after 6 weeks of healing.

Patients who fail to achieve adequate relief are recommended for surgery, which involves repairing the torn tendon. If the mallet finger involves a fracture of the bone fragment, then it can be stabilised and fixed using pins and a special K-wire.

Post-operative care

After mallet finger surgery, the patient is recommended for physical therapy or occupational therapy for flexibility and strengthening exercises.

Risks and complications

The common risks and complications associated with mallet finger surgery, include:

• Avascular necrosis (bone death from lack of blood supply)
• Infection
• Stiffness
• Nailbed damage
• Chronic tenderness

The radius (bone on the thumb side) and ulna (bone on the little-finger side) are the two bones of the forearm. Forearm fractures can occur near the wrist, near the elbow or in the middle of the forearm. Apart from this, the bones in children are prone to a unique injury known as a growth plate fracture. The growth plate, which is made of cartilage (flexible tissue) is present at the ends of the bones in children and helps in the determination of length and shape of the mature bone.

The healing of fractures in children is quicker than that in adults. Thus, if a fracture is suspected in a child, it is necessary to seek immediate medical attention for proper alignment of the bones.

Types of fractures

Forearm bones may break in many ways. Fractures may be “open”, where the bone protrudes through the skin or “closed”, where the broken bone does not pierce the skin. The common types of fractures in children include:

• Buckle or torus fracture: A stable fracture that compresses the bone on one side, forming a buckle on the opposite side of the bone, without breaking the bone
• Greenstick fracture: One side of the bone breaks and bends the bone on the other side
• Galeazzi fracture: Displacement of the radius, and dislocation of the ulna at the wrist where both bones meet
• Metaphyseal fracture: Fracture affecting the upper or lower portion of the bone shaft
• Monteggia fracture: Fractured ulna and dislocated head of the radius
• Growth plate fracture: Fracture occurring at or across the growth plate

Causes

Forearm fractures in children are caused due to a fall on an outstretched arm or direct hit on the forearm, which may result in breakage of one or both bones (radius and ulna).

Signs and Symptoms

A fractured forearm causes severe pain and numbness. Other signs and symptoms include:

• Swelling
• Tenderness
• Inability to turn or rotate the forearm
• Deformed forearm, wrist or elbow
• Bruising or discolouration of the skin
• Popping or snapping sound during the injury

Diagnosis

Forearm fractures in children can be diagnosed by analysing X-ray images of the wrist, elbow or the forearm.

Treatment

The treatment of forearm fractures in children is based on the location, type of fracture, degree of bone displacement and its severity.

Non-surgical therapy

Your child’s doctor will advise you to apply an ice pack over a thin towel on the affected area for 15-20 minutes 3-4 times a day, to relieve pain and swelling. For severe angled fractures, in which the bones have not broken through the skin, your doctor will align the bones properly without the need for surgery (closed reduction). A splint or cast may be required for 3 to 4 weeks for a stable buckle fracture. Immobilisation for 6 to 10 weeks is recommended for more serious fractures.

Surgical Treatment

Surgery may be necessary for severe fractures such as fractures of the growth plate or the joint. Other conditions, such as broken skin, bone displacement, unstable fractures, misaligned bones, and bones healing in an improper position may also require surgical repair. Your surgeon will first align the bones through an incision and use fixation devices like pins or a metal implants to hold the bones in place while the wound heals. A cast or a splint may be placed to hold the bones in place.

Conclusion

In the long run, the forearm of your child may have a slightly different or crooked look than before the fracture, which is normal. It may take around 1-2 years for the bones of the forearm to straighten while the bones undergo the process of remodelling (reshaping). For growth plate fractures, your child’s doctor will carefully monitor the hand for many years to ensure that growth occurs normally.