This is a condition where the terminal joint of a finger, near the nail droops or bends abnormally following an injury.
This may involve either the bone or may be without bony avulsion and affect purely tendon avulsion. Again there may or may not be joint subluxation.
The treatment is aimed at correction of the acute bend also known as mallet deformity.
While majority of patients can be treated conservatively without surgery, there are others who require surgery.
Conservative. Splint supporting the joint for 4 weeks to 8 weeks.
Fixation in place .Wires if kept outside the skin , make removal easier.
Chronic mallet deformity require ligament reconstruction called SORL Or Spiral Oblique Retinacular Ligament Reconstruction
While there are a significant number who do not require surgery, a few who underwent surgery are presented. Almost 10 methods of treatment are available.
The common methods of treatment include:
There are other group of patients who require an open reduction if the bony fragment is more the 1/3 of the width of the phalangeal base. These require interposition of volar plate called volar plate interposition arthroplasty.
FRACTURE BASE OF THE THUMB
Fr base of thumb . If the base (intra articular) of the thumb, the metacarpal one fractures into two pieces, it is called Bennett's fracture.
If the base(intra articular) of the thumb, the metacarpal one , fractures into more than two pieces, it is called Rolando fracture.
For lay public
As one falls, the hand is reflexly stretched out. The major impact is borne by the wrist. Among several injuries that may be sustained by the wrist, one of them may be fracture of the scaphoid bone.
For the injury to occur, the fall may be from a short height or off a two wheeler or while running on a play ground.
Put simply scaphoid is a bone at the base of the most bulky part of the thumb, somewhere near the location, where the doctor checks your pulse.
Following the fall on the outstretched hand, the person will develop a swelling, apparently insignificant, at the base of the thumb. Pain may often not be much. The insignificant swelling and pain may be presumed to be a sprain and but is not so and should not be neglected.
X rays are needed to confirm the diagnosis. Conventional x rays are done using dark room technology. Now at most places, computerized digital x ray technology is available.
Are x rays done differently for fracture scaphoid?
Routine x ray views are called AP(Antero-posterior)and lateral. These views may be misleading as they may not reveal the fracture. A very strong suspicion together with examination by the hand surgery specialist , will necessitate different x ray views. For fracture of the scaphoid, the wrist is placed at different angles. The x ray machine is angled in such a way to pick up a subtle fracture lines.
Figure 1.These are x ray pictures of the wrist of the same patient taken at the same time but in different positions of the wrist and the x ray machine. Focus on the content within the yellow circle. This is the scaphoid bone. In the first x ray view the fracture is not seen. In the second and the third view, the fracture is clearly shown by the arrow within the circle.
Can the fracture be still missed?
Inspite of the best efforts, the fracture can still be missed and not visualized on this first x ray.
Are there any other tests available to ascertain the fracture scaphoid?
Yes. MRI or CT scan, isotope scans can be done.
Shall I ignore my wrist pain if the initial xrays is normal?
No. Do not neglect this suspicion.The wrist needs to be protected in a splint or the plaster cast for about 2 weeks and than the x ray is repeated.
There are two methods of treatment :
The hand is immobilized and rested in a plaster for about 6to 8 weeks or more. Almost 85% of patients are treated this way.
How big is the plaster?
It covers 2/3 of the forearm and the hand. The fingers and the thumb are free. It may be replaced with another material which is fiberglass.
About 15 percent of patients with fracture of the scaphoid bone are treated by surgery.
Who are the patients, who need surgery for fracture scaphoid?
The decision is largely based on the x ray finding. But there are other factors like social aspect and delay in diagnosis, which may influence the plan of treatment.
1. Scaphoid fragments are displaced
2. Scaphoid is in multiple pieces, called a comminuted fracture.
3. There are associated fractures of the adjacent bones like the radius and other carpal bones.
4. The fracture of the scaphoid is associated with displacement of adjacent bones of the wrist. This in medical parlance is called transscaphoid perilunate dislocation.
5. Proximal pole fracture.
Scaphoid bonehas been designed in such away by nature that at one end there is rich blood supply and at the end closer to forearm the blood supply is scanty.This poor blood supply may jeopardize the healing of the fracture.Such a fracture which is near the forearm end of the scaphoid boner is called proximal pole fracture and necessitate surgery.
6. Fracture both hands.
Placing both hands in a plaster cast may make life difficult as far as personal care and eating is concerned .This may again make surgery necessary.
7. Exam next week?.
If one cannot get a writer and it is mandatory to use the hand, surgery is an option.
8. Delayed diagnosis.
There are times, the diagnosis is delayed.The delay in diagnosis can adversely affect healing .The time to healing is significantly prolonged.This may keep the person out of job for several months. Surgery is indicated in such a situations.
This is one of those unfortunate situations, where the bone will just not unite. This will again require surgery.
Can I have plaster cast for just about 2 weeks ?
Inadequate immobilization is an important cause of delayed union and non union of scaphoid. The immobilization has to be for adequate time till tenderness disappears which may be 6 to 8 weeks or more.
Can I go to work after surgery?
Yes, the patient is encouraged to use the hand after surgery. Just be careful and do not fall again!
What do you do in Surgery?
There are several options available. Very thin medical gradestraight stainless steel wires or needles which are called Kirschner wires,are introduced, which hold the fracture together. Than ,there are tiny screws about 20mm long and2 to3 mm thick which clamp the fracture together. These are made of a special material called titanium. Majority of patients are fixed with Titanium screws.
Will I require any supplementary surgery?
Yes you may require bone graft. The bone graft is needed if the scaphoid bone is crushed or the diagnosis is delayed or there is non-union.The bone graft may be harvested from the wrist itself or from the hip region, where you tie your undergarment. It does not harm you in any way.
Are there other types of bone grafts?
Yes, there are bone grafts whish are scooped out from one place and grafted at other place. While there are other grafts which are delivered with their blood supply. These are called vascularized bone graft.
What kind of special aids are needed during surgery?
Xray control or image intensifier or C arm as it is popularly called and magnification. All steps of surgery are precise and at each step, the position of screw placement is accurately determined.
What kind of anesthesia is administered?
It is done under local anesthesia. We call it regional anesthesia. An injection is given in the armpit and the arm goes to sleep for several hours. If you want general anesthesia, itcan be given or avoided based on the wishes of the patient. This is discussed with the patient and then only we proceed.
Does it require prolonged hospitalization?
It can be done on outpatient basis or one day hospitalization.
What if the bone does not unite?
Scaphoid nonunion may be painless to start with. But slowly it is going to damage all the adjacent bones of the wrist in5 to 7 years and lead to irreversible arthritis. So even if it is painless to start with, It should be treated to make it unite and avoid arthritis.
Treatment of scaphoid nonunion
The fracture may have led to deformity in the shape of the bone already. This is corrected with bone graft. The correct alignment is held steady with a screw. If there is early arthritis, this is corrected by excising new bone growth called styloidectomy or bump excision.
What if arthritis has set in following scaphoid non union?
The aim is to provide painless movement to the wrist. Various options are available. One such option involves reconstruction of a new joint by removing arrow of bones .This procedure is called proximal row carpectomy
Fingertip is the commonest injury seen in a hand surgery clinic.
It usually follows the finger getting jammed in the door or caught in a machine.
There are few scenarios:
An example is depicted:Before
In the procedure, the skin is transferred such that, the contour of the finger is restored with an identical colour match.
Image show injury due to door jam. The pulp was lost. The bone was exposed.
The wound was contaminated with dirt.
After debridement, under tourniquet cover, the index was covered with a flap.
The wounds healed primarily without infection.
There was restoration of soft supple skin to the finger tip
This is a story of a young man’s hand. It was caught under a heavy machine one evening. The close by hospital said it needed to be amputed from the wrist.
This would have been a disaster for the boy and his family. The personal officer of the industry took extra efforts and called up from a 70 kms distance.
The patient arrived at 9 in the same night.
Within minutes the patient was examined in the operation theatre.
Examination for us does not mean to see what is lost, but to assess what can be saved and how to make it functional.
Once examined, and told that the hand can be saved, there was no delight on the face of the scared employees but sheer confusion. While at one end there was a frank opinion of amputation, at the other end I was saying I will give a working hand. One of the workers volunteered and took a lead and said go ahead and save it. Rest is all science.
22 years girl got an epileptic fit while in the bathroom and the handremained immersed in the bucket of boiling water for about 3o minutes.
The ensuing oedema appeared like a compartment syndrome. Prompt fasciotomy of the palm was done. This was not of much help. The discolouration of all the digits followed, which had started to appear ominously shrivelled and black. With this discolouration, she had been advised amputation through the wrist.Photo1.
This was the status at presentation at 3 days. A young petite girl with aset of pale and black shrivelingdigits with all the apprehension written on her face and yet conveying in the unspoken words her desire, lay on the examination couch in front of me. The option of a quick amputation ofhand weighed heavily in my heart against an attempt at possible salvage with all the possible risks. Black digits would mean amputation. The mere idea of possible salvage meant an uphill task. It involved an unending saga of reconstructive procedures, each step likely to fail and fail miserably. The failure would have such a cascading effect that all previous procedures will be negated. This will end in amputation, where in fact, one had thought of to start with.
With all the experience and courage onmy part and faith and trust on the part of the girl and her parents and relatives, we embarked on journey of reconstruction, The stakes were high , not in terms of finances, but in terms of reputation for me and frustration on the part of patient.And most insurmountable was the question of survival of thehand. Will this girl have two hands? Will the hand survive? Will the hand work?
The aim was clear. She needed a working hand. The time schedule was clear. It has to be fast and in quick succession, without a break for a few months to start with,at least. We knew the cost of failure. It was amputation! There was not much to talk but everything to execute.
The wound was debrided and all the apparently and definitely dead part of skin and bone were excised. There were grey areas which appeared potentially salvageable.These were painstakingly saved. After a thorough debridement which lasted for hours, the patient was left with fingers which had lost a certain length and the palm. The salvaged finger and the back of the hand were bare as the deadskin had been removed totally. A huge stock of bare skeleton needed cover and that too immediately. Figure 2. The time was not to wait till next morning .The time was running out. In fact it had already run out. We were on spare fuel. It was now.
Such a large area of skin loss could only be transferred from a very few selected parts of the body.We chose the safety and colour match from her abdominal skin.The bare skeleton of the hand was buried in a pocket created in the abdominal wall. Figure3.
The skin healed nicely over the next few weeks. On the part of the patient,she tolerated the relatively awkward positionof lettingthe hand remain attached to her tummy for several weeks. There were several hitches in the healing. Certain length of the phalanges were lost. In spite of these minor hitches, the wound healed eventually but surely in the projected time frame.Figure4.
There was no infection, the most dreaded complication. We had overcome the first hurdle.The bare skeleton of the hand had been covered with the protective shield of soft, supple and pliable skin.
All the fingers and the thumb were within the cocoon of the new skin cover.Figure4.
Now the next step was creating a thumb.The thumb makes the hand, an organ for grasp. All the fingers and the thumb had been enveloped in the common sheet of skin. The skin had to be separated in such a way that the thumb could be separated from digits. Put simply, this step was reconstruction of the first web space.Figure5
Another successful step had been accomplished. Yet there were miles to go before I…….. .
The injury had left the thumb short. The plan was to give a longer thumb. The author had designed a mini external fixation device. The device was used to lengthen the thumb.Figure6. The short thumb grew painlessly over the device. Over the next few months, the growth was considered satisfactory, both on observation and on x ray. The device was than dismantled.Figure7.
One more mile stone achieved. Yes it may appear that the experience of prolonged treatment was harrowing. Probably yes and probably not.Probably yes ‘cos the mother accompanied the daughter, travelled a distance of 6hours by regular state transport bus and stayed with their local relatives. I say probably no ‘cos the result of each surgery unfolded something beneficial and yes the stakes were too high to be compromised at any stage, by anything. My job was to make things as easy as possible, which came with constant communication.
One should admire, applaud and appreciate the help, cooperation, patience, inconvenience and tolerance of the local relatives who went all out to extend them all possible help and letting them be guest for unscheduled,unrestricted and repeated stay intheir small houses .Heart was big, the house may havebeen small.
The thumb was long and strong.But it was curved.We wanted it to be straight and out or extended so that she can grasp larger objects. An extension osteotomy was done to achieve a wider web.Figure8.This gave a good pinch with the other digits.
While this had all been achieved on the radial side, there were importantmatters to be addressed on the ulnar side of the hand. Like the thumb which had been lengthened, the fifth metacarpal was lengthened on the ulnar side to give extra length to the ulnar post! The length was just about adequate to provide extra support and yet not look obviously grotesque.
The fingers were short. The index comes into play most often. There was a short stump of proximal phalanx which was still present over the index finger. A cannulated titanium screw was inserted into the proximal phalanx to augment the length of the index.figure9. This was another significant functional boost to the patient.
I was greatlyencouraged.
While the patient did better with each step, the mother returned every time only to ask if anything else can still be done. On the social front, the girl pursued her graduation and post graduation and finished her masters in a science stream.If this was not enough, she had a driving licence issued by the Regional transport Office, the RTO!
What is more, she got employed as a professor! She can write on the black board!
Encouraged, by her determination, perseverance for getting the hand look and function closer to normal, we created the second web. Creation of the second web gave her an index finger and a middle finger.The fingers were short, but for her, they were still, the index and middle fingers!
The fingers were slightly bulky with all the fat which came bundled with the abdominal skin which had been transferred initially. The extra fat and the skin were trimmedover the fingers,for the fingers to look slimmer.
At an earlier occasion, a titanium screw had been insertedin the index finger.This had done well without any sign of loosening,pain or infection. The second web created another independent finger; the middle finger. Soanother pair of titaniumscrewswere inserted into the middle finger to augment its length.
A young man sustained this injury in a machine.There was injury to the upper arm, with fracture of the upper arm bone called humerus. The major artery called Brachial artery was torn .The hand was cold and pulseless on arrival. The wound on the arm was soiled in industrial grease and dirt.Photo 1&2.>
Photo 1&2 : At presentation after injury.
As there was no blood supply. it was crucial to proceed very fast . Fast however never meant jumping red signal. Red signal here would mean follow all the required steps of surgery. The first step was cleaning the wound, and converts it into a clean wound. It meant removal of all dead and foreign material. It also meant not to damage any crucial structures . The crucial structures here were major nerves. Photo 3and 4.The bone, artery& veins were all repaired by the author himself.
Photo 3&4 :After cleaning (debridement).This is key to success. Nerves were intact, though contused, as seen here. Only one muscle ( Biceps) was intact. Nerves were meticulously cleaned and saved.
Picture 5&6: After fixation of bone, repair of major artery and veins.Wound healed primarily without infection.
Figure 7,8,9&10.Bone healed. Median and ulnar Nerves showed good recovery. There was some weakness of radial nerve innervated muscles.
Patient Name : Nandi
Photo 11,12, 13, 14. Secondary tendon transfers were done for wrist and finger extension . Full function achieved. Compare this to photo 1.