Closed crush injury of the metacarpophalangeal joint

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Seyler

and early rehabilitative efforts should be initiated to prevent residual stiffness. REFERENCES J. Chabner B, Myers C, Coleman N, Johns D. The clinical pharmacology of antineoplastic agents. N Engl J Med 1975;292:1159-68. 2. Yagoda A , Mukherji B, Young C, et al. Bleomycin, an antitumor antibiotic. Ann Intern Med 1972;77:861-70. 3. Bowers 00, Lynch JB. Adriamycin extravasation. Plast Reconstr Surg 1978;61:86-90. 4 . Larson D. What is the appropriate management of tissue extravasation by antitumor agents. Plast Reconstr Surg 1985;75:397-402.

5. Seyfer A, Solimando D. Toxic lesions of the hand associated with chemotherapy. J HAND SURG 1983;8:39-42. 6 . Yosowitz P, Ekland DA, Shaw RC, Parsons RW. Peripheral intravenous infiltration necrosis . Ann Surg 1975; 182: 553-6. 7. Loth TS, Eversmann WW. Treatment methods for extravasations of chemotherapeutic agents: A comparative study. J HAND SURG 1986;IIA:388-96 . 8. DOfT RT, Alberts DS. Modulation of experimental doxorubicin skin toxicity by beta adrenergic compounds. Cancer Res 1981;41:2428-32. 9 . Seyfer AE, Seaber AV, Dombrose F, Urbaniak JR. Coagulation changes in elective surgery and trauma. Ann Surg 1981;193:210.

Closed crush injury of the metacarpophalangeal joint Closed crush injuries from direct blows to the dorsum of the hand may produce significant metacarpophalangeal (MCP) joint symptoms or dysfunction. We have treated 11 patients who had chronic pain and swelling, but without extensor tendon subluxation, for an average of 7.4 months. Only two responded to nonoperative treatment. The nine who had exploratory surgery had a consistent anatomic lesion that consisted of a partial, arcuate tear of the sagittal fibers. All the patients improved postoperatively. Cadaver dissections of the dorsal MCP tendon mechanism in 11 fresh specimens (44 MCP joints) demonstrated that neither partial nor complete transection of the ulnar sagittal fibers produces radial dislocation of extensor tendons. Radial sagittal fiber transections frequently produced ulnar tendon dislocation. Patients who have closed impact injuries of the MCP joints and present with longstanding pain, swelling, and limited mobility without extensor tendon migration may have sustained unrecognized partial ulnar sagittal fiber disruption. Repair of the partial sagittal fiber tear and exploration of the MCP joint is indicated. (J HAND SURG 1987j12A[2 Pt 1]:750-7.)

Mark P. Koniuch, M.D., Clayton A. Peimer, M.D., Thomas VanGorder, M.D ., and Armando Moncada, M.D., Detroit, Mich. , Buffalo, N.Y., and McAllen, Texas

From the Hand Surgery Service, Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, Mich .. and the Division of Hand Surgery, Department of Orthopaedic Surgery, State University of New York at Buffalo, Buffalo, N.Y. Presented in part at the 41 st Annual Meeting of the American Society for Surgery of the Hand, New Orleans, La., February 1986. Received for publication Sept. 29, 1986; accepted in revised form Feb. 5, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mark P. Koniuch, M.D., Hand Surgery Service, 4160 John R, Suite 907, Detroit, Ml48201.

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AlthOUgh direct blows to the dorsum of the hand and metacarpophalangeal (MCP) joint occur frequently, it is not often appreciated that such closed crush injuries of the finger MCP joints may produce significant symptoms or dysfunction. In the absence of either tendon subluxation or positive radiographic findings, an anatomic disarrangement may not be recognized clinically. When a patient presents with chronic symptoms of discomfort and loss of motion after closed injury of the MCP joint, there is usually an associated injury to the dorsal tendon mechanism. This problem may be serious and functionally disabling.

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The normal and pathologic anatomy of the sagittal fiber mechanism at the MCP joint of the fingers has been well described by many authors. I •5 Most articles deal with pathologic changes secondary to inflammatory joint disease (i.e., the rheumatoid hand) and posttraumatic subluxation of the extensor tendons. 6. 12 Spontaneous tendon dislocation has also been described. 13. 14 However, we have found nothing written about a traumatic dorsal lesion of the tendon mechanism at the MCP joint without subluxation, which we have consistently observed in a series of young adult patients. This study describes this problem and the anatomy in which the lesion occurs and reviews the clinical course. We conducted a retrospective clinical review of 11 patients and performed cadaver dissections of the dorsal tendon mechanism at the MCP joint to produce simulated injuries in 11 fresh specimens (44 joints). Materials and methods I. Clinical study Presenting characteristics. Eleven men aged 18 to 52 years (average age, 29) were studied. All had either fallen and struck their hands, injuring the extensor mechanism at the metacarpal head, or they had been struck directly over the extensor mechanism (when they punched an object or received a direct blow). All injuries were closed. Initially regarded as having minor problems, the patients were referred to us 2 to 24 months (7.4 months average) after the incident that perpetrated the trauma. The dominant hand was affected in 10 of the 11 patients . The long finger was affected in four, the ring finger in five, and the small finger in two. None of the patients, initially or subsequently, had positive radiographic findings, and none had recollection of or demonstrated extensor tendon subluxation with active motion at our examination. There was no joint instability or subluxation. All had experienced persistent local swelling and often disabling discomfort and limited joint mobility. All had tenderness at the site of reported impact. After their injury, the II patients became consistently unable to participate in vigorous work or sports. On examination, in addition to discomfort with active extension, most were found to have an extensor lag of 10 to 45°, and some had evidence of skin dimpling and erythema. (See Table I.) Nonsurgical treatment. All 11 patients initially received at least a 3-month course of nonoperative treatment that included splinting, rehabilitative exercises, oral anti-inflammatory medication, and local steroid injection. Of these various treatments, only the injection provided temporary relief, but symptoms recurred in all within 3 months after several weeks or months of unrestricted activity.

Fig. 1. A 22-year-old laborer with a 9-month history of symptoms. Preoperative appearance of right long finger Mep joint swelling.

Operative treatment. Two of the 11 patients did not return for follow-up. In exploring the affected joint of the remaining nine, no tears of the collateral ligaments were found in any patient, and the tendons did not subluxate spontaneously or on manipulation. The consistent lesion was a partial, arcuate tear of the sagittal fibers (seven on the ulnar side and two on the radial side) tethered by scar tissue to surrounding skin and capsule. Because none of the patients had operations at the time of injury, it is difficult to gauge the exact nature of the (contiguous) capsular lesion, per se . In all cases, the MCP joint was explored, inspected, and lavaged if needed (Figs . 1 through 3). The lesions of the capsule and tom sagittal fibers were repaired in separate layers. Buried-knot nonabsorbable mattress sutures were used to restore continuity of the sagittal fibers (Fig. 4). Postoperative management. Postoperatively patients hands were immobilized for 5 to 10 days, then all were treated with lively (dynamic) MCP extension splints for 2 to 3 weeks (Fig . 5). Active flexion and passive extension exercises were done by the patients under the close supervision of a hand therapist. All patients were followed for 3 to 40 months (\3.3 average) postoperatively. II. Laboratory study To test the effect of sagittal fiber division on position and stability of the extensor tendon mechanism at the MCP joint and to approximate the injury in the labo-

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Table I. Patient data Hand affected dominate/ nondominant*

Finger affected

Side affected

D

Long

Ulnar

Rapid twist; felt pop

Student

D

Ring

Ulnar

Direct blow; clenched fist

M

Carpenter

D

Ring

Ulnar

Automobile accident

21

M

Assistant parts manager

ND

Long

Radial

Direct blow

D. S .

24

M

Youth aide

D

Ring

Ulnar

Twisting door knob

6.

D. V.

26

M

Millwright

D

Long

Ulnar

Direct blow

7.

N. Y.

52

M

Optometrist

D

Ring

Ulnar

Playing racquetball

S.

D.M .

24

M

Dentist

D

Small

Radial

Direct blow fall, rugby

9.

R. H.

53

M

Factory worker

D

Long

Ulnar

Fall onto fist

10.

E . F.

17

M

Student

D

Ring

Ulnar

Punch

II.

1. R.

43

M

Engineer

D

Small

Ulnar

Struck on machine

Patient

Age

Sex

1. M .

24

M

Factory worker

2. B . M.

IS

M

3. R. R.

22

4. G. S. 5.

I.

Occupation

Mec/umism of injury

*0. Dominant; NO. non-dominant. tPI. Postinjury. +Grip strength affected side; grip strength nonaffected side. (In kilograms force.) No.9 did well 8-10 months postoperatively. then symptoms increased; eventual Swanson implant. then fracture. then synovitis. then MPJ fusion.

ratory, we dissected 11 fresh cadaver hands. Specimens with previous trauma or systemic disease were excludecl from the study. Radiographic studies were done on all specimens studied to rule out skeletal disease. The skin was removed from the midmetacarpal to midproximal phalangeal level. Sagittal bands were then transected progressively with a scalpel in a proximal to distal direction for one third, two thirds, and the entire length of the fibers in the 44 MCP joints. Ulnar fiber transection was performed in four hands (16 joints) and radial fiber transection in seven hands (28 joints). Each digit was then gently manipulated at the MCP joint through a full range of motion. Simultaneously, the wrist joint was positioned passively through its range

of motion . The position and stability of each of the extensor tendons were observed with respect to three factors: length of sagittal fiber transection, position of wrist and MCP joint, and digit involved. Results

I. Clinical study The nine patients who had exploratory operations had at least a 50% arcuate tear of the sagittal band mechanism (seven on the ulnar side and two on the radial side), tethering by scar tissue to the MCP joint capsule, and in some cases, to overlying skin at the site of the reported impact. Due to the long interval from injury to operation, it is difficult to know exactly what type

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Duration of symptoms 8 mo

5 mo

2 mo

9 mo

2 yr

lImo

5 wk

7 mo

3 mo 8 mo 3 mo

Closed crush injury of metacarpophalangeal joint

Clinical findings

Treatment

Moderate, boggy nontender swelling 10° extension lag Tender, swelling, mild synovitis, puckering Full range of motion Tenderness, mild, swelling , 15° extension lag

Steroid injection

None

9 mo PI arthrotomy, removal loose bodies

Mild discomfort, crepitance puckering 10° extension lag Mild tenderness, swelling, puckering, 30° lag MP extension; 20° lag flexion Tenderness, boggy, swelling 15° extension lag

None

II mo PI arthrotomy, synovectomy with radial into release 27 mo PI repair extensor mechanism

Soft tissue bulge, swelling, some pain Full range of motion Tethered skin, pain 15° lag extension Tender, locally swollen 20° extension lag Tender, local swelling 20° extension lag 15° extension lag

Steroid injection

None

Operative findingst 12 mo PI repair extensor mechanism capsulotomy, arthrotomy No surgery

753

Follow-up! 15 mo regular job; 28/45 full ROM None

10 mo , regular duties; slight tenderness, full ROM 39/42 10 mo; full ROM (5° extension lag) 50/40 3 mos, regular duties, full ROM, 60/65

Steroid injection

23 mo PI resection arthroplasty

Self-applied splint

No surgery

Injection, splint better, than worse Injection, splint

Typical

II mo; full ROM; full use

Chondral fracture .loose body

*3'12 yr; MP] fusion

Typical

9 mo; full ROM; full use

Typical

7 mo; full ROM; full use

Injection. buddy-tape Injection, buddy-tape

of (contiguous) capsular lesion was present at trauma. Five of the patients had a moderate synovitis of the joint. One also had a large number of cartilaginous rice bodies and a tear of the palmar plate, and another had a chondral infraction of the metacarpal head. All but one of the patients returned to full activities within 4 months of operation, and none had tendon subluxation, recurrence of symptoms, or significant swelling. (See Table I.) II. Laboratory study A 50% radial subluxation occurred in two of the 16 digits after complete ulnar sagittal fiber division (one long and one ring finger), but only when tested at maximal wrist palmar flexion and simultaneous MCP joint flexion . Radial dislocation of the extensor tendon was not produced in any of the specimens on which ulnar

15 mo; changed jobs 15° MP extension lag, tenderness; 21/53 10 wk; full activities then lost to follow-up

fiber transections were done, regardless of the length of the transection or the position of the wrist, the MCP joints, or the finger tested. Complete ulnar dislocation of the extensor tendon was in evidence in 60% of index, long, and ring finger MCP joints. Dislocation occurred only after two thirds or more of the radial fibers had been transected and only at 90° of MCP joint flexion and with a minimum of 60° of wrist palmar flexion . Two fifths of the index, long, and ring fingers exhibited a 50% subluxation of the extensor tendons in maximal positions of joint flexion after fiber divisions of two thirds or more. All ulnarward subluxations occurred at 90° of MCP joint flexion and at a minimum of 60° of wrist palmar flexion . None of the seven small finger MCP joints tested had ulnarward extensor tendon dislocation after radial sag-

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Fig. 2. Partial acurate tear of sagittal fibers on ulnar aspect of Mep joint.

Fig. 3. Illustration of the "consistent lesion"; partial tear of sagittal fibers .

ittal fiber division . One specimen displayed extensor tendon subluxation in maximal flexion with division of two thirds of the radial fibers . The laboratory experiment on fresh-frozen cadaver hands showed that extensor tendon dislocation was not seen after even complete ulnar sagittal fiber division . Except in small finger specimens, there was a high incidence of either a complete ulnarward dislocation or subluxation of the extensor tendon in the ulnar direction after radial sagittal fiber division. Discussion The presence of significant clinical symptoms after closed crush and direct impact injuries to the finger

MCP joint is not commonly appreciated. Several authors have described swelling of the finger MCP joints secondary to repetitive trauma from boxing and karate,15. 16 a condition termed "boxer's knuckle" and hypertrophic infiltrative tendinitis. The cases described in this literature were not reported as having accompanying extensor tendon subluxation. The signs and symptoms in the description by Gardner l7 of an operative exploration of posttraumatic "infiltrative tendinitis," or dense scar tissue of the extensor tendon at the MCP joint, are similar to our observations . Scar tissue tethering of the extensor tendon proximal to the MCP joint similar to that which we found has been reported . 18 However, descriptions of intraoperative findings do not

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Fig. 4. Surgical repair of torn sagittal fibers.

include mention of a tear of the sagittal fiber mechanism. Nonetheless, we most commonly expect significant pathology at this site to be associated with tendon subluxation or dislocation during active motion. A variety of surgical reconstructive procedures to correct ulnarward extensor tendon dislocation secondary to trauma, inflammation, and spontaneous migration have been described. 8 • 19·23 A recent report deals with the successful, nonsurgical care of acute closed dislocation of extensor tendons at the Mep joint. 24 The clinical entity and posttraumatic syndrome described in this study differ from the cases in the literature. We identified a group of 11 patients who sustained closed impact injuries of the Mep joint. Although they had no evidence of either extensor tendon migration, joint instability, or positive radiographic findings, they all had symptoms of longstanding pain, swelling, and limited Mep joint mobility. All but two were apparently unresponsive to nonoperative treatment. At operation, we found a partial acurate tear of the ulnar sagittal fibers in seven patients. Two of the patients had partial arcuate radial sagittal fiber disruption without extensor tendon migration. Their signs and symptoms were identical to those patients with ulnar sagittal fiber damage except that, preoperatively, maximal tenderness was elicited by palpation to the radial side of the joint midline. In all of these patients, the site of the tear and the maximal symptoms were always the same. We did not appreciate this as an anatomic issue until we operated on the first few patients of this

Fig. 5. Postoperative lively extension splint.

group, all of whom had in common the fact that their symptoms did not disappear. Kettlekamp and associates 9 studied the effect of complete radial sagittal fiber disruption on the position and

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stability of the extensor tendon mechanism at the long finger MCP joint. The extensor tendon was shown to have a relatively poor fibrous attachment to the capsule. In our laboratory study we increased longitudinal transections of the sagittal fibers progressively on both radial and ulnar sides of the MCP joints, which were then passively manipulated from full extension to full flexion. We produced the expected ulnarward dislocation of the extensor tendon after radial sagittal fiber transection of two thirds or greater length (index, long, and ring). Interestingly, radialward dislocation did not occur after even complete transection of the sagittal fibers on the ulnar side. The reasons the extensor tendons did not dislocate after ulnar fiber transection are probably that the junctura tendinae exert a tethering effect, and the normal resting posture of the finger is in a position of slight ulnar deviation at the MCP joint.

Summary and conclusions 1. Patients with chronic symptoms after closed impact injuries of the MCP joint without extensor tendon migration or positive radiographs who are unresponsive to nonoperative treatment should be surgically explored. 2. The sagittal fiber tear and any contiguous capsular lesions should be repaired and the MCP joint explored to rule out accompanying intra-articular pathology seen in 25% of our patients. 3. Partial and even complete tears in the ulnar sagittal band fibers are not associated with extensor tendon migration and are, therefore, not as obvious clinically as radial fiber tears accompanied by such tendon subluxation. 4. Patients who sustain a closed crush injury of the metacarpophalangeal joint and thereafter have a history of chronic symptoms are likely to achieve improved motion, comfort, and a return to preinjury function after operative repair and early institution of hand therapy. The authors are grateful for the assistance of Frances S. Sherwin, M. S., in the preparation of the manuscript; and John Nyquist, Associate Medical Illustrator, State University of New York at Buffalo for his work.

REFERENCES 1. Kaplan EB. Anatomy, injuries and treatment of the extensor apparatus of the hand and digits. Clin Orthop 1959;13:24-41.

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2. Littler JW. The finger extensor mechanism. Surg Clin North Am 1967;47:415-32. 3. Eaton RG. Extensor mechanism of the finger. Bull Hosp Jt Dis Orthop Inst 1969;30:39-47. 4. Smith RJ. Balance and kinetics of the fingers under normal and pathological conditions. Clin Orthop 1974; 104:92-111. 5. Kaplan EB, Hunter JH. In: Spinner M, ed. Kaplan's functional and surgical anatomy of the hand. 3rd ed. Philadelphia: JB Lippincott Co, 1984:98-102. 6. Straus FH. Luxation of extensor tendons in the hand. Ann Surg III 1940;135. 7. Wheeldon FT. Recurrent dislocation of extensor tendons in the hand. J Bone Joint Surg [Am] 1954;36:612-7. 8. Elson RA. Dislocation of the extensor tendons of the hand. Report of a case. J Bone Joint Surg [Br] 1967; 49:324-6. 9. Kettlekamp DB, Flatt AE, Moulds R. Traumatic dislocation of the long-finger extensor tendon. A clinical, anatomical and biomechanical study. J Bone Joint Surg [Am] 1971 ;53:229-40. 10. Smith RJ. Intrinsic muscles of the fingers. Function, dysfunction, and surgical reconstruction. In: A.A.O.S. Instructional Course Lectures. St. Louis: The CV Mosby Co, 1975;24:200-20. 11. Posner MA. Injuries to the hand and wrist in athletes. Orthop Clin North Am 1977;8:593-618. 12. Doyle JR. In: Green DP, ed. Operative hand surgery. New York: Churchill Livingstone, 1982: 1447. 13. Harvey FJ, Hume KF. Spontaneous recurrent ulnar dislocation of the long extensor tendons of the fingers. J HAND SURG 1980;5:492-4. 14. Iftikhar TB, Hallmann BW, Kaminshi RS, Ray AK. Spontaneous rupture of the extensor mechanism causing ulnar dislocation of the long extensor tendon of the long finger. Two case reports. J Bone Joint Surg [Am] 1971; 53:229-40. 15. Sperryn PN. Traumatic bursitis in a boxer's hand. Proceedings XVIII World Congress of Sports Medicine. Br J Sports Med 1973;7:103. 16. McLatchie GR, Davies JE, Caulley JH. Injuries in karate. A case for medical control. J Trauma 1980;20:956-8. 17. Gardner RC. Hypertrophic infiltrative tendinitis (HIT syndrome) of the long extensor. The abused karate hand. JAMA 1970;211:1009-1O. 18. Schultz RH. Traumatic entrapment of the extensor digiti quinti minirni proprius resulting in progressive restriction of motion of the metacarpophalangeal joint of the little finger. J Bone Joint Surg [Am] 1974;56:428-9. 19. McCoy FJ, Winski AJ. Lumbrical loop operation for luxation of the extensor tendons of the hand. Plast Reconstr Surg 1969;44:142-6. 20. Harris SH. Reconstructive arthroplasty of the metacarpophalangeal joint using the extensor loop operation. Br J Plast Surg 1971;24:307-9.

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21. Kilgore ES, Graham WP, Newmeyer WL, Brown LG. Correction of ulnar subluxation of the extensor communis. Hand 1975;7:272-4. 22. Millender LH, Nalebuff EA, Feldon PG. In: Green DP, ed. Operative hand surgery. New York: Churchill Livingstone, 1982:1221-2.

Closed crush injury of metacarpophalangeal joint

23. Burton RI. In: Green DP, ed. Operative hand surgery. New York: Churchill Livingstone, 1982:1476-9. 24 . Ritts GO, Wood MB, Engber WO. Nonoperative treatment of traumatic dislocations of the extensor digitorum tendons in patients without rheumatoid disorders. J HAND SURG 1985;lOA:714-16.

Chronic compartment syndrome in the first dorsal interosseous muscle Fifteen patients with clinical signs that could indicate a chronic compartment syndrome of the first dorsal interosseous muscle of the hand were investigated by pressure recording at rest and during exercise. Objective data, verifying such a syndrome, were found in four of the patients. Increased muscle relaxation pressure during exercise and intramuscular pressure at rest after exercise compared with normal pressure were well correlated to the development of the symptoms of chronic compartment syndrome. Fasciotomy of the first dorsal interosseous muscle relieved the symptoms and normalized the pressure. (J HAND SURG 1987;12A[2 Pt 1]:757-62.)

lorma Styf, M.D., Ph.D., Per Forssblad, M.D., and Goran Lundborg, M.D., Ph.D. Goteborg. Sweden

Pain, induced by exercise, swelling, and impaired muscle function have been reported as typical symptoms of chronic compartment syndrome in the lower leg.' Pain localized to the first web space of the hand and impaired muscle strength of pinch grip may be symptoms in patients with "writer's cramp" and similar conditions. The first dorsal interosseous muscle

From the Department of Orthopaedic Surgery, East Hospital and Sahlgren Hospital, Giiteborg, Sweden. This work was supported by grants from the Giiteborg Medical Society, University of Giiteborg, and the Swedish Medical Research Council No. 5188. Received for publication Oct. 23, 1986; accepted in revised form Jan. 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Jorma Styf, M.D., Department of Orthopaedic Surgery, East Hospital, S-416 85 Giiteborg, Sweden.

(FDIM), together with the adductor of the thumb, may be exposed to strenuous static and dynamic loads in persons in professions in which the pinch grip, key grip, and chuck grip is often used. Only three cases of documented chronic compartment syndrome (CCS) in the first dorsal interosseous muscle (FDIM) of the hand have been reported.2.3 This study evaluated recordings of intramuscular pressure in painful and symptom-free hands at rest and during an exercise test in patients suspected on clinical grounds of suffering from CCS in the FDIM. The effect of fasciotomy of the FDIM on the symptoms of CCS and on the intramuscular pressure at rest and during exercise was studied to define the criteria for surgical treatment of the condition.

Materials The criteria in selecting patients for pressure recordings were as follows: (1) A history of recurrent pain over the first web space induced by exercise; (2) Swell-

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