Injuries
to the Bones of the Hand
Fracture of the scaphoid bone is common in young adults;
unless treated effectively, the fragments will not unite, and permanent weakness
and pain of the wrist will result, with the subsequent development of osteoarthritis.
The fracture line usually goes through the narrowest part of the bone, which,
because of its location, is bathed in synovial fluid. The blood vessels to the scaphoid
enter its proximal and distal ends, although the blood supply is occasionally
confined to its distal end. If the latter occurs, a fracture deprives the
proximal fragment of its arterial supply, and this fragment undergoes avascular
necrosis.
Deep tenderness in the anatomic snuffbox after a fall on the
outstretched hand in a young adult makes one suspicious of a fractured
scaphoid.
Dislocation of the lunate bone
occasionally occurs in young adults who fall on the outstretched hand in a way that causes hyperextension of the wrist joint. Involvement of the median nerve is common.
occasionally occurs in young adults who fall on the outstretched hand in a way that causes hyperextension of the wrist joint. Involvement of the median nerve is common.
Fractures of the metacarpal bones
can occur as a result of direct violence, such as the clenched fist striking a hard object.
can occur as a result of direct violence, such as the clenched fist striking a hard object.
The fracture always angulates dorsally. The “boxer’s
fracture” commonly produces an oblique fracture of the neck of the fifth and
sometimes the fourth metacarpal bones. The distal fragment is commonly
displaced proximally, thus shortening the finger posteriorly.
Bennett’s fracture
is a fracture of the base of the metacarpal of the thumb caused when violence is applied along the long axis of the thumb or the thumb is forcefully abducted. The fracture is oblique and enters the carpometacarpal joint of the thumb, causing joint instability.
is a fracture of the base of the metacarpal of the thumb caused when violence is applied along the long axis of the thumb or the thumb is forcefully abducted. The fracture is oblique and enters the carpometacarpal joint of the thumb, causing joint instability.
Fractures of the phalanges are common and usually follow direct
injury.
Compartment
Syndrome of the Forearm
The forearm is enclosed in a sheath of deep fascia, which is
attached to the periosteum of the posterior subcutaneous border of the ulna.
This fascial sheath, together with the interosseous membrane and fibrous
intermuscular septa, divides the forearm into several compartments, each having
its own muscles, nerves, and blood supply. There is very little room within each
compartment, and any edema can cause secondary vascular compression of the
blood vessels; the veins are first affected, and later the arteries.
Soft tissue injury is a common cause, and early diagnosis is
critical. Early signs include altered skin sensation (caused by ischemia of the
sensory nerves passing through the compartment),
pain disproportionate to any injury (caused by pressure on
nerves within the compartment), pain on passive stretching of muscles that pass
through the compartment (caused by muscle ischemia), tenderness of the skin
over the compartment (a late sign caused by edema), and absence of capillary
refill in the nail beds (caused by pressure on the arteries within the
compartment). Once the diagnosis is made, the deep fascia must be incised
surgically to decompress the affected compartment. A delay of as little as4
hours can cause irreversible damage to the muscles.
Volkmann’s
Ischemic Contracture
Volkmann’s ischemic contracture is a contracture of the
muscles of the forearm that commonly follows fractures of the distal end of the
humerus or fractures of the radius and ulna. In this syndrome, a localized segment
of the brachial artery goes into spasm, reducing the arterial flow to the
flexor and the extensor muscles so that they undergo ischemic necrosis. The
flexor muscles are larger than the extensor muscles, and they are therefore the
ones mainly affected. The muscles are replaced by fibrous tissue, which
contracts, producing the deformity. The arterial spasm is usually caused by an
overtight cast, but in some cases the fracture itself may be responsible. The
deformity can be explained only by understanding the anatomy of the region.
Three types of deformity exist:
■■ The
long flexor muscles of the carpus and fingers are more contracted than the
extensor muscles, and the wrist joint is flexed; the fingers are extended. If
the wrist joint is extended passively, the fingers become flexed.
■■ The
long extensor muscles to the fingers, which are inserted into the extensor
expansion that is attached to the proximal phalanx, are greatly contracted; the
metacarpophalangeal joints and the wrist joint are extended, and the
interphalangeal joints of the fingers are flexed.
■■
Both the flexor and extensor muscles of the forearm are contracted. The wrist
joint is flexed, the metacarpophalangeal joints are extended, and the
interphalangeal joints are flexed.
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