MALLET FINGER INJURY

It arises as a result of impacts to the farthest joint of the finger. The tendon (extensor tendon) which flattens the finger was injured in the area where it adheres to the bone on the farthest knot (distal phalanx). It is mostly observed after closed injuries that no cut is present on the finger.

When the patient was told to flatten his/her finger, she/he can not do this, the finger may be flatten by only with the other hand and the doctor who examines. (Figure 1)

In some cases it is observed that a small fracture accompanies the subject in direct X-rays. (Figure 2)

Ice application and non steroid anti inflammatory drugs will be useful for the pain in the early period (Figure 3). The patients without bone fractures may be treated with mallet finger brace which may be obtained from orthopaedic shops is applied for 2 months without taking off from the finger.

The decision that the patient may be followed by only the brace without any surgical intervention should be given by the doctor in this step.

Surgical intervention is required in cases with open injury and bone fracture. This intervention is performed with local anesthesia. Both fractured bone part and the injured tendon are repaired. By placing a wire which will keep the farthest two knots for approximately two months, the patient’s finger is fixed during this period.

Some of patients do not apply to a specialist by considering that it is only a problem of view. But some of untreated cases may become to a severe shape and movement problem that we call swan-neck deformity by shortening of injured tendon and moving to downward. Therefore, it is very important to get the concerned information from specialists and to have the recovery process under their follow-up.

Source: mallet finger injury

INJURY OF NERVES

Nerves are the transmission systems that transmit signals incoming from the brain to various parts of the body and vice versa. Nerves are made up of thousands of fibers, which progress in cables coiled in protective sheat as groups inside the nerves. The system that bears the cabled transmission is surrounded by a protective insulant.

There are two types of nerves as motor nerves that function to transmit signals from brain to muscles and control the movements, and sensory nerves that function to transmit pain, pressure, temperature and such sensations from various parts of the body.

Nerves can be damaged due to compression, pressure and cut-off. In case of stretching and pressure injuries, the structure of the protective layer surrounding the nerve is not interrupted, yet the transmission system breaks down due to fibers damages, hence the nervous system fails to function. In case of cut-off, not only the nerve fibers but also the surrounding protective layer is damaged. After damages, transmissions cannot be conveyed from brain to the muscles, hence they become dysfunctional or sensory transmissions received from different parts of the body cannot be transmitted to the brain.

Once the nerve fibers are damaged, the structure of the surrounding protective layer subsists. Part of the damaged nerve fibers up to upper transmission station die away and melt down, leaving the protective layer in the form of hollow tubes. Recovery period begins in a while. If the protective sheat is not damaged or the sheat is repaired, fibers continue to grow through the innards of hollow tubes and recovers up to the receptors of motor or sensory nerves. Nerves are the tissues that heal the most slowly in our body. If the protective sheat structure is not repaired, nerve endings that undergo a recovery period and grow on cannot find their way, hence cysts called neuroma are formed at the nerve ending. These cysts form painful electric signals when pressed on them.

If the nerves are fully cut, both nerve endings are identified for treatment and the surrounding protective sheat is repaired by way of thinnest stitches as possible (Fig. 1). Objective of the treatment is to ensure sustainability of the surrounding sheat structure and to enable the nerve fibers, which are now in a healing process, find their way up to the final transmission points. Nerve sheats should be treated carefully with the thinnest stitches as much as possible by way of microsurgery methods to avoid excessive scar tissue and pressure in the nerve healing area. Nerves thin down particularly on hand and finger levels and progress adjacent to vascular structures in general. When a damaged nerve is identified, the vascular damages are often identified in parallel. As very thin stitches are used, a 3-week plaster treatment is applied to protect the repaired area.

Nerve sheats are intended to be sewn back to their original place with the help of vascular structures upon nerves; however, hollow tubes do not often find their original place no matter how original the stitches are in terms of surgery. It is not possible for millions of fibrils to find their original place.

If the injury is very contaminated and is to be left open, nerves may not be sewn in the first surgical operation. In case of nervous defects, a nerve graft often collected from the leg is inserted in between to enable nervous sustainability.

It takes 3 to 4 weeks for nerve fiber to grow up against following the repairs. Fibrils usually progress 1 mm on average within the nerve tubes depending on the age of the patient, type of injury, smoking etc. For this purpose, sensory recovery may take up to 1 or 2 months and 6 or 8 months depending on the proximity of the injury to the target. During this time, the patient should be careful about finger tip injuries while touching warm objects and working. Activity of the muscles stimulated by the nerves should not be lost during the expected nerve recovery.

Source: injury of nerves

FLEXOR TENDON INJURIES

Muscles that provide fingers to bent inside are called flexor muscles. They are connected to finger bones with structures which exits from the current muscles in the forearm and look like chords and called tendons. Flexor muscles start from the elbow and forearm and extends to finger ends by converting into tendons in the middle of the arm (Figure 1). Flexor tendons in the finger passes inside of tunnels called pulleys. Pulleys prevent tendons to move away from the bone by forming tunnels on tendon and they provide active operation of joints.

Flexor tendon injuries may arise after deep cuts of the forearm, wrist, hand and fingers.

Flexor tendons are very close with vessel-nerve structures anatomically. Therefore, in palmar side injuries of the hand, injury is frequently together with vessel, nerve injuries as well as flexor tendons. When tendon injury is occurred, tendon ends move away from each other due to muscle traction. Tendon ends may not be found in the cut area immediately. When flexor tendon cut arises, the patient can not bend his/her finger. If the tendon is not completely cut, bending may be possible by the patient. Generally pain accompanies to this situation. If incomplete tendon cuts are not treated, tendon may be broken away from the cut region.

If tendon ends are not exposed surgically, recovery is not provided. If repair of tendon cuts delays, length of the tendon shorten due to muscle traction and tendon exposing may not be possible. To protect tunnels called pulley that tendons pass in is very important for tendons to perform its functions after the recovery. Vessel-nerve structures which are very close to tendons should be repaired with microsurgerical methods during the surgery. 3-4 weeks of bracing is made to protect sutured structures after the surgical intervention. Movement is not provided just after the plaster is removed. During tendon recovery, cohesion arises to surrounding tissues. Early physical therapy may start with plaster or physical therapy should be given after the plaster. Generally professional physiotherapy is required after flexor tendon injuries. If providing movements are insufficient even after the physiotherapy, cohesion around the tendon should be opened and physiotherapy should start immediately. Early term physiotherapy is important. If physiotherapy does not start on time, to gain movements will be difficult.

Source: flexor tendon injuries

EXTENSOR TENDON INJURIES

Extensor tendons take place on the upper surface of the hand. They play role in lifting the hand and fingers. Extensor tendons are chorda extensions of forearm muscles extending to the fingers. Tendons in the finger tapers and flattens. Besides chorda extensions staring from muscles of the palm (lumbrical and interosseos) also participates to the extensor mechanism which lifts the fingers. (Figure 1.2)

They play important role in finger movements and coordination.

Extensor tendons are just under the skin. Therefore, extensor mechanism injury may arise even with small cuts. After traumas such as compression and crashing, disconnection of thin tendons by dissevering from bone connection points (mallet finger, boutoniere deformity) may be observed. Fingers up-lifting is not performed after extensor mechanism injuries. Surgical treatment may gain old functions in extensor tendon injuries.

Treatment of extensor mechanism cut or disintegration is provided by sewing the cut or disintegrated area. For injuries which is close to finger joints, joints should be fixed by a wire to protect continuity of sutured thin tendon structure. Because of natural features of the extensor tendon, 5 weeks of brace treatment is required for relaxing and not having debility for lifting the finger up.

In cases that extensor mechanisms separate from connection of the extensor mechanism after compression and crushing (mallet finger, boutoniere deformity), re-connection of the tendon from disintegration place is provided by methods such as bracing, finger ring application, using three point braces. Patient compliance is very important in these treatment methods. Another treatment option is to fix by threading pin from bones and joints.

CONGENITAL ARM PARALYSIS (Congenital brachial plexus injuries)

The five big nerves which are extension of the spine, combines with each other with different ways after exits from neck vertebras on side of the neck and under the scapula and forms a nerve web called brachial plexus. Nerve branches which exits from the brachial plexus are responsible either movements of a part of back and chest, arm, forearm and hand or sense of these body parts.

Congenital arm paralysis are those arisen in the brachial plexus due to various reasons before or after the birth. It is mostly unilateral. Symptoms may change according to the severity of the nerve damage. If the baby moves one arm less than the other or if the baby can not move one arm, if the effected hand can’t be made fist, the difference between arms, if one arm is softer than the other, if objects are always clutched by one arm in bigger babies, if the baby can’t take his hand to his mouth; these findings point out brachial plexus damage.

Surgery may be required in about 10% of babies who were effected by brachial plexus injury and the above mentioned problems. But babies born with arm paralysis should be under the control of a team including surgical and physiotherapy of brachial plexus injuries whether surgical treatment is required. First, it should be set forth that if the current paralysis sourced from central nervous system or a problem in the brachial plexus.

In problems that upper nerve roots are involved, shoulder and elbow movements are absent or insufficient. Usually hand movements are complete. If the baby can not take his hand to his mouth in the sitting position in 6-9. months; surgery is considered. (Figure 1)

In another frequent form of the injury, hand sense and movement is insufficient. The child doesn’t respond to stimulus that will give pain to his hand. Shoulder and elbow movements are absent or insufficient. A slight ptosis on the eyelid in the same side of the problem may be observed and the pupil may be smaller according to the other side. Surgery may be thought for patients whom this table doesn’t progress positively from the 3rd month. (Figure 1, 2)

The important is which of these five nerve roots were damaged with which levels in operations performed in this period. A nerve transplant from less used nerves in the daily life may be required for spine level damaged nerve roots. For lower level injuries, nerves taken from legs are used by making a bridge between deficit area. If necessity is thought for nerve operations, it should be applied before one year. Nerves which are taken from the leg are sensory nerves that is not related with movement. Scars in the area that nerves are taken should be ignored for arm functions that will be gained.

One of the most important points that should be remembered related with either brachial plexus surgery or other nerve operations is that operation results will be taken after a long while. The nerve progresses about 1 mm for every day to the finger tip starting from the repaired point by budding. Therefore, a long time between 6 months and 2 years until nerve buds reach to muscles. The patients should be followed with physiotherapy for a long period before and after the surgery.

After it is convinced that nerve recovery is completed, other operating muscles may be transferred instead of non operating muscles in the arm and bone correction operations may be performed if necessary. If these operations are needed, the preferred period is 3. and 5. ages and preschool period. Compatibility of the child for braces that will be used after the operation and physiotherapy process that will be performed increases the success positively.

The thing that is aimed to be obtained after a difficult treatment protocol is to form a helper extremity to the other firm extremity by providing the maximum function that will be able to be provided (a recovery with 100% and complete function should not be waited). But even this may be possible with operations that will be performed within appropriate periods, a compatible follow-up between the patient-family-doctor and physiotherapy process and a big patience.

Source: congenital arm paralysis

ARM PARALYSIS SEEN IN ADULTS

(TRAUMATIC BRACHIAL PLEXUS INJURIES)

Branches of five nerve roots which exits from neck vertebras control movement and sense of all upper extremity by forming a web (Figure 1).

Nerves give the electrical stimulus to our muscles that provide our movements. When nerves are out of function, movement is impossible in muscles that they give electric.

Arm paralysis of adults arise after motorcycle accidents, other traffic accidents, falling from high and forearm wounding. In closed injuries the patient is followed up for three months and some tests are run. In cases that nerve structural integrity is not damaged but regression arises, transmission losses are expected to regress at most within three months. Accompanying tissue injuries such as bone fractures, vessel injuries that may occur in the trauma area are examined and treated. Advanced radiological tests (MRI, Myelo CT) that will help to show whether the nerve is damaged and if it is, the level of injury; and tests that shows nerve transmission and if the muscles take stimulus or not lighten the differential diagnosis.

As in all nerve injuries, operations that will be performed immediately after the diagnosis provides more successful results. Nerves grow by extending 1 mm rate daily from the repair area to downwards. While waiting function from shoulder and elbow muscles is possible, muscles that provide detailed hand movements are the farthest aims. Reason for this is muscles that nerves will give electric turns into the connective tissue slowly and looses their contraction features irreversible. If requirement for nerve operations is considered, it should applied before one year. In this term, how many nerve roots are damaged and their damage levels are important. For nerve roots that are damaged on spine level, transplantation from nerves that we use less may be required. In lower level injuries that nerve roots are visualized, nerves taken from legs are used by making bridge between the deficient region. Nerves taken from the leg are sensory nerves that do not cause any movement failure. Scars of the area that they are taken should be ignored for arm functions.

One of the most important points that the patient and patient relatives should remember related with either brachial plexus or other nerve operations is operations results will be taken after a long time. The purpose after this difficult treatment protocol that may last for years is to form a helper extremity that helps to the stable extremity by providing the maximum function in the arm and the hand (one hundred percent recovery and providing all functions should never be waited). But even this is possible with surgeries that will be performed in a long term, with a complying follow-up between the patient and the doctor and physiotherapy process and a big patience.

Source: arm paralysis seen in adults