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The diagnosis is generally based on symptoms and supported by X-rays.
Diagnosis by a doctor’s examination is the most common, often confirmed by x-rays. X-ray is used to display the fracture and the angulations of the fracture. A CT scan may be done in very rare cases to provide a more detailed picture.
"Any finger injury that is sustained by a young adolescent (12–16) should be seen by a physician and have x-rays performed. These skeletally immature athletes are very susceptible to developing debilitating joint arthritis later in adulthood."
RSIs are assessed using a number of objective clinical measures. These include effort-based tests such as grip and pinch strength, diagnostic tests such as Finkelstein's test for De Quervain's tendinitis, Phalen's Contortion, Tinel's Percussion for carpal tunnel syndrome, and nerve conduction velocity tests that show nerve compression in the wrist. Various imaging techniques can also be used to show nerve compression such as x-ray for the wrist, and MRI for the thoracic outlet and cervico-brachial areas.
Management of tendon injuries in the fingers is to follow the RICE method.
- Immediately cease climbing and any other activity that puts stress on the injured finger. Consult a doctor if there is noticeable "bowstringing" on the flexor tendon or if you are the least unsure about the nature of the injury.
- There are different theories out there for the preferred line of approach. Some argue for the use of NSAIDs and ice for visible swelling only, others argue diclofenac sodium should be applied and carefully rubbed in on the injury until the swelling starts to give.
- When the pain and swelling is gone (depending of the grade of the injury, 1–4 weeks), begin with an active healing process – containing squeezing putty clay or a stress ball. Combine this with light massage and mild stretching to ensure your finger will heal properly and better prepared for future stress. The use of heating pads and cold water baths are also mentioned in several sources in order to increase blood flow. Use this therapy for about twice as long as the previous resting period (2–8 weeks) before gradually returning, with the utmost care, to climbing.
- Gradually return to climbing while using prophylactic taping every time you climb, and spend the first weeks climbing relatively easy routes with big holds, good footholds and keep your sessions short and stay away from overhangs and campus areas/boards.
- Return to full-force climbing if easy climbing yields no pain. Continue taping (it will also serve as a mental note of the previous injury) and avoid tweaky crimps and pockets for several months, since complete tendon healing can take 100 days or more.
Boxers and other combat athletes routinely use hand wraps and boxing gloves to help stabilize the hand, greatly reducing pain and risk of injury during impact. Proper punching form is the most important factor to prevent this type of fracture.
Climbers often develop calluses on their fingers from regular contact with the rock and the rope. When calluses split open they expose a raw layer of skin that can be very painful. This type of injury is commonly referred to as a flapper.
The use of magnesium carbonate (chalk) for better grip dries out the skin and can often lead to cracked and damaged hands
There are a number of skincare products available for climbers that help to treat calluses, moisturise dry hands and reduce recovery time.
Dupuytren’s disease has a high recurrence rate, especially when a person has so called Dupuytren’s diathesis. The term diathesis relates to certain features of Dupuytren's disease and indicates an aggressive course of disease.
The presence of all new Dupuytren’s diathesis factors increases the risk of recurrent Dupuytren’s disease by 71% compared with a baseline risk of 23% in people lacking the factors. In another study the prognostic value of diathesis was evaluated. They concluded that presence of diathesis can predict recurrence and extension. A scoring system was made to evaluate the risk of recurrence and extension evaluating the following values: bilateral hand involvement, little finger surgery, early onset of disease, plantar fibrosis, knuckle pads and radial side involvement.
Minimally invasive therapies may precede higher recurrence rates. Recurrence lacks a consensus definition. Furthermore, different standards and measurements follow from the various definitions.
Diagnosis is made almost exclusively by history and physical examination alone. More than one finger may be affected at a time, though it usually affects the index, thumb, middle, or ring finger. The triggering is usually more pronounced late at night and into the morning, or while gripping an object firmly.
The classically used Leddy and Packer Classification classifies Jersey finger tendon injuries based on the degree of tendon injury, retraction, and presence of a concomitant fracture.
Often, surgical pins are inserted into the injured digit to stabilize the bone and tendon in their proper alignment. Post surgical complications can include infection, pin failure and nail and joint deformity. Surgery is often accompanied by a rehabilitation protocol to strengthen the injured muscle and help the patient regain as much range of motion (ROM) as possible at the affected joint. The finger may never return normal extension ROM.
No specific work up is defined. Stenosing tenosynovitis is a clinical diagnosis. However, if rheumatoid arthritis is suspected, laboratory evaluation of is granted (e.g. rheumatoid factor). Imaging studies are not needed to diagnose the condition. However, they can be valuable adjuvants to achieve a diagnosis. An ultrasound or MRI ( the most reliable study) can demonstrate increased thickness of the involved tendons. Thickening and hyper-vascularization of the pulley are the hallmarks of trigger fingers on sonography.
Treatment is generally with a splint that holds the finger straight continuously for 8 weeks. The split may be worn for a few more weeks after this just at night. This should be begun within a week of the injury.
Surgery generally does not improve outcomes. It may be required if the finger cannot be straitened by pushing on it or the break has pulled off more than 30% of the joint surface. If the problem has been present a long time surgery may also be required. An open fracture may be another reason. Surgery will put the finger in a neutral position and drill a wire through the DIP to the PIP, forcing immobilization.
Climber's finger is one of the most common climbing injuries within the sport of rock climbing. It is an overuse injury that usually manifests in a swollen middle or ring finger due to a damaged flexor tendon pulley, normally the A2 or A4 pulley. It is caused by a climber trying to support his or her body weight with one or two fingers, and is particularly common after a repeated utilization of small holds. Continued climbing on an injured finger may result in increased downtime in order to recover.
Needle aponeurotomy is a minimally-invasive technique where the cords are weakened through the insertion and manipulation of a small needle. The cord is sectioned at as many levels as possible in the palm and fingers, depending on the location and extent of the disease, using a 25-gauge needle mounted on a 10 ml syringe. Once weakened, the offending cords can be snapped by putting tension on the finger(s) and pulling the finger(s) straight. After the treatment a small dressing is applied for 24 hours, after which people are able to use their hands normally. No splints or physiotherapy are given.
The advantage of needle aponeurotomy is the minimal intervention without incision (done in the office under local anesthesia) and the very rapid return to normal activities without need for rehabilitation, but the nodules may resume growing. A study reported postoperative gain is greater at the MCP-joint level than at the level of the IP-joint and found a reoperation rate of 24%; complications are scarce. Needle aponeurotomy may be performed on fingers that are severely bent (stage IV), and not just in early stages. A 2003 study showed 85% recurrence rate after 5 years.
A comprehensive review of the results of needle aponeurotomy in 1,013 fingers was performed by Gary M. Pess, MD, Rebecca Pess, DPT and Rachel Pess, PsyD and published in the Journal of Hand Surgery April 2012. Minimal followup was 3 years. Metacarpophalangeal joint (MP) contractures were corrected at an average of 99% and proximal interphalangeal joint (PIP) contractures at an average of 89% immediately post procedure. At final follow-up, 72% of the correction was maintained for MP joints and 31% for PIP joints. The difference between the final corrections for MP versus PIP joints was statistically significant. When a comparison was performed between people aged 55 years and older versus under 55 years, there was a statistically significant difference at both MP and PIP joints, with greater correction maintained in the older group. Gender differences were not statistically significant. Needle aponeurotomy provided successful correction to 5° or less contracture immediately post procedure in 98% (791) of MP joints and 67% (350) of PIP joints. There was recurrence of 20° or less over the original post-procedure corrected level in 80% (646) of MP joints and 35% (183) of PIP joints. Complications were rare except for skin tears, which occurred in 3.4% (34) of digits. This study showed that NA is a safe procedure that can be performed in an outpatient setting. The complication rate was low, but recurrences were frequent in younger people and for PIP contractures.
The most-often prescribed treatments for early-stage RSIs include analgesics, myofeedback, biofeedback, physical therapy, relaxation, and ultrasound therapy. Low-grade RSIs can sometimes resolve themselves if treatments begin shortly after the onset of symptoms. However, some RSIs may require more aggressive intervention including surgery and can persist for years.
General exercise has been shown to decrease the risk of developing RSI. Doctors sometimes recommend that RSI sufferers engage in specific strengthening exercises, for example to improve sitting posture, reduce excessive kyphosis, and potentially thoracic outlet syndrome. Modifications of posture and arm use (human factors and ergonomics) are often recommended.
One way to prevent this injury from occurring is to be informed and educated about the risks involved in hurting your wrist and hand. If patients do suffer from median nerve palsy, occupational therapy or wearing a splint can help reduce the pain and further damage. Wearing a dynamic splint, which pulls the thumb into opposition, will help prevent an excess in deformity. This splint can also assist in function and help the fingers flex towards the thumb. Stretching and the use of C-splints can also assist in prevention of further damage and deformity. These two methods can help in the degree of movement the thumb can have. While it is impossible to prevent trauma to your arms and wrist, patients can reduce the amount of compression by maintaining proper form during repetitive activities. Furthermore, strengthening and increasing flexibility reduces the risk of nerve compression.
As of July 2000, hypermobility was diagnosed using the Brighton criteria. The Brighton criteria do not replace the Beighton score but instead use the previous score in conjunction with other symptoms and criteria. HMS is diagnosed in the presence of either two major criteria, one major and two minor criteria, or four minor criteria. The criteria are:
It is important that hypermobile individuals remain fit - even more so than the average individual - to prevent recurrent injuries. Regular exercise and exercise that is supervised by a physician and physical therapist can reduce symptoms because strong muscles increase dynamic joint stability. Low-impact exercise such as closed chain kinetic exercises are usually recommended as they are less likely to cause injury when compared to high-impact exercise or contact sports.
Heat and cold treatment can help temporarily to relieve the pain of aching joints and muscles but does not address the underlying problems.
Non-specific treatments include:
- Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen or aspirin
- Heat or ice
- A counter-force brace or "elbow strap" to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.
Before anesthetics and steroids are used, conservative treatment with an occupational therapist may be attempted. Before therapy can commence, treatment such as the common rest, ice, compression and elevation (R.I.C.E.) will typically be used. This will help to decrease the pain and inflammation; rest will alleviate discomfort because golfer's elbow is an overuse injury. The patient can use a tennis elbow splint for compression. A pad can be placed anteromedially on the proximal forearm. The splint is made in 30–45 degrees of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve.
Therapy will include a variety of exercises for muscle/tendon reconditioning, starting with stretching and gradual strengthening of the flexor-pronator muscles. Strengthening will slowly begin with isometrics and progresses to eccentric exercises helping to extend the range of motion back to where it once was. After the strengthening exercises, it is common for the patient to ice the area.
Simple analgesic medication has a place, as does more specific treatment with oral anti-inflammatory medications (NSAIDs). These will help control pain and any inflammation. A more invasive treatment is the injection into and around the inflamed and tender area of a long-acting glucocorticoid (steroid) agent. After causing an initial exacerbation of symptoms lasting 24 to 48 hours, this may produce an improvement of the condition in some five to seven days.
The ulnar nerve runs in the groove between the medial humeral epicondyle and the olecranon process of the ulna. It is most important that this nerve should not be damaged accidentally in the process of injecting a golfer's elbow.
If all else fails, epicondylar debridement (a surgery) may be effective. The ulnar nerve may also be decompressed surgically.
If the appropriate remediation steps are taken - rest, ice, and rehabilitative exercise and stretching - recovery may follow. Few patients will need to progress to steroid injection, and less than 10% will require surgical intervention.
The diagnosis is based on symptoms and signs alone and objective testing is expected to be normal. This syndrome may be clinically tested by flexing the patients long finger while the patient extends the wrist and fingers. Pain is a positive finding.
The chief complaint of this disease is usually pain in the dorsal aspect of the upper forearm, and any weakness described is secondary to the pain. Tenderness to palpation occurs over the area of the radial neck. Also, the disease can be diagnosed by a positive "middle finger test", where resisted middle finger extension produces pain. Radiographic evaluation of the elbow should be performed to rule out other diagnoses.
Most hand injuries are minor and can heal without difficulty. However, any time the hand or finger is cut, crushed or the pain is ongoing, it is best to see a physician. Hand injuries when not treated on time can result in long term morbidity.
Antibiotics in simple hand injuries do not typically require antibiotics as they do not change the chance of infection.
The natural history of disease for trigger finger remains uncertain.
There is some evidence that idiopathic trigger finger behaves differently in people with diabetes.
Recurrent triggering is unusual after successful injection and rare after successful surgery.
While difficulty extending the proximal interphalangeal joint may persist for months, it benefits from exercises to stretch the finger straighter.
Because lesions to different areas of the median nerve produce similar symptoms, clinicians perform a complete motor and sensory diagnosis along the nerve course. Decreased values of nerve conduction studies are used as indicators of nerve compression and may aid in determining the localization of compression.
Palpation above the elbow joint may reveal a bony consistency. Radiography images may show an abnormal bony spur outgrowth (supracondyloid process) just proximal to the elbow joint. Attached fibrous tissue (Struthers' ligament) may compress the median nerve as it passes underneath the process. This is also known as supracondylar process syndrome. Compression at this point may also occur without the bony spur; in this case, aponeurotic tissue found at the location of where Struthers' ligament should be is responsible for the compression.
If patients mention reproduction of symptoms to the forearm during elbow flexion of 120–130 degrees with the forearm in maximal supination, then the lesion may be localized to the area underneath the lacertus fibrosus (also known as bicipital aponeurosis). This is sometimes misdiagnosed as elbow strain and medial or lateral epicondylitis.
A lesion to the upper arm area, just proximal to where motor branches of forearm flexors originate, is diagnosed if the patient is unable to make a fist. More specifically, the patient's index and middle finger cannot flex at the MCP joint, while the thumb usually is unable to oppose. This is known as hand of benediction or Pope’s blessing hand. Another test is the bottle sign—the patient is unable to close all their fingers around a cylindrical object.
Carpal tunnel syndrome (CTS) is caused by compression of the median nerve as it passes under the carpal tunnel. Nerve conduction velocity tests through the hand are used to diagnosis CTS. Physical diagnostic tests include the Phalen maneuver or Phalen test and Tinel's sign. To relieve symptoms, patients may describe a motion similar to "shaking a thermometer", another indication of CTS.
Pronator teres syndrome (also known as pronator syndrome) is compression of the median nerve between the two heads of the pronator teres muscle. The Pronator teres test is an indication of the syndrome—the patient reports pain when attempting to pronate the forearm against resistance while extending the elbow simultaneously. The physician may notice an enlarged pronator teres muscle. Tinel's sign the area around the pronator teres heads should be positive. The key to discerning this syndrome from carpal tunnel syndrome is the absence of pain while sleeping. More recent literature collectively diagnose median nerve palsy occurring from the elbow to the forearm as pronator teres syndrome.
In uncooperative patients, the skin wrinkle test offers a pain-free way to identify denervation of the fingers. After submersion in water for 5 minutes, normal fingers will become wrinkled, whereas denervated fingers will not.
In "Ape hand deformity", the thenar muscles become paralyzed due to impingement and are subsequently flattened. This hand deformity is not by itself an individual diagnosis; it is seen only after the thenar muscles have atrophied. While the adductor pollicis remains intact, the flattening of the muscles causes the thumb to become adducted and laterally rotated. The opponens pollicis causes the thumb to flex and rotate medially, leaving the thumb unable to oppose. Carpal tunnel syndrome can result in thenar muscle paralysis which can then lead to ape hand deformity if left untreated. Ape hand deformity can also be seen in the hand of benediction deformity.
The Anterior Interosseus Nerve (AIN), a branch of the median nerve, only accounts for the movement of the fingers in hand and does not have any sensory capabilities. Therefore, the AIN syndrome is purely neuropathic. AINS is considered as an extremely rare condition because it accounts for less than 1% of neuropathies in the upper limb. Patients suffering from this syndrome have impaired distal interphalangeal joint, because of which they are unable to pinch anything or make and "OK" sign with their index finger and thumb. The syndrome can either happen from pinched nerve, or even dislocation of the elbow.
About 1.8 million people go to the emergency department each year due to hand injuries.
Ice and elevation may help reduce pain and swelling, and allow the injury to begin to recover.
Severe sprains accompanied by significant pain and swelling may need to be immobilized.