Finger Conditions

Guidelines below can be used to determine when to refer of a patient for hand therapy or surgery.

To make an appointment to see a hand therapist phone the Auckland Hand Institute on 09 444 9450

To make an appointment to see surgeon Dr Michael Boland phone (09) 443 3469

 Trigger Finger

Diagnosis: Trigger finger or stenosing tenosynovitis involves a volume mismatch between the flexor tendons and the A1 pulley, at the level of the metacarpophalangeal (MCP) joint. The patient will present with tenderness and thickening at the A1 pulley, possibly associated with direct trauma to the area, or overuse of the fingers. They will complain of pain in thisarea associated with active flexion/extension of the digit, and may report clicking or catching, which is palpable to the clinician over the pulley. In severe cases the digit may become fixed in flexion, and the patient will report having to force it straight.

Management: Conservative management of trigger finger will involve splinting for 6 weeks with the MCP joint held in extension. This reduces compressive forces between the tendons and the pulley ligament, and encourages differential glide between flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS).

Surgery: Following 6 weeks the patient is reviewed, and if there has not been significant improvement in symptoms they are referred to the hand and wrist surgeon for consideration of other treatment options including corticosteroid injection, and surgical release of the pulley.

 Mallet Finger

Diagnosis: Mallet finger is a disruption of the terminal extensor tendon at its insertion at the distal phalanx. It is associated with direct trauma to the tip of the finger, with the distal interphalangeal joint being forced into flexion. The patient will present with pain proximal to the fingernail, with the distal phalanx sitting naturally in flexion. The patient will be unable to actively extend at the distal interphalangeal (DIP) joint. Plain x-rays are indicated, as a bony avulsion involving greater than 30% of the articular surface necessitates surgical review.

Management: Conservative management of mallet finger involves 6 weeks of splinting, in which the DIP joint is held in extension without interruption. Following 6 weeks the splint is removed and the integrity of the terminal extensor tendon assessed. If union has been achieved graduated range of motion and splint weaning is begun.

Surgery: Paragraph about surgical options …

 Volar Plate Injury

Diagnosis: Volar plate sprain or disruption normally occurs at the proximal interphalangeal (PIP) joint, but may occur at the DIP joint also. It is associated with forced hyperextension of the joint, or a strong longitudinal force applied through the digit. A common mechanism of injury is the fingertip being struck firmly by a ball. The patient presents with pain or laxity with passive hyperextension of the joint, and tenderness over the volar aspect. Plain x-rays may show an avulsion fragment.

Management: The joint is splinted to block full extension for 3-4 weeks, and to avoid strain to the healing tissue. Active flexion is permitted. If satisfactory healing occurs with splinting, graduated mobilisation is begun.

Surgery: Sentence about surgical options …

 Boutainaire Deformity

Diagnosis: This occurs when the central slip component of the extensor mechanism is disrupted. This may occur due to direct trauma to the dorsal aspect of the PIP joint, or dislocation of the joint in a volar direction. The patient will present with the PIP joint sitting in flexion, with the DIP joint hyperextended. There may be marked swelling in the joint. There will also be resistance to active and passive flexion of the DIP joint.

Management: The PIP joint will be splinted in extension for 6 weeks, with active DIP movement encouraged. Following this period if the deformity has resolved, splint weaning and graduated mobilisation of the joint will begin.

Surgery: Paragraph about surgical options …

 Swan Neck Deformity

Diagnosis: This deformity involves hyperextension at the PIP joint and flexion at the DIP joint. It may occur for several reasons including as a compensatory mechanism for untreated mallet finger, a consequence of volar plate laxity, or due to rheumatoid arthritis.

Management: Treatment depends on the specific underlying cause, but may involve splinting, exercises or referral to the appropriate specialist.

Surgery: Paragraph about surgical options …

 Stable Fractures

Diagnosis: Usually there is a history of high-velocity trauma. Metacarpal fractures are often associated with striking a person or object with a closed fist (boxer’s fracture), and present with swelling, tenderness, and possible deformity of the dorsum. Phalanx fractures are often sports-related, and again present with swelling and tenderness. Fracture of the proximal phalanx will often have a volar angulation due to the pull of the intrinsic muscles of the hand.

Management: Treatment of choice is a thermoplastic splint to support the fracture as it heals. Complete immobilisation of the joint is avoided if at all possible, especially the interphalangeal joints, as significant stiffness can result.

Surgery: Paragraph about surgical options …

 PIP Joint Sprain/Dislocation

Diagnosis: These can range in severity from a mild sprain to a complete dislocation requiring reduction under nerve block. In all cases there is likely to be swelling, tenderness, and stiffness at the joint. Severity is gauged by degree of laxity present with stress testing of the restraining structures of the joint, including collateral ligaments, capsule, and volar plate. Plain x-rays are useful to determine presence of avulsion fractures.

Management : If there is complete rupture of the collateral ligaments (empty end-feel) surgical review is indicated, otherwise conservative management is the treatment of choice. This will typically involve a rigid custom-made splint to hold the PIP joint in extension to prevent excessive loading of healing tissue, combined with gentle range of motion exercises.

Surgery: Paragraph about surgical options …


Thumb Conditions

CMC/STT Osteoarthritis

Diagnosis: The patient will typically report gradually increasing pain associated with gripping activities. There may have been recent trauma to the hand, such as a fall, which has caused irritation of previously asymptomatic degenerative changes. On examination deformity may be present, with a pronounced step at the base of the metacarpal, and compensatory hyperextension at the MCP. Plain x-rays are useful for determining severity.

Management: Custom splinting can be extremely enabling for the patient by reducing pain with gripping activities, and allowing continuation of meaningful activities. Hand therapists can also advise on ongoing management strategies, including ergonomic devices, task-modification, and pain management.

Surgery: Paragraph about surgical options …

MCP Collateral Ligament Tear

Diagnosis: Typically associated with a fall onto an outstretched hand, where the thumb MCP is forcefully radially deviated. The classic mechanism of injury is the skier falling onto the hand while gripping the ski pole. Subluxation or dislocation may occur at the time of injury, and there will be swelling and tenderness of the MCP joint, with possible laxity on testing. It is crucial to identify a Stener lesion if present, where the ulnar collateral ligament ruptures and is unable to heal spontaneously due to interposition of the adductor pollicis muscle. This lesion always necessitates surgical repair.

Management: Grade I and II sprains of the UCL can be treated conservatively with a handbased thumb splint, or a cast initially. Low-profile splints can be fabricated to protect the joint for return to sport after 3-4 weeks of rest. Grade III tears require surgical repair.

Surgery: Paragraph about surgical options …