Chapter

| 31 |

Finger and thumb pathology

Joy C MacDermid, Ruby Grewal, B Jane Freure

CHAPTER CONTENTS
Introduction
Digital fractures
Epidemiology: incidence, prevalence,
economic impact
Anatomy
Pathology

392
392
392
393
393

Metacarpal fractures

393

Phalangeal fractures

393

Thumb fractures

Diagnosis of digital fractures

Prognosis for digital fractures
Conservative treatment of digital fractures
Ulnar collateral ligament (UCL) injury of
the thumb
Epidemiology
Anatomy
Pathology
Diagnosis
Prognosis
Conservative treatment of UCL injury
Other digital tendon injuries
Osteoarthritis of the digits
Epidemiology
Anatomy
Pathology
Diagnosis
Prognosis

392

394

394
394
397
397
397
397
398
398
399
399
399
399
399
399
399
400
400

Conservative treatment of digital arthritis

Rheumatoid arthritis affecting the digits
Conclusion

400
400
401

INTRODUCTION
Physical therapy for the hand must embrace an understanding of the hand as an organ that interfaces the person with
their world by bringing in sensory information, and allowing the person to engage in activity that determines function
and quality of life. The hand has intricate anatomical structures in close proximity that contract, glide, and heal following injury. Maintaining joint mobility and stability while the
structures in the proximity remain free to glide and resist
contractile forces are critical to hand motor performance.
Issues of motor control and sensory motor integration are
critical to the functionality of the hand. Exquisitely innervated, the hand can serve as a sensory organ or contribute
painful stimuli that alter the cortex and produce chronic
pain. Manual therapy techniques can contribute to normalizing the neurosensorimotor function of the hand, in combination with other techniques. In the current chapter we
highlight the most prevalent conditions affecting the digits.

DIGITAL FRACTURES
Epidemiology: incidence, prevalence,
economic impact
Hand fractures are a common traumatic injury usually
arising during work place, sporting or recreational activities. Fractures of the metacarpals and phalanges are most

2011 Elsevier Ltd.

DOI: 10.1016/B978-0-7020-3528-9.00031-5

Chapter | 31 |

Finger and thumb pathology

common (Hove 1993, Van Onselen et al 2003, Aitken &

Court-Brown 2008, Feehan & Sheps 2008a). Border digits
are the most commonly affected (thumb/small finger).
The majorities are treated conservatively (Feehan & Sheps
2008b). Metacarpal fractures represent 35% of hand
fractures.

Anatomy
To better understand hand fractures one must first understand the relationship between both soft tissue and bony
factors that contribute to both soft tissue and skeletal
stability. We suggest that readers consult a standard anatomy text or The Electronic Textbook of Hand Surgery
(http://www.eatonhand.com/hom/hom033.htm) website
for details of hand/wrist anatomy as we only will highlight key elements. The latter website has primal pictures
used with permission, some radiographic images of anatomy and pathology and information on various bony and
soft tissues providing accessible and clearly visualize
aspects of key anatomical features. More detailed descriptions of anatomical features are available in classic anatomic textbooks.

Pathology
Bone fractures result from excessive force, in comparison
to bone strength. Fracture angulation is determined by
the forces exerted by the soft tissues on both the proximal
and distal fragment. Movement recovery following fracture can be affected by the nature and severity of the original fracture, associated soft tissue injuries and the extent
of malalignment in bony structure that occurs following
bony healing.
The mechanism of injury plays a role in the type of fractures that should be anticipated. A direct blow will result
in a transverse fracture, a twisting injury will cause a spiral
fracture and combination of torque and axial force will
result in a short oblique fracture. Fractures are further classified based on the location (head, neck, shaft or base of a
specific hand bone) and any associated soft tissue injury.
All fractures are associated with soft tissue injury. The
nature of these injuries can be difficult to determine even
with imaging and clinical examination. Muscle and ligament injuries can be important aspects of the fracture
and may become more evident as the fracture heals and
swelling subsides, or when movement is initiated. Scar
healing of injured soft tissue can be a substantial component of active movement limitation.

Metacarpal fractures
The metacarpal bones have intrinsic stability provided by
strong interosseus ligaments binding them to the carpal
bones and proximally by the transverse metacarpal ligament which links all metacarpal heads. Ligaments tend

to prevent excessive displacement with injury. The fifth

metacarpal is commonly fractured during a punch mechanism (the majority of these injuries occur in males) and
are treated conservatively since full motion/function is
often obtained despite malrotation. There is generally a
good blood supply which supports high rates of healing,
usually within 46 weeks. The most important soft tissue
concerns are preserving MP joint flexion and maintaining
EDC glide.
Fractures of the base of metacarpals are intra-articular
fractures that result usually from high forces that disrupt
the rigid carpal ligaments of the index and middle finger
or overwhelm the normal flexibility of the ulnar metacarpals. Shaft fractures are extra-articular fractures that usually arise during a fall or blow and usually angulating
dorsally (with components of shortening or rotation).
They are described as transverse, oblique or spiral. Intrinsic muscle tension will cause both ends of the metacarpal
bone to flex into an apex dorsal presentation. This causes
a shortening which compromises the extensor mechanism
by altering the muscle length relationship. Metacarpal
neck fractures are the most common metacarpal fracture
(boxers fracture). The impact of a closed fist causes a
break at the extra-articular neck. If associated with a bite,
infection is a potential complication which can substantially increase tissue damage. Metacarpal head fractures
are intra-articular fractures caused by high axial loading
that may involve collateral ligaments and substantial
comminution. These fractures can lead to chronic pain
and joint instability.

Phalangeal fractures
Phalangeal fractures have greater tendency towards instability as the phalanges lack intrinsic muscle support and
are adversely affected by the mechanical forces of the
extrinsic flexors and extensors. However these fractures
are also more likely to become stiff with immobilization
(Shehadi 1991) (predicted motion return of 84%). If
immobilization is longer than 4 weeks, predicted motion
is 66%.
Intra-articular fractures of the base of the proximal phalanx (PP) usually occur following an abduction force most
commonly seen in sports injuries or a fall. Displaced fractures may not be reducible conservatively because of collateral ligament avulsion which worsens the fracture
displacement with MP flexion. This can lead to higher rates
of non-union with conservative management (Shewring &
Thomas 2006). PP shaft fractures have the poorest prognosis for regaining full ability as they occur in the flexor zone
two. Since 90% of the proximal phalanx surface is covered
by gliding structures these can easily become adherent to
the fracture callus. PP condyle fractures usually occur with
the lateral deviation force and may be associated with collateral ligament injury. This is a common sports injury, and
a common missed diagnosis.

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The wrist and hand regions

The interossei and lumbricals muscles are the prime

MCP flexors. The lumbricals originate from the tendons
of the flexor digitorum profundus tendon and the three
palmar and four dorsal interossei muscles originate from
the volar and dorsal surface of the metacarpal respectively
(Smith 1975). The interossei insert onto the antero-lateral
base of the proximal phalanx and on the extensor mechanism forming part of the lateral band with the lumbricals,
which also inserts dorsally into the extensor apparatus.
These intrinsic muscles, along with the extrinsic flexor tendons create deforming forces on the fractured metacarpal
shaft resulting in apex dorsal angulation (Flatt 1996).
A proximal phalanx fracture will typically angulate with
an apex volar deformity because the interossei will flex
the proximal fragment due to their insertion at the proximal phalangeal base while the distal fragment is pulled
into hyperextension by the central slip which inserts at
the base of the middle phalanx and acts to extend the distal fragment.
Fractures of the shaft of the MP occur less commonly,
and may displace dorsally or volarly. Intra-articular fractures at the base of the middle phalanx (MP) occur commonly from a fall or direct force. These may be
associated with PIP joint dislocation and damage to the
volar plate and/or central slip. If the compression trauma
is severe, a comminuted fracture of the articular surface,
with depression of the fragments into the bone shaft or
pilon fracture occurs. MP fractures of the distal third tend
to angulate with an apex volar deformity as the flexor digitorum superficialis (FDS) acts to flex the proximal fragment. A proximal third fracture usually angulates with
an apex dorsal deformity as the FDS will flex the distal
fragment while the central slip extends the proximal
fragment.
DP fractures are common during crush injuries and
may not displace significantly because the presence of a
rigid nail plate dorsally helps to preserve alignment. However, due to the space restrictions inherent in the fingertip
anatomic structures and their dense innervations, these
injuries can be particularly painful. The distal phalanx
(DP) accounts first 50% of hand fractures, which may
be attributed to its vulnerability as the fingertip. Tendons
avulsion alone or with a variable amount of the articular
surface chip fracture can occur. This commonly occurs
in sports and hence there are sport-related names for these
injuries (jersey FDP avulsed from the volar base of the
DP or baseball avulsion of the terminal extensor tendon from the DP). PP shaft fractures are proximal to the
nail bed and usually result from direct trauma. PP tuft
fractures are the most distal fracture and can be quite
painful and difficult to manage since union may be slow.

Thumb fractures
The first CMC joint is a double saddle-joint, which allows
movement in both the flexion/extension plane and in

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abduction/adduction. Because of the wide range of

motion present at the thumb CMC joint, angulation of
up to 30 is well tolerated allowing rehabilitation to
achieve full function even when re-morbid joint mobility
is not attained. In extra-articular fractures dorsal angulation occurs because the abductor pollicus brevis, adductor
pollicis and flexor pollicis brevis muscles attaching at the
base of the proximal phalanx and act to flex the distal
fragment while the abductor pollicus longus muscle
(which attaches to the metacarpal base) extends the proximal fragment. A Bennett fracture is an intra-articular fracture involving the metacarpal base. The fracture fragment
involves the volar ulnar portion of the metacarpal base.
This fragment is held undisplaced by the anterior oblique
ligament. The remainder of the thumb metacarpal usually
subluxes radially, proximally and dorsally by the forces
exerted by the abductor pollicus longus.

Diagnosis of digital fractures

The focus of assessment depends on the stage of healing.
Clinical and radiographic assessment of fracture union
should be performed until union is established. Clinical
signs of non-union include exquisite local pain at the fracture site and movement of the fractured components.
Computerized tomography can be a useful adjunct to
radiographs as they help to accurately delineate the degree
of articular displacement and can identify other associated
injuries. Radiographs are routinely used to identify fractures and to determine the degree of displacement;
however X-ray cannot be used to rule out a rotational
deformity. Patients can be asked to actively flex their digits
to determine if there is any scissoring of the digits (i.e.
overlap). If pain from the acute injury precludes an active
flexion effort, passive wrist flexion and extension will
place a flexion moment across the fingers with the tenodesis effect allowing an assessment of rotation to be made.
A thorough clinical assessment should determine whether
there is any associated soft tissue or neurovascular injury
and identify any rotational deformity. Assessment should
include evaluation of impairments and disabilities arising
from fracture complications or treatment sequelae. A summary of these and potential treatment approaches are
described in Table 31.1.

Prognosis for digital fractures

Prognosis varies according to the outcome of interest.
Successful union of the fracture, restoration of normal
anatomy, pre-injury movement/grip strength and function are typical goals and outcomes evaluated. Union is
dependent on the persons individual capacity for bone
healing and thus affected by prognostic factors that affect
bone healing in a generic sense, including individual
physical factors (nutrition, comorbidity, age, bone

Chapter | 31 |

Finger and thumb pathology

Table 31.1 Summary of treatment problems and associated treatment techniques for hand fractures*
Problem

Physiotherapeutic treatment strategies

Fracture protection (Fess et al 2004)

Custom-made or off-the-shelf orthoses

Pain

Frequent, low intensity active exercise of unaffected joints and affected joints when
stable
Adequate fracture protection and oedema management
Desensitization programme
Electro-thermal agents
Co-ordinate pharmacological management and therapy

Nerve irritation/ neuroma

Desensitization programme (Robinson & McPhee 1986, Waylett-Rendall 1988)

Iontophoresis with lidocaine evidence in other conditions (Fedorczyk 1997,
Baskurt et al 2003, Bolin 2003, Yarrobino et al 2006, Polomano et al 2008)
Mirror box therapy (Altschuler & Hu 2008, Ezendam et al 2009) limited evidence
Visualization exercises limited evidence
Nerve gliding/neurodynamic techniques focused on at-risk or symptomatic nerve
bias

Oedema

Exercise in elevation
Compression (compressive gloves, retrograde massage, Coban wrap, string
wrapping (Flowers 1988) (especially for digits)
Thermal agents (cold in acute stages for those who can tolerate; heat should be
used only in elevation with monitoring of volume)
Physical agents (high voltage stimulation) (Stralka et al 1998)

Loss of joint motion (Michlovitz

et al 2004)

Loss of power

Progressive resisted exercise (Hostler et al 2001, Bautmans et al 2009)

Loss of endurance

Progressive resisted exercise

Progressive functional activity

Scissoring

Buddy tape to adjacent digit

May require osteotomy

Joint Instability

Buddy taping, taping, custom or premade orthoses

Activity modification to avoid lateral stress

Non-union

Low dose ultrasound (Busse et al 2002, Griffin et al 2008)

Abnormal sensorimotor integration

or motor control

Sensorimotor retraining (focused, progressive retraining of normal sensory

responses)
Motor control exercises
Dexterity training/functional activity

Prevention of future fractures

Assess risk for future fracture (based on age mechanism of injury and comorbid
status)
Manage modifiable risk factors (safety training, activity modification, protective
devices, fall prevention, balance training as needed)

Active exercise of affected joints (stable fixation or healed)

Physiological and accessory joint mobilization
Static progressive splinting
Dynamic splinting
Continuous passive motion (Soffer & Yahiro 1990) (low evidence in other upper
extremity joints)
Constrained movement therapy (blocking or casting of adjacent mobile digits to
enforce movement of stiff joints)

Continued

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The wrist and hand regions

Table 31.1 Summary of treatment problems and associated treatment techniques for hand fractures*contd
Problem

Physiotherapeutic treatment strategies

General

In simple, closed metacarpal fractures, early motion has the potential to result in
earlier recovery of mobility and strength, facilitate an earlier return to work, and not
affect fracture alignment (Feehan & Bassett 2004)

Dorsal skin scar contracture

MP joint contracted an extension

Early positioning MP joint at 70

Later dynamic or static progressive splinting of MPs

Intrinsic muscle contracture

Early active intrinsic minus exercises; blocking exercise

Later dynamic splinting; muscle stimulation

Absence of MP head

Educate patient about shortening of metacarpal; assess whether any functional

implications (may not affect functional outcome)
Assess functionality of extensors; if redundancy is apparent splinting extension at
night and strengthen intrinsic
Assess alignment volar prominence volar angulation and may require adaptive
padding/gloves/positioning or osteotomy
Communicate with health care team

Loss of IP extension

Blocking exercises
MP block extension splint during the day
PIP extension splint thing at night
Neuromuscular stimulation to EDC and interrosei
Joint mobilizations

Loss of IP flexion

FDP/FDS tendon glide exercises

Daytime MP flexion blocks blunting
Dynamic or static progressive nights splinting
Heat and composite stretching
Joint mobilizations
Stretch of oblique retinacular ligament

Boutonniere deformity

Early DIP active flexion to maintain length of lateral bands

Later splinting

Swan neck deformity

Orthotic to hold MP joint in flexion

Silicone gel/topical agents to superficial scars

Scar massage/ mobilization for adherence
Simultaneous heat, stretch and tendon gliding exercises (Wehbe 1987)
Scar mobilization with hand-held suction device
Ultrasound
Laser

*From: Freeland et al 2003, Hardy 2004.

quality), the bone affected (composition, blood supply,

biomechanics), behavioural (compliance with fixation,
immobilization, re-mobilization, rehabilitation; activity
levels), injury (type of fracture, size of defect, soft tissue
components, associated injuries) and complications
(nerve compression, infection, loss of reduction).
Optimal anatomic outcomes and functional outcomes
are moderately related, in that malunion can lead to
decreased pain, grip strength, scissoring, or loss of joint

396

motion (Synn et al 2009). However, poor functional outcomes can occur in the presence of good anatomic restoration, particularly where pronounced joint stiffness, chronic
pain, or chronic regional pain syndrome exist (Field et al
1992, Field & Atkins 1997). Conversely, adequate functional outcomes are attained in older sedentary individuals
despite lack of restoration of normal anatomy (Grewal &
MacDermid 2007). When fracture malunion results in scissoring, a corrective rotational osteotomy may be required.

Chapter | 31 |

Finger and thumb pathology

Evidence on prognosis and fractures is generally sparse

and poor quality (level IV studies). Functional (DASH),
aesthetic and fracture union outcomes in metacarpal shaft
and neck fractures were not affected by palmar angular
deformity, but functional and aesthetic outcomes were
better in non-operatively managed patients (Westbrook
et al 2008). Spiral/long oblique fractures of the shaft of
the metacarpal are at risk of shortening and resultant
extension lag and reduced grip strength. However, there
may be progressive recovery of the extension lag by 1 year
and a mean of 94% of the contralateral hand motion by
1 year after injury (Al-Qattan 2008). In 51 unstable
metaphyseal MP and PP fractures where fixation was
maintained with miniature titanium plates union, the
final range of total active motion (% TAM) was excellent
(> 85%) for 26, good (7084%) for 17, fair (5069%)
for 5, and poor (< 49%) for 3 (Omokawa et al 2008).
Postoperative complications included loss of reduction
(2 cases), condylar head collapses (2 cases), and one
superficial infection. Plates were removed in 30 cases,
and additional surgery was required in 20 cases. Postoperative grip strength averaged 87% of the contralateral side.
Older age, intra-articular fracture, phalangeal bone
involvement, and soft tissue injury were associated
with poorer range of finger motion following fracture
(Omokawa et al 2008). A level IIb study of 120 MC and
PP emergency room fractures indicated that infection,
increased bony defect and associated soft tissue injury
increased the risk of nonunion (Ali et al 2007). In another
study, 36% of MC or PP fractures showed different complications, PP and open fractures were at higher risk for
stiffness, non-union, plate prominence, infection, and
tendon rupture (Page & Stern 1998).

Conservative treatment of
digital fractures
The general principles of fracture management is to
reduce the fracture (open or closed) in a manner that will
restore normal anatomy and maintain the reduced position through an immobilization/fixation technique that
is sufficient to withstand the potential for loss of reduction through deforming or external forces. Since immobilization leads to comorbid stiffness/weakness, early
mobilization is preferable where it does not compromise
reduction. In keeping with these goals (Fig 31.1), the general principles of rehabilitation of fractures are divided
into two stages (MacDermid 2004):

Stage 1 Early rehabilitation, which includes protect

the healing fracture, minimize pain and oedema,
restore normal motion and tissue extensibility,
monitor patients for associated injuries or
complications, prevent therapy-induced
complications, to assist patients in dealing with their
injury using appropriate coping mechanisms and

avoidance of patterns that increase the risk of

developing chronic pain/disability syndromes and to
help patients to understand their injury, the role of
healthcare providers, and how to take an active role in
their rehabilitation.
Stage 2 Later rehabilitation, which includes
amelioration of joint contracture, restoration of hand
and arm strength, adaptation to residual physical
impairments, transitioning into normal work or
activity and to teach the prevention strategies to
reduce risk of a second fracture.

There is a lack of clinical trials comparing different treatment approaches for digital fractures. A single small lowquality trial suggested the use of a compression glove
avoided the loss of function imposed by splintage and
was associated with a greater range of movement during
the second and third weeks following a metacarpal fracture (McMahon et al 1994). Management is based on
the stage of bone healing and presenting fracture sequelae
(see treatments based on presenting problems in
Table 31.1). Poor quality studies support the use of metacarpal bracing for early mobilization.

ULNAR COLLATERAL LIGAMENT (UCL)

INJURY OF THE THUMB
Epidemiology
UCL injuries can be acute or chronic. Acute injuries are
much more common and are the result of an acute valgus stress rupturing the ligament. Chronic injuries are
referred to as gamekeepers thumb. This is also an injury
of the UCL; however, it is the result of attenuation of the
ligament due to a chronic, repetitive radially directed
force on the ulnar side of the thumb. This was traditionally noticed in Scottish gamekeepers who fractured the
necks of the rabbits between their thumbs and index
fingers.

Anatomy
The thumb MP joint has both static and dynamic stabilizers. The static restraints include the volar plate, proper
and accessory collateral ligaments. The proper collateral
ligament acts as the primary stabilizer of the MP joint in
flexion, and in extension, the accessory collateral ligament
and the volar plate are the primary joint stabilizers
(Minami et al 1984, Heyman et al 1993). The dynamic
stabilizers include both the thumb extrinsic (EPL, EPB
and FPL) and intrinsic (APB, FPB, and adductor pollicis
muscles) structures. The adductor pollicis is the most
important dynamic stabilizer of the thumb MP joint. It
inserts into the extensor hood (through its aponeurosis)
and lies superficial to the joint and the UCL.

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Part | 5 |
Callus
Fracture

The wrist and hand regions

Fig 31.1 Progression in the
rehabilitation process.

New bone growth

Normal bone

Week 1
Immobilization
Early (safe) mobilization

Weeks 2 6
Manage pain and edema
ROM unaffected joints
Safe active motion if fracture stable (closed
undisplaced or rigid fixation)

Weeks 4 6+ (graduated mobilization with clinical union)

Progressive active, gentle passive techniques
Assess and treat specific emerging impairments
within safety margins (table 1)

Weeks 8 12+ (remodeling and functional restoration)

Passive techniques and joint mobilization
Progressive strength and function program
Dynamic or progressive static orthotics
Manage residual disability and future fracture risk

Pathology

Diagnosis

When a valgus stress is applied to the thumb (i.e. a fall

onto the abducted thumb) the dynamic and static stabilizers fail sequentially depending on the magnitude of the
force. When the injury is limited to the dynamic stabilizers, the thumb will be stable on valgus stress testing.
When the proper collateral ligament ruptures valgus instability will be present in MP flexion. When the accessory
collateral is also torn, there will be valgus instability in
both flexion and extension, indicating a complete tear
(Heyman et al 1993). At times, the ruptured distal end
of the ligament can become displaced such that it lies
superficial and proximal to the adductor aponeurosis.
This entity was first described by Stener in 1962 and the
lesion bears his name (Stener 1962). Due to interposition
of the adductor aponeurosis this injury will not heal without operative intervention.

Patients will report a history of a valgus injury and complain of pain and swelling over the ulnar aspect of the
MP joint. Pain will be exacerbated by forceful pinch and
activities such as unscrewing jar tops and holding large
objects because of a lack of power from the thumbs
inability to generate counter-pressure on the object. Occasionally a Stener lesion may be evident as a palpable mass
on the ulnar aspect of the joint; however, lack of such a
mass does not rule out a Stener lesion. Radiographs
should be obtained and viewed prior to stress testing of
the ligament to rule out an avulsion fracture thereby
avoiding potential displacement of the fracture fragment.
Stress testing of the UCL is performed by placing a valgus
stress across the MP joint 30 of flexion and then extension. If there is more than 30 of laxity (or 15 more than
the contralateral side) in flexion (30 of MP flexion)

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Finger and thumb pathology

rupture of the proper collateral ligament is likely. The valgus stress is then applied in extension. If there is less than
30 of valgus laxity in extension, the accessory collateral is
intact, precluding a Stener lesion. If there is greater than
30 of laxity in both flexion and extension, the accessory
collateral ligament is also ruptured and the probability
of an underlying Stener lesion is approximately 80%
(Stener 1962). Radiographs demonstrate radial deviation
at the MP joint and possible volar subluxation.

repair are required to ensure tendons glide is restored

without compromising repair (tendon rupture or gapping). Active motion with differential gliding is emphasized during rehabilitation. When tendons scarring limits
differential gliding, tenolysis may be required.

OSTEOARTHRITIS OF THE DIGITS

Epidemiology

Prognosis
There are no specific prognostic studies on this topic.
Inadequate mobilization or failure to detect a Stener
lesion can lead to chronic instability and pain.

Conservative treatment of UCL injury

Management consists primarily of immobilization sufficient to permit ligament reattachment/healing. Although
biomechanical evidence suggests early control of mobilization might be feasible (Harley et al 2004), it has not
been tested in clinical trials. Casting or customized splinting can be used for mobilization but removable splints
are best reserved for compliant patients. A Stener lesion
or failures to achieve a stable thumb with minimal pain
during pinch are indications for surgery (Dinowitz et al
1997): early repair or late ligament reconstruction.
Progressive strengthening and protection from lateral
stress (functional splinting/taping) will allow remodeling
of collagen fibres to ligament orientations that provide
tensile strength. Stretching the UCL prematurely can lead
to chronic instability.

OTHER DIGITAL TENDON INJURIES

Other tendon injuries that affect the digits can occur
through lacerations, avulsion injuries (e.g. mallet/jersey
finger), acute boutonniere, pulley ruptures. Lacerations
of the flexor tendons that rupture in zones one or
two require surgical repair and specific tendon rehabilitation protocols (Groth 2005, Newport & Tucker 2005,
Libberecht et al 2006, Koul et al 2008, Soni et al 2009).
These may involve active (protected) early mobilization
in specially selected cases where repair strength is sufficient. Early passive mobilization protocols remain more
common. Consultation with the referring surgeon and
awareness of hand therapy rehabilitation protocols are
required (Klein 2003, Chai & Wong 2005, Sueoka & LaStayo 2008, Yen et al 2008). Extensor tendon rupture or
lacerations in the digits require extension splinting (46
weeks), and in some cases surgical repair. Gradually progressed protected active range of motion protocols instituted within the safety margins allowable by the specific

Digital osteoarthritis (OA) is the most prevalent form of

degenerative arthritis, although functional consequences
vary (Doherty et al 2000, Hunter et al 2004). The DIP is
the most affected, although functional consequences tend
to be more severe in the carpometacarpal (CMC) joint of
the thumb, which affects 1 in 4 women and 1 in 12 men.
In patients older than 75 the prevalence of radiographic
CMC degeneration increases to 40% in women and 25%
in men (Armstrong et al 1994, Doherty et al 2000, Caspi
et al 2001).

Anatomy
The CMC joint acts as a universal joint, allowing motion
in extension, flexion, adduction and abduction. Together,
these movements allow the complex movements of the
thumb such as opposition, retro-pulsion, palmar and
radial abduction, and adduction. The CMC joint has little
intrinsic stability and relies on static ligamentous
restraints to limit translation of the metacarpal base during these movements. There are three ligaments that help
to stabilize this joint. The primary stabilizer of the CMC
joint is the anterior oblique ligament, or volar beak ligament. It is an intra-capsular structure which originates
from the palmar tubercle of the trapezium and inserts
on the ulnar side of the metacarpal base, along the articular margin. It resists abduction, extension and pronation
forces. The secondary stabilizers include the dorso-radial
and inter-metacarpal ligaments. The dorso-radial ligament
resists dorsal and radial translation of the CMC joint and
is the most robust of the CMC joint ligaments. The intermetacarpal ligament lies between the base of the first and
second metacarpals and prevents radial translation of the
base of the first metacarpal (Bettinger et al 1999). The thenar muscles also play a role as dynamic stabilizers of the
CMC joint. These muscles work in concert, stabilizing
the thumb in position to allow activities such as pinching.

Pathology
OA is a degenerative condition characterized by pain,
intermittent inflammation and cartilage degeneration.
The pathological processes that underlie this degeneration
are multifactorial and not fully defined but include

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The wrist and hand regions

genetic and biomechanical factors. Loss of joint space,

sub-chondral sclerosis, loss of cartilage, osteophytes and
joint deformities occur. The DIP joint can also be affected
with mucous cysts which occur during the early stages of
degenerative joint disease.
Doerschuk et al (1999) conducted a cadaveric study
and demonstrated that the degree of degeneration in the
anterior oblique ligament was correlated with the stage
of the OA. Eaton & Littler (1973) also demonstrated a
strong association between excessive laxity at the thumb
CMC joint and premature degenerative changes. Laxity
combined with repetitive loading may predispose certain
individuals to synovitis, and with continued loading, the
articular surfaces gradually wear resulting in joint space
narrowing and osteoarthritis. orso-radial subluxation
occurs at the base of the thumb metacarpal while distally
the adductor pollicis pulls the thumb into an adducted
position (Blank & Feldon 1997). This adducted posturing
of the thumb leads to difficulty spreading the hand
around objects for grasping and leads to compensatory,
progressive hyperextension of the MP joint. The aetiology
of CMC joint laxity has been attributed to hormonal
influences (i.e. prolactin, relaxin and oestrogen), thus
potentially explaining the increased incidence of CMC
OA seen in women.

Diagnosis
Hand OA is diagnosed using clinical features with radiographic substantiation (Zhang et al 2009). Heberden
and Bouchard nodes are clinically defined postero-lateral
firm/hard swellings of the IP in PIP joints respectively.
Nodal OA exists in the presence of these nodes plus
underlying IP joint arthritis defined clinically and/or
radiological. Non-nodal OA is defined by IP joint OA in
the absence of nodes. Erosive OA is defined radiographically by sub-cortical erosion, cortical destruction and
subsequent reparative change and may include bony
ankylosis. Generalized OA is when hand arthritis exists
in combination with OA at other sites. Thumb base OA
is when the first CMC joint is involved in the scaphotrapezial joint.
Typical hand OA symptoms are pain on usage, mild
morning pain, inactivity stiffness particularly when affecting only single or a few consistent joints. Lateral deviation
of IPs, subluxation or adduction of the thumb base are
the common deformities.
The diagnosis of CMC OA is based on history and clinical exam. The typical presentation is a woman in her 50s
to 70s with radial sided hand or thumb pain. Clinical
examination will reveal tenderness localized to the CMC
joint, with a positive grind test (axial compression of
the thumb) reproducing pain and crepitus. Radiographs
are used to confirm the diagnosis. Various stages of
joint involvement can be seen, ranging from a widened
joint space (joint effusion or synovitis) to joint space

400

narrowing, subluxation, sclerosis and osteophyte formation. Differential diagnosis includes psoriatic arthritis,
rheumatoid arthritis, gout and haemochromatosis, each
tends to have different target sites of involvement that
can be used to assist with differential (Zhang et al 2009).

Prognosis
Genetic factors, female sex, age over 40, menopausal status, obesity, higher bone density, greater for muscle
strength, joint laxity, prior hand injury, higher occupational recreational use are all associated with increased
risk of hand OA and its severity and progression (Zhang
et al 2009).

Conservative treatment of
digital arthritis
Hand OA is a multi-joint problem and treatment
approach. EULAR evidence-based recommendations for
management suggest a combination of pharmacological
and non-pharmacological treatment be individualized to
the patient (Klein 2003, Chai & Wong 2005, Sueoka &
LaStayo 2008, Yen et al 2008). Education about joint protection and exercise are recommended for all patients.
Local application of heat, especially prior to exercise,
splints for thumb OA and orthotics to prevent or correct
lateral angulation flexion deformities are recommended.
Local treatments are preferred over systemic for mild to
moderate pain and when only a few joints are affected.
Topical NSAIDs and capsaicin are effective and safe treatments. Pharmacological and surgical interventions should
be considered in patients with marked pain or disability
or when conservative treatments have failed. There is
insufficient evidence to choose between different orthotics
options (off-the-shelf/custom fit, long/short opponens,
dorsal/volar, thermoplastic/neoprene/other materials).
Orthotics should be customized according to the joint
deformity/damage, functional requirements and patient
preferences. It is common for patients with hand arthritis
to have multiple orthoses that suit different activities or
levels of disease activity. Exercise and education have been
shown to be more efficacious than OA information alone
(Moe et al 2009).

RHEUMATOID ARTHRITIS AFFECTING

THE DIGITS
Rheumatoid arthritis is an inflammatory arthritis that has
diffuse digital and other involvement. In the past severe
hand deformities were common, but are now uncommon
because of pharmacological advances in management
of the disease. Older patients may continue to present
with severe deformity and for surgical reconstruction.

Chapter | 31 |

Finger and thumb pathology

Rheumatoid arthritis hand deformity can include boutonniere, swan neck, ulnar drift, caput ulna, tendon rupture
and sagittal band/tendon subluxation.

CONCLUSION
Injuries to the joints, tendons, ligaments and nerves in the
digits are common and require attention to detail during
rehabilitation to restore fine precision movement is

necessary that essential that function. Principles suggest that

protected motion during healing/joint irritability, progressive active movement and strengthening that incorporates
functional activities and selected use of joint mobilization
techniques to enhance joint kinematics is required. Oedema
management and integration of sensory and motor assessment/retraining are particularly important. Reliance on
principles is essential given the dearth of physical therapy
evidence for digital disorders and the specific lack of attention to this area within manual therapy literature.

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