Fractures Flashcards
Indications for operation
- Irreducible fractures
- Malrotation (spiral and short oblique)
- Intra-articular fractures
- Subcapital fractures (phalangeal)
- Open fractures
- Segmental bone loss
- Polytrauma with hand fractures
- Multiple hand or wrist fractures
- Fractures with soft tissue injury (vessel, tendon, nerve, skin)
- Reconstruction (i.e., osteotomy)
Brewerton View
For Metacarpal fractures
MCP 65° flexed - dorsum of the hand to the x-ray plate - than tube angled 15° from ulnar to radial
Surgery metacarpal head fractures
dorsal approach - often comminuted fractures - cleaning and debridement - pinning or headless screws - by defects use metatarsal bone - if necessary splinting in 70° for 3 weeks - often needs secondary tenolysis and arthrolysis - early motion is important - avoid prosthesis on index finger and with bone loss - arthrodesis is alternative - maybe very difficult to fix
Metacarpal neck fractures
most common on the 4. and 5. ray - boxers fracture - normally hitting the wall or a hard object - more mobility in the 4. and 5. ray than the 2. and 3. ray - so angulation can be more accepted in the 4. and 5. ray - there are a lot of studys who accepted 40 - 70° of angulation with a cast and early motion - patients are satisfied - sometimes they have malrotation and an unalignement of the metacarpal heads - feeling the head in palm - angulation of the 2. and 3. ray should not be accepted when there is more than 10-15° angulation
could develop “pseudoclawing” from hyperextension of the MCP and flexion the PIP because of the angulation of the metacarpal head
Surgery metacarpal neck fractures
Jahass Manoever to reduct the fracture - less tight from the intrisic mechanism - tight collateral ligaments - flexed MCP in 90° - pressure to the proximal phalanx - than a ulnar gutter cast with pressure on the dorsal metacarpal and volar metacarpal head with held in 70° - early motion from 2 weeks depending on the patient
indications:
- malrotation - unreducible
- more than one fracture
- pseudoclawing
- open fracture
- more than 70° in 5. ray
- less for the other rays
- soft tissue damage - human bites are treated otherwise
surgery:
closed reduction and pinning - different techniques - antegrad intramedullar pinning is the best from outcome although of pin migration an possible cartilage defects - most difficult to achieve the best close reduction - most popular osteosynthesis with special implants for this fracture - possible is transfixation to the next head with early motion - transverse pinning and retrograd pinning is not so good - important is a good compliance from the patient to achieve early motion exercises
mostly remove cross pins after 2-3 weeks for motion exercises - plate only if necessary - greater complications of stiffness and tendon adhesions - maybe lateral plates with good anatomic configuration - early motion exercises
Metacarpal shaft fractures
most of these fractures can be treated conservative - when there is no malrotation or instability - maybe without splinting when the patient is compliant - if a splint is needed use a clam-digger splint allowing a good mobilisation for the PIP and DIP - MCP in flexed position - than a dorsal roof for the long fingers to achieve full extension - wrist in extension for 30-40° - MCP in 80° flexion - so the intrinsic system is not tight - so there will be no secondary palmar dislocation - make a buddy tape to a finger to hold the rotation
Surgery metacarpal shaft fractures
best is intramedulläre pins - 3-4 with 0,9mm which are buried - we use prevot pins 2 with 1,5mm which where put lateral to the shaft no to compremise the extensor tendon - cross k-wires are possible but have more secondary complications to the tendon - splinting for 2-3 weeks - early mobilization
open reduction is needed:
- malrotation
- great angulation unreducible
- open fracture
- aesthetic aspects
- workes with metacarpal head in palm
- pseudoclawing
- malalignement
- multiple fractures
- and 3. ray - 10° angulation
- ray more than 20-30° angulation
- ray more than 30-40° angulation
multipel techniques has been decribed - intramedullary pinning with steinmann pins or prevot are possibile - as is many k-wires with a gauge of 0,9mm - early mobilization is possible with a short time of splinting - k-wires with stainless steel wire are more stable
plate fixation and screws: open reduction - close the periosteum - use microplates - screws in 90° degree position not to near! - careful preperation - early motion excercise
complications:
plate breaking - CRPS - tendon adhesions - bone loss - pseudarthrosis
external fixation
more disadvantage - use for bone loss and later bone reconstruction - damage control
removal of plates after 6 month - removal of pins early after 3-4 weeks
Metacarpal bone loss
Two stratgies for treatment
hold the bone in position - than soft tissue management and after complete recovery the bone is inserted from the ilac crest with plate or intramedullary fixation
other groups prefer a wound debridement with cleaning up for 7 to 10 days than bone transplantation and soft tissue management
with more than two metacarpal bones use great bone transplants from the iliac crest
Metacarpal basis fracture
- and 3. metacarpal are rare in fracture - treatment is not clear - operative and non-operative treatment is possible - a CT scan is necessary - maybe the joint has to be restored or the extensors have to be refixed - fractures are rare because of the minimal motion of the CMC joints
- metacarpal is rare too - CT scan - maybe closed reduction or open reduction is needed and transfixation
- metacarpal is common - two facets of the MHK Basis to the IV MHK basis and to the hamate - normally luxation proximal and dorsally because of the pull from the ECU Tendon - different treatments are used - we use a closed reduction with a fixation to the MHK IV and a diagonale K-wire to the hamate - the joint has to be reconstructed in a good alignement because many patients get problems after 4,3 years - maybe ORIF is necessary
if there is an osteoarthritis just do an arthrodesis - no further hand function problems are expected
Metarcarpal fracture complications
dorsal angulation
if there is pseudoclawing or problems with the grip in the palm - a closed wedge osteotomy is performed leaving the palmar cortical bone intact - than a plate is used to hold the correcture
open wedge is possible - than a trapezoid bone transplant from the iliac crest is interposed a dorsal plate is used for the bone fixation
malrotation:
osteotomy is done to the base of the metacarpus - correction within 25° can achieve - the correction is difficult not to under- or overtreated the malrotation - k-wires or plates can be use for fixation
others:
osteomyelitis, non-union, tendon adhesion, capsule shrinking, intrinsic dysfunction
distal phalanx
most common - tuft, shaft and intra-articular fractures
tuft fracture - nail trepenation - short period of immobilization - attention to nail or matrix laceration - if there is a nail trepentation maybe oral antibiotics should be given
shaft fracture - normally conservative - transverse displaced should be fixed by k-wires
epiphyseal fracture - so called seymour fracture - salter harris class I or II - with laceration of the nail matrix - extensor tendon to proximal fragment - distal fragment to flexor tendon - often overseen - open debridement - irrigation - reduction and nail bed repair - little splint to hold the distal fragment in position
proximal phalanx
most stable fractures of the phalanx can be managed by buddy taping
outcome depends on age first two decades 88% mobility restored - 6. and 7. decade only 60%
good results and resurfacing of the joint - stabilty is more important
fractures associated with bone loss, unstability or deformity prone to residual disabilities regardless from method of treatment
soft tissue laceration often have more correlation to disability
immobilization less than 4 weeks - 80% active motion
more than 4 weeks - 66% active motion
condylar fractures:
classification from Weiss-Hastings
I - oblique volar
II - long sagittal
III - dorsal coronal
IV - volar coronal
comminuted fractures or bicondylar fractures often leads to stiffness of the PIP
unicondylar fractures proximal phalanx
often surgery -
try close reduction - if unpossible than open reduction - enter PIP joint between lateral band and central tendon
detachement of the collateral ligament may result in instability or osteonecrosis
splinting for 5 to 7 days - remove k-wires after 3-4 weeks - early exercises should be achieved
special: displaced collateral ligament avulsions - treated with open reduction
extensively comminuted fractures should be treated closed or non-operatively because of soft tissue damage
dorsal, volar or lateral base fractures of the middle and proximal phalanx
dorsal:
central tendon deatechement - displaced more than 2mm - than open reduction and fixation - careful oberservation - boutonnière deformity!!!
volar:
colleteral ligament avulsion - minimally displaced can be treated with splinting - early range of motion after 2 weeks
displaced fractures - proximal phalanx - need open reduction and fixation - approach from volar to the A1- and A2-Pulley - than open up the volar plate of the fracture side to fix the bony fragment - if screws are taken - active motion can be apply on the first postop. visit.
lateral base fractures of the middle phalanx are articular compression fractures and need cancellous bone grafting
pilon fractures - use of distraction external fixation - significant remodelling of the joint surface with good function - carefully select candidates for open reduction - maybe external fixation and intramedullar reduction over the back side of a k-wire - external fixation for 4 to 7 weeks
if the dorsal aspect of the bone is intact and there is more than 40-50% of surface destroying maybe a hemihamate autograft could be transplanted and fix with screws - motion begins one week after operation
shaft fractures involving the joint - mostly open reduction and fixation
condylar fractures of the middle phalanx can be treated conservatively with early mobilization - diminshed DIP joint motion should be anticipated
non-articular fractures
neck fractures:
uncommon in adults - closed reduction and pinning
children more complex and more common - mostly when the finger is trapped in a closing door - true lateral view is necessary
classification modified by Al-Qattan
Type I - not displaced
Type II - little displaced
Type III - full displacement to dorsal with rotation of the fragment about 90°
middle phalanx - axial k-wire through the DIP joint ofter open reduction - approach through lateral band
proximal phalanx - one or two k-wires - approach through lateral band and central tendon
shaft fractures:
spiral and oblique more in the proximal phalanx - mostly with an angulation with apex to the volar side from the strong intrinsic muscles
transverse more in the middle phalanx have varies angulation
comminuted fractures - open reduction and fixation - when there is open fracture or soft tissue laceration maybe stabilization with an external device
open reduction and internal fixation - always try to achieve a rigid contruct for early motion of the joints
K-wires are very good because of less affection to the soft tissue in comparison to plates or screws - easy to remove - different studies show different results for leaving the k-wire through the skin or not - always a cast is necessary because this is not rigid construct - better with stainless steel wire - 26gauge
study:
proximal phalanx 92% range of motion
middle phalanx 76% range of motion
complex fractures in comparison from screws and k-wires - screws are better because they can move earlier
plates are bad - common used with comminuted fractures with mass of soft tissue laceration - condylar plate have shown more mobility of the PIP joint than dorsal plate positioning
biomechanical screws and plates are more strong than k-wires or k-wires with stainless wire loops
