Hand and wrist fracture, dislocation Flashcards
discuss xray for hand fracture
- AP/Lateral/Oblique for all plus/minus:
o Brewerton view (MPJ flexed 65° with dorsum of digits lying flat on X-ray plate, tube angled 15° in an ulnar–to-radial direction) – helpful to see collateral avulsion #’s
o Skyline metacarpal view (MPJ’s and IPJ’s fully flexed, beam directed parallel to the dorsal shaft of the proximal phalanx) – helpful to visualize the metacarpal head
o Stress views
o Pre and post reduction
how do you classify hand fractures?
- open vs closed
- Specific bone and site (e.g.metacarpal head)
- Fracture pattern (oblique, spiral, transverse, comminuted)
- Displacement, angulation, shortening
- Etiology (pathological vs traumatic; high vs low energy)
- Intra vs extra articular
discuss classification of pediatric epiphyseal fractures
Type
Location
Management
Prognosis
I (5%) - Straight
- Physis
- Splint/Observe
- Good – low impact growth
II (75%) - Above
- Physis + Metaphysis
- Closed reduction
- Good – low impact growth
III (10%) - Low
- Physis + Epiphysis (intra-articular)
- ORIF
- Moderate impact growth
IV (10%) - Through
- Physis + Metaphysis + Epiphysis (intra-articualr)
- ORIF
- Moderate impact growth
V (rare) - cRush
- Physis (crush)
- Splint/Observe
- Worst impact growth
indications for operative intervention of metacarpal/phalangeal fractures
- Any malrotation or scissoring
- Shortening of 2-5mm
- Unable to obtain or maintain a reduction
- Grossly comminuted w/ segmental bone loss
- Fractures with soft tissue injury (vessel, tendon, nerve, skin)
- Reconstruction (ie. osteotomy)
- Open (relative)
- Intra-articular (relative)
- Other (often relative): major ligamentous / tendinous avulsion; Polytrauma with hand fractures; Multiple hand or wrist fractures
indications for non-operative management
- can be achieved through closed reduction and immobilization if stable:
- · No rotation or scissoring
- · Stable
· <10⁰ lateral deviation
· <3-4mm shortening
· <45⁰ angulation for 5th MC neck
· >50% bony apposition
list options and relative advantages of different methods of operative fixation
- percutaneous pinning
- advantages:
- can be utilized using closed reduction
- no soft-tissue dissection or peri-osteal stripping required
- simple, easy
- Disadvantages
- non-rigid, no compression, requires immobilization
- risk of infection through pin site
- advantages:
- intra-osseous wiring
- advantages: useful for specific situations, minimizes extent of periosteal stripping
- disadvantages:
- Tension band
- advantages: compress and apply tension across angulating force, limited soft tissue disruption, minimizes risk of fragmentation
- Plate fixation
- advantages: rigid fixation, permits early ROM
- disadvantages: greatest extent of dissection, periosteal stripping, hardware complications (permanent, palpable, loosens, tendon injury), stiffness, edema
- Lag screw fixation
- advantages: minimal soft tissue dissection or peri-osteal stripping, rigid fixation and applies compression force
- disadvantages: need to follow principles, permanent hardware
- disadvantages: finicky
what are princples of lag screw fixation
- for oblique or spiral fracture where length of fracture is 2-3 x width of bone (2:1 = 2 screws; 3:1 permits 3 screws)
- apply at angle that bisects the 90’ to bone axis and 90’ to fracture axis
- ensure that anatomic reduction is achieved and maintained w/ bone-holding forceps
- overdrill proximal cortex (2mm drill bit) and regular drill distal cortex (1.5mm or 1.8mm drill)
- will compress when picks up distal cortex
discuss surgical approaches to the hand
Region
Preferred Incision
Metacarpal
- Dorsal longitudinal
MCPJ/Metacarpal Head
- Dorsal longitudinal with tendon splitting
Proximal/Middle Phalanx
- Lazy S or straight dorsal with tendon splitting
- or midlateral incision
PIPJ**
- Lazy S or straight dorsal with tendon splitting
- Vs. volar
DIPJ
- Dorsal Y/champagne or hemichampagne
Distal Phalanx
- Dorsal Y/champagne or hemichampagne
Thumb Metacarpal Base/CMCJ
- Wagner incision
Thumb Phalanges
- Dorsal longitudinal incision with EPL tendon left intact
- ** indications for volar approach to PIPJ: comminuted base of MP; volar plate avulsion #; dorsal PIP fracture-dislocation
- ** indications for shotgun approach to PIPJ (i.e. to add hyperextension to volar approach): severe comminution or impaction of fragments
discuss treatment of Bennett fracture
Closed reduction + K-wire –> for any fracture that can be reduced by this means
◦ longitudinal traction, pressure at metacarpal base, pronation
◦ 1 K-wire thumb MC (0.045) à trapezium, or 2 K-wires into 2nd MC (or one to trapezium, one to 2nd MC) – none in fragment unless large
◦ Accept if <2mm articular step-off, immobilize in thumb spica
Consider ORIF if # fragment >20% articular surface
◦ Wagner incision, reflect thenar muscles, incise joint capsule
◦ 1 lag screw (2.0 or 2.7 mm): can start AROM at 10d postop
◦ 2 K-wires (0.035 inch) across # x 6wks ± 1 transarticular K-wire x 4wks
◦ 2 intermetacarpal K-wires
describe bennett fracture
- intra-articular fracture of base of thumb MC
- displacement of large fragment by proximal and dorsal pull of APL
- maintenance of small fragment by volar beak ligament
discuss treatment of rolando fracture
3 part # with large fragment –> Wagner incision, ORIF 2.4 or 2.7mm T or L plate
Significant comminution –> do not open (use ligamentotaxis)
◦ Thoren oblique traction –> radial – ulnar 0.062 k-wire through small incision, crimp proximal end, oblique traction through 1st webspace to Banjo outrigger
◦ Quadrilateral ex-fix (2 pins each in 1st & 2nd MC)+ articular reduction with K-wire ± cancellous bone graft to metaphysis
what is a Stener lesion
- in context of presumed thumb UCL injury; a Stener lesion is only present when there is a complete UCL tear
- Adductor aponeurosis interposed between distally avulsed ligament and its insertion into the base of the proximal phalanx, preventing its reapposition with PP with immobilization
how do you diagnose complete UCL tear?
- complete tear: > 35’ radial deviation or no endpoint or >15⁰ compared to contralateral – test in 30⁰ flexion to minimize VP contribution to stability) –> x-ray (see small bony Stener lesion), US, MRI to r/o - less common
discuss treatment scenarios of partial and complete UCL tear, thumb
- Acute Partial –> thumb spica x 4wks (in slight ulnar deviation)
- Acute Complete (Skier’s Thumb) – most common is distal avulsion
- Conservative (thumb spica) if no radiologic Stener lesion – controversial
- Operative: Stener Lesion or complete tear
- Dorsal lazy-s incision, ID adductor aponeurosis & incise longitudinally parallel/volar to EPL
- Reflect the adductor aponeurosis volar to expose ulnar aspect MCPJ
- Repair ligament (direct repair; secure to PP modified Kessler pull-out suture over button with Keith needle and 3.0 nylon/prolene; cerclage wire; or mini mitek bone anchor)
- If large bony avulsion
- Typically NOT a Stener, bc the ligament is attached to bone fragment
- Consider operative intervention (below) if: > 20% joint surface; > 2mm step deformity; significant instability; suspected Stener; combination injury (tear and avulsion)
- Bony repair options: k wire, mini plate, pull out suture vs. excise small bony fragments and suture UCL into defect
- Repair ligament to VP, repair dorsal-ulnar capsule, repair adductor aponeurosis
- Test repair – gentle radial stress; ± K-wire in slight ulnar deviation/flexion; thumb spica x4/52 then custom splint
- Complication: neurapraxia of radial sensory nerve branches
discuss treatment of chronic thumb UCL injury
- Key Management Point: define degenerative arthritis clinically (history of pain, tenderness at MCPJ, + grind) and radiologically
- MPJ arthrodesis indicated when clinical plus radiological evidence of symptomatic OA
- If no OA:
o Dynamic Reconstruction
§ Adductor pollicis advancement from ulnar sesamoid to ulnar base of PP
§ ½ EPB used to reconstruct UCL
o Static Reconstruction
§ Direct repair, plication, capsulodesis
§ Bone anchor, cerclage wire, pull-out over button
§ Tendon graft reconstruction (PL, plantaris, toe extensors, APL, FCR ½)
Discuss operative indications and options for fracture of MC head in digit
Operative Indications
o Open (human bite) require I&D +/- ORIF & antibiotics
o > 25% articular surface
o > 1-2 mm articular step
Operative options
o Two part intra-articular –> K-wire, screw fixation, or blade plate (more rigid = earlier movement = ↓ stiffness)
§ Antegrade fixation if large fragment; retrograde fixation if small fragment
o Severely comminuted à traction (if prox phalangeal base # as well), silicone arthroplasty (need ligamentous stability & adequate bone stock – rare primary treatment, not for younger/active people); Ex-Fix (bone loss or lack of soft tissue)
o Arthrodesis – not acutely
o Delay internal fixation in contaminated wounds (e.g. human bite)
what are operative indications of MC neck fracture, digit?
Operative Indications (after failed at closed reduction)
- >3mm shortening (every 2mm = 70 extensor lag)
- Extensor lag
- Rotation/scissoring
- <50% bony apposition
- >10o lateral deviation
- Angulation: Index >10o, Long >20o, Ring >30o, Small >40o
- Unstable but reducible à K-wire percutaneous fixation + splint
what are operative management options for MC neck fracture, digit?
- Crossed k-wires +/- dorsal tension band
- 4 hole plate:2 screws in head, 2 in shaft; T or L plate
- Intramedullary K-Wire (bouquet technique)
- Transverse pinning to an adjacent intact MC
- Immobilization for 7-10 days then x-ray; satisfactoryàbegin protected ROM, pins out at 3-4 weeks
list indications for intervention of MC shaft fractures, digits
- Closed but Displaced –> Closed reduction + splinting
- Reduction for – Angulation > 300 D5, 200 D4, ~ 100 in D2,3; Shortening > 2-5mm;
- Operative Indications
- Open #, unstable # after closed reduction, multiple #, most spiral/oblique # good for lag screw or plate, polytrauma (can’t cooperate/tolerate immobilization)
List normal values for radial height, inclincation, tilt
- Radial height - measured on AP - 11mm (13mm)
- Radial inclincation - measured on AP - 22mm (23)
- Articular step-off - measured on AP - congruous
- Radial volar tilt - measured on lateral - 11’
