Hand Fractures Flashcards by M A

Metacarpal fractures typically assume an apex dorsal deformity,
proximal phalangeal fractures result in an
apex volar deformity

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Rotational deformity may
be subtle, yet clinically significant, and is evaluated through active
range of motion or wrist tenodesis

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5° of metacarpal rotation leads to 1.5 cm of digital overlap

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Three-view (posteroanterior, lateral, oblique) plain radiographs of the hand are mandatory to assess
fracture anatomy

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Definitive fracture treatment is
performed when the wound is clean and stable soft tissue coverage
can be ensured

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all closed hand fractures can be initially managed with
closed reduction and splinting.

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metacarpal and phalangeal fractures are adequately treated by 3 to 4 weeks
of continuous immobilization

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the
duration of immobilization should be as short as possible to allow
fracture healing

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Base fractures assume an
apex dorsal deformity resulting from the pull of the central slip and
the flexion moment imparted by the flexor digitorum superficialis
(FDS) insertion

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Middle phalanx fractures distal to the FDS insertion
assume an apex volar posture because the FDS flexes the shaft and the
extensor mechanism extends the distal fragment

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Indication of surgery in hand fracture

■ Articular incongruity
■ Digital malrotation, shortening, or angulation
■ Multiple fractures
■ Open fractures
■ Fractures with soft tissue injury or bone loss

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K-wires alone, however, do not provide rigid
fixation or compression across the fracture site

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Additional immobilization may be necessary after putting K-wire

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a single K-wire does not impart rotational stability,

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K-wires
should never cross at the fracture site, as this will lead to distraction
ofthe fracture fragments and limited fracture stability

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Tension band wiring is a modification of K-wire fracture fixation
that increases construct strength

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Compression screws may be used for oblique or spiral fractures
using the lag principle

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Compression screws is ideal when the fracture
length is at least twice the diameter of the bone

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Lag screw fixation
requires drilling a hole in the near cortex that is the same diameter
as the outer diameter of the screw.

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Multiple screws are required to achieve anatomic
reduction and impart axial stability of the construct

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a countersink should
be used to prevent screw head prominence

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interosseous wiring is a technically demanding procedure that provides rigid fixation and fracture site compression.

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Indication of intraosseous wiring ?

transverse fractures of the phalanges or metacarpals, in joint arthrodesis, or in digital replantation

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Plate fixation provides a highly stable construct for hand fracture
treatment

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Plate fixation commonly used for metacarpal shaft fractures and for the treatment of nonunion and malunion, where restoring length and stability are essential

Plate fixation is rarely used for phalangeal fractures

plate fixation in the phalanges frequently leads to tendon scarring and stiffness

the extensor tendons overlying the metacarpals do not sit directly on bone and, as such, are at low risk for adhesions after plate fixation

, plate and screw application requires a relatively large amount of soft tissue dissection and periosteal stripping

tenolysis and/or plate removal may be needed after fracture healing

External fixation fractures with substantial soft tissue injury, marked comminution, bone loss, and/or contamination

Rarely is external fixation the definitive solution for hand fracture management

the most common fractures in the hand

Distal phalangeal fracture

Tuft fractures most frequently occur in combination with nail bed injuries

The healing of the tuft fracture is very well !!!

Tuft fractures often heal with a malunion, but these are rarely symptomatic

Articular fractures of the dorsal base of the distal phalanx involve the extensor tendon insertion

managed with distal interphalangeal (DIP) joint splinting in full extension for 6 weeks

When we should use K-wire fixation for the fracture of the distal phalanx

Dorsal block K-wire fixation is recommended for fractures involving more than one-third of the articular surface or in the setting of volar subluxation of the distal fragment

Seymour fracture can lead to osteomyelitis

Phalangeal condylar fractures are classified

type I (unicondylar and nondisplaced), type II (unicondylar and displaced), and type III (bicondylar).

Extreme care must be exercised when performing open repair of condylar fractures to avoid injury to the vascular supply arising from the attached collateral ligaments

Phalangeal neck fractures are inherently unstable

majority of these injuries are treated with K-wire fixation

Nondisplaced shaft fractures may be managed with splinting or buddy tape to an adjacent uninjured digit for 3 to 4 weeks

When should do reduction and fixation for phalangeal shaft fracture

If malrotated or displaced greater than 10° to 25° in the sagittal plane or 10° to 15° in the coronal plane,

Long oblique and spiral fractures are treated with interfragmentary screw fixation

The screw diameter should be less than one-third of the length of the fracture

Nondisplaced phalangeal base fractures are treated with splint immobilization for 3 to 4 weeks.

Metacarpal head fractures are rare

Computed tomography scan may better visualize the fracture pattern and assist in surgical planning

Nonoperative management is recommended for fractures with less than 25% articular involvement.of MCP

Indication of surgery in metacarpal head fracture

fractures with greater articular involvement, > 1 mm articular incongruity, or collateral ligament instability,

Avascular necrosis of the metacarpal head is common

F is rare

headless screw fixation is an optimal choice of fixation for metacarpal head fractures

comminuted or associated with joint disruption of MCP joint what are the options

best treated by dynamic external fixation or acute arthroplasty

Metacarpal neck (i.e., boxer's) fractures are common and typically involve the fifth metacarpal

Indication of surgery in Metacatpal neck fracture

pseudoclawing excessive shortening, and malrotation after attempted closed reduction

up to 70° in the fifth metacarpal neck angulation accepted

Buried antegrade intramedullary pin application may be superior because it avoids the extensor mechanism and obviates the risk for pin tract infection

less angular deformity is tolerated in the metacarpal shaft

Nondisplaced oblique and spiral fractures are usually unstable and are often best treated with surgery

If the fracture is obliquely oriented and the fracture length is at least twice the bone diameter, lag screws may be the best choice

A disadvantage of Percutaneous pinning of the metacarpal shaft?

longer periods of immobilization and delayed initiation of therapy

Extra-articular metacarpal base fractures are managed similarly to shaft fractures

Given the substantial mobility of the thumb CMC joint, a relatively large amount of displacement is well tolerated

Reduction is indicated if the distal fragment is flexed greater than 30°Why?

this amount of deformity leads to compensatory thumb MCP joint hyperextension.

Bennett fracture represents an oblique intra-articular fracture-dislocation of the thumb metacarpal base.

The metacarpal subluxates proximally, radially, and dorsally ,why?

secondary to the pull of the abductor pollicis longus, extensor pollicis brevis, and adductor pollicis

The way of fixation of Bennett fracture

place a K-wire across the articular surface perpendicular to the long access of the metacarpal into the second metacarpal base. additional wire is placed retrograde across the trapeziometacarpal joint

segmental loss management

External fixation soft tissue loss Bone graft tendon reconstruction

complications are more frequent after phalangeal and open fractures than with metacarpal fractures

Stiffness with active and passive motion results from joint contracture, whereas diminished active motion only is often the result of tendon adhesions

Complication of hand fractures

Stiffness Malunion Fracture nonunion Infection chronic pain

Metacarpal fractures lead to an apex dorsal deformity due to intrinsic muscle pull on the metacarpal head

Proximal phalanx fractures typically result in an apex volar deformity because the intrinsic muscles flex the base and the extensor mechanisms extend the distal shaft.

indications for reduction of a phalangeal fracture.

fractures with greater than 10° to 25° of sagittal plane deformity, 10° to 15° of coronal plane deformity, shortening of more than 2 to 4 mm, intra-articular incongruity, multiple open fractures, and fractures with soft tissue injury and/or bone loss.