Hand Fractures Flashcards
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
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
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
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Plate fixation is
rarely used for phalangeal fractures
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plate fixation in the phalanges frequently leads to tendon scarring and
stiffness
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the extensor tendons overlying the metacarpals
do not sit directly on bone and, as such, are at low risk for adhesions
after plate fixation
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, plate and screw
application requires a relatively large amount of soft tissue dissection
and periosteal stripping
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tenolysis and/or plate removal may be needed after fracture healing
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External fixation fractures with substantial soft tissue injury, marked comminution,
bone loss, and/or contamination
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Rarely is external fixation the
definitive solution for hand fracture management
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the most common fractures in the hand
Distal phalangeal fracture
Tuft
fractures most frequently occur in combination with nail bed injuries
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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
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managed with distal interphalangeal (DIP)
joint splinting in full extension for 6 weeks
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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
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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
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Phalangeal neck fractures are inherently unstable
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majority of these injuries are treated with K-wire fixation
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Nondisplaced shaft fractures may be managed with splinting or buddy tape to an adjacent uninjured digit for 3 to 4 weeks
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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
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The screw diameter should be less than one-third of the length of
the fracture
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Nondisplaced phalangeal base fractures are treated with
splint immobilization for 3 to 4 weeks.
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Metacarpal head fractures are rare
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Computed tomography scan may better visualize the fracture pattern and assist in surgical planning
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Nonoperative management is recommended for fractures with less than 25% articular involvement.of MCP
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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
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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
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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
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Buried antegrade intramedullary pin application may be
superior because it avoids the extensor mechanism and obviates the
risk for pin tract infection
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less angular deformity is
tolerated in the metacarpal shaft
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Nondisplaced oblique and spiral
fractures are usually unstable and are often best treated with surgery
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If the fracture is
obliquely oriented and the fracture length is at least twice the bone
diameter, lag screws may be the best choice
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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
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Given the substantial
mobility of the thumb CMC joint, a relatively large amount of displacement is well tolerated
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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.
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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
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Stiffness with active and passive motion
results from joint contracture, whereas diminished active motion
only is often the result of tendon adhesions
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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
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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.
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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.
