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Upper Extremity > Hand Fractures & Dislocations > Flashcards

Hand Fractures & Dislocations Flashcards

1
Q

What view is used for assessment of collateral avulsion F# at MCP jt?

A

Brewerton view

  • MPJ flexed at 65’, ulnar to rad 15’ angle
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2
Q

What is view is used for metacarpal head>

A

Skyline metacarpal view

  • with MCP and PIP jt fully flexed, beam shot down shaft of PP
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3
Q

How do you classify hand fractures?

A
  • Specific Bone & site
  • Pattern
  • Open/closed
  • intra/extra-articular
  • angulation
  • displacement
  • etiology
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4
Q

Describe the salter harris classificatoin

A

for pediatric fractures adjacent to epiphyseal plates

  • 1 = Physis
    • Tx - Splint/Observe
  • 2= Physis + metaphysis
    • Tx = Closed reduction
  • 3= Physis + Epiphysis (intra-articular)
    • Tx = ORIF (moderate impact on growth)
  • 4= Physis + Epiphysis + metaphysis (intra-articular)
    • Tx= ORIF (moderate impact on growth)
  • 5= Physis crush
    • Tx =splint/observe (worst impact on growth)
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5
Q

What are indications for ORIF of metacarpal and phalangeal fractures

A
  • failed closed reduction
  • intra-articular fracture
  • segmental bone loss
  • associated nerve/tendon, vessel damage
  • open fractures
  • Multiple Metacarpal fractures
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6
Q

What are indications for non-operative treatment?

A
  • <45’ angulation D5 MC neck
  • <3-4mm shortening
  • <10’ lateral deviation
  • no rotation
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7
Q

How do you manage a thumb METACARPAL FRACTURE

A
  • EPIBASAL = EXTRAARTICULAR
    • <30’ angulation, splint
    • >30’ angulation, CR (longitudinal traction, pressure on dorsal apex, pronate, Kwire to Trapezium
  • BENNETTS = INTRAARTICULAR F#-DISLOCATION
    • dislocated proximal, radial, dorsal and supinates b/c of APL and AdP pull
    • ulnar fragment stabilized by anterior volar oblique lig to Tm and D2base
    • BENNETTS NEEDS OR
      • If <20% articular surface: CR w traction +pronation Kwire along shaft into Tm + D2 MC or 2kwire to D2MC. Thumb spica
      • If >20% of artic surface, ORIF w wagner incision, b/w APL thenar, 1lag screw (2 or 2.7mm) and ROM POD10, or 2kwire (0.035) 4wks
  • ROLANDO = INTRA-ARTICULAR COMMINUTED
    • 3 piece F#: ORIF w 2.4/2.7mm T plate
    • ++comminuted; banjo outrigger splint or ex fix
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8
Q

How do you manage THUMB PHALANGEAL F#?

A

THUMB PP

  • >30’ angulation not accepted => IP extensor lag
  • CR and thumb spica
  • if unstable, Kwire, then ORIF

THUMB DP

  • as above

THUMB MALLET

  • as mallet fractures
    • splint 6wks
    • if <20% articular surface, splint
    • if >20% articular surface, kwire extension blocking
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9
Q

What are the five stabilizing ligaments of the CMC jt

A
  • Anterior (volar) oblique lig
  • Posterior oblique lig
  • Dorsoradial ig
  • Anterior Intermetacarpal ligament
  • Poserior intermetacarpal ligament
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10
Q

how do you manage a CMC jt thumb dislocation?

A

Dislocation of thumb CMC is rare

  • Partial=>CR, stable on xray =>thumb spica 6wks
  • Complete=> unstable=> ORIF and volar beak lig recon w FCR
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11
Q

How do you manage UCL injury

A
  • stabilizers of MCP jt is proper CL (dorsal) and accessory CL (volar)

UCL - partial = end pt, complete = no end pt

  • Acute partial - thumb spica 6wks
  • Acute complete -
    • conservative - thumb spica 6wks
    • Operative (large bone avulsion, <2mm displaced, stener lesion)
  • Chronic complete (>6wks)
    • conservative - thumb spica 6wks
    • Operative
      • Dynamic recon
      • Static recon
      • MCP arhrodesis
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12
Q

Descrbie the operative intervnetions for acute complete vs chronic complete UCL injuries

A

INDICATIONS for operative intervention for acute UCL

  • >2mm displacement
  • sterner lesion
  • >10% of articular surface

ACUTE UCL (distal avulsion)

  • Dorsal ulmar lazy S incision, watch DRSN br!
  • Reflect adductor aponeurosis, incise capsule volar to EPL, ID UCL
  • Repair ligament (direct, mitek, kessler pull out suture)
  • Repair bone if large fragment (Kwire, pull out suture)
  • Repair ligament attachment to VP, dorsoulnar capsule, adductor aponeurosis
    • +/- Kwire in ulnar deviation
    • thumb spica 4wks then custom splint

CHRONIC UCL

  • Repair ligament
  • Dynamic recon
    • EPB slip
    • AdP advancement from sesamoid to PP base
  • Static recon (PL, 1/2FCR, APL tendon graft)
    • debrice remaining UCL
    • drill hole in PP base at 1 and 5o’clock (12 dorsal). Drill hole in radial MC head. Pass gaft through PP, then MC head and secure
    • +/- Kwire in ulnar deviation, thumb spica
  • MCP arthodesis
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13
Q

How do you manage MCP dislocation

A

DORSAL dislocation reducible >>>VOLAR (irreducible)

  • risk cnverting to complex dislocation
  • Dorsal - VP may interpose, FPL + thenar form noose around neck of MC
  • Volar - dorsal capsule/EPL may interpose

REDUCTION

  • NOT longitudinal traction
  • HYPEREXTENSION and puch PP base
  • splint MCPj fleion 20’ for 2wks hen AROM in extension Blockign splint

IF IRREDUCIBLE
- Open reduction - volar bruner, remove interposed tissue, reduce. If unstable, Kwire

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14
Q

How do you manage METACARPAL HEAD fractures? D2-D5

A
  • xray view +/- brewerton (collateral avulsion F#), skyline (head F#)

Non-op

  • congruent joint, undisplaced

Operative indications

  • fight bite/open requiring I&D
  • >25% articular surfcae
  • >1-2mm articular step

Operative treatment

  • 2piece - Kwire, minicondylar plate/screw, blade plate
  • comminuted - traction, cerclageslicone arthroplasty (delayed), ex-fix
  • contaminated - delay internal fixation
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15
Q

What are complications of metacarpal head fractures>

A
  • avascular necrosis
  • stiffness
  • epiphyseal arest in kids
  • malunion non union
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16
Q

How do you manamage METACARPAL NECK F#?

A

Assessment

  • rotational deformity
  • pseudoclawing (PIP flexion and MCp hyperextension)
  • all dorsallly angulate b/c of IO

Non-op

  • CR with Jahss maneuver (MCP PIP flex 90, push drosal on PP and volar on MC), ulnar gutter 3wks

Operative indications

  • rotation post reduction
  • lateral displacement 10’
  • angulation D2 >10’, D3 20’, D4 30’ D5 40’
  • <50% bony apposition
  • shortening >3mm (2mm = 7 ‘ extensor lag)
  • extensor lag

Operative treatment

  • unstable post reduction =>Kwire
  • Kwire - crossed, intrameduallry bouquet, trasnverse to adjacent MC
  • Plate screw =>T/L shapped w 2screws in head 2 in shaft
17
Q

List complcations for METACARPAL F# and treatment of complicaitions

A
  • malunion (malrotation/angulation, shortening)
  • step-cut, opening/closing wedge osteotomy +/-BG
  • non-union
  • resect pseudoarthrosis, BG, plate fixation
  • tedon adhesions
  • PT/OT, tenolysis
  • Intrinsic contracture
  • intrinsic release
18
Q

How do you manage a Baby Bennets

A
  • Always operative
  • Closed reduction + Kwire fixation to D4 +/- hamate
  • ORIF if multiple CMC #/dislocation
19
Q

What is a Baby Bennett’s?

A
  • Fracture dislocation of D5 MC - look for D4 or hamate F# too
  • dorsal, proximal dislocation b/c of ECU pull
  • radial segment remains in place b/c intermetacarpal ligament
20
Q

How do you manage METECARPAL SHAFT FRACTURE?

A
  • issue is rotation =>5’ rotation causes 1.5cm digit overlap
  • Closed reduction if (Kwire in addition if unstable)
  • Angulation D5 >30’, D4 >20’, any angle D2,3
  • Shotening >2-5mm
  • Any rotation
  • ORIF if:
  • open F#, unstable F#
  • multiple #
  • spiral/oblique #
  • polytrauma (cant cooperate for physio/immoblization)
  • Fixation options
  • IM Kwire (PB)
  • cross/trasnverse/composite Kwire
  • plate (5hole, 2mm) (if multiple, trasnverse, mal/nonunion)
  • Lag screw
  • Exfix (bone loss, septic no union
21
Q

How do you manage a segmental bone loss of MC?

A
  • fixation to maintain legnth (ex fix, traction)
  • BG with ICBG when clean and fixate w plate
22
Q

How do you manage NON_ARTICULAR PHALANGEAL FRACTURES of PP and MP?

A
  • PP angulate volar
  • MP angulate dorsal if F# distal to FDS
  • MP angulate volar if F# proximal to FDS

Most non-op with EBS and buddy tape

OPERATIVE INDICATIONS

  • pediatric PP juxta-epiphyseal (neck) with 90-180’ rotation and interposed VP
  • angulation >25’
  • unstable

Undisplaced => EBS + buddy tape 7-10days, f/u q1-2wks to ensure no displacement

Displaced+stable post reduction => EBS 2wks, then EBS+buddy tape to flex 2wks. F/u q1wk

Displaced + unstable => CR + kwire or lag. Splint 3wks w early protected ROM. Kwire out at 4wks

Disaplced + comminuted =>exfix, ORIF plate/screw

23
Q

How do you manage articular F# of the proximal phalanx head?

A

LONDON CLASSIFICATION of PP head F#

  • unicondylar - transverse
    • stable (b/c CL holds it)
    • Tx: dorsal EBS, xray qwk
  • unicondylar - oblique
    • ALWAYS UNSTABLE b/c CL unstable
    • Tx: CR Kwire
    • Or, ORIF - lag screw, 2kwire, blade plate
    • Post-op early AROM, pins out at 4wks
  • bicondylar
    • UNSTABLE
    • Tx: if possible ORIF w plate. if not ossible b/c high comminution, immobilize 2wks or traction then AROM
    • if condyle missing, costochondral graft from toe, arthroplasty, arthrodesis
24
Q

How do you manage base of MIDDLE PHALANX fractures?

A
  • Central slip (bony boutonniere)
    • if <2mm displacement =>boutonniere splint 6wks
    • if >2mm, ORIF w 2kwire in fragment and one kwire across joint
  • Collateral ligament
    • if undisplaed =>EBS 14days then protected AROM
    • displaced - ORIF
  • Pilon F#
    • outigger traction that spans PIP
    • if >50% articular suface, hemihamate
25
Q

How do you manage DISTAL PHALANX F#

A
  • Tuft - mallet splint 14days
  • Shaft
    • undisplaced - mallet splint 3wks
    • displaced - Stax splint 3wks +/_ kwire
  • MALLET (dorsal base of DP)
    • CLASSIFICAION - DOYLE
    • 1 = closed, +/- F#
      • tx 6wks splint, then 2wks protected
    • 2 = open
      • tx -dermatotenodesis 6wks splint
    • 3 = open with loss of tendon/skin
      • local flap for skin, delayed tendon graft
    • 4A - epihyseal plate F# (seymour if interposed nail)
    • 4B - F# with 20-50% articular surface
      • Tx as above w stax splint
    • 4C - F# with >50% articular surface
      • Tx with Extension block kwiring or ORIF w longitudinal kwire and bunnell button pull out
26
Q

How do you manage MCP dislocations?

A
  • Most commonly DORSAL dislocation
  • Classified as simple (subluxation) or complete/complex (VP interposition)
  • Do not use longitudinal traction - will tighten strctures around joint
    • D2 - Flexor ulnar, lumbrical radial
    • D5 - ADM FDM ulnar, flexor lumbircal radial
    • thenar +/- FPL

TREATMENT

  • Simple - flex wrist, PUSH dorsal to volar on base of PP - once reduced, EBS and early ROM
  • Complex - PP will be HYPERETENDED, articular surfcae lying diretly no dorsum of MC b/c VP is on head
  • attempt reduction as for simple but will likely need Open reduction

Volar approach - release A1, reduced VP, watch radial NV bundle stretched over head of MC

Splint MCP at 30 for 2ks then DBS and AROM

27
Q

How do you manage radial CL ruptures?

A

immobilize 3wks with 30’ flexion then buddy tape 3wks

If unstable at 6wks, ORIF

28
Q

How do you manage PIP F# dislocations

A

Hastings Classification of DORSAL PIP dislocations

Based on F# of MP base F# of VP

  • 1=> < 30% articular surface
    • DBS 3wks
  • 2=> 30-50%, tenuous
    • if reducible in flexion, treat as above
  • 3=> >50%, unstable
    • ORIF, hemihamate, VP arthroplasty

Eaton-Littler Classification of DORSAL PIP dislocations

Based on similar to above

  • 1=> hyperextension (aka subluxation - contact remains b/w dosal PP and MP base)
  • 2=> dorsal dislocation (complete - base of MP does not have contact w articular surface of PP)
    • Tx for both 1/2
    • DBS 2wks max and buddy tape, then continue w AROM
  • 3=> F# dislocation
    • <40% articular surfcae = stable=> treat as 1/2 but 3wks of DBS
    • >40% articular surfcae =>unstable
      • DBS at 10’ mroe flexion then where unstable. Active PIP flexion in splint and increase extension 10’/wk
      • Dynamic skeletal traction (#comminuted)
      • ORIF - shotgun approach, fixation 0.028 kwire, mini frag scew
      • Hemihamate autograft - dorsal distal hamate at 4/5 CMC artiulation, rotate 180 in 2planes, fix w 2-3 minifrag screws
      • VP arthroplasty
      • Extension block pinning - kwire placed through head of PP to block extension passed pt of subluxation
        *
29
Q

How do you amnage CHRONIC DORSAL PIP dislocations

A
  • Likely due to type 1 leading to swan neck deformity
  • SWAN NECK
    • Need to distinguish if its a VP laxity issue of extenor mechanism balance issue
    • hold PIP in extension and attempt to actively extend DIP
    • IF LAG of DIP= extensor issue
      • FDS tenodesis - sublimis sling - trasnsect radial proima lto PIP, wrap around A2 - becomes checkrein lig against hyperextension
      • Lateral band trasnposed volarly and scured in A3 pulley system
    • IF NO LAG - VP injury - repair VP
30
Q
A

Upper Extremity (27 decks)

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