Hand Fractures & Dislocations Flashcards
What view is used for assessment of collateral avulsion F# at MCP jt?
Brewerton view
- MPJ flexed at 65’, ulnar to rad 15’ angle
What is view is used for metacarpal head>
Skyline metacarpal view
- with MCP and PIP jt fully flexed, beam shot down shaft of PP
How do you classify hand fractures?
- Specific Bone & site
- Pattern
- Open/closed
- intra/extra-articular
- angulation
- displacement
- etiology
Describe the salter harris classificatoin
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)
What are indications for ORIF of metacarpal and phalangeal fractures
- failed closed reduction
- intra-articular fracture
- segmental bone loss
- associated nerve/tendon, vessel damage
- open fractures
- Multiple Metacarpal fractures
What are indications for non-operative treatment?
- <45’ angulation D5 MC neck
- <3-4mm shortening
- <10’ lateral deviation
- no rotation
How do you manage a thumb METACARPAL FRACTURE
- 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
How do you manage THUMB PHALANGEAL F#?
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
What are the five stabilizing ligaments of the CMC jt
- Anterior (volar) oblique lig
- Posterior oblique lig
- Dorsoradial ig
- Anterior Intermetacarpal ligament
- Poserior intermetacarpal ligament
how do you manage a CMC jt thumb dislocation?
Dislocation of thumb CMC is rare
- Partial=>CR, stable on xray =>thumb spica 6wks
- Complete=> unstable=> ORIF and volar beak lig recon w FCR
How do you manage UCL injury
- 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
Descrbie the operative intervnetions for acute complete vs chronic complete UCL injuries
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
How do you manage MCP dislocation
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
How do you manage METACARPAL HEAD fractures? D2-D5
- 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
What are complications of metacarpal head fractures>
- avascular necrosis
- stiffness
- epiphyseal arest in kids
- malunion non union
How do you manamage METACARPAL NECK F#?
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
List complcations for METACARPAL F# and treatment of complicaitions
- 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
How do you manage a Baby Bennets
- Always operative
- Closed reduction + Kwire fixation to D4 +/- hamate
- ORIF if multiple CMC #/dislocation
What is a Baby Bennett’s?
- 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
How do you manage METECARPAL SHAFT FRACTURE?
- 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
How do you manage a segmental bone loss of MC?
- fixation to maintain legnth (ex fix, traction)
- BG with ICBG when clean and fixate w plate
How do you manage NON_ARTICULAR PHALANGEAL FRACTURES of PP and MP?
- 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
How do you manage articular F# of the proximal phalanx head?
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
How do you manage base of MIDDLE PHALANX fractures?
- 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
How do you manage DISTAL PHALANX F#
- 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
How do you manage MCP dislocations?
- 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
How do you manage radial CL ruptures?
immobilize 3wks with 30’ flexion then buddy tape 3wks
If unstable at 6wks, ORIF
How do you manage PIP F# dislocations
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
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How do you amnage CHRONIC DORSAL PIP dislocations
- 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
