Hand trauma Flashcards
1
Q
What do the thumb collateral injuries include?
A
- Radial collateral ligament- Rare
-
Ulnar collateral ligament- most common
- aka Gamekeepers thumb- chronic injury
- Skiers thumb- acute injury
-
Steiner Lesion= avulsed ligament w/wout bony attachment is displaced ABOVE ADDUCTOR APONEUROSIS
- won’t heal without surgical repair
2
Q
What is the epidemiology of thumb collateral injuries?
A
- Ulnar more common than radial
3
Q
What is the aetiology of ulnar collateral injury?
A
- Hyperabduction or extension at MCPJ
4
Q
Describe the anatomy of the UCL?
A
-
Proper collater ligament
- Runs MC head to volar aspect of prox phalanx
- resist valgus load w thumb in Flexion
- primary contraint in flexion
-
Accessory collateral ligament & volar plate
- Runs palmar to proper ligament inserts into volar plate
- resist valgus load w thumb in EXTENSION
- Primary contrainst w volar plate in extension
- __Valgus laxity in both flexion and extension = complete UCL rupture
5
Q
What are the signs and symptoms of collateral thumb injury?
A
HX
- Hyperabduction injury to thumb
Symptoms
- Pain at ulnar aspect of Thumb at MCPJ
Signs
- Mass from torn ligament & possible bony avulsio may be present
- Stress joint w radial deviation both at NEUTRAL/30o
- Instability in 30o flexion = injury PROPER UCL
- Instability in neutral - ACCESSORY UCL injury
- compare to uninjured thumb!
6
Q
What investigations are useful to dx thumb collateral damage?
A
- xrays- AP , lateral and oblique of thumb
- Valgus stress view may aid diagnosis if bony avulsionhas been ruled out
- MRI - aid dx
7
Q
What is a stener lesion?
A
- Displacement of the distal end of the completely ruptured UCL such that it comes to lie SUPERFICIAL and PROXIMAL to ADDUCTOR APONEUROSIS
- Must be operated on!!
8
Q
What is the TX of thumb collateral damage?
A
Non operative
-
Immobilisation 4-6/52
- partial tears with <20o side to side variation
Operative
-
Ligament repair
- In acute injury >20o side to side variation
- >35o of opening
-
Stener lesion
- can use suture/ suture anchor/ small screw to repair ligament
-
Reconstruction of ligament w tendon graft, MCP fusion, adductor advancement
- chronic injury
9
Q
What is the tx of radial collateral ligmanet injuries?
A
- rare
- tx is non operative= **Immobilisation **
- indicated in most cases
- Stener lesion - doesn’t occur
10
Q
Describe a repair of UCL?
A
- Vertical Lazy S shaped incision in direction of UCL on ulnar border of MCPJ thumb
- Protect dorsal sensory nerve- retract palmar
- thru aponeurois
- UCL proximal and superficial to this normally
- Capsulotomy
- Drill hole base of Proximal Phalanx- suture anchor
- repair UCL
- Close capsule and aponeurosis
- then skin
- POP 5 weeks
- http://www.youtube.com/watch?v=Kx5CR2MmhB8
- https://www2.aofoundation.org/wps/portal/!ut/p/c1/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3Q1dDA08XN59Qz8AAQwMDA6B8JJK8haGFgYFnqKezn7GTH1DahIBuP4_83FT9gtyIcgBttnJy/dl2/d1/L2dJQSEvUUt3QS9ZQnB3LzZfQzBWUUFCMUEwRzFFMTBJREZMVUlRUDEwMDA!/?contentUrl=%2fsrg%2f76%2f04-Approaches%2f12-Dorsoulnar-MCP-JoinThumb.jsp&bone=Hand&segment=Thumb&showPage=approach&classification=&treatment=&method=&implantstype=&redfix_url=&approach=Dorsoulnar%20approach%20to%20the%20MCP%20joint%20of%20the%20thumb
11
Q
Define digital collateral ligament injury?
A
12
Q
What is the epidemiology of scaphoid fractures?
A
- Most frequently fractured carpal bone
- Accounts for up to 15% acute wrist injuries
- location
- waist -65%
- Proximal third- 25%
- Distal third 10%
- distal pole is most common location in kids due to ossification sequence
13
Q
Describe the pathoanatomy of scaphoid fractures?
A
- Axial load across hyper-extended and radially deviated wrist
- Common in contact sports
- transverse fractures more stable than vertical/oblique fractures
14
Q
What is the prognosis of Scaphoid fractures?
A
- Incidence of AVN with fracture location
- Proximal 5th AVN rate = 100%
- Proximal 3rd AVN rate= 33%
15
Q
Describe the anatomy of the scaphoid?
A
- 75% scaphoid covered in CARTILAGE
- Blood supply
- major supply- DORSAL CARPAL Branch of radial artery- enters scaphoid in a nonarticular ridge on dorsal surface and supplies proximal 80% scaphoid via a RETROGRADE blood flow
- minor via SUPERFICIAL PALMAR Arch branch of volar radial artery- enters DIstal TUBERCLE and supplies 20% DISTAL SCAPHOID
- Both intrinsic/extrinisic ligaments attach
- Scaphoid flexes w wirst flexion & radial deviation adn extends during wrist extension& ulnar deviation
16
Q
Describe the signs and symptoms of scaphoid fracture?
A
O/E
- Anatomic snuffbox tenderness dorsally
- Scaphoid tubercle tenderness volarly
- Pain w reisted pronation
17
Q
What investigations are useful in DDx scaphoid fracture?
A
-
Xrays
- AP and lateral
- Scaphoid view- 30o wrist extension, 20o ulnar deviation
- 45o pronation view
- no fracture but suspicion rpt 7-14 days
-
Bone scan
- diagnose occult fracture at 72 hrs
- specificity 98%, sensitivity 100%, PPV 85-93% within 72hrs
- MRI
- Most sensitive method within 24hrs
- also vasularity of prox pole
- CT Scan
- less effective than bone scan/ MRI
- Useful for location of ffracture and progression of nonunion/union post surgery
18
Q
Describe the tx of scaphoid fracture?
A
Non operative
- stable non displaced fractures
- normal xray- cast then immobilise 12-21 days and reexam/rpt xrays
- Start immobilisation early- non union rates increase w delay of immobilisation > 4 wks post injury
- no concensus on casting- can use volar cast
- duration of casting
- distal fracture- 3/12
- mid waist- 4/12
- proximal third -5 /12
- outcomes fractures with <1mm displacment union 90%
Operative
ORIF vs Percutaneous screw fixation
19
Q
what are the indications for surgery for scaphoid fractures?
A
- Unstable fractures
- Proximal pole fractures
- Displacment >1mm
- 15 o humpback deformoty
- radiolunate angle >15o= DISI
- Scaphoid frac ass with perilunate disslocation
- comminuted fractures
- in undisplaced fractures- to allow decreased time to union, faster return to work/sport, cheaper costs to casting- McQueen et al JBJS Br 2008
20
Q
What are the outcomes of surgery for scaphoid fracture?
A
- Union rates of 90-95%
21
Q
CAn you describe the technique for fixation of scaphoid fracture?
A
Approach
- Dorsal approach for Proximal Pole fractures
- Preserve blood supply when entering dorsal rige by limiting exposure to proximal half of scaphoid
- Percutaneous higher risk of unrecongnised screw pentetration of sunchondral bone
- Volar approach- for waist and distal pole fractures w humpback flexion
- allows exposure of whole scaphoid
- uses interval between FCR and radial artery
- Arthroscopic assisted also described
- Fixation is optimised by long screw down CENTRAL AXIS of SCAPHOID
- Radial stylectomy preformed if impaction between radial styloid adn scaphoid
22
Q
Describe the complications of scaphoid fixation?
A
- Non union->
- SNAC wrist- degenerative changes first in radioscaphoid area followed by pancarpal /midcarpal arthritis
- Tx with
- **Interposition (Fisk) bone graft- **open wedge graft, 72-95% unon rates
- Inlay (Russe) bone graft- minimal deformity, 92% union rates
- Vascular bone graft from radius- 1-2 intercompartmental supraretinaculuar artery ( branch of radial artery) harvested to provide vascular bone graft from dorsal aspect wrist
- Outcomes:
- Punctate bleeding during surgery good prognostic indicator of union
- 92% w obvious bleeding, 71% questionable bleeding, 0% no bleeding
- Pt w scaphoid nonuions>5 yrs or proximal pole necrosis have less favourable outcomes
23
Q
What do hamate fractures include?
A
- Hook of hamate- most common
- Hamate body fractures- v rare
24
Q
What is the hx of hamate fractures?
A
- Hx of blunt trauma to palm of hand
- often seen racquet sports
- hockey
- golf- miss ball hit ground
- tennis
- Must distinguish from BIPARTITE HAMATE- Smooth cortical surfaces
25
Describe the symptoms of hamate fractures?
* Hypothenar symptoms- Pain
* **Decreased grip strength**
* **Parathesisa** in ring and small fingers - ulna N compression in Guyon's canal, numbness in thumb, index, middle and ring finger from median n compression in carpal tunnel
* Motor weakness of intrinsics- Ulnar n compression in Guyon's canal
26
What imaging is useful in Hamate fractures?
* Difficult to visualises on AP
* Best seen on **CARPAL TUNNEL VIEW**
* **CT** best to make diagnosis
27
Describe the TX of hamate fractures?
Non operative
* **Immobilise 4-6 weeks**
* Acute hook of hamate fractures
* body of hamate fractures
**Operative**
* **Excision of hamate fracture fragment- return to level of sport 7-10 wks**
* Chronic hook of hamate fractures
* _ORIF is possible but little benefit_
28
What is this?
**Pisiform fracture**
29
Describe the anatomy of the pisiform?
* A **sesmoid bone**
* located within **FCU tendon**
* **Contributes to stability of ulnar column by preventing TRIQUETRAL subluxation**
* Acts as a fulcrum for forces transmitted from forearm to hand
30
What is the epidemiology, aetiology of pisifrom fractures?
Name any associated fractures?
* 1-3% of carpal fractures
* fall on outstretched hand
* 50% pisiform fractures occur with distal radius, hamate or triquetral fractures
31
Describe the signs and symptoms of pisiform fracture?
Symptoms
* Ulnar sided wrist pain
Signs
* Point tenderness
32
What investigations are useful for ddx of pisiform fractures?
Radiographs
* **Lateral with 30 degrees of supination** or carpal tunnel view
* **CT scan-** best seen
33
Describe the treatment of pisiform fractures?
Non operative
* Immobilisation- first line
* **Short arm cast with 30o wrist flexion** & ulnar deviation 6 wks
* Outcomes- heal without posttraumatic arthritis
Operative
* **Pisiformectomy-** painful NON union
* Outcomes- pisiformectomy reliable way to relieve apin & doesn;t impair wrist function
34
What do base of thumb fractures include?
* **Bennett fracture**- Intra-articular
* **Rolando Fracture**- intra-articular
* **Extra-articular fractures**
35
What is the epidemiology of bse of thumb fractures?
* 80% thumb fractures involve **METACARPAL BASE**
* most common variant is **BENNET Fracture**
36
What is the pathophysiology of base of thumb fractures?
* Most fracture caused by **_AXIAL force_** applied to Thumb
* 3 muscles deforming forces at base of thumb
* **Abductor pollicis Longus**- PIN
* **Extensor pollicis longus**- PIN
* **Adductor pollicis** - Ulnar N
37
Describe what a Bennet's fracture is?
* **Inra-articular fracture of base of 1st MC characterised** by
* **VOLAR LIP OF Metacarpal base attached to VOLAR OBLIQUE LIGAMENT**
* ligament holds this fragment in place
* small fragment of 1st MC continues to articulate with trapezium
38
Describe the pathoanatomy of bennett's fracture?
* **Lateral retraction of distal 1st MC shaft** by **APL and Adductor pollicis**
* **Volar- ulnar fragement is held reduced by ant oblique ligament while strong deforming forces pull the reamining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate it.**
* **Abductor pollicis longus-** inserts MC base- pulls MC shaft proximally & dorsally
* **Adductor pollicis**- inserts ulnar base proximal phalanx - angulates MC shaft ulnarly and supinates it
* **EPL**- less important inserts base of distal phalanx adn adds to ulnar angulation of distal fragament
39
What is the prognosis of the bennet's fracture?
* Better than Rolando
40
What investigations are helpful in DDX of Bennet's fracture?
* **Hyper-pronated thumb view**
* Minimal joint step-off considered best
41
Describe the TX of Bennet's fracture?
Non operative
* Closed Reduction & cast Immobilisation
* non displaced fractures
* reduction with **traction, extension, pronation and adduction**
Operative
* **Closed reduction and Percutaneous pinning**
* Volar fragment too small to hold with screw
* Anatomic reduction unstable
* can attempt reduction of shft to trapezium to hold reduction
* **ORIF**
* large fragment
* 2mm+ joint displacement
42
What are the complications of a Bennet's fracture?
* **Post traumatic arthritis**
* There is no agreement regarding the relationship of post- fixation joint incongruity and post traumatic arthritis.
43
What is a Rolando fracture?
* **Intra-articualar fracture of base of the 1st metacarpal** characteised by
* **intra-articular comminution**
44
What is the epidemiology and pathophysiology of Rolando fracture?
* Less common than Bennet's fracture
Pathoanatomy
* Deforming forces are the same as Bennett's fracture
* **Lateral retraction of 1st distal metacarpal shaft by Abductor Pollic Longus and adductor pollicis**
* **Volar- ulnar fragement is held reduced by ant oblique ligament while strong deforming forces pull the reamining metacarpal shaft proximally adn dorsally, angulate the shaft ulnarly and supinate it.**
* **Abductor pollicis longus- inserts MC base-**
* *pulls MC shaft proximally & dorsally**
* **Adductor pollicis- inserts ulnar base proximal phalanx -**
* *angulates MC shaft ulnarly and supinates it**
* **EPL- less important inserts base of distal phalanx**
* *and adds to ulnar angulation of distal fragament**
* typically the base spit into volar and dorsal fragment
* commonly called a **Y fracture**
45
What is the prognosis of Rolando fracture?
* Worse than a bennet's fracture
46
What is the TX of Rolando fracture?
Non operative
* Immobilisation- severe comminuted, stable
* start early rom
Operative
* **External fixation, CRPP**
* **severe comminuation, unstable**
* can approximate large fragment w K wires
* **ORIF**
* **MOST common fixed method**
* **use T plate or blade plate**
* can use K wire if fragments are too small
47
What are the complications of rolando's fracture?
* Post - traumatic arthritis
48
What types can extra-articular fratures be?
* Transverse of Oblique in nature
49
Describe the tx of extr-articular thumb fractures?
Non operative
* Spica casting
* **if joint reduced & \<30o of angulation**
Operative
* **CRPP**
* If reduction cannot be held to result in less than 30o of angulation
* Typically these fractures have the best outcome
50
What can metacapral fractures be divided into?
* Metacarpal head, neck and shaft fractures
* Tx based on which MC involved & location of fracture
* Acceptable angulation vaires on location
* _NO degree of malrotation acceptible_
51
Describe the epidemiology of MC fractures?
* Accounts for **40% o**f all hand injuries
* **Men aged 10-29 **most common
* **Metacarpal Neck** is most common site
*
**5TH Metacarpal** is most commonly injured
52
What is the aetiology of MC fractures?
* **Direct blow** to hand or **rotational injury with axial load**
* **HIgh energy injuries-\>** multiple injuries
53
Name any associated injuries with MC fractures?
* Wounds= open fractures
* Tendon lacerations
* Neurovascular injury
* compartment syndrome
* closed injury mutiple fractures
* Crush injuries
54
Describe the anatomy of MC ?
* Concave on palmar side
* 1st,4th,5th digits-\>Mobile border
* 2nd,3rd digits-\> stiffer central pillar
* index MC most firmly fixed, while thumb MC articulated with Trapzium & acts independently from others
* **3 Palmer and 4 Dorsal Interosssei** arise from MC shafts
* **ECRL/B** - inserts base MC 2, 3- assists with wrist extension/ radial flexion
* **ECU**- inserts base 4, extends/flexes wrist when digits being flexed, assist ulnar flexion of wrist
* **Abductor pollicis longus**- inserts trapezium and base of MC 1- adducts thumb in frontal plane, extends thumb at CMCJ
* **Opponens Pollicis**- inserts MC I, Flexes MC 1 to OPPOSE thumb to fingertips
* **Opponens digiti minimi**- inserts medial side of MC V, flexes MC V at CMCJ when little finger is moved into opposition with tip of thumb, deepens palm of hand
55
What are the signs of MC fracture?
Signs
* Inspect openw wounds
* fight bite over MCP open until proven otherwise
* Extensor tendon lacerated and retracted
* Dorsal wounds over MC - often open
* Deformity
* At MC base may indicate CMCj Dislocation
* Shortening- cf contralateral side
* Malrotation- fingernails in part felxion- see pics
* Motor exam- flexor/extensor tendons
* NV exam
* dorsal wounds = affect dorsal sensory branch of radial/ulnar n
* volar wounds - involve digitial nerves
56
What investigations are helpful in DDX MC fracture?
* Xray
* Standard AP, Oblique & lateral
* **Oblique-** evaluate CMCJ
* 30o pronated lateral = 4/5th CMC
* 30o Supinated lateral-= 2/3 CMC
* Roberts view= thumb CMCJ
* Brewerton view= MC head fractures
* CT scan
* inconculsive CMC fract/dislocations
* Multiple CMC dislocations
* complex MC head fractures
57
Describe the accepted angulation , shaft shortening and neck angulation for consx tx for MC fractures?
* Index/ Middle ringer
* Shaft Angulation 10-20o
* shaft shortening 2-5mm
* Neck angulation 10-15o
* Ring Finger
* Shaft angulation 30o
* Shaft shortening 2-5mm
* Neck angulation 30-40o
* Little Finger
* Shaft angulation 40o
* Shaft shortening 2-5mm
* Neck angulation 50-60o
58
What are the operative indications fof MC fractures?
* Intra-articular fractures
* Rotational malalignment
* Significantly displaced fractures
* Mutliple MC shaft fractures
* Loss inherent stability from border digit during healing process
59
Describe the operative Tx of MC fractures?
* **ORIF**
* no degress of articular displacment is acceptable
* Majority required surgical fixation- see pic
* **External fixation**
* Severely comminuted fractures
* **MCP Arthroplasty**
* Severely comminuted fractrues
* **MCPJ fusion**
* rarelt done due to limited rom of hand
60
Describe the operative technique for ORIF for MC Head fractures?
* Approach
* **dorsal incision**
* either **centrally splt extensor apparatus or release and repair sagittal band**
* Hardware cannot protrude joitn surface
* FIX w multiple small screws in collateral recess , headless screws or K wires
* ideal fixation should allow early motion
61
What are the complications of MC head fractures?
* Stiffness
* most common
* prevent by early motion
* CRPS
62
Describe the TX for MC shaft fractures?
Non operative
* Immobilisation
* Non displaced MC neck fractures
* Acceptable angulation
* No malrotation
* Shortening- aethetic problem only
* Immobilise **MCPJ 70-90o**
* Cast **4 weeks**
Operative
* **ORIF vs CRPP**
* for open fractures
* unacceptable angulation
* any malrotation
* multiple fractures
* **CRPP=** place retrograde thru MC base /antegrade thru collateral recess remove pins 4/52
* **Open reduction w lag screw**
* mutliple lags for long spiral fractures- at least 2
* **Open reduction w dorsal plating**
* best for transverse fractures
* try to cover plate w periosteum to prevent tendon irritation
* begin early motion to prevent tendon irritation
63
Describe the TX for MC neck fractures?
Non operative
* **Reduction and casting**
* Acceptble degrees of apex dorsal angulation
* Immobilise MCP 70-90 flexion, leave PIPJ free
* Cast 4 weeks
* Reduce **Jahss technique**
* 90o flexion, dorsal pressure thru proximal phalanx whilst stabilising MC shaft
Operative
* **Reduction and Fixation**
* ****Unaccetpable angulation
* open fracture
* any malrotation
* intrarticular fractures
* **CRPP w MCP flexed**
* Antegrade thru MC base
* Retrograde thru Collateral recess
* **ORIF**
* Perform if cannot get reduction with CRPP
* Difficult ro place because of limited bone distal fixation
64
What is this?
* Dorsal PIP dislocation
65
What is the epidemiology of dorsal PIP dislocations?
* More common than volar dislocations
* leads to **injury to VOLAR PLATE** and at least the **COLLATERAL ligament **
* **Swann neck deformity** will result if left
66
Describe the classification system of PIP dislocations?
* **Simple**- middle phalanx in contact with condyles proximal phalanx
* **Complex**- Base of middle phalanx not in contact with condyle of proximal phalanx, Bayonet appearance
* volar plate acts as block to reduction with longitudinal traction
67
Describe the TX for dorsal PIP dislocations?
Non operative
* Reduce and buddy tape to adjacent finger 3-6 wks
* dislocation is reducible
* usually preformed by patient
* if complex reduce w HYPEREXTENSIONof middke phalanx followed by palmar force
* complx- Swan neck deformity ( volar plate injury)
Pipj Flexion contracture- pseudoboutonniere
Operative
* Open reduction & extraction of volar plate
* Failed reduction
* closed reduction failed often due to **volar plate interposition**
* Open reduction failed due to **dislocated FDP tendon**
* **dorsal approach w incision between central slip & lateral band**
68
What is this?
* **Dorsal PIP fracture dislocation**
69
Name and describe the classification system of dorsal PIP fracture dislocations?
* **Hastings**
* Based on amount of P2 articular surface involvement
* **Type 1- Stable**
* **\<30%** -= tx dorsal based extension block splint
* **Type 2- Tenous**
* **30-50%** - if reducible in flexion, dorsal based extension block splint
* **Type 3- Unstable**
* **\>50%** - ORIF/HAMATE Autograft, Volar plate arthroplasty
70
Describe the tx of dorsal fracture dislocation of PIP?
Non operative
* Dorsal extension block splint
* if \<40% joint involved & stable
* much achieve adequate joint redcution for favourable outcome
Operative
* **ORIF vs CRPP**
* If \>40% joint involved/ unstable
* reduction of middle phalanx on condyles of prox phalanx is primary goal
* adequate volar exposure of volar plate requires resection of **proximal C2 pulley, Entire A3 pulley and distal C1 pulley**
* **Dynamic Distraction external fixation**
* ****highly comminuted pilon fracture
* follw w early mobiliasation
* **volar plate arthroplasty/arthrodesis**
* chronic injuries
71
What is this?
* **A volar pip dislocation**
* Less common than dorsal
* leads to injury to **CENTRAL SLIP and at least ONE COLLATERAL Ligament**
* failure to tx -\> **Boutonniere deformity**
72
Describe the tx of volar PIP fracture/ dislocation?
Non operative
* **Spinting in extension 6-8 wks**
* most pip dislocations
* If **Fracture \<40%** joint involved & stable
Operative
* **ORIF vs CRPP**
* reduction of middle phalanx on condyles of proximal phalanx is primary goal
* i**f joint \>40% involved**
73
What could this be?
* **Rotatory PIP dislocation**
* One of phalangeal condyles is **buttonholed between central slip & lateral band**
74
Describe how you would tx rotatory PIP dislocation?
Non operative
* Only of reduction successful
* reduce by applying traction to finger with **MPJ & PIPJ in 90o Flexion**
* Flexion relaxes volar displaced lateral band , allowing to slip back dorsally
* Reduction is confirmed w post reduction lat xray
Operative
* **Open reduction**- most cases
75
What is this?
* Dorsal DIP dislocation with fracture
76
What is the tx of dorsal DIP fracture dislocation?
Non operative
* **Closed reduction, immobilisation in slight flexion w dorsal splint for 2 weeks**
* first line
* Tuft fractures no specific tx- temporary splinting
Operative
* **Open reduction**
* 2 failed attempts at reduction
* **Volar plate interposition** is most common block to reduction in irreducible **closed** DIP joint dislocation
* **FDP** may be blocking if injury **open**
* May require percutanoeus pinning to suport nail bed injury
* **Amputation**
* if highly comminuted injuries with significant soft tissue loss
