Hands - Clinical (Fractures)

Question 1

Classification of Distal Phalanx Fractures

Answer 1

Tuft
Shaft (transverse, longitudinal)
Base (volar, dorsal/mallet)
(Seymour)

Question 2

Classification of Middle/Proximal Phalanx Fractures

Answer 2

Head
Neck
Shaft
Base

Question 3

Classification of Proximal phalanx head fractures

Answer 3

Unicondylar (Weiss-Hastings Classification)
- Class I: oblique volar
- Class II: long sagittal
- Class III: dorsal coronal
- Class IV: Volar coronal

Bicondylar

Question 4

Classification of neck/shaft fractures

Answer 4

Fragments: Simple vs comminuted

Pattern:
- Short oblique
- Long oblique
- Transverse
- Spiral

Displacement:

Question 5

Bony Mallet - features & management

Answer 5

Caused by hyperflexion
Dorsal base fracture or extensor mechanism avulsion fracture

X-ray: fracture displacement, volar subluxation (v-sign), amount of articular surface involved

Management:
Non-operative: Extension splint (mallet/zimmer/thermaplast) 6-8 weeks.
- If >50% of articular surface, inadequate reduction, open injury: modified Ishiguro k-wire.

Question 6

Doyle’s Classification of Mallet Injury

Answer 6

Type I: Closed injury, ± small avulsion fracture
Type II: Open injury with tendon laceration
Type III: Open injury with loss of skin, subcutaneous tissue, and tendon
substance
Type IVA: Transepiphyseal plate fracture in children
Type IVB: Fracture of 20 to 50% of articular surface
Type IVC: Fracture of >50% of articular surface, volar subluxation of distal phalanx

Question 7

DP tuft fracture - features & management

Answer 7

Commonly caused by crush injury
Associated with sublingual haematoma/nail bed injury
Require removal of nail plate + evacuation of haematoma +/- NBR. Rarely require fixation. Splint immobilisation 3-4 weeks and hand physio follow up.

Question 8

Seymour fracture - features & management

Answer 8

Paediatric distal phalanx base fracture. Caused by hyperflexion.
Salter Harris I/II
Associated with nail bed injury
Rx:
- Irrigation and debridement
- Antibiotics
- Repair of the lacerated nail matrix
- Fracture reduction (axial k-wire)

Question 9

Proximal phalanx fractures - features & management

Answer 9

Open vs Closed
Fracture pattern/geometry
Assess for displacement/dislocation, angulation, rotational deformity (scissoring)

Non-operative: buddy strap vs splinting
Operative:
- MUA + splinting
- Cross K-wire
- Lag screw
- Dorsal locking plate
- IM screw

Question 10

Complications of phalangeal fractures

Answer 10

Malunion (malrotation, volar angulation, lateral angulation, shortening)
Nonunion
Stiffness/loss of ROM
PIPJ extensor lag
Infection
Tendon rupture/entrapment

Question 12

Indications for operative management of hand fractures

Answer 12

Irreducible fractures
Malrotation
Articular fractures
Open fracture

Subcapital fractures (phalangeal)
Segmental bone loss
Polytrauma with hand fractures
Multiple hand or wrist fractures
Fractures with soft tissue injury (vessel, tendon, nerve, skin)
Reconstruction (i.e., osteotomy)

Question 13

Rates of infection in hand fractures

Answer 13

Swanson et al 1991. Hand fractures distal to carpus.

Type I: 1.4%
a. Clean wounds with minimal delay in treatment
b. No systemic illness

Type II: 14%
a. Gross contamination (bite, grossly dirty, farming injury
b. Delay in treatment >24hrs
c. Major systemic illness

Question 14

Initial approach to Hand/Digit Amputation

Answer 14

A-E approach ruling out other life or limb threatening injuries.

Focused Hx and Examination.
- Time & Mechanism (crush/incision).
- Level of amputation
- Hand dominance, occupation, hobbies
- Previous hand injuries, PMHx, DHx, allergies, smoking
- Last food & drink
- ICE (replant vs terminalisation)
- Remove rings & Careful examination of other damaged structures.
- Examine amputated part

AATX: Abx, analgesia, tetanus, x-ray: 3 views of hand/finger, X-rays of amputated part(s).

Patient: gentle irrigation to remove gross contamination. Non-adherent dressing, bulky dressings. POP if other fractures.

Amputated parts: gentle irrigation, wrap in NaCl soaked gauze, place in plastic bag or specimen container. Place in slurry of ice water at 4C. Not directly on ICE

Question 15

Pre-operative approach to attempted hand/digit replantation

Answer 15

NBM.
Mark & Consent.
Discuss with on call consultant. Discuss with theatre coordinator/CEPOD.
Prep theatre/brief: sterile arm tourniquet, microscope, hand set, micro set, hepsal.

Question 16

Consent for attempted hand/digit replantation

Answer 16

Procedure: replantation RT IF +/- bone/nerve/vein/skin graft

Intended benefits: restore function

Risks:
Pain, bleeding, infection, scarring, stiffness, CRPS

Explanation of expected IP course: prolonged admission/rehab/time off work.

Further procedures.
Failure of replantation. Proceed to terminalisation.

Expected successful outcome: stiffness, reduced sensation, reduced function

GA Risks, VTE, peripheral tissue injury.

Question 17

Operative principles of replantation

Answer 17

Preparation: Supine, arm board.
Prep whole arm. Sterile arm tourniquet.
Access to leg (vein graft) +/- TEDS/Flowtrons. Catheter. Gel matts. Monopolar plate. Bipolar. Bear hugger.

Procedure:
Digit: washout, surgical prep. ulnar & radial mix axial incisions. Expose and examine neuromuscular bundles. Tag structures. Remove nail plate.

Site:

Question 18

Warm/Cold Ischaemia time: definitions & principles

Answer 18

Warm ischaemia time: time from avascular and no cooling
Cold ischaemia: time from avascular and cooling

Tolerance of warm ischaemic time is inversely proportional to the amount of muscle. ie more muscle lower tolerance to ischaemia.
Forearm (4-6hours) < hand < digit (12 hours)

Question 19

Goals of amputation/terminalisation

Answer 19

Maintain length.
Maximize function. Early return to work and recreation.
Stable and durable soft-tissue coverage. Preserve sensation.

Prevent symptomatic neuromas. Prevent adjacent joint contractures
Allow for early prosthetic fitting (if applicable)

Question 20

Indications for replantation

Answer 20

Thumb amputation
Multiple digit amputation
Any amputation in a child
Hand amputation through palm/wrist
More proximal forearm (sharp, clean injury pattern)
Single-digit amputation distal to flexor digitorum superficialis (FDS) insertion
(zone I injury)

Question 21

Contraindictions for replantation

Answer 21

Severely crushed or mangled parts
Multilevel amputations
Other severe traumatic injuries or significant medical comorbidities
Prolonged warm ischemia time for proximal amputations

Single-digit amputation proximal to FDS insertion (zone II injury)
* Exceptions: Musician or other person requiring all 10 digits, Children