Main 0 (fracture, luxation) Flashcards
Describes safe position of immobilization
Wrist in 20 to 30° extension,
MCP joint in 70 to 90° flexion, Interphalangeal joints in full extension
Indications for operative management for MC head fracture (4)
- > 25% involvement of articular surface
- > 1 mm of articular step off
- Malrotation
- échec de réduction fermée
- Lésion concomittante à autre structure
Surgical management of simple and communicated metacarpal head fractures
Simple
* Minicondylar plate or screw
* Buried headless compression screw
* k-wire (more stiff)
Comminuted: K-wire
qu’est-ce qu’une ‘‘vrai’’ blessure du boxer
lésion de la bandelette sagittale de D5
Indication for surgical management of metacarpal **neck **fracture (4)
Angular deformity:
D2-D3: 10-15°
D4: 30-40°
D5: 50-70°
Malrotation
Shortening >3mm in Janis (vs 5mm in CME)
Extensor lag
Maneuver for metacarpal neck reduction
Jahss maneuver
Flex MCP 90° to relax intrinsics
Flex PIP 90°
Apply dorsal directed force to P1 and volar directed force to proximal MC
Indications for reduction of metacarpal shaft fractures (3)
1.Angulation
Any angulation degree D2 and D3
More than 20° angulation D4
More than 30° angulation D5
2.Malrotation
3.Shortning >3mm
Define a Bennett fracture
Unstable IA single fragment fracture MC base of thumb
Ligament that holds fragment in place in Bennett fracture
Volar Beak Ligament
Forces that causes displacement of Bennett fracture (4)
- APLpulls proximal fragment proximally
- **Adductor pollicis **pulls distal fragment in adducted and supinated position
- EPL: tire proximal, radial et dorsal le fragment distal
- APB and FPB pulls distally causing apex dorsal angulation and subluxation
Reduction maneuver for Bennett fracture (4 movements)
TAPE:
Traction
Abduction
Pronation
Extension
Define reverse Bennett fracture
Unstable IA fracture of MC base D5
Forces that deform reverse Bennett fracture, which is strongest? (3)
ECU (especially causing proximal and dorsal migration)
FCU
ADM
Define Rolando fracture
Comminuted IA fracture of thumb MC base
Surgical management of Bennett fracture
if <20% IA involvement: closed reduction + K wire
ORIF if >2mm displacement after attempted close reduction, use lag screws
Surgical management of reverse/baby Bennett
Closed reduction + pinning
Reduction: Longitudinal traction + pressure on dorsal aspect of the base of D5 MC followed by passive wrist extension
ORIF: if delayed treatment, unsuccesfull closed reduction, multiple CMC joint fracture dislocation, associated dorsal shear fracture of the hamate
Method of healing of tuft fractures
Fibrous union
Treatment of symptomatic non union of distal phalanx
Open volar midline approach
Bone graft + kwire
Define Seymour fracture
Open pediatric fracture of distal phalanx epiphysis
SH type 2
Proximal mail matrix interposed in fracture site
Consequences of failure to recognize Seymour fracture (3)
Nail plate deformity
Physeal arrest
Chronic OM
Classification of phalangeal head fracture
London classification
Type 1: stable fracture sans déplacement
Type 2: Unicondylar unstable fracture
Type 3: Bicondylar comminuted fracture
***Weiss-Hasting est une classification spécifique des fracture unicondylaire
Type I consists of stable fractures without displacement; type Il includes unicondylar, unstable fractures; and type III fractures are bicondvlar or comminuted.
Angulation of proximal phalanx shaft fracture, explanation
Apex volar
Les intrinsèques vont être des extenseurs du fragment distal, et des fléchisseurs de la MP
Fx base de P2: quel type d’apex et pourquoi?
Apex dorsal car insertion du FDS fait fléchir fragment distal
et insertion du central slip fait étendre fragment proximal
Fx mid/distal P2: quel type d’apex et pourquoi?
Apex palmaire dès que la fracture est distale à l’insertion des FDS qui vont venir fléchir le fragment proxiaml
Treatment of proximal and middle phalanx shaft fracture if displaced vs non displaced
Non displaced: buddy taping and/or splinting
Displaced with adequate reduction: Immobilise in SAFE position
Irreducible: K-wire vs interfragmentary screw vs wiring vs plate (stiffness++)
Surgical indication for phalanx base fracture
> 25° angulation
Deformity associated with middle or proximal phalanx base fracture (3)
Pseudoclawing
Hyperextension at MCP and extension lag at PIP
Define Pilon fracture
Comminuted IA base of middle phalanx fracture
Indication for operative treatment of base of P1 (2) intraarticulaire
Articular step off >2mm
Joint instability
Criteria for stability of base of middle phalanx fracture
Involves <40% of articular surface
Treatment of base of P2 volar or lateral fracture
Buddy tapping
Implication and treatment of dorsal base of P2 fracture
Central slip avulsion
Extension splinting PIP 6 weeks
Fixation options for unstable fracture of base of P2 (4)
K-wire
Screw if fragment allows
Suzuki frame
Hemihamate arthroplasty
Indication for Suzuki frame from base P2 fracture
Comminuted intra-articular fracture of PIP
Mechanism of action of the Suzuki frame
Ligamentotaxis
Indication for hemihamate arthroplasty for base P2 fracture
If dorsal cortex intact but fracture involves >50% PIP and impaction
What is the “Cam effect”
translation of rotary motion into linear motion
flexion of MCP joint tightens collateral ligaments compared to extension
Describ simple vs complex dorsal MCP subluxation
Simple: volar plate intact
Complex: volar plate impingement: widening of point space on x ray
Reduction of simple dorsal MCP subluxation
Flexion of wrist (relax flexors)
Volar pressure on P1
Encourage early ROM
*Do not do traction or hyperextension as can pull volar plate into joint and convert simple to complex subluxation
Reduction of complex dorsal MCP subluxation + immobilisation
Surgical: must divide volar plate surgically
Immobilise MCP in 30° flexion for 2 weeks followed by dorsal blocking 10°
Grade of MCP collateral ligament injury and management (3)
Grade 1: pain without laxity (splint)
Grade 2: laxity with passive stress stop at 60° (splint)
Grade 3: ligament avulsion no endpoint on stress test (repair)
Splint for grade 1 and 2 MCP collateral ligament rupture
Immobilisation in 30° flexion
Thumb MCP collateral ligaments, position in which they are tight/relaxed
Proper collateral ligaments: tight in flexion and loose in extension
Accessory collateral ligament (inserts volarly on sesamoid bone): tight in extension, loose in flexion
Thumb MCP UCL avulsion definition and treatment
+ 2 indications chirurgicales
UCL avulsion at its insertion
Tx: immobilisation
If fracture involves >10° articular surface and >2mm displacement –> fixation
Describe UCL Stener lesion
Complete UCL rupture
Adductor aponeurosis becomes interposed between PROXIMAL-UCL and base of proximal phalanx
Thumb UCL injury treatment
Partial rupture: 4 weeks cast immobilization followed by 2 weeks splint for AROM
Complete rupture or Stener: surgical repair
UCL repair technique thumb MCP (2)
Bone anchor
Pull out suture
4 weeks post-op immobilisation
Entity for chronic UCL thumb injury and definition and symptoms
Gamekeeper’s thumb
Progressive UCL attenuation
Chronic instability and weakness
Gamekeeper’s thumb treatment
Direct UCL repair if it can be mobilized from scar
Free tendon graft
Arthrodesis if MCP OA
Structures that can block a thumb MCP dislocation reduction (3)
Volar plate
FPL
sesamoid bone
Types of PIP dorsal dislocation (3)
Type 1: hyperextension, partial articulation
Type 2: complete dorsal dislocation no joint articulation
Type 3: fracture dislocation
Stable vs unstable PIP dorsal fracture dislocation
Stable if involves <40% articular surface
Reduction technique for PIP dorsal dislocation
Extension stress + pressure on proximal middle phalanx to slide it over joint
Immobilization of type 1 and 2 dorsal PIP dorsal dislocation after reduction
If stable: buddy tape
If unstable: dorsal blocking splint in 10° flexion
Immobilization of type 3 dorsal PIP dorsal dislocation after reduction
Stable: 3 weeks dorsal blocking split
Unstable:
-Dorsal blocking splint if lateral stability intact and is stable with less than 30° extension blocking
-Suzuki frame if comminuted fracture
-ORIF if large single volar fragment
-Volar plate arthroplasty (if <40% IA) combine with pinning in 20-30° flexion
What is the principle of “ligamentotaxis”
Mise en tension des ligaments péri-articulaire permettent d’optimiser la guérison anatomique de la fracture intra-articulaire
Name special metacarpal imaging views (3)
- Brewerton view
- Roberts view
- Betts view
Name 2 advantages and disadvantages of percutaneous pinning
Advantages
1. minimizes soft tissue trauma
2. less costly
3. Flexible technique pattern
Disadvantage
1. Less stable than ridgid fixation
2. Infection risk
3. Reduction more technically challenging than open
Name 2 advantages and disadvantages of plate fixation
Advantages
1. More ridgid and stable
2. open approach allows better reduction
Disadvantages
1. soft tissue stripping
2. Increased risk of extensor tendon adhesion
3. Need adequate soft tissue coverage
4. More costly than k-wire
Name 2 advantages and disadvantages of lag screw
Advantages
1. less soft tissue stripping
2. less prominent on tendons
Disadvatanges
1. less rigid than plate
2. limited fracture pattern application
3. requires soft tissue dissection vs exfix or k-wire
Name 2 advantages and disadvantages of intramedullary screw
Advantages
1. Ridgid fixation with minimal soft tissue dissection
2. Anterograde or retrograde is feasible
Disadvatanges
1. Rotational control is difficult
2. Hardware removal challenging if infection or refracture
Name 2 advantages and disadvantages of external fixation
Advantages
1. No soft tissue disruption
2. Spanning of segments of bone loss
3. Distration of joint is needed dor reduction
Disadvantages
1. Risk of pin-site infection
2. Risk of adhesions
3. Bulky hardware (ADLs difficult)
4. Expensive
5. Overdistraction
What are the 3 phases of fracture healing
1.Inflammation
- immediate lasts a few days
- hematoma formation
-osteogenis precursors
2.Repair
- <24hrs and peaks at 2-3 weeks
- collagen deposition
- cartillagenous callus formation
- endochondral ossification
3.Remodelling
- months to years
- lamellar bone formation
- resorption of callus
During which phase of fracture healing does hematoma formation occur
Inflammation (immediately to a few days)
During which phase of fracture healing does endochondral ossification occur
Repair (>24hrs and peaks at 2-3 weeks)
During which phase of fracture healing does resorption of callus occur
Remodeling (months ot years)
During which phase of fracture healing does lamellar bone formation occur
Remodeling phase (months to years)
Which drugs should be avoided in the setting of acute fracture
NSAIDS - studies have shown increased rates of nonunion.
NSAIDS disrupt the inflammation phase of fracture healing
You consent a patient who has a metacarpal fracture. What complications should you mention
- Infection
- Malunion
- Angulation
- Shortning
- Nonunion
- Ankylosis
Describe the 2 patterns of fracture non-union
et 3 facteurs de risque
Atrophic: Lack of callus. Requires bone grafting
Hypertrophic: Callus has formed. Requires more rigid fixation
FDR: réduction instable, plaie contaminée
Which factors are associated with loss of motion in the context of hand fractures
- Tendon adhesions
- Capsular contracture
- Immobilization >4 weeks
- Joint injury
- Multiple fractures in one digit
- Crush injury
In which finger would you avoid a metacarpal head implant arthroplasty as your management option for treatment of a fracture
Index finger (implant failiure common because of sheer stress)
Which mechanism of injury is most likely to result in a metacarpal neck fracture
Axial load applied to clenched fist
What explains the apex dorsal angulation seen in metacarpal neck fractures
Intrinsic muscles lie volar to the axis of rotation of the MP and maintain a flexed head posture
Which fingers can better compensate for metacarpal fracture angulation and why?
4th and 5th fingers
Because their CMC joints have more mobility in sagittal plane (20-30o)
When should you attempt to reduce a metacarpal shaft fracture?
- Any degree of angulation of index and middle
- > 20o angulation of ring finger
- > 30o angulation little finger
Name 5 surgical treatment options for metacarpal shaft fractures
- Kwire
- Tension band wiring
- Cerclage
- Intramedullary fixation
- Compression screws (lag screw)
- Plate fixation
- External fixation
- Bioabsorbable fixation
What are the rules of 2 of lag screws (5)
- 2 vis
- 2mm
- Au moins a une distance de 2 têtes de vis de la fx
- 2 axes (spiralées)
- Longueur fx au moins 2x largeur de l’os
Pour chaque degré d’angulation et de shortening, combien de déficit d’extension?
Nommer 5 structures qui stabilisent la MP
- Plaque palmaire
- Ligament métacarpien transverse profond
- Ligament collatéral accessoire
- Fléchisseurs et extenseurs
Nommer les 4 structures impliquées dans un Kaplan lesion
FDP (ulnaire)
Lumbrical (radial)
Ligament superficiel transverse (profond)
Ligament natatoire (superficiel)
2 complications de luxation MP tardive ou traumatique
Ostéonécrose de la tête du méta
Arthrose
