Week 9 Wrist and Hand Fractures Flashcards
Goals of Upper extremity fracture care
(Mobilize/Stabilize) fractures - role limited if not stable
Eliminate angular and rotational deformity - especially in the hand because it’ll lead to overlapping of the fingers
Restore angular anatomy
Care for associated soft tissue injury - was it a crush, open or closed fracture? Crush injury = more going on
(Slow/Rapid) mobilization
Stabilize; Rapid
Distal Radius Fractures
Colles’ Fracture
MOI: fall on an (flexed/extended) wrist
(Dorsal/volar) displacement of the radius
(Intraarticular/Extra-articular) - does not involve the articular surface
(Least/Most) common distal radius fx
extended; dorsal; extra-articular; most
Distal Radius Fractures
Smith’s Fracture - Sometimes referred to as a “Reverse Colles’ Fracture”
MOI: fall on a (flexed/extended) wrist
(Dorsal/Volar) displacement of radius
Happens suddenly, pt doesn’t have time to catch themselves.
Typically extraarticular and can be intraarticular
flexed; volar;
Distal Radius Fractures
Barton’s fracture
(Extraarticular/Intra-articular) fracture
Distal radius fracture with dislocation of (midcarpal/radiocarpal) joint
(Volar/Volar or dorsal) displacement
Extends all the way to the articular surface of the distal radius
Typically workplace injury, motorcycle injury
Fall on the (flexed and supinated/extended and pronated) wrist.
These pts are coming after having been to some sort of doctor
Intra-articular; radiocarpal; volar or dorsal; extended and pronated
Distal Radius Fractures
Chauffeur’s fracture
(Radial/Ulnar) styloid fracture
(Extraarticular/Intra-articular) fracture - Extends into the articular surface
Usually require surgery
If pts have hand on steering wheel and have to brake suddenly and they are in an accident, the steering wheel hits back into their palm
Radial; intra-articular;
Distal Radius Fractures
Die-punch fracture
(Elevation/Depression) of the lunate fossa of the radius
Allows (distal/proximal) migration of the lunate and/or proximal carpal row
(Intraarticular/Extraarticular) fracture of the lunate fossa of the radius
For younger population – Mva, sport injury, something high impact. More common in the younger population.
Elderly – osteoporosis – can get it on a fall on an outstretched hand
Typically requires surgery to fix.
Depression; proximal; Intraarticular;
Fracture Healing
(Primary/Secondary) Bone Healing
Direct bone-to-bone healing without external callus: Open Reduction Internal Fixation (ORIF) provides absolutely stability and compression of fracture to allow bone healing to occur
Can work with pts sooner
(Primary/Secondary) Bone Healing
Fractures treated by external support or coaptive implants > reduce fracture but do not provide compression
Relies on callus formation to bridge fracture gap
Coaptive implants – relative stability w/o compression, hold bone fragments in place while the callus forms. Relying on the callus to bridge the fracture gap.
Primary; secondary
(Primary/Secondary) bone healing
Advantages
Precise anatomic reduction
Early initiation of ROM without endangering fracture alignment -
Helpful if associated nerve or tendon repair
Can get them moving very quickly, typically in the first couple of weeks.
Disadvantages:
2 sites to heal: fracture and soft tissue incision
More than one thing that has to heal
Primary
(Primary/Secondary) Bone Healing
Advantages
Minimal soft tissue disruption
Periosteum isn’t stripped
Disadvantages
Relatively long immobilization period required - Soft tissues can become contracted or adherent to callus
Even 3-4 weeks of immobilization can lead to tissue shortening or adherence
Have to lock them up for a longer time so these pts will stiffen quickly and the adhesions can form in the callus of the fracture site.
Notes:
When they do the ORIF they have to strip the periosteum to put the bone down.
Secondary
Surgical fixation of fractures of the distal radius
External fixation
External Fixator” or “Ex-Fix”
Provides traction to (aid in/prevent) shortening or angulation of the fracture
Pin site care > watch for infection
Pin sites are a common place for infections.
(common/not common)
Fixation is external, pins go through the skin to the bone and the device is external. If you see this there was probably a (nondisplaced/comminuted) fracture or (dislocation/crush) injury.
prevent; not common; comminuted; crush;
Surgical fixation of fractures of the distal radius
Closed Reduction Percutaneous pinning (CRPP)
K-wire fixation of a (Colles’/Chauffer’s) Fracture (radial styloid)
No open incision is happening.
Going through the skin to pin the fracture site.
Chauffers;
Surgical fixation of fractures of the distal radius
Open reduction internal fixation
Uses:
(Stable/Unstable) fractures
(Closed/Open) fractures
Fractures with (low/high) incidence of non-union
Fractures with bone (growth/loss)
Fractures that require (early/late) motion - Associated nerve or tendon repair
Probably stripping the periosteum and placing the plate and screws to the bone.
Able to get the pt moving quicker and able to provide absolute stability of the fracture.
“Nonunion and malunion fractures are identified with defective healing: nonunion describes the failure of a fractured bone to heal and mend after an extended period of time”
Unstable; Open; high; loss; early
General management for Distal radius fractures
Conservative Management
Protection Phase (- weeks):
Casting or protective orthosis
Edema control
Maintain finger and elbow ROM - Don’t ignore the shoulder either!
Mobilization Phase:
Regain (AROM/PROM)
(AROM/PROM) as needed
Progressive strengthening
Surgical Management:
Goal: achieve fracture (mobilization/stabilization)
Maintain ROM of involved joints- Finger stiffness tends to correlate with poorer outcomes overall
Initiate AROM depending on type of fixation (often in the first _ weeks)
PROM typically held until _ weeks
- weeks: Progressive strengthening and weightbearing
Notes:
Want to work on the wrist after get casting off.
If they have a short arm cast and they come to you, maintain ROM of all uninvolved joints and keep edema under control.
Flexion/extension of the elbow. These pts will be guarding.
The shoulder can stiffen up a lot and you don’t want someone to develop adhesive capsulitis just from being immobile. Encourage shoulder extension ROM and even some table slides (once or twice a day to maintain that motion).
(AROM/PROM) – safer way to start after fractures of the hand or wrist.
Surgical management
PROM – still don’t want to do that too early
4-8; AROM; PROM; stabilization; 2; 4; 6-8; AROM;
Complications/considerations With Distal Radius Fractures
Soft tissue injury with internal fixation
Tendon adherence
Especially FPL
Extrinsic finger tightness - Extrinsic instead of intrinsic because it is coming from outside of the hand (thinking of the EDC). Still haven’t got full excursion of the extrinsics.
Tendon rupture
EPL
FPL with volar plating
Avoid EDC substitution during wrist extension -pts are trying to force extension and as they come up they’ll pull the fingers up and think they’re getting more extension. If we can only move the wrist into extension and the finger into extension it will affect their ADLS. Once they start doing that it is a hard habit to break down the line. Have them extend wrist while gripping something to have fingers flexed.
Assess shoulder regularly for ROM deficits
If cant flex or extend thumb get them back to their surgeon.
Can be shortening of the radius with distal radius fractures and that will (increase/decrease) ulnar variance which compresses structures on the ulnar side of the wrist like the TFCC. These pts might have (radial/ulnar) side complaints.
(CTS/Covid) is a common complication after a distal radius fracture.
Extrinsic; increase; ulnar; CTS
Carpal Fractures
Scaphoid fracture
MOI: fall on outstretched hand in (flexion/extension)
Symptoms: pain, swelling, and tenderness in (pisiform/snuffbox)
Negative X-rays do not exclude scaphoid fx
(Least/Most) common carpal bone fx (60-70%)
Depends on the amount of (flexion/extension) of the wrist to determine whether distal radius fracture or scaphoid fracture.
Scaphoid hides behind other carpal bones in Xrays, just not clear.
If no callus forms at the fracture site have to get surgery
extension; snuffbox; Most; extension;
Carpal Fractures
Scaphoid Fracture
Potential for healing for scaphoid fx
Blood supply enters largely (proximal to distal/distal to proximal)
(Distal/Proximal) pole is vulnerable to avascular necrosis
Periods of Immobilization/Healing Time:
Distal Third: 6-8 weeks
Waist: 8-12 weeks
Proximal Pole: 12-24 weeks
(Proximal/Distal) portion of the scaphoid will have the best potential for healing and the (proximal/distal) will have a decreased potential in healing.
Avascular necrosis of the scaphoid is called prizers disease.
distal to proximal; proximal; Distal; proximal
Carpal Fractures
Scaphoid Fracture
Pic - fracture of the proximal pole. Screw had to stabilize the fx.
Coo
Carpal Fractures
Triquetrum fracture
MOI: wrist forced into (flexion and RD/extension and UD)
Types: body or dorsal chip fx
(2nd/3rd) most common carpal fracture
Symptoms: tenderness and swelling in (radial/ulnar) wrist
Pic: Arrow – a chip fracture from mva with hand on steering wheel. Can handle conservatively, tend to do very well. Pain and swelling on ulnar side of the hand. Can begin AROM after cast is off. WB gives them trouble. Pressure over the hypothenar eminence is going to be painful .
extension and UD; 2nd; ulnar;
Carpal Fractures
Hook of the hamate fracture
MOI: (fall into extension/direct blow)
Handle of bats/racquets impacts (thenar/hypothenar) eminence
(Radial/Ulnar) nerve can be impacted
Symptoms: tenderness over hook, exacerbated by club/racquet sports, or resistive abd/add of (small finger/index finger)
Can happen from a mva on the hand on the steer wheel
Pain with gripping
Pain with symptoms in guyons canal area
direct blow; hypothenar; Ulnar; small;
Fractures of the thumb
Bennett fracture
Fracture and dislocation of (CMC/IP) of thumb
Cause: forced (adduction/abduction) and axial loading
Usually (conservative/surgical) management
(Most/least) common for the thumb
(APL/FPL) is going to cause the dislocation of the CMC Joint. Pts will need surgery because it will end up being displaced and get a closed reduction.
(2/3) part fracture
Any time there is a pull on the fracture segment - will cause instability.
CMC; abduction; surgical; most; APL; 2
Fractures of the thumb
Rolando fracture
Bursting fracture at base of (metacarpal/IP) in a T or Y shape ((2/3) part fracture)
Cause: increased (abduction tear/axial loading)
(More/Less) common than Bennett’s Fx
Same thing as Bennett’s but in three pieces instead of in two. Going to be a comminuted fracture.
metacarpal; 3; axial loading; Less
Metacarpal fractures
Named based on location of the (IP/metacarpal) fracture
Metacarpal (neck/head) is the most common metacarpal fx.
These fractures have a good blood supply and heal quickly (sometimes as early as 3 weeks)
metacarpal; neck;
Metacarpal Fractures
Boxer’s Fracture
Treatment:
Splint with MCP’s in (flexion/extension)
Maintain length of collateral ligament
Tendon glides - Consider isolated EDC exercises
Combined wrist/finger (flexion/extension) can assist with extrinsic tightness
(Flex/extend) the MCPs to maintain the length of the collateral ligaments
In pip this will be in (flexion/extension)
If EDC pulls through, helps prevent extensor lag and encourages proximal glide of the tendon
Wrist/finger flexion – maximize excursion of the EDC.
flexion; flexion; flex; extension
Metacarpal Fractures
Boxer’s Fracture
Complications
Malrotation - Fingers overlapping
Extensor tendon adherence:
(Flexor/Extensor) lag
Extrinsic (flexor/extensor) tendon tightness
Decreased grip strength
Loss of prominence of MCP joint in full fist - Seen with bone shortening
Pic - When we make a fist, all fingers are aiming towards the scaphoid tubercle
When fracture of the metacarpal we can have a malrotation. Ring finger isn’t pointing towards the scaphoid tubercle – scissoring of the fingers. Need surgery for this.
Loss of prominence – they’ll say I don’t have a knuckle anymore. With shortening of the bone it won’t be as prominent. Looks like it veers off at the MCP.
extensor; extensor;
Finger Fxs
Proximal/middle phalanx fractures
Type of Fx: Spiral - Usually (stable/unstable) Oblique Usually (stable/unstable) Transverse Comminuted: 3 or more pieces - More soft tissue damage
Location of Fx:
Base fractures
Shaft fractures
Condylar fractures
Healing Rates:
Proximal phalanx heals (faster/slower) than the middle phalanx
Proximal Phalanx: - weeks
Middle Phalanx: - weeks
Condylar – can be unicondylar, bicondylar fx - goes across both at the distal aspect of the pahalnx.
unstable; unstable; faster; 6-8; 6-14;
Finger Fractures
Proximal/middle phalanx fractures
Treatment:
Edema control - prevent adhesions forming at the flexor tendons
Hand-based splint
Often buddy taping
(AROM/PROM)- Consider blocking exercises to encourage tendon gliding
Complications:
Malrotation
Tendon adherence at fracture site
PIP (flexion/extension) contracture or (flexor/extensor) lag
Middle phalanx – single finger splint because we can keep the mcp moving but need to protect the PIP and dip.
Pic - Buddy taping
Blocking exercises – flexor tendons (fds and fdp). Fds sits on top of the fdp and the fds has to split and come wrap around and attach sooner to the middle phalanx while the fdp has to travel to the distal pahalanx. A lot of adhesions, contractures, and lags start to happen when we have proximal and middle phalanx fx. Block exercises to encourage tendon gliding. Ex: block middle and proximal pahalnx while flexing the DIP.
Tendon adherence – encourage tendon glides
AROM; flexion; extensor
Finger fractures
Distal phalanx fractures
Tuft fracture - (proximal/distal) portion of the (proximal/distal) phalanx.
distal; distal
Finger fractures
Distal phalanx fractures
Mallet fx (Bony mallet)
Avulsion fracture of the (flexor/extensor) tendon
extensor
Finger fractures
Distal phalanx fractures
Tuft Fracture
MOI: typically (crush or blow injury/sprain)
Painful/possible hematoma present
Often involves nailbed injury
Displacement not an issue > no tendon forces beyond the base of the distal phalanx
Super sensitive – all nerve endings that are there. Hematoma can form which creates sensitivity
Tend to be stable. Fdp inserts before it gets to the tuft so don’t have to worry about displacement.
Want to give them protection from the environment in terms of hitting your finger on things.
crush or blow injury;
Finger fractures
Distal phalanx fractures
Mallet Fracture (Bony Mallet)
(Proximal/Terminal) tendon disruption + bony fragment
Usually unstable > 2/2 pull of FDP
Attachment to the (fdp/fds) is going to pull on the distal phalanx so have to splint right away or have surgery
Terminal;fdp
Surgical fixation of metacarpal and finger fractures
Types of fixation
(Closed Reduction Percutaneous Pinning (CRPP)/Open Reduction Internal Fixation (ORIF))
K-wires
Will be removed by surgeon after fracture is healed
(Closed Reduction Percutaneous Pinning (CRPP)/Open Reduction Internal Fixation (ORIF))
Plates
Lag Screws
Pic - pining of the distal phalanx that was likely a mallet fracture. If they have surgery for it will have a pin placed there. Not moving pt until pin is removed.
ORIF – plates and lag screws on different fingers ^
K wires removed 4-6 weeks after surgery
Closed Reduction Percutaneous Pinning (CRPP); Open Reduction Internal Fixation (ORIF)
Role of PT in Hand fractures
Edema Management
Elevation
Compression wraps or edema gloves
Think of the hand as a muscle pump:
Role of tendon gliding as appropriate
(Early/Late) mobilization to promote venous return via muscle contraction in stable fractures
Can measure using a volumeter (compare to contralateral side)
The more edema, the stiffer the fingers are so the poorer the outcome the pt is going to have.
Always elevate !! First thing you teach the pt to do.
Have to educate to prop their hand up to the pillow or if walking for a long time elevate the hand.
Pic - Edema glove – edema throughout the hand. Can happen after wrist fracture, shoulder surgery. Helps put compression throughout the entire hand. Can wear edema glove just at night - at night the fluid settles in the hand. Glove will put them in a better starting point in the beginning as far as all the build up of fluid.
Early
Role of PT in Hand fractures
Edema Management
Wrapped finger for edema. Start at the tip of the finger and then overlap halfway down the finger. Only wrapping (once/twice). Teach the pt to go down to move the fluid out of the finger.
once
Role of PT in Hand fractures
Pain Control
Modalities
Address hypersensitivity
(Increase/Decrease) complaints of stiffness
When pts are in pain they won’t want to move.
Use modalities
With stiffness and pain, moist heat does well . Sometimes they are guarding and need to get that relaxed
Hypersensitivity – a lot of times dealing with pts who have this after injury or procedure
Pic – sticks that have all types of different textures. Can teach pt to use a cotton ball, fleece blanket and will go all over the area that is sensitive (texture sticks). No matte where the hypersensitivity is they can use it. Keep constant contact with the skin so it gets to the nerve endings. At least 5 min at a time. Start with a softer texture and as they can tolerate, move on.
Bath particles – have pt have big tupperware bowl and have rice and have them just stir with their hand and it goes around the whole hand. As they get better over time ..have marbles in the rice and then have the pt look straight ahead and moving the hand and try to tell the difference to try and find the marble. Using the sensory input to try and tell the difference. Cheap option for your pt to use at home, it is just knowing what to tell them. Have them stir for 5 min at a time.
Decrease
Role of PT in Hand fractures
Range Of Motion
A/PROM as indicated
Tendon Gliding
Maintain ROM of all uninvolved joints
The big thing is always maintain the ROM of the uninvolved joint. If you cant move the DIP due to the fracture, can still maintain the ROM of the PIP and other joints in the digit.
Pics – tendon glides she gives to her patients.
Work into a hook fist to get the differential glide between the FDS and FDP and get into a full fist to get the FDP to glide in its sheath and then lumbrical position is for the lumbricals, straight fist for the FDS to glide in its sheath.
Trigger finger – no full fist, can do table top or lumbrical position.
Tendon glides are helpful even if pts have an unrelated surgery.
Got it
Role of PT in Hand fractures
Strengthening
Typically - weeks after injury or surgical intervention
(Strengthening/ROM) needs to be primary focus
Pic: Putty - can do so much with it. Person is working a hook fist. Can work a key pinch. It’s so versatile and cheap.
6-8; ROM;
Role of PT in Hand fractures
Strengthening
Towel curls - If a pt is not ready for true gripping, can start with towel curls. Can focus on the hook fist and not the full fist. The thicker it gets the (less/more) resistant it will be. Can work the extension to push it back out. Really good for finger injuries. Good precursor to the strengthening.
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