fractures of hand bones
TRANSCRIPT
FRACTURES OF METACARPALS AND PHALANGES
Dr Sumer YadavMch plastic and reconstructive surgery
dr sumer yadav, mch plastic surgery.
INTRODUCTION
Most common fractures of the upper limb Most common cause of functional
disability in labor population Most common in males in the age of 1o-
40yrs Most fractures are functionally stable Outer rays of hand are most frequently
injured Goal is rapid & full restoration of hand
functiondr sumer yadav, mch plastic
surgery. [email protected]
Wrist/ hand Anatomy - bones
Carpals (proximal row) (distal row)
Metacarpals Phalanges
dr sumer yadav, mch plastic surgery.
SKELETAL ANATOMY OF HAND
5 metacarpal bone Head Shaft base
14 phalanges 3 for each finger 2 for thumb
Head Shaft base
dr sumer yadav, mch plastic surgery.
Hand Anatomy
• Bony Anatomy• Carpals
• Scaphoid• Lunate• Triquetral• Trapezium• Trapezoid• Hamate• Pisiform
dr sumer yadav, mch plastic surgery.
ANATOMY CONT…….
Key skeletal element Has 3 arches,2 transverse arches &
1longitudinal arch
dr sumer yadav, mch plastic surgery.
Splinting Position
Position of FunctionPosition of SafetyYES NOdr sumer yadav, mch plastic
surgery. [email protected]
Thumb spica
Basic Splinting
Position of “safety”
dr sumer yadav, mch plastic surgery.
Hand Functions
Grasping patterns Hook, spheres, cylinders
Pinches Key, tripod, inferior/superior
Fine motor manipulation Sensation
Pain, touch, discrimination, object identification, vibration
dr sumer yadav, mch plastic surgery.
INDICATIONS FOR FIXATION OF METACARPAL& PHALANGEAL#
Irreducible fractures Malrotation Intra articular fractures Open fractures Sub capital fractures Segmental bone loss Polytrauma with hand fractures Multiple hand or wrist fractures fractures With soft tissue injury osteotomy
dr sumer yadav, mch plastic surgery.
METACARPAL#
Metacarpal head fractures Rare, intraarticular As a result of axial loading or direct
trauma, complex dorsal MCP dislocations
IVX-x-ray-3 views—PA,LATERAL,OBLIQUE,brewerton skyline metacarpal
Ct scandr sumer yadav, mch plastic
surgery. [email protected]
Classification of fractures of metacarpal head
1)epiphysael Ligamentous avulsion Osteochondral slices Two part fractures in different
planes Comminuted Bone loss Occult compression #
dr sumer yadav, mch plastic surgery.
TREATMENT OF METACARPAL HEAD #
1)displaced ligamentous avulsion & osteochondral #-open reduction & internal fixation with k-wire or interfragmentary screws
2)for partial loss of bone->auto grafts taken from toe
3)comminuted intra articular #-> open reduction & internal fixation or skeletal traction or silicone arthro plasty
4)open fractures->clean & open reduction & internal fixation
dr sumer yadav, mch plastic surgery.
complications
Most common- stiffness-it is due to extensor tendon adhesions,collateralligament or dorsal capsule contractures
Epiphyseal growth arrest Avascular necrosis
dr sumer yadav, mch plastic surgery.
METACARPAL NECK FRACTURES
Boxers fracture Commonly involves-ring & small
fingers Occur when clenched MCP strikes
solid objects & angulates with apex dorsal
dr sumer yadav, mch plastic surgery.
Boxer’s Fracture
• Mechanism: impaction force exerted through the distal end of the metacarpal in closed fist potion
• Pathology: Fracture through the neck of the fifth metacarpal/volar displacement
dr sumer yadav, mch plastic surgery.
TREATMENT
For closed # with no pseudo clawing-cock –up splint
Pseudo clawing-closed reduction with JAHSS maneuver then buddy & give cock up splint-check x-ray
For index & mid metacarpal neck #--angulation >15* is unacceptable
For ring angulation of 30-40*is acceptable For little finger-angulation of 50-60* is
acceptable
dr sumer yadav, mch plastic surgery.
Cont…..
Immobilisation-12-14days & then AROM exercises
After 6 weeks –join duty If closed reduction fails---ORIF with
k-wire
dr sumer yadav, mch plastic surgery.
METACARPAL SHAFT FRACTURES
CLASSIFICATION—transverse, oblique comminuted
dr sumer yadav, mch plastic surgery.
transverse metacarpal shaft fracture
AXIAL LOADING Indications for intervention-any
angulation for index & mid finger,>20* ring finger,>30* for little finger
Treatment-closed reduction & internal fixation by k-wire,open reduction & internal fixation by k-wire,intramedullary fixation k-wire
dr sumer yadav, mch plastic surgery.
OBLIQUE OR SPIRAL FRACTURES
IF ROTATION >10* GO FOR INTERVENTION
Treatment-CRIF by k-wire ORIF by k-wire inter fragmentary screw fixation Tran osseous wire+-k-wires intra medullary fixation k-wire
dr sumer yadav, mch plastic surgery.
RIGID FIXATION
Indications-multiple #,isolated transverse#,malunion,pseudo arthrosis,bone loss
Types –interfragmentary compression screws, plates & screws
dr sumer yadav, mch plastic surgery.
EXTERNAL FIXATION
Indications-severe comminuted compound contaminated fractures in which anatomic reconstruction is not possible
Septic nonunion Advantages-no osteo
penia,secondary reduction can be carried ,provides ready access to wounds
dr sumer yadav, mch plastic surgery.
COMPLICATIONS OF INTERNAL FIXATION
Pin tract infection Osteomyelitis Fracture through pin holes Neuro vascular injury Over distraction Loss of reduction Impair tendon excursion
dr sumer yadav, mch plastic surgery.
OPEN REDUCTION & INTERNAL FIXATION FOR METACARPAL SHAFT #
Indications-displacement>10*--second & third metacarpal
>20*--fourth metacarpal >30*--fifth metacarpal Most spiral & oblique # Multiple meta carpal # Soft tissue injury Bone loss
dr sumer yadav, mch plastic surgery.
BI ABSORBABLE FIXATION
Polyglycolic acid,poly lactic acid,poly Para dioxanone
Disadvantage->non infectious inflammatory response
dr sumer yadav, mch plastic surgery.
METACARPAL BASE # & CARPOMETACARPAL # DISLOCATION
Treatment-for second & third –ORIF—k-wire
For fourth & fifth—for simple # dis—CRIF k-wire
For multiple # dis—ORIF-k-wire
dr sumer yadav, mch plastic surgery.
COMPLICATIONS OF METACARPAL FRACTURES
1)mal union 2)dorsal angulation 3)malrotation 4)osteomyelitis 5)nonunion
dr sumer yadav, mch plastic surgery.
PHALANGEAL FRACTURES
FRACTURES OF DISTAL PHALANX Classificatuion:1)tuft # simple # comminuted# Shaft #---transverse—stable or
unstable ----longitudinal Articular#---volar, epiphyseal,dorsal
dr sumer yadav, mch plastic surgery.
TREATMENT OF DISTAL PHALANGEAL #
TUFT #-drain subungual hematoma finger splint Shaft #-- CRIF—k-wire Epiphyseal #--ORIF Complications– nonunion -malunion
dr sumer yadav, mch plastic surgery.
FRACTURES OF MID & PROXIMAL PHALANX
ARTICULAR #(london)--1)condylar # Type1-stable #without
displacement Type2-unicondyle,unstable Type3-bicondyle,comminuted
dr sumer yadav, mch plastic surgery.
UNICONDYLAR FRACTURES
Classification-Weiss &Hastings Class1-oblique volar Class2-longsaggital Class3-dorsal coronal Class4-volarcoronal Treatment-CRIF OR ORIF with k-wire or
screws AT 5-7DAys—arom, splint PIP in full
extension Remove k wires 3-4 weeks
dr sumer yadav, mch plastic surgery.
TREATMENT OF BYCONDYLAR FRACTURES
ORIF WITH PLATES & SCREWS Dynamic splint External fixation Interfragmentary screws
dr sumer yadav, mch plastic surgery.
PSEUDOBOUTTONOUIRE DEFORMITY
IN FRACTURES OF HEAD OF PHALANX WHEN THERE IS DISPLACED collateral ligamentous injury & healing occurs ,when there is adhesions between the adjacent lateral band,& oblique retinacular ligament& volar plate
dr sumer yadav, mch plastic surgery.
Other fractures of head of phalanx
1)avulsion # of dorsal base of mid phalanx->detachment of central tendon insertions a result of ant pip jt dislocation
Treatment- ORIF
dr sumer yadav, mch plastic surgery.
CONT….
#lateral base of proximal or mid phalanx—it represents collat ligament avulsion
Treatment-a) uncomplicated—splint for 10-14 days
B) complicated—ORIF with k-wire # BASE OF PROXIMAL PHALANX- Treatment-ORIF
dr sumer yadav, mch plastic surgery.
Cont…
SHAFT # INVOLVING JOINT- Treatment ORIF Proximal traction phalanx splint- noninvasive, minimal stiffness,
comminuted#
dr sumer yadav, mch plastic surgery.
NECK FRACTURES
Common in toddlers Classification->type1-nondisplaced type2-displaced with some bone
contact Type3-completely displaced Treatment-ORIF with k-wire or
dr sumer yadav, mch plastic surgery.
SHAFT FRACTURES
They can be transverse, oblique, spiral, comminuted
Treatment 1)nondisplaced & stable-cock-up
position 2)displaced-stable after CR-cock-up
position slab Displaced unstable after reduction- A) spiral &oblique-CR& IF with kwire
dr sumer yadav, mch plastic surgery.
CONT
Transverse#-ORIF with kwire& intra osseous wire
Displaced unstable & comminuted-external fixation,miniplate & screws
dr sumer yadav, mch plastic surgery.
COMPLICATIONS OF PHALANGEAL FRACTURES
MALUNION-classified-a) malrotation,volar angulation,lateral angulation,
It is usually seen after oblique or spiral #
Treatment-osteotomy with plate fixation,lateralwedge osteotomy,corrective osteotomy
dr sumer yadav, mch plastic surgery.
CONT…
Intrarticular malunion Nonunion Loss of motion Pip joint extensor lag infection
dr sumer yadav, mch plastic surgery.
Fractures of the thumb bones
Fractures of phalanx-a) extra articular
B) Intra articularEXTRA ARTICULAR-1)distalp-
longitudnal,transervse,tuftTreatment-repair of dermal nail
matrix, application of splint,CRIF WITH k wire, ORIF with k wire
dr sumer yadav, mch plastic surgery.
FRACTURES OF PROXIMAL PHALANX
Head & neck#-CRIF WITH K WIRE ORIF WITH K WIRE Angulation of 20-30* is
unacceptable
dr sumer yadav, mch plastic surgery.
Intraarticular # & avulsion
1)dorsal base of distal phalanx-mallet thumb
Treatment-external splint 2)ulnar base of proximal phalanx-
game keeper thumb Treatment-reinsertion of collateral
ligament or CRIF with k wire
dr sumer yadav, mch plastic surgery.
FRACTURES OF THUMB METACARPAL
Metacarpal head fractures-displaced Treatment-ORIF OR CRIFwith k
wire& repair of radial collateral ligament
Shaft #-1)epibasal#-may extend into trapezio-metacarpal joint
Treatment-CRIF with k wire
dr sumer yadav, mch plastic surgery.
BENNET FRACTURE
#OF base of thumb metacarpal True lateral view It is # subluxation Injury due to axial loading of
partially flexed thumb Fragment- variable size, pyramidal Goals of treatment-a) restore
stability of cmc jointdr sumer yadav, mch plastic
surgery. [email protected]
TREATMENT
WHEN fragment is <15-20% of articular surface-CRIF with k wire
if > 25%-ORIF COMPLICATIONS-mal union
dr sumer yadav, mch plastic surgery.
ROLANDO FRACTURE
# base of metacarpal with Y or T shape
Any comminuted intraarticular # of base of metacarpal
Treatment-ORIF with k wire or plate & screws, bone graft
dr sumer yadav, mch plastic surgery.
