Hand and wrist fracture, dislocation Flashcards Preview

Upper Extremity > Hand and wrist fracture, dislocation > Flashcards

Flashcards in Hand and wrist fracture, dislocation Deck (48)
Loading flashcards...
1

discuss xray for hand fracture

  •  AP/Lateral/Oblique for all plus/minus:

    o  Brewerton view (MPJ flexed 65° with dorsum of digits lying flat on X-ray plate, tube angled 15° in an ulnar–to-radial direction) – helpful to see collateral avulsion #’s

    o  Skyline metacarpal view (MPJ’s and IPJ’s fully flexed, beam directed parallel to the dorsal shaft of the proximal phalanx) – helpful to visualize the metacarpal head

    o  Stress views

    o  Pre and post reduction

2

how do you classify hand fractures?

  • open vs closed
  • Specific bone and site (e.g.metacarpal head)
  • Fracture pattern (oblique, spiral, transverse, comminuted)
  • Displacement, angulation, shortening
  • Etiology (pathological vs traumatic; high vs low energy)
  • Intra vs extra articular

3

discuss classification of pediatric epiphyseal fractures

Type

Location

Management

Prognosis

I (5%) - Straight

  • Physis
  • Splint/Observe
  • Good – low impact growth

II (75%) - Above

  • Physis  + Metaphysis
  • Closed reduction
  • Good – low impact growth

III (10%) - Low

  • Physis + Epiphysis  (intra-articular)
  • ORIF
  • Moderate impact growth

IV (10%) - Through

  • Physis + Metaphysis + Epiphysis (intra-articualr)
  • ORIF
  • Moderate impact growth

V (rare) - cRush

  • Physis (crush)
  • Splint/Observe
  • Worst impact growth

4

indications for operative intervention of metacarpal/phalangeal fractures

  • Any malrotation or scissoring
  • Shortening of 2-5mm
  • Unable to obtain or maintain a reduction
  • Grossly comminuted w/ segmental bone loss
  • Fractures with soft tissue injury (vessel, tendon, nerve, skin)
  • Reconstruction (ie. osteotomy)
  • Open (relative)
  • Intra-articular (relative)
  • Other (often relative): major ligamentous / tendinous avulsion; Polytrauma with hand fractures; Multiple hand or wrist fractures

5

indications for non-operative management

  • can be achieved through closed reduction and immobilization if stable:
  • ·   No rotation or scissoring
  • ·   Stable

    ·   <10⁰ lateral deviation

    ·   <3-4mm shortening

    ·   <45⁰ angulation for 5th MC neck

    ·   >50% bony apposition

6

list options and relative advantages of different methods of operative fixation

  • percutaneous pinning
    • advantages:
      • can be utilized using closed reduction
      • no soft-tissue dissection or peri-osteal stripping required
      • simple, easy
    • Disadvantages
      • non-rigid, no compression, requires immobilization
      • risk of infection through pin site
  • intra-osseous wiring
    • advantages: useful for specific situations, minimizes extent of periosteal stripping
    • disadvantages:
  • Tension band
    • advantages: compress and apply tension across angulating force, limited soft tissue disruption, minimizes risk of fragmentation
  • Plate fixation
    • advantages: rigid fixation, permits early ROM
    • disadvantages: greatest extent of dissection, periosteal stripping, hardware complications (permanent, palpable, loosens, tendon injury), stiffness, edema
  • Lag screw fixation
    • advantages: minimal soft tissue dissection or peri-osteal stripping, rigid fixation and applies compression force
    • disadvantages: need to follow principles, permanent hardware
      • disadvantages: finicky

7

what are princples of lag screw fixation

  • for oblique or spiral fracture where length of fracture is 2-3 x width of bone (2:1 = 2 screws; 3:1 permits 3 screws)
  • apply at angle that bisects the 90' to bone axis and 90' to fracture axis
  • ensure that anatomic reduction is achieved and maintained w/ bone-holding forceps
  • overdrill proximal cortex (2mm drill bit) and regular drill distal cortex (1.5mm or 1.8mm drill)
  • will compress when picks up distal cortex

8

discuss surgical approaches to the hand

Region

Preferred Incision

Metacarpal

  • Dorsal longitudinal

MCPJ/Metacarpal Head

  • Dorsal longitudinal with tendon splitting

Proximal/Middle Phalanx

  • Lazy S or straight dorsal with tendon splitting
  • or midlateral incision

PIPJ**

  • Lazy S or straight dorsal with tendon splitting
  • Vs. volar

DIPJ

  • Dorsal Y/champagne or hemichampagne

Distal Phalanx

  • Dorsal Y/champagne or hemichampagne

Thumb Metacarpal Base/CMCJ

  • Wagner incision

Thumb Phalanges

  • Dorsal longitudinal incision with EPL tendon left intact
  • ** indications for volar approach to PIPJ: comminuted base of MP; volar plate avulsion #; dorsal PIP fracture-dislocation
  • ** indications for shotgun approach to PIPJ (i.e. to add hyperextension to volar approach): severe comminution or impaction of fragments

9

 discuss treatment of Bennett fracture

Closed reduction + K-wire -->  for any fracture that can be reduced by this means

◦  longitudinal traction, pressure at metacarpal base, pronation

◦  1 K-wire thumb MC (0.045) à trapezium, or 2 K-wires into 2nd MC (or one to trapezium, one to 2nd MC) – none in fragment unless large

◦  Accept if <2mm articular step-off, immobilize in thumb spica

Consider ORIF if # fragment >20% articular surface

◦  Wagner incision, reflect thenar muscles, incise joint capsule

◦  1 lag screw (2.0 or 2.7 mm): can start AROM at 10d postop

◦  2 K-wires (0.035 inch) across # x 6wks ± 1 transarticular K-wire x 4wks

◦  2 intermetacarpal K-wires

 

10

describe bennett fracture

  • intra-articular fracture of base of thumb MC
  • displacement of large fragment by proximal and dorsal pull of APL
  • maintenance of small fragment by volar beak ligament

11

discuss treatment of rolando fracture

3 part # with large fragment --> Wagner incision, ORIF 2.4 or 2.7mm T or L plate

Significant comminution --> do not open (use ligamentotaxis)

◦  Thoren oblique traction --> radial – ulnar 0.062 k-wire through small incision, crimp proximal end, oblique traction through 1st webspace to Banjo outrigger

◦  Quadrilateral ex-fix (2 pins each in 1st & 2nd MC)+ articular reduction with K-wire ± cancellous bone graft to metaphysis

12

what is a Stener lesion

  • in context of presumed thumb UCL injury; a Stener lesion is only present when there is a complete UCL tear
  • Adductor aponeurosis interposed between distally avulsed ligament and its insertion into the base of the proximal phalanx, preventing its reapposition with PP with immobilization

13

how do you diagnose complete UCL tear?

  • complete tear: > 35’ radial deviation or no endpoint or >15⁰ compared to contralateral – test in 30⁰ flexion to minimize VP contribution to stability) --> x-ray (see small bony Stener lesion), US, MRI to r/o - less common

14

discuss treatment scenarios of partial and complete UCL tear, thumb

  • Acute Partial --> thumb spica x 4wks (in slight ulnar deviation)
  • Acute Complete  (Skier’s Thumb) – most common is distal avulsion
  • Conservative (thumb spica) if no radiologic Stener lesion – controversial
  • Operative: Stener Lesion or complete tear
    • Dorsal lazy-s incision, ID adductor aponeurosis & incise longitudinally parallel/volar to EPL
    • Reflect the adductor aponeurosis volar to expose ulnar aspect MCPJ
    • Repair ligament (direct repair; secure to PP modified Kessler pull-out suture over button with Keith needle and 3.0 nylon/prolene; cerclage wire; or mini mitek bone anchor)
  • If large bony avulsion
  • Typically NOT a Stener, bc the ligament is attached to bone fragment
  • Consider operative intervention (below) if: > 20% joint surface; > 2mm step deformity; significant instability; suspected Stener; combination injury (tear and avulsion)
  • Bony repair options: k wire, mini plate, pull out suture vs. excise small bony fragments and suture UCL into defect
    • Repair ligament to VP, repair dorsal-ulnar capsule, repair adductor aponeurosis
    • Test repair – gentle radial stress; ± K-wire in slight ulnar deviation/flexion; thumb spica x4/52 then custom splint
    • Complication: neurapraxia of radial sensory nerve branches

15

discuss treatment of chronic thumb UCL injury

  • Key Management Point: define degenerative arthritis clinically (history of pain, tenderness at MCPJ, + grind) and radiologically

  • MPJ arthrodesis indicated when clinical plus radiological evidence of symptomatic OA

  •  

    If no OA:

    o  Dynamic Reconstruction

    § Adductor pollicis advancement from ulnar sesamoid to ulnar base of PP

    § ½ EPB used to reconstruct UCL

    o  Static Reconstruction

    § Direct repair, plication, capsulodesis

    § Bone anchor, cerclage wire, pull-out over button

    § Tendon graft reconstruction (PL, plantaris, toe extensors, APL, FCR ½)

16

Discuss operative indications and options for fracture of MC head in digit

Operative Indications

o  Open (human bite) require I&D +/- ORIF & antibiotics

o  > 25% articular surface

o  > 1-2 mm articular step

Operative options

o  Two part intra-articular --> K-wire, screw fixation, or blade plate (more rigid = earlier movement = ↓ stiffness)

§ Antegrade fixation if large fragment; retrograde fixation if small fragment

o  Severely comminuted à traction (if prox phalangeal base # as well), silicone arthroplasty (need ligamentous stability & adequate bone stock – rare primary treatment, not for younger/active people); Ex-Fix (bone loss or lack of soft tissue)

o  Arthrodesis – not acutely

o  Delay internal fixation in contaminated wounds (e.g. human bite)

17

what are operative indications of MC neck fracture, digit?

Operative Indications (after failed at closed reduction)

  • >3mm shortening (every 2mm = 70 extensor lag)
  • Extensor lag
  • Rotation/scissoring
  • <50% bony apposition
  • >10o lateral deviation
  • Angulation:  Index >10o, Long >20o, Ring >30o, Small >40o
    • Unstable but reducible à K-wire percutaneous fixation + splint

18

what are operative management options for MC neck fracture, digit?

  • Crossed k-wires +/- dorsal tension band
  • 4 hole plate:2 screws in head, 2 in shaft; T or L plate
  • Intramedullary K-Wire (bouquet technique)
  • Transverse pinning to an adjacent intact MC
    • Immobilization for 7-10 days then x-ray; satisfactoryàbegin protected ROM, pins out at 3-4 weeks

19

list indications for intervention of MC shaft fractures, digits

  • Closed but Displaced --> Closed reduction + splinting
  • Reduction for – Angulation > 300 D5, 200 D4, ~ 100 in D2,3; Shortening > 2-5mm;
  • Operative Indications
  • Open #, unstable # after closed reduction, multiple #, most spiral/oblique # good for lag screw or plate, polytrauma (can’t cooperate/tolerate immobilization)

20

what are operative options for MC shaft fractures?

o  Closed reduction and percutaneous fixation – check stability through ROM (tenodesis) & intra-op fluoroscopic imaging

o  Intramedullary K-Wire (insert through the #, down shaft, then anterograde into distal MC; min access/open

o  Transverse or crossed K-wires; closed/open

o  90/90 Intra-osseous wiring or composite wiring (IO wire + K-wire); open

o  Plate fixation (5 hole 2.0 mm plate): multiple #’s, isolated transverse #, malunion, nonunion, pseudoarthrosis; ± lag screw (for short oblique #); open

o  Lag screw fixation (hold with bone clamps, 2 x 2.0mm): long oblique or spiral #s; open

o  Short intramedullary Steinmann pins; open

o  Ex fix: ++ bone loss, septic nonunion, loss of soft tissue, displaced comminuted intra-articular #

21

what do you do w/ segmental MC bone loss?

·   stabilize/maintain length (traction, transfixion pins, ex-fix), bone graft when clean (5-14 days) ICBG + dorsal plate

22

describe "baby bennett" fracture

·   Baby Bennett’s #/dislocation: pull of ECU --> dorso-proximal displacement of main MC #, radial fragment remains articulating with hamate and 4th MC (intermetacarpal ligaments)

23

what are treatment options for baby bennett fracture?

Always inspect for 4th MC base and hamate fractures – may be missed on x-ray --> 5th MC with 30⁰ pronation or consider CT

Treatment

  • Closed reduction & perc pin: axial traction + K-wire to 4th MC ± to hamate/carpus
  • ORIF: if unable to reduce closed, severe comminution, multiple CMC #/dislocations
    • Dorsal ulnar incision then K-wire immobilization (dorsal sensory br of ulnar N) or screw fixation of hamate/base 5th MC if larger fragments
  • Severe comminution: arthrodesis using corticocancellous graft

24

discuss complication of MC fracture and suggest an intervention for each.

Malunion

o  Malrotation – step cut osteotomy with removal dorsal strip

o  Dorsal angulation – closing wedge / opening wedge osteotomy for unacceptable angulation

o  Shortening - Opening osteotomy with grafting

Nonunion - Rare in the hand --> initially treat as delayed union (recommend further immobilization) then resect pseudoarthrosis, bone graft, stable internal fixation

Tendon adhesion – PT/OT --> tenolysis if fails

Intrinsic contracture – esp with closed crush injuries

Intrinsic muscle dysfunction/clawing – loss of innervation, soft tissue or 2⁰ contracture

25

26

discuss indications for intervention of proximal and middle phalanx fracutres

 

  • any rotational deformity / scissoring
  • D/V angulation of > 15' (some say 15-25)
  • lateral angulation
  • shortening > 2-5mm
  • open
  • unstable

27

discuss treatment strategies for proximal and middle phalanx fractures of the digits

 

  • Stable & non-displaced
  • Extension block splint (IE MCP 70-90; and IP straight) + buddy tape for protection (7-14 days)
  • Follow up (day 7 & 14) to ensure no collapse
  • Displaced fractures (Stable post-reduction)
  •  if stable after CR--> extension block splint x 2/52, then active flex digits, buddy tape x2/52 +, f/u q1week
  • Spiral & oblique fractures tend to displace & shorten after reduction --> f/u q 1/52 clinically and x-ray
  • Transverse #’s tend to be stable & amenable to closed reduction
  • Displaced Fractures (Unstable post-reduction)
  • Spiral & oblique
    • Closed reduction, 2 x K-Wire fixation across fracture or lag screws if unstable
    • Splint for 3 weeks then early protected range of motion, wire out at 4/52
  • Transverse
    • Closed pinning through flexed MP joint
    • 3 weeks of immobilization then ROM as above
    • If unstable with pins:  ORIF with tension band or plate (plates – generally not used à stiffness)
  • Displaced unstable and comminuted
  • Ex-fix
  • ORIF with plates & screws

28

classify intra-articular / condylar # of proximal or middle phalanx

London classification

  • type 1: stable fractures without displacement (uni-condylar w/ transverse component for stability)
  • type 2: unstable uni-condylar fractures with displacement (can describe these as short oblique, long sagittal oblique, volar or dorsal oblique)
  • type 3: unstable bicondylar or comminuted fractures
    • type 2 & 3 are always unstable and require operative intervention to restore joint congruity

29

how would you treat intra-articular fractures of head (condyle) of proximal or distal phalanx (include approach where appropriate)

  • Type I – Stable fractures without displacement
  • Dorsal extension block splint, q1/52 x-ray r/a
  • Type II – Unicondylar fractures
  • Always unstable (displaced or not) due to collateral ligament rotating fragment
  • Always need intervention
  • Closed reduction + k-wire
  • ORIF - Dorsal radial/ulnar incision, enter joint b/w central tendon and lateral band (condylar blood supply is from the CL, so try not to disrupt it)
    • 2 parallel k-wires (1 is not enough) OR lag screw OR mini-plate fixation e.g. 1.5mm blade plate)
  • Post-op: early active motion, IP splinted in extension, K-wires can be removed in 3-4 weeks
  • Type III: Bicondylar or comminuted
  • Inherently unstable --> always ORIF (or comminuted = traction)
  • Reconstruct joint surface (2 condylar pieces together), then fix this fragment to the shaft using a condylar plate or longitudinal K wire
  • Significant comminution: do not open; traction (ex-fix) or immobilize X 10-14 days and then start gentle AROM
  • Missing condyle: toe DIP/PIPJ graft, arthroplasty or arthrodesis

30

HOW WOULD YOU TREAT CENTRAL SLIP AVULSION FRAGMENT?

o  Usually from an anterior PIP joint dislocation

o  PIP flexion deformity (due to unopposed flexors) --> volar migration of lateral bands beyond axis of rotation --> further PIP flexion deformity

o  if < 2mm displaced avulsion fragment boutonniere splint x 6 weeks

o  if > 2 mm displaced, consider ORIF to prevent progression of boutonniere (K-wire, fixation screw)