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Flashcards in Hand trauma Deck (76):
1

What do the thumb collateral injuries include?

  • Radial collateral ligament- Rare
  • Ulnar collateral ligament- most common
    • aka Gamekeepers thumb- chronic injury
    • Skiers thumb- acute injury
    • Steiner Lesion= avulsed ligament w/wout bony attachment is displaced ABOVE ADDUCTOR APONEUROSIS
      • won't heal without surgical repair

2

What is the epidemiology of thumb collateral injuries?

  • Ulnar more common than radial

3

What is the aetiology of ulnar collateral injury?

  • Hyperabduction or extension at MCPJ

4

Describe the anatomy of the UCL?

  • Proper collater ligament
    • Runs MC head to volar aspect of prox phalanx
    • resist valgus load w thumb in Flexion
    • primary contraint in flexion
  • ​Accessory collateral ligament & volar plate
    • Runs palmar to proper ligament inserts into volar plate
    • ​resist valgus load w thumb in EXTENSION
    • Primary contrainst w volar plate in extension
  • Valgus laxity in both flexion and extension = complete UCL rupture

5

What are the signs and symptoms of collateral thumb injury?

HX

  • Hyperabduction injury to thumb

Symptoms

  • Pain at ulnar aspect of Thumb at MCPJ

​Signs

  • Mass from torn ligament & possible bony avulsio may be present
  • Stress joint w radial deviation both at NEUTRAL/30o
  • Instability in 30o flexion = injury PROPER UCL
  • Instability in neutral - ACCESSORY UCL injury
  • compare to uninjured thumb!

 

A image thumb
6

What investigations are useful to dx thumb collateral damage?

  • xrays- AP , lateral and oblique of thumb
    • Valgus stress view may aid diagnosis if bony avulsionhas been ruled out
  • MRI - aid dx

A image thumb
7

What is a stener lesion?

  • Displacement of the distal end of the completely ruptured UCL such that it comes to lie SUPERFICIAL and PROXIMAL to ADDUCTOR APONEUROSIS
  • Must be operated on!!

A image thumb
8

What is the TX of thumb collateral damage?

Non operative

  • Immobilisation 4-6/52
    • partial tears with <20o side to side variation

Operative

  • Ligament repair
    • In acute injury >20o side to side variation
    • >35o of opening
    • Stener lesion
      • ​can use suture/ suture anchor/ small screw to repair ligament
  • Reconstruction of ligament w tendon graft, MCP fusion, adductor advancement
    • chronic injury

 

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9

What is the tx of radial collateral ligmanet injuries?

  • rare
  • tx is non operative= Immobilisation 
  • indicated in most cases
  • Stener lesion - doesn't occur

10

Describe a repair of UCL?

11

Define digital collateral ligament injury?

12

What is the epidemiology of scaphoid fractures?

  • Most frequently fractured carpal bone
  • Accounts for up to 15% acute wrist injuries
  • location
    • waist -65%
    • Proximal third- 25%
    • Distal third 10%
    • distal pole is most common location in kids due to ossification sequence

 

13

Describe the pathoanatomy of scaphoid fractures?


  • Axial load across hyper-extended and radially deviated wrist 



  • Common in contact sports 






  • transverse fractures more stable than vertical/oblique fractures
     

14

What is the prognosis of Scaphoid fractures?

  • Incidence of AVN with fracture location
  • Proximal 5th AVN rate = 100%
  • Proximal 3rd AVN rate= 33%

15

Describe the anatomy of the scaphoid?

  • 75% scaphoid covered in CARTILAGE
  • Blood supply
    • major supply- DORSAL CARPAL Branch of radial artery- enters scaphoid in a nonarticular ridge on dorsal surface and supplies proximal 80% scaphoid via a RETROGRADE blood flow
    • minor via SUPERFICIAL PALMAR Arch branch of volar radial artery- enters DIstal TUBERCLE and supplies 20% DISTAL SCAPHOID
  • ​Both intrinsic/extrinisic ligaments attach
  • Scaphoid flexes w wirst flexion & radial deviation adn extends during wrist extension& ulnar deviation

A image thumb
16

Describe the signs and symptoms of scaphoid fracture?

O/E

  • Anatomic snuffbox tenderness dorsally
  • Scaphoid tubercle tenderness volarly
  • Pain w reisted pronation

 

A image thumb
17

What investigations are useful in DDx scaphoid fracture?

  • Xrays
    • AP and lateral
    • Scaphoid view- 30o wrist extension, 20o ulnar deviation
    • 45o pronation view
    • no fracture but suspicion rpt 7-14 days
  • Bone scan
    • diagnose occult fracture at 72 hrs
    • specificity 98%, sensitivity 100%, PPV 85-93% within 72hrs
  • MRI
    • Most sensitive method within 24hrs
    • also vasularity of prox pole
  • CT Scan
  • less effective than bone scan/ MRI
  • Useful for location of ffracture and progression of nonunion/union post surgery

18

Describe the tx of scaphoid fracture?

Non operative

  • stable non displaced fractures
  • normal xray- cast then immobilise 12-21 days and reexam/rpt xrays
  • Start immobilisation early- non union rates increase w delay of immobilisation > 4 wks post injury
  • no concensus on casting- can use volar cast
  • duration of casting
    • distal fracture- 3/12
    • mid waist- 4/12
    • proximal third -5 /12
  • outcomes fractures with <1mm displacment union 90%

​Operative

ORIF vs Percutaneous screw fixation

 

 

19

what are the indications for surgery for scaphoid fractures?

  • Unstable fractures
  • Proximal pole fractures
  • Displacment >1mm
  • 15 o humpback deformoty
  • radiolunate angle >15o= DISI
  • Scaphoid frac ass with perilunate disslocation
  • comminuted fractures
  • in undisplaced fractures- to allow decreased time to union, faster return to work/sport, cheaper costs to casting- McQueen et al JBJS Br 2008

20

What are the outcomes of surgery for scaphoid fracture?

  • Union rates of 90-95%

21

CAn you describe the technique for fixation of scaphoid fracture?

Approach

  • Dorsal approach for Proximal Pole fractures
    • Preserve blood supply when entering dorsal rige by limiting exposure to proximal half of scaphoid
    • Percutaneous higher risk of unrecongnised screw pentetration of sunchondral bone
  • Volar approach- for waist and distal pole fractures w humpback flexion
    • allows exposure of whole scaphoid
    • uses interval between FCR and radial artery
  • Arthroscopic assisted also described
  • Fixation is optimised by long screw down CENTRAL AXIS of SCAPHOID
  • Radial stylectomy preformed if impaction between radial styloid adn scaphoid

 

22

Describe the complications of scaphoid fixation?

  • Non union->
  • SNAC wrist- degenerative changes first in radioscaphoid area followed by pancarpal /midcarpal arthritis
  • Tx with
    • Interposition (Fisk) bone graft- open wedge graft, 72-95% unon rates
    • Inlay (Russe) bone graft- minimal deformity, 92% union rates
    • Vascular bone graft from radius- 1-2 intercompartmental supraretinaculuar artery ( branch of radial artery) harvested to provide vascular bone graft from dorsal aspect wrist
  • Outcomes:
    • Punctate bleeding during surgery good prognostic indicator of union
    • 92% w obvious bleeding, 71% questionable bleeding, 0% no bleeding
    • Pt w scaphoid nonuions>5 yrs or proximal pole necrosis have less favourable outcomes

23

What do hamate fractures include?

  • Hook of hamate- most common
  • Hamate body fractures- v rare

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24

What is the hx of hamate fractures?

  • Hx of blunt trauma to palm of hand
  • often seen racquet sports
    • hockey
    • golf- miss ball hit ground
    • tennis
  • Must distinguish from BIPARTITE HAMATE- Smooth cortical surfaces

A image thumb
25

Describe the symptoms of hamate fractures?

  • Hypothenar symptoms- Pain
  • Decreased grip strength
  • Parathesisa in ring and small fingers - ulna N compression in Guyon's canal, numbness in thumb, index, middle and ring finger from median n compression in carpal tunnel
  • Motor weakness of intrinsics- Ulnar n compression in Guyon's canal

26

What imaging is useful in Hamate fractures?

  • Difficult to visualises on AP
  • Best seen on CARPAL TUNNEL VIEW
  • CT best to make diagnosis

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27

Describe the TX of hamate fractures?

Non operative

  • Immobilise 4-6 weeks
  • Acute hook of hamate fractures
  • body of hamate fractures

Operative

  • Excision of hamate fracture fragment- return to level of sport 7-10 wks
  • Chronic hook of hamate fractures
  • ORIF is possible but little benefit

 

 

 

28

What is this?

Q image thumb

Pisiform fracture

29

Describe the anatomy of the pisiform?

  • A sesmoid bone
  • located within FCU tendon
  • Contributes to stability of ulnar column by preventing TRIQUETRAL subluxation
  • Acts as a fulcrum for forces transmitted from forearm to hand

30

What is the epidemiology, aetiology of pisifrom fractures?

Name any associated fractures?

  • 1-3% of carpal fractures
  • fall on outstretched hand

 

  • 50% pisiform fractures occur with distal radius, hamate or triquetral fractures

31

Describe the signs and symptoms of pisiform fracture?

Symptoms

  • Ulnar sided wrist pain

Signs

  • Point tenderness

32

What investigations are useful for ddx of pisiform fractures?

Radiographs

  • Lateral with 30 degrees of supination or carpal tunnel view
  • CT scan- best seen

A image thumb
33

Describe the treatment of pisiform fractures?

Non operative

  • Immobilisation- first line
    • Short arm cast with 30o wrist flexion & ulnar deviation 6 wks
    • Outcomes- heal without posttraumatic arthritis

Operative

  • Pisiformectomy- painful NON union
    • Outcomes- pisiformectomy reliable way to relieve apin & doesn;t impair wrist function

34

What do base of thumb fractures include?

  • Bennett fracture- Intra-articular
  • Rolando Fracture- intra-articular
  • Extra-articular fractures

35

What is the epidemiology of bse of thumb fractures?

  • 80% thumb fractures involve METACARPAL BASE
  • most common variant is BENNET Fracture

36

What is the pathophysiology of base of thumb fractures?

  • Most fracture caused by AXIAL force applied to Thumb
  • 3 muscles deforming forces at base of thumb
    • Abductor pollicis Longus- PIN
    • Extensor pollicis longus- PIN
    • Adductor pollicis - Ulnar N

37

Describe what a Bennet's fracture is?

  • Inra-articular fracture of base of 1st MC characterised by
  • VOLAR LIP OF Metacarpal base attached to VOLAR OBLIQUE LIGAMENT
    • ligament holds this fragment in place
    • small fragment of 1st MC continues to articulate with trapezium

A image thumb
38

Describe the pathoanatomy of bennett's fracture?

  • Lateral retraction of distal 1st MC shaft by APL and Adductor pollicis
    • ​Volar- ulnar fragement is held reduced by ant oblique ligament while strong deforming forces pull the reamining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate it.
      • ​Abductor pollicis longus- inserts MC base- pulls MC shaft proximally & dorsally
      • Adductor pollicis- inserts ulnar base proximal phalanx - angulates MC shaft ulnarly and supinates it
      • EPL- less important inserts base of distal phalanx adn adds to ulnar angulation of distal fragament

A image thumb
39

What is the prognosis of the bennet's fracture?

  • Better than Rolando

40

What investigations are helpful in DDX of Bennet's fracture?

  • Hyper-pronated thumb view
  • Minimal joint step-off considered best

41

Describe the TX of Bennet's fracture?

Non operative

  • Closed Reduction & cast Immobilisation
    • non displaced fractures
    • reduction with traction, extension, pronation and adduction

Operative

  • Closed reduction and Percutaneous pinning
    • Volar fragment too small to hold with screw
    • Anatomic reduction unstable
    • can attempt reduction of shft to trapezium to hold reduction
  • ORIF
    • large fragment
    • 2mm+ joint displacement

 

42

What are the complications of a Bennet's fracture?


  • Post traumatic arthritis

    • There is no agreement regarding the relationship of post- fixation joint incongruity and post traumatic arthritis.
       

 

 

 

43

What is a Rolando fracture?

  • Intra-articualar fracture of base of the 1st metacarpal characteised by 
  • intra-articular comminution

A image thumb
44

What is the epidemiology and pathophysiology of Rolando fracture?

  • Less common than Bennet's fracture

Pathoanatomy

  • Deforming forces are the same as Bennett's fracture
  • Lateral retraction of 1st distal metacarpal shaft by Abductor Pollic Longus and adductor pollicis
    • ​Volar- ulnar fragement is held reduced by ant oblique ligament while strong deforming forces pull the reamining metacarpal shaft proximally adn dorsally, angulate the shaft ulnarly and supinate it.

    • Abductor pollicis longus- inserts MC base-

      pulls MC shaft proximally & dorsally




    • Adductor pollicis- inserts ulnar base proximal phalanx -



      angulates MC shaft ulnarly and supinates it





    • EPL- less important inserts base of distal phalanx





      and adds to ulnar angulation of distal fragament





    • typically the base spit into volar and dorsal fragment
    • commonly called a Y fracture

A image thumb
45

What is the prognosis of Rolando fracture?

  • Worse than a bennet's fracture

46

What is the TX of Rolando fracture?

Non operative

  • Immobilisation- severe comminuted, stable
    • start early rom 

Operative

  • External fixation, CRPP
    • ​severe comminuation, unstable
    • can approximate large fragment w K wires
  • ​ORIF
    • ​MOST common fixed method
    • use T plate or blade plate
    • can use K wire if fragments are too small

47

What are the complications of rolando's fracture?

  • Post - traumatic arthritis

48

What types can extra-articular fratures be?

  • Transverse of Oblique in nature

A image thumb
49

Describe the tx of extr-articular thumb fractures?

Non operative

  • Spica casting
    • if joint reduced & <30o of angulation

​​Operative

  • CRPP
  • If reduction cannot be held to result in less than 30o of angulation
  • Typically these fractures have the best outcome

50

What can metacapral fractures be divided into?

  • Metacarpal head, neck and shaft fractures
  • Tx based on which MC involved & location of fracture
  • Acceptable angulation vaires on location
  • NO degree of malrotation acceptible

51

Describe the epidemiology of MC fractures?


  • Accounts for 40% of all hand injuries 




  • Men aged 10-29 most common 






  • Metacarpal Neck is most common site 






  •  

    5TH Metacarpal is most commonly injured
     

52

What is the aetiology of MC fractures?

  • Direct blow to hand or rotational injury with axial load
  • HIgh energy injuries-> multiple injuries

53

Name any associated injuries with MC fractures?

  • Wounds= open fractures
  • Tendon lacerations
  • Neurovascular injury
  • compartment syndrome
    • closed injury mutiple fractures
    • Crush injuries

54

Describe the anatomy of MC ?

  • Concave on palmar side
  • 1st,4th,5th digits->Mobile border
  • 2nd,3rd digits-> stiffer central pillar
    • index MC most firmly fixed, while thumb MC articulated with Trapzium  & acts independently from others
  • 3 Palmer and 4 Dorsal Interosssei arise from MC shafts
  • ECRL/B - inserts base MC 2, 3- assists with wrist extension/ radial flexion
  • ECU- inserts base 4, extends/flexes wrist  when digits being flexed, assist ulnar flexion of wrist
  • Abductor pollicis longus- inserts trapezium and base of MC 1- adducts thumb in frontal plane, extends thumb at CMCJ 
  • Opponens Pollicis- inserts MC I, Flexes MC 1 to OPPOSE thumb to fingertips
  • Opponens digiti minimi- inserts medial side of MC V, flexes MC V at CMCJ when little finger is moved into opposition with tip of thumb, deepens palm of hand

55

What are the signs of MC fracture?

Signs

  • Inspect openw wounds
    • fight bite over MCP open until proven otherwise
    • Extensor tendon lacerated and retracted
    • Dorsal wounds over MC - often open
  • Deformity
    • At MC base may indicate CMCj Dislocation
    • Shortening- cf contralateral side
    • Malrotation- fingernails in part felxion- see pics
  • Motor exam- flexor/extensor tendons
  • NV exam
    • dorsal wounds = affect dorsal sensory branch of radial/ulnar n
    • volar wounds - involve digitial nerves

A image thumb
56

What investigations are helpful in DDX MC fracture?

  • Xray
    • Standard AP, Oblique & lateral
    • Oblique- evaluate CMCJ
      • 30o pronated lateral = 4/5th CMC
      • 30o Supinated lateral-= 2/3 CMC
    • Roberts view= thumb CMCJ
    • Brewerton view= MC head fractures
  • CT scan
    • inconculsive CMC fract/dislocations
    • Multiple CMC dislocations
    • complex MC head fractures

57

Describe the accepted angulation , shaft shortening and neck angulation for consx tx for MC fractures?

  • Index/ Middle ringer
    • Shaft Angulation 10-20o
    • shaft shortening 2-5mm
    • Neck angulation 10-15o
  • ​Ring Finger
    • Shaft angulation 30o
    • Shaft shortening 2-5mm
    • Neck angulation 30-40o
  • Little Finger
    • Shaft angulation 40o
    • Shaft shortening 2-5mm
    • Neck angulation 50-60o

58

What are the operative indications fof MC fractures?

  • Intra-articular fractures
  • Rotational malalignment
  • Significantly displaced fractures
  • Mutliple MC shaft fractures
  • Loss inherent stability from border digit during healing process

59

Describe the operative Tx of MC fractures?

  • ORIF
    • no degress of articular displacment is acceptable
    • Majority required surgical fixation- see pic
  • External fixation
    • Severely comminuted fractures
  • MCP Arthroplasty
    • Severely comminuted fractrues
  • MCPJ fusion
    • rarelt done due to limited rom of hand

A image thumb
60

Describe the operative technique for ORIF for MC Head fractures?

  • Approach
    • dorsal incision
    • either centrally splt extensor apparatus or release and repair sagittal band
    • Hardware cannot protrude joitn surface
    • FIX w multiple small screws in collateral recess , headless screws or K wires
    • ideal fixation should allow early motion

61

What are the complications of MC head fractures?

  • Stiffness
    • most common
    • prevent by early motion
  • CRPS

62

Describe the TX for MC shaft fractures?

Non operative

  • Immobilisation
    • Non displaced MC neck fractures
    • Acceptable angulation
    • No malrotation
    • Shortening- aethetic problem only
    • Immobilise MCPJ 70-90o
    • Cast 4 weeks

Operative

  • ORIF vs CRPP
    • for open fractures
    • unacceptable angulation
    • any malrotation
    • multiple fractures
  • CRPP= place retrograde thru MC base /antegrade thru collateral recess remove pins 4/52
  • Open reduction w lag screw
    • mutliple lags for long spiral fractures- at least 2
  • Open reduction w dorsal plating
    • best for transverse fractures
    • try to cover plate w periosteum to prevent tendon irritation
    • begin early motion to prevent tendon irritation

 

63

Describe the TX for MC neck fractures?

Non operative

  • Reduction and casting
    • Acceptble degrees of apex dorsal angulation
    • Immobilise MCP 70-90 flexion, leave PIPJ free
    • Cast 4 weeks
    • Reduce Jahss technique
      • 90o flexion, dorsal pressure thru proximal phalanx whilst stabilising MC shaft

Operative

  • Reduction and Fixation
    • Unaccetpable angulation
    • open fracture
    • any malrotation
    • intrarticular fractures
  • CRPP w MCP flexed
    • Antegrade thru MC base
    • Retrograde thru Collateral recess
  • ORIF
    • Perform if cannot get reduction with CRPP
    • Difficult ro place because of limited bone distal fixation

64

What is this?

Q image thumb

  • Dorsal PIP dislocation

65

What is the epidemiology of dorsal PIP dislocations?

  • More common than volar dislocations
  • leads to injury to VOLAR PLATE and at least the COLLATERAL ligament 
  • Swann neck deformity will result if left

66

Describe the classification system of PIP dislocations?

  • Simple- middle phalanx in contact with condyles  proximal phalanx
  • Complex- Base of middle phalanx not in contact with condyle of proximal phalanx, Bayonet appearance
  • volar plate acts as block to reduction with longitudinal traction

67

Describe the TX for dorsal PIP dislocations?

Non operative

  • Reduce and buddy tape to adjacent finger 3-6 wks
    • dislocation is reducible
    • usually preformed by patient
    • if complex reduce w HYPEREXTENSIONof middke phalanx followed by palmar force
    • complx- Swan neck deformity ( volar plate injury)

                       Pipj Flexion contracture- pseudoboutonniere 

Operative

  • Open reduction & extraction of volar plate
    • Failed reduction
    • closed reduction failed often due to volar plate interposition
    • Open reduction failed due to dislocated FDP tendon
    • dorsal approach w incision between central slip  & lateral band

 

68

What is this?

Q image thumb

  • Dorsal PIP fracture dislocation

69

Name and describe the classification system of dorsal PIP fracture dislocations?

  • Hastings
  • Based on amount of P2 articular surface involvement

 

  • Type 1- Stable
    • <30% -= tx dorsal based extension block splint
  • Type 2- Tenous
    • 30-50% - if reducible in flexion, dorsal based extension block splint
  • Type 3- Unstable
    • >50% - ORIF/HAMATE Autograft, Volar plate arthroplasty

70

Describe the tx of dorsal fracture dislocation of PIP?

Non operative

  • Dorsal extension block splint
    • if <40% joint involved & stable
    • much achieve adequate joint redcution for favourable outcome

Operative

  • ORIF vs CRPP
    • If >40% joint involved/ unstable
    • reduction of middle phalanx on condyles of prox phalanx is primary goal
    • adequate volar exposure of volar plate requires resection of proximal C2 pulley, Entire A3 pulley and distal C1 pulley
  • ​Dynamic Distraction external fixation
    • highly comminuted pilon fracture
    • follw w early mobiliasation
  • volar plate arthroplasty/arthrodesis
    • chronic injuries

 

A image thumb
71

What is this?

Q image thumb

  • A volar pip dislocation 
  • Less common than dorsal 
  • leads to injury to CENTRAL SLIP and at least ONE COLLATERAL Ligament
  • failure to tx -> Boutonniere deformity

72

Describe the tx of volar PIP fracture/ dislocation?

Non operative

  • Spinting in extension 6-8 wks
    •  most pip dislocations 
    • If Fracture <40% joint involved & stable

Operative

  • ORIF vs CRPP
    • reduction of middle phalanx on condyles of proximal phalanx is primary goal
    • if joint >40% involved

73

What could this be?

Q image thumb

  • Rotatory PIP dislocation
  • One of phalangeal condyles is buttonholed between central slip & lateral band

74

Describe how you would tx rotatory PIP dislocation?

Non operative

  • Only of reduction successful
  • reduce by applying traction to finger with MPJ & PIPJ in 90o Flexion
    • Flexion relaxes volar displaced lateral band , allowing to slip back dorsally
    • Reduction is confirmed w post reduction lat xray

Operative

  • Open reduction- most cases

75

What is this?

Q image thumb

  • Dorsal DIP dislocation with fracture

76

What is the tx of dorsal DIP fracture dislocation?

Non operative

  • Closed reduction, immobilisation in slight flexion w dorsal splint for 2 weeks
    • ​first line
    • ​​Tuft fractures no specific tx- temporary splinting

Operative

  • Open reduction
    • 2 failed attempts at reduction
    • Volar plate interposition is most common block to reduction in irreducible closed DIP joint dislocation
    • FDP may be blocking if injury open
    • May require percutanoeus pinning to suport nail bed injury
  • Amputation
    • if highly comminuted injuries with significant soft tissue loss