fractures of hand bones

FRACTURES OF METACARPALS AND PHALANGES

Dr Sumer YadavMch plastic and reconstructive surgery

dr sumer yadav, mch plastic surgery.

sumeryadav2004@gmail.com

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. sumeryadav2004@gmail.com

Wrist/ hand Anatomy - bones

Carpals (proximal row) (distal row)

Metacarpals Phalanges

SKELETAL ANATOMY OF HAND

5 metacarpal bone Head Shaft base

14 phalanges 3 for each finger 2 for thumb

Head Shaft base

Hand Anatomy

• Bony Anatomy• Carpals

• Scaphoid• Lunate• Triquetral• Trapezium• Trapezoid• Hamate• Pisiform

ANATOMY CONT…….

Key skeletal element Has 3 arches,2 transverse arches &

1longitudinal arch

Splinting Position

Position of FunctionPosition of SafetyYES NOdr sumer yadav, mch plastic

Thumb spica

Basic Splinting

Position of “safety”

Hand Functions

Grasping patterns Hook, spheres, cylinders

Pinches Key, tripod, inferior/superior

Fine motor manipulation Sensation

Pain, touch, discrimination, object identification, vibration

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

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

Classification of fractures of metacarpal head

1)epiphysael Ligamentous avulsion Osteochondral slices Two part fractures in different

planes Comminuted Bone loss Occult compression #

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

complications

Most common- stiffness-it is due to extensor tendon adhesions,collateralligament or dorsal capsule contractures

Epiphyseal growth arrest Avascular necrosis

METACARPAL NECK FRACTURES

Boxers fracture Commonly involves-ring & small

fingers Occur when clenched MCP strikes

solid objects & angulates with apex dorsal

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

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

Cont…..

Immobilisation-12-14days & then AROM exercises

After 6 weeks –join duty If closed reduction fails---ORIF with

k-wire

METACARPAL SHAFT FRACTURES

CLASSIFICATION—transverse, oblique comminuted

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

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

RIGID FIXATION

Indications-multiple #,isolated transverse#,malunion,pseudo arthrosis,bone loss

Types –interfragmentary compression screws, plates & screws

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

COMPLICATIONS OF INTERNAL FIXATION

Pin tract infection Osteomyelitis Fracture through pin holes Neuro vascular injury Over distraction Loss of reduction Impair tendon excursion

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

BI ABSORBABLE FIXATION

Polyglycolic acid,poly lactic acid,poly Para dioxanone

Disadvantage->non infectious inflammatory response

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

COMPLICATIONS OF METACARPAL FRACTURES

1)mal union 2)dorsal angulation 3)malrotation 4)osteomyelitis 5)nonunion

PHALANGEAL FRACTURES

FRACTURES OF DISTAL PHALANX Classificatuion:1)tuft # simple # comminuted# Shaft #---transverse—stable or

unstable ----longitudinal Articular#---volar, epiphyseal,dorsal

TREATMENT OF DISTAL PHALANGEAL #

TUFT #-drain subungual hematoma finger splint Shaft #-- CRIF—k-wire Epiphyseal #--ORIF Complications– nonunion -malunion

FRACTURES OF MID & PROXIMAL PHALANX

ARTICULAR #(london)--1)condylar # Type1-stable #without

displacement Type2-unicondyle,unstable Type3-bicondyle,comminuted

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

TREATMENT OF BYCONDYLAR FRACTURES

ORIF WITH PLATES & SCREWS Dynamic splint External fixation Interfragmentary screws

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

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

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

Cont…

SHAFT # INVOLVING JOINT- Treatment ORIF Proximal traction phalanx splint- noninvasive, minimal stiffness,

comminuted#

NECK FRACTURES

Common in toddlers Classification->type1-nondisplaced type2-displaced with some bone

contact Type3-completely displaced Treatment-ORIF with k-wire or

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

Transverse#-ORIF with kwire& intra osseous wire

Displaced unstable & comminuted-external fixation,miniplate & screws

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

CONT…

Intrarticular malunion Nonunion Loss of motion Pip joint extensor lag infection

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

FRACTURES OF PROXIMAL PHALANX

Head & neck#-CRIF WITH K WIRE ORIF WITH K WIRE Angulation of 20-30* is

unacceptable

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

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

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

Bennett’s Fracture

TREATMENT

WHEN fragment is <15-20% of articular surface-CRIF with k wire

if > 25%-ORIF COMPLICATIONS-mal union

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

fractures of hand bones

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