Fractures And Dislocations of Hand

Dr Aftab Alam

Basic Anatomy

Bones

Lumbricals and interossei

Blood supply

MR Angiogram of hand

Principles of Management-Mechanism of injury should be assessed regarding magitude ,

direction, point of application.-Fracture reduction, reduction maneuvres should not cause

additional trauma and should be gentle.-Complete neurovascular examination should be done.-Injuries to tendons should be addressed.-Splints should immobilize minimum no. of joints and allow

unrestricted motion at other joints.-Total duration of immobilization should rarely exceed 4 weeks.

-Plain radiographs , atleast 2 projections centered at level of interest, oblique views may show displacements not evident on other views.

Injuries of the Thumb

• First CMC joint - Most important• Injuries (# SL DL) cause limitation of motion pain & weakness

Bennett Fracture• Bennett , Irish , 1882• Intraarticular # through base of first MC• Shaft dislocated laterally due to pull of Abductor Pollicis

Longus• Medial fragment remains in place due to Volar Oblique Lig.• Reduction easy but difficult to maintain.• Closed Pinning• Open fixation with K wires / 2- 2.7 mm screw

Wagner Tech for closed pinning

• Postoperative Care – Cast for 4 wks If screw fixation is used active ROM with intermittent

splinting at 2 wks.

• Complications – Malunion with CMC arthritis (1-3mm tolerated) Reduction not to be attempted after 6 wks Corrective Osteotomy by Giachino Arthritis –Arthrodesis /Arthroplasty

Rolando Fracture

• Comminuted First Metacarpal Base #• Presents as ‘Y’ or ‘T’ Pattern• Differs from Bennette that usually no diaphyseal displacement• Likely for Posttraumatic arthritis – accurate reduction• Fixed with small wires placed under the subchondral bone

supplemented with a larger transarticular / transmetacarpal pinning.

• TBW with Ex Fix• T plate

• If reduction and fixation achieved well results are excellent.

Thumb Carpometacarpal Joint Dislocation

• Rare Injury• Reported cases mostly Dorsal dislocations• Dorsoradial & Volar Ob Lig most imp in preventing dislocation• Should be reduced and immobilized early for 4-6 wk.• If unstable OR and pinning with DR lig repair, immobilize for 4-

6wk.• Recurrent dislocation warrants ligament repair and

immobilization.

Thumb immobilizer

Thumb Metacarpophalangeal Fractures

• Usually involve ulnar margin of proximal phalynx due to UCL avulsion

• Small frag/ <2-3 mm disp – no surgery• Large frag / Angulated /Displaced – require surgery

Thumb Metacarpophalangeal Dislocations

• Most common -Dorsal dislocation • Mech- hyperextension injury• Most common among all MCP dislocations• Simple- reducible closed• Complex- Irreducible by closed methods due to interposition

of sesamoids , volar plate , flexor tendon – open reduction• Immobilized in 20 deg flexion for 4 wks

Thumb MCP Joint UCL Rupture

• Originally described by Campbell in 1955 as Gamekeeper’s thumb actually referred to attritional injury in baseball players.

• Skiing accidents/falls with forceful radial and palmer abduction- Skier’s thumb

Stener Lesion - adductor aponeurosis interposed between the ruptured ulnar collateral ligament and its site of insertion on the base of the proximal phalanx.

Prevents healing -> chronic instability -> arthroses

Associated injuries - avulsion # , dorsal capsular rupture , volar plate tears.

• Plane Xray – if <2mm disp signifies absence of Steiner lesion and heals with casting only.

• Avoid stress at joint to prevent Steiner lesion• Salter Harris I/II injuries stress films contraindicated

• USG, Arthrography,MRI Incomplete rupture – thumb spica 4-6 wk Complete rupture – surgical repair

Thumb MCP Radial Collateral Ligament Injury

• Less frequent than UCL injury• No lesion like steiner exist.• Incomplete tears/tears without volar , rotational subluxation-

treated with cast for 4-6 wks• Complete tear with subluxation – direct repair.• Supplemental PL tendon graft , advancement of APB for

chronic instability.

Improper treatment leads to painful instability during ‘push off’

Carpometacarpal Fracture-Dislocations

• Often obscured due to swelling and metacarpal overlap on xray lat.

• Most commonly involved 5th MC displaced dorsally with 4th • Alternatively all 4 may be displaced volarly• Loss of parallel joint surfaces at the CMC articulations in xray• CT is helpful in determining the extent of injury• Closed reduction and fixation with k wires.• Delayed presentations may require resection of proximal end

of MC with fusion or interposition arthroplasty.

#dislocation of 5th mc , reduced and fixed with k wires

CMC dislocation 4th 5th MC

HamatoMC #dislocaton

Intraarticular Fracture of the Fifth Metacarpal Base

• Disabling injury• If unattended, malunion results in weakness of grip and

painful joint.• Lesion somewhat similar to Bennett # due to ECU attachment• Reduction and pinning• Malunion may require corrective osteotomy and resection

arthroplasty.

Malunion , resection arthroplasty , ECU tendon should be reattached

Finger Metacarpophalangeal Dislocations

• Less common than IP dislocations• Commonly seen in Index finger• Dislocation results in Kaplans lesion• Fibrocartilaginous plate avulses from volar aspect of the

second metacarpal neck(weakest attachment).• The flexor tendons and the pretendinous band are displaced

ulnarly and the lumbrical radially to the metacarpal head .

Reduction of MCP dislocation

• Incomplete dislocation- easy reduction• Complete dislocation - 50 % success by closed reduction -50% require open reduction by volar or dorsal approach and

requires complete division of volar plate.• Subsequently protect joint from hyperextension for 3 wks

Metacarpal Shaft or Neck Fractures

• Generally treated by closed methods• OR & fixation req if multiple/assoc with soft tissue injury• Most imp factor in reduction- Rotational alignment• Transverse shaft #s fixed with IM K wires• Oblique #s can be fixed with interfragmentary screws

Boxer’s Fracture

• Metacarpal neck # involving little finger• Metacarpal head is freed from any proximal stabilizing

influence so metacarpal head tilts volarly causing joint to lie in hyperextension & collateral ligaments become slack.

• If joint is allowed to remain in hyperextension, collateral ligaments will shorten, leading to limited MCP flexion.

• An infrequent variant of Boxer’s # may involve MC head

Angulation (measured-15)

• Non Operative Treatment• Clawing results from the palmar displacement of the

metacarpal head & resulting imbalance of extrinsic tendons Pt may have cosmetic deformity, but good function

• Reduction method Collateral ligs must be placed in a tightened position to

control distal fragment and achieve reduction. MC joint flexed to 90 to tighten collateral, flexed metacarpal is

directed dorsally, which effects reduction of metacarpal head by correction of volar angulation.

• Criteria for acceptable reduction Lateral view -angulation > 30-40 deg- functional deficit (pc) may

result - consider percutaneous pin fixation. 30 deg of angulation results in loss of 22% of finger ROM

AP view -little or no angulation should be accepted -indicates mal-rotation of the digit

• Casting Buddy taping should always be done irrespective of method

of casting. This prevents malrotation.

Bouquet Pinning of Metacarpal Neck FractureCare should be taken to protect wrist extensors tendons by

giving an incision and partially elevating them

Sharp tip is cut off , bent about 3mm from leading end.Enter the canal at most acute angle possiblePut several k wires through the # site Goal is to tension the wires off the intact proximal cortex and

enter the distal fragment in various locations, creating a “bouquet” effect.

• Operative treatment can be done with K wires

Indications for plating of MC shaft #s

• Multiple fractures with gross displacement or additional soft tissue injury

• Displaced diaphyseal transverse, short oblique, or short spiral fractures

• Comminuted intraarticular and periarticular fractures• Comminuted fractures with shortening or malrotation or both• Fractures with substance loss or segmental defects.

Metacarpal Head Fractures

• Intraarticular , often of 4th and 5th MC heads• Occurs during fist fight,hitting opponents teeth

IM K wire fixation of 4th MC shaft

Tech for percutaneous pinning

Tech for ORIF of MC shaft #

Plating for MC shaft

Multiple #s treated with plating

Ex Fix for 5th MC shaft

MC shaft # fixed with Interfragmantary screws

Fracture of the Middle or Proximal Phalanx

Direct blow over dorsum

Palmer angulation with clawing

Pratt’s method ORIF

Proximal Interphalangeal Joint Fracture-Dislocation

Always an unstable dorsal displacement of the middle phalanx caused by disruption of the attachment of the volar fibrocartilaginous plate.

If – single VOLAR fragment with >50% jt space – ORIF -- <50% of articular space – active motion of PIP jt while

maintaining finger in extension block splint.Other modalities include Hemi-hamate autograft

• Closed Reduction and Extension Block Splinting

Excessive comminution of middle phalynx shaft is better treated by traction than by open methods.

Various available devices allow early motion at PIP and DIP jt

Dynamic External Splint ReductionThis technique relies on coupling distraction and volarly directed

forces across the joint in # dislocation of PIP jt

Interphalangeal DislocationsMostly dorsalEasily reduced Collaterals usually intactIf ligaments are ruptured, repair is required ,especially radial

collateral lig.With persistent dorsal subluxation, the joint may be pinned in 20

degrees of flexion for 2 to 3 weeks.

Undiagnosed Interphalangeal Dislocations

Rarely a dislocation may be obscured by swelling.Joint cartilage may be eroded by pressure from articular edge in

a weeks time,open reduction is necessary

Distal Phalangeal Fractures

Usually crushed comminuted #sRequire only splintingIn cases of near amputations 22-gauge hypodermic needle can

be used for supporting the bone while the soft tissues heal.Sometimes may be fixed with compression screws to prevent

nonunion

Mallet finger

Distal interphalangeal joint extension lag due to disruption of the terminal extensor tendon.

Mechanism of injury

Full passive joint extension is present.Proximal migration of extensor apparatus may result in swan

neck deformity

Type 1: Closed or blunt trauma with loss of tendon continuity with or without a small avulsion fracture

Type 2: Laceration at or proximal to the distal interphalangeal joint with loss of tendon continuity

Type 3: Deep abrasion with loss of skin, subcutaneous cover, and tendon substance

Type 4: 4A—transphyseal fracture in children 4B—hyperflexion injury with fracture of articular surface

of 20% to 50% 4C—hyperextension injury with fracture of the articular

surface usually greater than 50% with early or late volar subluxation of the distal phalanx.

Treatment for type 1(most common) Contineous extension of DIP jt with splint

Type 2 can be treated by tendon suture repair and Kirschner wire fixation of the distal interphalangeal joint in full extension.

Type 3 mallet fingers require soft tissue coverage and pinning of the distal interphalangeal joint and possible primary arthrodesis.

Type 4 Open reduction and K wire fixation of the epiphyseal fragment is indicated if closed reduction cannot be obtained

Type 4 mallet finger treated with pinning and pullout wire

ComplicationsIncreased association of complications seen with - rigid internal fixation (attributed to necessity) - intra/periarticular injuries

Complications can be - malunion/nonunion - hardware associated - extensor lag - infection - contractures - instability

InfectionsSeen despite excellent vascularity.Often seen in injuries associated with crushing componentPreoperative wound culture proves to be of no helpMost commonly associated organism S.Aureus

Open wound , non contaminated with intact vascularity role of antibiotics in reducing infection rate has not been supported

Stiffness Most common and most feared complicationResultant Stiffness is contributed by magnitude of original trauma age and genetic composition of the patient duration of immobilisation position of immobilisation invasiveness of intervention

Position of immobilisation should follow the principles of splinting ligaments at full length and balancing tendon forces that act across a joint.

First webspace contractures are common , can be prevented by splinting the first metacarpal in max abduction

Once a fixed contracture has developed , tenocapsulolysis can be done if patient desires to improve motion

Hypersensitivity• Small size of hand with complex distribution of fine nerves

provide very few areas to have clear incision or percutaneous pins maintaining a distance of 1 cm

• Crush injuries- invariably assoc. with hypersensitivity• Neuroma formation should be guarded especially while

operating on -ulnar side of thumb MP(high conc. Of dorsal digital N

branches. -radial side of wrist (near superficial radial N)

Treatment – gabapentin , amytriptyline , pregabalin , contact desensitisation therapy

Malunion and DeformityFrequently encountered due to - lack of understanding hand biomechanics belief that all hand # do well with non op treatment due to a non compliant patient

Malunions should be managed with corrective osteotomy at deformity site/ compensatory Rotational corrections best done at MC base(cancellous)(25-30)Rotational deformity is result of improper choice of non op RxCorrective osteotomies are more successfulful at MC level than

phalyngeal level

• Tenolysis alone improves extensor lag• Intraarticular osteotomy can be done for selected cases of

intraarticular malunion at MC head.• IA malunion may cause OA ,decreased grip and pain • Exact pattern of osteotomy should be assessed for chosing

the type of osteotomy (opening wedge closing wedge , pivot osteotomy oblique osteotomy)

• Shortening should be considered if closed osteotomy planned• Extensor lag of 7 degrees predictable for every 2 mm

shortening

NonunionRare in hand fractures with exception of distal phalynx.Seen where - CRIF has caused distraction or - ORIF with excessive stripping of periosteum

Hypertrophic nonunion addressed by DCP aloneVariable pitch compression screws for distal phalynx #Osteonecrosis of MC head in IA # as it lacks independent blood

supply

Residual InstabilityMore common proximally (cmc) following dislocation.Pure dislocations tend to be more unstable as all ligaments are

torn and require Lig-Lig or Lig-Bone healingFracture dislocations,one or more of key stabilizing ligaments

remain intact.CMC #dislocations can be assesed by injecting local anaesthetic,

if it relieves pain, Arthrodesis (5th in 20-30deg)

Posttraumatic arthritisIA # and residual joint instability may cause accelarated hyaline

cartilage wear.There is poor corelation between radiographic appearance and

clinical loss of function and pain.Fusion can be done for CMC of index and middle finger.Fusion of MP and PIP jt results in loss of function

Tendon rupturesMissed tendon ruptures associated with dislocations may lead to

deformity posture mallet finger it DIP boutonniere deformity at PIP

Treatment involves arthrodesis in flexion at DIP whereas effort should be made at PIP jt to restore extension as arthrodesis is not well tolerated here.