hand & carpal fracturess3.amazonaws.com/fxofwristhandfingers/tns hand & carpal... ·...

4/21/2015

1

Hand & Carpal Fractures

Kim Kraft PT, DPT, CHT

Accessed 2/28/15http://adswithoutproducts.com/2009/07/19/dollar-sign-on-the-muscle-out-for-the-season-broken-knuckles/

4/21/2015

2

Accessed 2/28/15http://adswithoutproducts.com/2009/07/19/dollar-sign-on-the-muscle-out-for-the-season-broken-knuckles/

Topics

1. Hand Fracture Reduction Methods

2. Fracture Healing Essentials

3. Therapy Basics

4. Characteristics of Specific Fractures

5. Special Cases

4/21/2015

3

Hand Fracture Reduction Methods

Retrieved 4/2/15

Handsurgery.sp

Open reduction with screws

Open reduction with plate and screws

4/21/2015

4

Closed Reduction

• Cast vs Splint

• Splint = Orthosis

• Prevents displacement

of a fracture with good alignment

• Protects tendon and soft tissue injuries

• Works by compression of soft tissues

• Three point support of the fracture in all directions

ORIF Open Reduction Internal Fixation

• Unstable fracture

• Displaced fracture

• Soft tissue injury

• Fractures with bone loss

• Rotational deformity

• Angulation

4/21/2015

5

Surgical FixationRequires…

1. Good soft tissue skills & knowledge of anatomy

2. Understanding of hand incisions

3. Rehabilitation

4. Motion within 2-3 days after surgery

5. Protection

6. Edema management and wound care

Closed Reduction Internal FixationClosed Reduction External Fixation

• Approximates fracture ends

• Has some wiggle

• K Wires, Pins, External Fixation

• Splinting/casting

4/21/2015

6

Immobilization Position

Ruedi TP, Buckley RE, Moran CG, eds. (2007)AO Principles of Fracture Management. AO Publishing, Switzerland.Copyright by AO Publishing, Switzerland

• MP ligaments are taut in flexion

• IPs are tight in extension• “Safe” position prevents

contractures is MP flexion, IP extension

Video: Abduction with and without MP Flexion

4/21/2015

7

FRACTURE HEALING ESSENTIALS

Retrieved 3/4/15http://www.intechopen.com/books/gene-therapy-applications/gene-therapy-applications-for-fracture-repair

4/21/2015

8

How Fractures Heal

No callus

Open reduction

No motion at the fracture

Fracture ends in contact

Cutting cones

Primary

Callus

Casting, Splinting, Wires/Pins

Stress-strain at fracture site

Plastic

Soft callus ossification

Secondary

Primary Bone Healing

Retrieved 3/7/15http://www.dginet.de/web/dgi/gomi/wiki/English/Bone+remodeling/pop_up;jsessionid=64953D049904CE14641F958DFDAB08F2?_36_viewMode=print

Cutting Cone = Zamboni of the Haversian Canal System

4/21/2015

9

Accessed 2/28/15http://www.nuigalway.ie/anatomy/wilkins/practicals/bone/html/bone_15.html

http://histoweb.co.za/012/012img020.html

4/21/2015

10

Secondary Bone Healing

• PAIN & SWELLING before callus formation

• Less painful after SOFT CALLUS forms (cartilage)

• HARD CALLUS (cartilage turns to bone)

• Calcification & remodeling

Wolff’s Law of Bone RemodelingResults From Stress & Strain

Retrieved 3/4/15http://www.nature.com/nrrheum/journal/v8/n3/fig_tab/nrrheum.2012.1_F1.html

4/21/2015

11

Therapy Basics

Edema Control

• Prevents throbbing

• Improves active motion

• Ultimately less scar tissue

Physiological Goals:

Increase tissue hydrostatic pressure

Reduce the intravascular pressure

Support lymphatic return

4/21/2015

12

Edema Control

1. Compression

Very effective with early low-protein edemaPRECAUTION: VASCULAR COMPROMISE, LACK OF SENSATION, GRAFTS AND WOUNDS, CIRCUMFERENTIAL OR TOO TIGHT BANDAGES CAUSE TOURNIQUET,

NEED TO WAIT UNTIL AROM PERMITTED TO DON GLOVE

Edema Control

2. Elevation “On the shoulder, the sofa, the pillow” Increases intravascular pressure, reduces capillary filtration pressure because peripheral arterial and venous pressures are affected by gravity.

3. Light cardiovascular exercise

Increased diaphragm activity & compression of interstitial spaces, veins, lymphatic vessels, create increased lymphatic activity.

4. Active motion when permitted

Soft tissue motion, compression of interstitial spaces, counter pressure of compressive dressing or glove/stocking, increase lymphatic

return.

4/21/2015

13

Kinesiotape

• “Lifts” epidermis

• Opens lymph channels

• Effective on the back of the hand (metacarpal fractures)

• Creates motion between tissue layers

PRECAUTION: MAY OPEN INCISIONS IF NOT COMPLETELY HEALED, CAN TEAR or CONTUSE

Making Motion: AROM & PROM

Retrieved 3/16/15

http://radiopaedia.org/cases/flexor-and-extensor-insertions-at-the-hand-and-wrist

4/21/2015

14

Active Motion

• 3-4 days after ORIF • 2-4 weeks for closed

reduction• Balance tendon forces to

prevent deformity• TENDON MOBILITY

prevent adhesion between tissue layers

Retrieved 3/16/15http://radiopaedia.org/cases/flexor-and-extensor-insertions-at-the-hand-and-wrist

Active Motion

• Blocking

• Flexor Digitorum Profundus

• Flexor Digitorum Superficialis

• Flexor Pollicis Longus

• Tendon Gliding

• Fist

• Hook Fist

• Straight Fist

• Reverse Blocking

Retrieved 3/28/15http://biorobotics.harvard.edu/hand_therapy.html

4/21/2015

15

Video: AROM

Passive Motion

Fracture stability first, in 4-6 weeks with Xray evidence of bone healing

Low-Load Prolonged Stress

Heat

Joint mobility

1. Elastic loops:10 minutes 4x/day

2. Tape: Can be used with heat

3. LMB: 10-15 minutes 4x/day

4. SPLINTING

4/21/2015

16

Passive Motion

Splinting

30 minutes

4 times per day1. Static

2. Dynamic

3. Static Progressive

Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: 105-116.

Video: PROM

4/21/2015

17

Strengthening

• Putty & light resistive exercise

• Begin after 6-8 weeks if healing1.Grip

2.Pinch

3.Opposition

4.Finger & thumb extension

5.Abduction/Adduction

Video: Strengthening

4/21/2015

18

Phalanx Fractures “P1, P2, P3”

Retrieved 4/2/15

https://www.jaaos.org/content/16/10/586/F2.expansion

Distal Phalanx Fractures

Tuft

• Nailbed injury

• Sensitivity

Shaft

Base

• FDP Avulsion

• Bony Mallet

4/21/2015

19

Distal Phalanx

• Insertion of FDP palmar base

• Insertion of extensors by terminal tendon dorsal base

• Germinal matrix &nail bed

Retrieved 3/16/15http://eorif.com/WristHand/Phalanx%20distal%20class.html

Retrieved 3/16/15 http://stepbystepintoenglish.blogspot.com/2012/05/fingernailzhijia.html

Distal Phalanx Shaft & Tuft Fractures

• Immobilize IP joints straight “mallet splint” that includes the DIP but not the PIP

• 2-3 weeks before active motion

Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.


4/21/2015

20

Distal Phalanx Shaft & Tuft Fractures

DESENSITIZATION• AROM

• FDP Blocking

• FDP Gliding • Vibration

• Rice bucket

• Massage

10 minutes 2-4x/day

Works within 2 weeks


Distal Phalanx Base FracturesAre TENDON INJURIES

FDP AVULSION

• “Jersey finger”

• Wire to stabilize & dorsal button

• Zone 1 Flexor Tendon Repair: follow Modified Duran flexor tendon repair program

BONY MALLET• “Baseball fracture”

• Immobilized 6 weeks, then at night and heavy activity

• Active fisting ex program

• No DIP BLOCKING

• (causes extension lag)Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: 105-116.

4/21/2015

21

Distal Phalanx Fracture

Middle Phalanx Fractures

Condyles and lateral ligaments for stability with DIP joint

Special Considerations• Volar plate injury

• Insertion of FDS at the base

4/21/2015

22

Middle Phalanx Fractures “P2”

• IP Gutter

• Extension gutter or buddy tapes if shaft fracture

• Slight flexion of PIP for 6 weeks if a dorsal dislocation with volar plate injury or articular fracture ORIF



Active MotionMiddle Phalanx Fractures

1. FDS blocking

2. Reverse blocking

3. Tendon gliding

• Fist

• Hook

• Straight fistHardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.

4/21/2015

23

Middle Phalanx Fracture

Proximal Phalanx Fractures Base, Shaft, Head

• NO complicating tendon insertions

• Immobilization in MP flexion where collateral ligaments are elongated

• Intrinsics flex proximal piece; extensors extend distal piece

4/21/2015

24

Splinting Proximal Phalanx Fractures “P1”

• Forearm based radial gutter / ulnar gutter

• Include neighboring digit for stability

• SAFE Position

MP Flexion

IP Extension


Proximal Phalanx Fracture

4/21/2015

25

Thumb Fractures

• Proximal and distal phalanx (P1, P2)

• Tendon insertions: EPB, APB, EPL, FPL

• Fractures displaced by tendon pull, pinch/grip

Metacarpal Fractures

Retrieved 4/2/15

http://www.aliem.com/trick-of-the-trade-reducing-the-metacarpal-fracture/

4/21/2015

26

Metacarpal Fractures

Special problems

1. angulation

2. malrotation

3. shortening

Metacarpal Malunion

1. Angulation

• Apex dorsal because of pull of interossei

• 30⁰ tolerated in small finger, 20 ⁰ ring⁰

2. Shortening

• Relative lengthening of the common finger extensors.

• 2mm of metacarpal shortening = 7⁰ extensor lag at the MP joint

3. Malrotation

• 5⁰ at the shaft creates 1.5 cm of overlap of the digit during fisting

• Buddy tape while immobilized to prevent malrotation

4/21/2015

27

Boxer’s Fracture

Special fracture of the 5th

metacarpal

Usual mechanism of injury: hitting a wall or

other hard object

Boxer’s Fracture

4/21/2015

28

Thumb Metacarpal Fractures

Thumb Fractures

Special Problems

• Tendon adherence

FPL/EPL

• Loss of web space

• Loss of pinch strength

Rolyan Wrist and Thumb Immobilizer

4/21/2015

29

Metacarpal NeckFracture

Bennett’s First Metacarpal Fracture

• Partial articular fracture dislocation at the base of the first metacarpal

• Mechanism: Axial load on a flexed first CMC joint, FOOSH

• Causes OA

Retrieved 1/6/15/lifeinthefastlane.com/education/who-was/eponymous-fractures/

4/21/2015

30

.

Bennett’s Fracture

Gedda, K-O., and Eric Moberg. "Open reduction and osteosynthesis of the so-called Bennett's fracture in the carpo-metacarpal joint of the thumb." Acta Orthopaedica 22.1-4 (1952): 249-257.

Palmar oblique

ligament

Thumb extensors

Abductor pollicislongus

4 Adductor pollicis

Bennett’s Fracture“Before”

4/21/2015

31

Bennett’s Fracture

Rolando’s First Metacarpal Fractures

• 3 piece intra-articular fracture at the base of the first metacarpal

• “T” or “Y” shaped

• Complete articular fracture

Retrieved 1/6/15/lifeinthefastlane.com/education/who-was/eponymous-fractures/

4/21/2015

32

Rolando’s Fracture

Rolando Fracture

Carlsen BT, Moran SL. "Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries." The Journal of hand surgery 34.5 (2009): 945-952.

Proubasta IR. "Rolando's fracture of the first metacarpal. Treatment by external fixation." Journal of Bone & Joint Surgery, British Volume 74.3 (1992): 416-417.

4/21/2015

33

Carpal Fractures

Retrieved 4/2/15https://blog.solidconcepts.com/evolution-custom-manufacturing/best-3d-printing-articles-of-2013/

RETRIEVED 3/31/15

TRULIFE.COM

4/21/2015

34

Scaphoid Fracture

• Men 15-29 years old

• Most common carpal fracture in kids

• 80% of the scaphoid are articular surfaces

• Onset: FOOSH, MVA, direct blow to radial wrist https://sites.google.com/site/activecarep

hysiotherapyclinic/scaphoid-injury

Retrieved 3/25/15orthopedicsone.com

Scaphoid Fracture

1. Palpation in the anatomic snuffbox with ulnar deviation, or

2. Transverse wrist crease

3. 2% don’t appear on initial X-ray

•Blood flow from distal to proximal

•Healing 8-24 weeks

•Return to sport/activity 10-12 weeks after cast removed

4/21/2015

35

Scaphoid Fracture

http://radiopaedia.org/images/5848770

TrapeziumFracture

• 1-5 % of carpal fractures

• Chip fractures are not treated

• Axial force of the 1st

MC causes splaying of waist fractures

• Palpation: base of the 1st metacarpal in small finger opposition


4/21/2015

36

HamateFracture

• Injury by compression (bat swing is classic), treated with wire, excision, or cast

• Fracture becomes displaced by ligaments

• Ulnar nerve sensitivity

Brach P, Goitz R. An update on the management of carpal fractures. J Hand Ther 2003; 16: 152–160.


CapitateFracture

• 6 weeks casted before beginning AROM

• 1% carpal fractures

• ORIF: Mobilize scar, Continuous US with steroid



Retreieved 4/2/14http://www.thefemalecelebrity.info/Fractured-Scaphoid-Treatment.html

4/21/2015

37

Pisiform

• Caused by a direct blow, maybe repetitive stress

• Excision common (nonunion)

• Scar sensitivity & grip weakness

Pisiform Fracture


TriquetrumFracture

• Second most common carpal fracture

• 4 weeks in cast

• Complaints of ulnar wrist pain, local tenderness

• Pisiform lies on top

4/21/2015

38

LunateFracture

• Caused by impact with wrist extension

• Casted 6-8 weeks

• Associated with ligament injuries

“It’s Complicated”

• Keinbock’s = avascular necrosis of the lunate

• May lose wrist ROM

Hand Physeal Closure Ages

Lightdale-Miric N, Kozin SH. Fractures and dislocations of the hand and carpal bones in children. In :Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkin’ Fractures in Children 2015, Walters Kluwer Health Philadelphia. P265.

Middle and Distal Phalanges 14-16 years

Proximal Phalanges 14-16 years

Metacarpal Head14-16 years

Thumb Metacarpal14-16 years

• Open physis is weaker than surrounding bone

• Differential growth of the physis can correct for some malalignment of the fracture site

• Physeal arrest from mishandling

4/21/2015

39

Salter-Harris

Retrieved 4/3/15Studyblue.com

HAND PHYSES

4/21/2015

40

Special Pediatric Fractures

1. Seymour fracture• Fracture of the physis of the distal phalanx

• Results in infection, growth arrest, mallet deformity

2. Tuft fracture• 2-3 year olds

• Very painful-needs cushioning and protection (tip protector)

Osteoporotic Fractures

1. Age

2. Post-menopausal female

3. Glucocorticoids

4. Smoking

5. Alcoholism

6. High protein diet

7. Balance deficit

8. Failure of fixation

Biophosphonates-Treatment for osteoporosis, slows osteoclast activity; also slows fracture healing; half life in bone is 1.5-10 years, shows a higher rate of non-union

4/21/2015

41

Fracture Complications

• Nonunion, delayed union, malunion, avascular necrosis, osteomyelitis, amputation, stiffness/motion loss, instability, laxity, poor durability, lack of coverage, contracture, tendon adhesions, motion lag, numbness, hypersensitivity , pain, CRPS, ischemia, venous congestion, sensitivity, joint laxity

Hand Compartment Syndrome

Retrieved 3/29/15Galleryhip.com

Retrieved 3/29/15Scienceopen.com

• Pressure in enclosed space• Soft tissue injury from crush,

burn, tight bandaging

4/21/2015

42

References

1. Baldwin PC, Wolf JM. Outcomes of hand fracture treatments. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; 621-630.2. Brach P, Goitz R. An update on the management of carpal fractures. J Hand Ther 2003; 16: 152–160.3. Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: 105-116.4. Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. J Hand Surg 2009; 34: 945-52.5. Day CS, Stern PJ. Fractures of he metacarpals and phalanges. In: Wolfe SW, Hotchkiss RN, Pederson WC, e al,editors. Green's operative hand surgery. 6th edition.

Philadelphia: Elsevier Churchill Livingstone; 2011; 239-90.6. Flowers K, LeStayo P. Effect of total end range time on improving passive range of motion. J Hand Ther 1994; 7:150-5.7. Foster RJ, Hastings H II. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orth Rel Res 1987; 21: 121-29.8. Gedda KO, Moberg E. Open reduction and osteosynthesis of the so-called Bennett's fracture in the carpo-metacarpal joint of the thumb. Acta Orth 1952; 1-4: 249-57.9. Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J Orthop Sports Phys Ther 2004; 34(12): 781-99.10. Hardy MA, Freeland AE. Hand fracture fixation and healing : skeletal stability and digital mobility. In: Skirven TM, Osterman AL, Fedorczyk, et al, editors. Rehabilitation of the

hand and upper extremity. 6th

edition. Philadelphia: Elsevier Mosby; 2011; 361-76.11. Hays PL, Rozental TD. Rehabilitative strategies following Hand Fractures. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; 585-

600.12. Lightdale-Miric N, Kozin SH. Fractures and dislocations of the hand and carpal bones in children. In :Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkin’ Fractures

in Children 2015, Walters Kluwer Health Philadelphia; 2015; 265. 13. Markiewitz AD. Complications of hand fractures and their prevention. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; 601-

620. 14. McNemar TB, Howell JW, Chang E. Management of Metacarpal Fractures. J Hand Ther;2003:16:143-151.15. Michlovitz SL. Is there a role for ultrasound and electrical stimulation following injury to tendon and bone? J Hand Ther 2005; 18:292-296.16. Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving joint range of motion: a systematic review. J Hand Ther 2004; 17:118-31.17. O'Brien L. The evidence on ways to improve patient's adherence in hand therapy. J Hand Ther 2012; 25:247-50..18. Proubasta IR. Rolando's fracture of the first metacarpal. Treatment by external fixation. J Bone Joint Surg, Br 1992; 74.3: 416-17.19. Ruedi TP, Buckley RE, Moran CG, eds. AO Principles of Fracture Management. AO Publishing, Switzerland 2007.20. Sarmiento A, Latta L. The Nonsurgical Treatment of Fractures in Contemporary Orthopedics. Joyce Brothers, New Delhi 2011.21. Shin AY, Amadio PC. The stiff finger. In: Wolfe SW, Hotchkiss RN, Pederson WC, e al,editors. Green's operative hand surgery. 6th edition. Philadelphia: Elsevier Churchill

Livingstone; 2011; 355-88.22. Villeco JP. Edema: A silent but important factor. J Hand Ther 2012; 25:153-62.23. Watson HK, Weinzweig, eds. The Wrist. 2001, Lippincot Williams & Wilkins, Philadelphia PA.

Questions? Answers? Pearls?

hand & carpal fracturess3.amazonaws.com/fxofwristhandfingers/tns hand & carpal... ·...

Documents