Hand Surgeon (CMC Vellore) Hand fractures Dr Shrenik M Shah Hand Surgeon (CMC Vellore) Shrey Hospital Ahmedabad www.eswtindia.in

2ND yr OG resident with infected #

What went wrong? Decision making Planning Implants Instrumentation Asepsis Tissue handling Previous surgery Suture material Immuno-compromised

Debridement and irrigation

Final clinical picture

Final X ray

Epidemiology Hand #-15–19% of fractures in adults. 59% of hand fractures occur in the phalanges, 33% in the metacarpals, and 8% in the carpal bones. About half of all hand injuries occur in individuals between 15 and 34 years of age. The single most common # site in the hand is the subcapital region of the M5 bone (Boxer’s Fracture) Falling on an outstretched hand is the most common cause of hand fractures. The second most common cause is sports-related injury.

Goals of treatment restoration of articular anatomy correction of angular or rotational deformity stabilization of fractures rapid mobilization

Pathophysiology group of gliding bones surrounded by soft tissue Immobile segment: M2,M3-more precise reduction to ensure proper function. Mobile segment: M1, 4,5 may tolerate a greater degree of angulation without disability

Disability Disability from hand injuries may result in loss of sensation, strength, and flexibility Prevention maintaining the structural relationships of the intrinsic hand structures as well as musculotendinous connections from the forearm

History Hand dominance of patient Hand that is injured Occupation and hobbies requiring dexterity Did injury occur in a clean or dirty environment? Were crush injuries sustained? What was the position of the hand at time of injury? Was injury the result of high-pressure grease, water, air, or paint injection? Did a thermal, electric, or chemical injury occur? Was patient wearing any type of jewelry on fingers? If so, has it been removed?

Assessment of rotational deformity In fractures distal to the PIP joint, rotational overlap occurs only in the presence of fairly large degree of displacement. In such cases operative treatment is indicated, if malrotation can not be corrected by closed reduction.

Digital nerves If bleeding is present, do not clamp or ligate a vessel blindly, as nerves closely follow blood vessels. Remember to assess nerve integrity prior to instillation of anesthetics- 2point discrimination, loss of sweating

X ray –AP, lateral and oblique

Routine Radiographs AP & Obl

Traction view

Distal phalanx fractures comminuted tuft # No angulation or displacement septa hold fragments in place on the volar surface nail acts as a splint

Mallet finger

Transverse # Distal Px Stable Splintage K wire TBW( Hemant Patankar)

# middle and proximal Px Transverse/oblique/spiral # Rotational alignment-nails True lateral X ray of finger Significant angulation tendon MIDDLE Px Unpredictable stability Gutter Splint/ buddy strapping if stable Not for transverse # Follow up x ray at 7 days 3

Transverse # of proximal Px unstable fractures, as interosseous muscles pull proximal fragments in a volar direction and central slip pulls the distal fragments dorsally

Clinical pics of # PPx

ORIF PER OP 8 WEEKS POST OP

Condylar # of Px Oblique X rays Closed reduction and functional position ORIF

Decision algorithm of # Px

COMPLICATIONS Mal rotation degenerative arthritis adhesion of tendon to bone joint stiffness from immobilization Boutonniere deformity Swan neck deformity Flexor tendon rupture

Metacarpal # Most metacarpal fractures have good functional results with non operative treatment. Surgery always causes some disturbance in the extensor mechanism, MCP joint capsule, or intrinsic muscles. Rotational mal alignment is poorly tolerated and must not be overlooked. Crush injuries of the metacarpals may be associated with: Fractures and dislocations of the carpus and CMC area Compartment syndrome and carpal tunnel syndrome

Metacarpal head # Often comminuted poor healing Complications: Mal rotation of finger extensor tendon injury posttraumatic arthritis avascular necrosis.

Metacarpal neck # direct blow to knuckles Boxer’s #- M5 neck # Angulation and rotation M2,3 –fixed at distal carpal rows angulation<10-15* M4,5- mobile MCP joint angulation up to 30-40* Ext tendon injury Collateral ligament injury

Metacarpal shaft # Dorsal angulation Mal rotation : scissoring, nail plate, diameter of # fragments on X rays. Angulation –M2,3 < 10* M4,5 < 20* transverse metacarpal ligaments hold fragments- prevents shortening-accept 3 mm Splintage -4-6 weeks ORIF

Illustrative case 1- MC neck #

Management with bouquet fixn

Metacarpal Base # M2,3- rare M5- common, subluxation of metacarpal-hamate jt fix M1- mobile, #-rare

Metacarpal base # dislocation

Bennett # M1- oblique, intraarticular fracture at the volar base of the ulnar aspect APL pull large fragment Subluxation of CMC Jt Percutaneous wire Fixn

Rolando # T or Y shape# Small palmer and large dorsal fragments Comminuted ORIF

COMPLICATIONS Mal rotation Degenerative arthritis Adhesion of tendon to bone (more likely in open or widely angulated fractures) Joint stiffness from immobilization Boutonniere deformity (may result from improperly treated middle phalanx fracture) Nonunion of fractures resulting in prolonged disability

Illustrative case-2

Immediate post op

Post op rehab –dynamic splintage

6 weeks post op

arthrolysis

Final follow up

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