1. Hand Surgeon (CMC Vellore)
Hand fractures
Dr Shrenik M Shah
Hand Surgeon (CMC Vellore)
Shrey Hospital
Ahmedabad

2. 2ND yr OG resident with infected #

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

4. Debridement and irrigation

5. Final clinical picture

6. Final X ray

7. 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.

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

9. 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

10. 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

11. 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?

12. 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.

13. 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

14. X ray –AP, lateral and oblique

15. Routine Radiographs AP & Obl

16. Traction view

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

18. Mallet finger

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

20. # 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

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

22. Clinical pics of # PPx

23. ORIF
PER OP
8 WEEKS POST OP

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

25. Decision algorithm of # Px

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

27. 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

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

29. 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

30. 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

31. Illustrative case 1- MC neck #

32. Management with bouquet fixn

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

34. Metacarpal base # dislocation

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

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

37. 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

38. Illustrative case-2

39. Immediate post op

40. Post op rehab –dynamic splintage

41. 6 weeks post op

42. arthrolysis

43. Final follow up

44. Thank you