Fracture of the hand

1. FRACTURES OF METACARPALS AND PHALANGES

2. 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 10- 40yrs
⦁ Most fractures are functionally stable
⦁ Outer rays of hand are most frequently injured
⦁ Goal is rapid & full restoration of hand function

3. Wrist/ hand Anatomy - bones
⦁ Carpals
● (proximal row)
● (distal row)
⦁ Metacarpals
⦁ Phalanges

4. SKELETAL ANATOMY OF HAND
⦁ 5 metacarpal bone
Head
Shaft
base
⦁ 14 phalanges 3 for each finger 2 for
thumb
Head
Shaft base

5. HAND ANATOMY
BONY ANATOMY
CARPALS
1. Scaphoid
2. Lunate
3. Triquetral
4. Trapezium
5. Trapezoid
6. Hamate
7. Pisiform
KEY SKELETAL ELEMENT
⦁ Has 3 arches,2 transverse
arches & 1longitudinal arch

8. SPLINTING POSITION
Position of Function
NO
Position of Safety

9. THUMB SPICA
BASIC SPLINTING
POSITION OF “SAFETY”

10. Hand Functions
⦁ Grasping patterns
● Hook, spheres, cylinders
⦁ Pinches
● Key, tripod, inferior/superior
⦁ Fine motor manipulation
⦁ Sensation
● Pain, touch, discrimination, object
identification, vibration

11. 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

12. 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 scan

13. Classification of fractures of metacarpal
head
⦁ 1)epiphysael
⦁ Ligamentous avulsion
⦁ Osteochondral slices
⦁ Two part fractures in different
planes
⦁ Comminuted
Bone loss
⦁ Occult compression #

14. 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

15. complications
⦁ Most common- stiffness-it is due to
extensor tendon
adhesions,collateralligament or
dorsal capsule contractures
⦁ Epiphyseal growth arrest
⦁ Avascular necrosis

16. METACARPAL NECK FRACTURES
⦁ Boxers fracture
⦁ Commonly involves-ring & small
fingers
⦁ Occur when clenched MCP strikes
solid objects & angulates with apex
dorsal

17. 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
•

18. 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

19. Cont…..
⦁ Immobilisation-12-14days & then
AROM exercises
⦁ After 6 weeks –join duty
⦁ If closed reduction fails---ORIF with
k-wire

20. METACARPAL SHAFT FRACTURES
⦁ CLASSIFICATION—transverse,
oblique
comminuted

21. dr sumer yadav, mch plastic
surgery.
sumeryadav2004@gmail.com

23. TRANSVERSE METACARPAL SHAFT FRACTURE
AXIAL LOADING
⦁ Indications for intervention-any
angulation for index & mid finger
⦁ >20* ring finger
⦁ >30* for little finger
Treatment:
1. Closed Reduction & Internal Fixation By K-wire
2. Open Reduction & Internal Fixation By K- Wire
3. Intramedullary Fixation K-wire

25. 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

31. RIGID FIXATION
⦁ Indications-multiple #,isolated
transverse#,malunion,pseudo
arthrosis,bone loss
⦁ Types –interfragmentary
compression screws, plates &
screws

34. 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

40. COMPLICATIONS OF INTERNAL FIXATION
⦁ Pin tract infection
⦁ Osteomyelitis
⦁ Fracture through pin holes
⦁ Neuro vascular injury
⦁ Over distraction
⦁ Loss of reduction
⦁ Impair tendon excursion

41. 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

42. BI ABSORBABLE FIXATION
⦁ Polyglycolic acid,poly lactic acid,poly Para
dioxanone
⦁ Disadvantage->non infectious
inflammatory response

43. 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

46. COMPLICATIONS OF METACARPAL
FRACTURES
⦁ 1)mal union
⦁ 2)dorsal angulation
⦁ 3)malrotation
⦁ 4)osteomyelitis
⦁ 5)nonunion

47. PHALANGEAL FRACTURES
⦁ FRACTURES OF DISTAL PHALANX
⦁ Classificatuion:1)tuft #
🞆
🞆
simple #
comminuted#
⦁ Shaft #---transverse—stable or
unstable
🞆 ----longitudinal
⦁ Articular#---volar, epiphyseal,dorsal

49. TREATMENT OF DISTAL PHALANGEAL #
⦁ TUFT #-drain subungual hematoma
🞆 finger splint
⦁ Shaft #-- CRIF—k-wire
⦁ Epiphyseal #--ORIF
⦁ Complications– nonunion
🞆 -malunion

50. FRACTURES OF MID & PROXIMAL
PHALANX
⦁ ARTICULAR #(london)--1)condylar
#
⦁ Type1-stable #without
displacement
⦁ Type2-unicondyle,unstable
⦁ Type3-bicondyle,comminuted

65. 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

66. TREATMENT OF BYCONDYLAR FRACTURES
⦁ ORIF WITH PLATES & SCREWS
⦁ Dynamic splint
⦁ External fixation
⦁ Interfragmentary screws

67. 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

68. 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

69. 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

70. Cont…
⦁ SHAFT # INVOLVING JOINT-
⦁ Treatment ORIF
⦁ Proximal traction phalanx splint-
noninvasive, minimal stiffness,
comminuted#

71. NECK FRACTURES
⦁ Common in toddlers
⦁ Classification->type1-nondisplaced
🞆 type2-displaced with some bone
contact
⦁ Type3-completely displaced
⦁ Treatment-ORIF with k-wire or

72. 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

73. CONT
⦁ Transverse#-ORIF with kwire& intra
osseous wire
⦁ Displaced unstable & comminuted-
external fixation,miniplate & screws

74. 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

75. CONT…
⦁ Intrarticular malunion
⦁ Nonunion
⦁ Loss of motion
⦁ Pip joint extensor lag
⦁ infection

76. Fractures of the thumb bones
⦁ Fractures of phalanx-a) extra
articular
B) Intra articular
EXTRA ARTICULAR-1)distalp-
longitudnal,transervse,tuft
Treatment-repair of dermal nail
matrix, application of splint,CRIF
WITH k wire, ORIF with k wire

81. FRACTURES OF PROXIMAL PHALANX
⦁ Head & neck#-CRIF WITH K WIRE
🞆 ORIF WITH K WIRE
⦁ Angulation of 20-30* is
unacceptable

86. 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

87. 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

88. 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 joint

89. Bennett’s Fracture

90. TREATMENT
⦁ WHEN fragment is <15-20% of
articular surface-CRIF with k wire
🞆
🞆
if > 25%-ORIF
COMPLICATIONS-mal union

91. 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