Orthopedic

1. Fractures Of Hand
Presented by:
Dr. Ahsan Shaheen

2. ANATOMY
• 27 bones
• Carpals (8), metacarpals (5) and phalanges(14).
• The shaft of each metacarpal is curved - characteristic cup
shape.
• MCPJ- Condyloid joints , flexion and extension of the digits,
as well as a very small degree ofabduction and adduction
when the digits are extended.
• Phalanges - has a base, shaft, neck and head that is formed
from two condyles.
• PIPJ, DIPJ - Hinge joints, flexion and extension.

4. • The joint capsule is reinforced on its volar aspect
by the thickened ligament known as the volar plate
that prevents hyperextension of the joint.

7. INTRODUCTION
• One of the most commmon encountered injuries.
• Phalangeal (23%) and metacarpal (18%) fractures
to be the second and third most common fractures
below the elbow.

9. Injury Mechanisms
• The mechanism of injury description should
include ,
magnitude
direction
point of contact
type of force

11. Signs and symptoms
• Pain, swelling, deformity, stiffness,
weakness, and loss of coordination.
• Numbness and tingling - nerve involvement
• Signs - tenderness, swelling, ecchymosis,
deformity, crepitus, and instability.

12. Assessment of rotation

14. FUNCTIONAL STABILITY
Fractures as:
• Functionally stable
If patients could actively move the adjacent joint
more than 30% of the expected range while the
alignment of fracture remained within acceptable
range.
• Unstable fracture
If the patient was not able to move the adjacent
joint more than 30% of the expected range of
movement resulted in malalignment.

15. IMAGING
• Anteroposterior
• Lateral
• Splay lateral views
- varying amounts of flexion to prevent phalangeal
override
- best show only one digit in a true lateral projection.
• Oblique views -assessing reduction of articular
fractures.

16. Description of fractures
• Location within the bone
-(HEAD, NECK, SHAFT, BASE)
• Direction of the fracture plane
-(TRANSVERSE, SPIRAL, OBLIQUE, COMMINUTED)
• Degree of displacement.
• Dislocations -direction the distal segment travels
(DORSAL, VOLAR, ROTATORY)

17. METACARPAL FRACTURES
INTRODUCTION
Fracture patterns - head, neck, and shaft.
• Metacarpal Head Fractures: Rare, intraarticular.
• As a result of axial loading or direct trauma,
complex dorsal MCP dislocations
• Treatment include open reduction & internal
fixation with k-wire or interfragmentary screws
• comminuted intra articular fracture require open
reduction & internal fixation or skeletal traction or
silicone arthro plasty.

20. Treatment
• For closed fracture 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 Fracture -
angulation >15* is unacceptable.
• For ring angulation of 30-40*is acceptable.
• For little finger-angulation of 50-60* is acceptable.
• If closed reduction fails---ORIF with k-wire

23. Bouquet Pinning of Metacarpal Neck
Fracture
• Care 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 possible
• Put 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.

25. METACARPAL SHAFT FRACTURES
• CLASSIFICATION—transverse,
oblique,
comminuted.
• Generally treated by closed methods.
• OR & fixation req if multiple/assoc with soft tissue
injury.
• Most imp factor in reduction- Rotational alignment.

26. Transverse metacarpal shaft
fracture
• Indications for intervention-any angulation for
index & mid finger,>20* ring finger,>30* for little
finger
• Treatment-closed reduction & internal fixation by
k-wire,open reduction & internal fixation by k-
wire,intramedullary fixation k-wire

28. IM K-wire fixation of 4th MC shaft

29. Tech for percutaneous
pinning

31. 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
• Plates.

33. RIGID FIXATION OF METACARPAL SHAFT:
• Indications-multiple #,isolated
transverse#,malunion,pseudo arthrosis,bone
loss
• Types –interfragmentary compression
screws, plates & screws

36. 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. Fractures of the Thumb

41. Fracture 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

42. BennettFracture
• 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.
• WHEN fragment is <15-20% of articular surface-
CRIF with k wire
• if > 25%-ORIF with K wires / 2- 2.7 mm screw.
• COMPLICATION-mal union

47. Rolando Fracture
• Comminuted intraarticular First Metacarpal Base #
• Presents as ‘Y’ or ‘T’ Pattern
• Differs from Bennette that usually no diaphyseal
displacement
• Fixed with small wires placed under the subchondral
bone supplemented with a larger transarticular /
transmetacarpal pinning.
• TBW with Ex Fix
• T plate

48. Rolando Fracture

52. Introduction to Distal Phalanx (P3)
Fractures
• Terminal point of contact.
• Soft tissue coverage is limited.
• Soft tissue injury is of greater significance
• Hematoma can be seen beneath the nail plate-
Open fracture.
• Mechanism – crushing.
• Radiographs - isolated views of the injured digit.

54. PATHOANATOMY
• Fractues in three primary regions:
-the tuft,shaft, and base
• The two mechanisms .
-sudden axial load (as in ball sports)
-crush injury

56. • Crush fractures of the tuft are often stable.
• Proximally, the digital flexor and terminal extensor
tendons insert on the volar and dorsal bases of the distal
phalanx.
• Majority of bone flakes at the volar base P3 are FDP
tendon ruptures

57. Treatment Options
CONSERVATIVE
• Digital splints
• should leave the PIP joint free
• needs to cross the DIP joint simply to gain enough
foundation

59. Operative
• K-wire
• Lag screw fixation
• Extension block pinning

66. Middle Phalanx (P2) Fractures
• Intra-articular fractures that occur at the base of
the middle phalanx.
• Most functionally devastating of all fractures.
• the most technically difficult to treat.
• head, neck, shaft, and base.

67. Pattern
• Unicondylar or bicondylar fractures of the head.
• Intra-articular fractures of the base.
• Partial articular fractures
-Dorsal base
-Volar base
-Lateral base
• Complete articular fractures
-“pilon” fractures. “
-Unstable in every direction including axially.

68. Pathoanatomy and Applied
Anatomy

69. Middle Phalanx Fracture- Treatment
Options
Static Splinting.
• Crushing- comminution with no significant displacement.
Dynamic Extension Block Splinting.
• Volar base of P2 - less than 40% of the articular surface
Condylar fractures
• CRIF- converging or diverging.
Unstable shaft fractures
• CRIF – K wiring
• ORIF – Lag screw fixation – if rotational instabiity.
• Plate and screw fixation – if axial instability.

70. Temporary Transarticular Pinning for Partial
Articular Base Fractures.
Volar Base Fractures
• CRIF /ORIF
Pilon fractures.
• Highly unstable,stifness of PIPJ.
• Dynamic traction / dorsal spring mechanism.
• The general principle is to establish a foundation at
the center of rotation in the head of P1.

78. Proximal Phalanx (P1) Fractures
• Head - Intraarticular fractures
- partial or complete articular
• Neck - extra-articular fractures
-(extreme PIP limitation)
• Base - extra-articular and intra-articular.
• Shaft extra-articular fractures
-transverse, short oblique, long oblique, or spiral

79. Treatment options
Non operative:
• Stable proximal fractures, Transverse shaft.
• Dorsal splinting with the MP joint in flexion.
• discontinued at 3 weeks, followed by AROM .
• Stable + undisplaced – immediate AROM with
buddy strapping.
• Weekly folllow up.
Operative – CRIF/ORIF

80. Closed Reduction + Internal
Fixation.
• Reducible but unstable isolated fractures.
• For long oblique and spiral fractures
-three K-wires- perpendicular to the fracture
• For neck fractures
-retrograde pinning may be necessary
• For short oblique and transverse fractures,
-longitudinal K-wires .

84. Open Reduction and Internal
Fixation
Indications :
• Open fractures
• multiple fractures
• intra-articular fractures with displacement
• Spiral fractures
-lag screws
-to achieve precise control over rotation.