บรรยายให้แพทย์และพยาบาลเวชปฏิบัติทั่วไปในการประชุมวิชาการ "Orthopaedics for non-orthopedist ครั้งที่ 3" วันพฤหัสบดีที่ 15 มิถุนายน 2560 ณ โรงพยาบาลมหาราชนครราชสีมา

1. Common Hand
Fractures & Dislocations
นายแพทย์ณัฐกุล แย้มประเสริฐ
กลุ่มงานออร์โธปิดิกส์ โรงพยาบาลมหาราชนครราชสีมา
1
“Common Things Happen Commonly!”

2. Outline
• Fracture of distal end radius
• Metacarpal neck fracture (Boxer’s fracture)
• Proximal phalangeal fracture
• PIP joint dislocation
• Mallet injury
• Central slip injury

3. Fracture of Distal End Radius

4. DER
Distal End Radius
Periarticular area —> Metaphysis

7. Fernandez’s Classification
Bending
Shearing
Compression
Avulsion
Combined / High velocity

8. Image Source: https://www.miamihandcenter.com/hand/distal-radial-fractures

11. *
3-point fixation

12. เฝือกโค้ง มี 3 point fixation

13. Distal palmar crease

14. สามารถทำ opposition ได้

15. Radiographic Parameter
Volar tilt Radial Height
Radial inclination Ulnar variance
11° 11mm
23° 0/-

16. Acceptable Reduction
• <15° dorsal and <20° palmar tilt
• >15° radial inclination
• <5° radial shortening
• Ulnar variance negative or neutral
• Articular step <1 mm
• Articular gap <2 mm

17. Modified Lafontaine’s Criteria
• Dorsal angulation >20°
• Dorsal comminution >50%, Palmar comminution, Articular comminution
• Initial displacement >1cm
• Initial shortening >5mm
• Associated ulnar fracture
• Severe osteoporosis
3+
Suggested Unstable!

19. Guideline for Management
• Closed reduction
• Immobilization with short arm AP slab/short arm cast
• ROME of shoulder, elbow and hand as soon as possible
• F/U q 1-2 weeks
• Immobilization 6-8 weeks

20. Hematoma
Block

23. Guideline for Management
Refer to specialist in case of…
• Unacceptable alignment after reduction (esp. young active pt.)
• Any type of fracture with open wound around the wrist
• Displaced intra-articular fracture
• Fracture with neurovascular injury
• Multiple fracture/multiple trauma

24. Pitfalls & Errors

25. Slab ยาวเกิน distal palmar crease!

26. Slab ยาวเกิน distal palmar crease!

27. Image source: https://musculoskeletalkey.com/the-wrist-and-hand-3/

28. Pressure sore

29. Pressure sore

34. Metacarpal Neck Fracture
(Boxer’s Fracture)
Image source: http://photo.cultjer.com/img/cache/width/1000/ug_photo/2014_08/the_leftovers_wallpaper_1920x120140820011822.jpg

35. Image source: https://s0www.utdlab.com/contents/image?imageKey=SURG/60633
Jahss Maneuver

38. Guideline for Management
• Closed reduction “Jahss maneuver”
• Immobilization with radial gutter/ulnar gutter slab
• AROME
• F/U q 1 week
• Immobilization 2 weeks + protected load 6 weeks

39. Guideline for Management
Refer to specialist in case of…
• Multiple metacarpal neck fracture
• Open fracture
• Neurovascular injury

40. Remove Ring First!

41. Malrotation

42. OMG!
Malrotation

43. Proximal Phalangeal Fracture

44. Proximal Phalangeal Fracture

45. Proximal Phalangeal Fracture

46. Move distal part to proximal part

47. Proximal Phalangeal Fracture

49. Guideline for Management
• Closed reduction
• Immobilization with radial gutter/ulnar gutter slab
• AROME
• F/U q 1 week
• Immobilization 2-3 weeks + protected load until 8 weeks

50. Guideline for Management
Refer to specialist in case of…
• Intra-articular fracture
• Multiple digital fracture
• Open fracture
• Neurovascular injury

51. PIP Joint Dislocation

53. Guideline for Management
• Closed reduction
• Dorsal block splint 3 weeks
• Early active/passive PIP joint flexion exercise

55. Extension block splint

56. Guideline for Management
Refer to specialist in case of…
• Fracture-dislocation
• Open injury
• Neurovascular injury

57. Mallet Finger

58. Mallet Finger

60. Guideline for Management
Soft tissue mallet/nondisplaced fracture:
• Closed reduction and splinting DIP joint in slightly
hyperextension
• AROME of PIP, MCP joint
• F/U q 1-2 weeks to recheck splint position
• Full-time immobilization 6 weeks + night splint 6 weeks

65. Guideline for Management
Displaced mallet fracture:
• DIP joint splinting
• Refer to specialist for surgical intervention

70. Initial 2 mo.

72. Central Slip Injury

73. Static PIP Joint Extension Splint

74. Guideline for Management
• Reduction PIP joint to full extension
• Dynamic PIP joint extension splint 6 weeks or
• Static PIP joint extension splint 3 weeks + AROME
• F/U q 1-2 weeks to recheck splint position

75. Guideline for Management
Refer to specialist in case of…
• Irreducible PIP joint extension
• Open injury

76. Take
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