managing hand fractures in singapore

1. Hand and Wrist Fractures
in The Elderly
Mr Vaikunthan Rajaratnam
Senior Consultant Hand Surgeon
This work is licensed under a Creative Commons Attribution 4.0 International License.

2. I heard the old, old men say,
“Everything alters
And one by one we drop away”.
They had hands like claws, and their knees
Were twisted like the old thorn trees
By the waters
W B Yeats

3. Ageing Hand
age-related degenerative changes in the
• musculoskeletal,
• vascular, and
• nervous systems.
• a combination of local structural changes (joints,
muscle, tendon, bone, nerve and receptors, blood
supply, skin, and fingernails) and more distant changes
in neural control.
• accompanied by underlying pathological conditions
(osteoporosis, osteoarthritis, rheumatic arthritis, and
Parkinson's disease)
J Gerontol A Biol Sci Med Sci. 2003 Feb;58(2):146-52.
The aging hand.
Carmeli E, Patish H, Coleman R.

4. Effects of aging on hand function.
PARTICIPANTS:
• Healthy, independent, young (n = 27, range 20-35 years)
and older (n = 28, range 65-79 years) subjects.
• The decrease in the ability to maintain steady submaximal
pinch force was more pronounced in women than men.
CONCLUSION:
• Aging has a degenerative effect on hand function, including
declines in hand and finger strength and ability to control
submaximal pinch force and maintain a steady precision
pinch posture, manual speed, and hand sensation.
J Am Geriatr Soc. 2001 Nov;49(11):1478-84, Ranganathan VK,
Siemionow V, Sahgal V, Yue GH, Cleveland

5. Effects of aging on adult hand
function.
study was conducted examining relationships between prehension pattern type and
frequency, hand strength, and performance time in functional tasks.
Four groups of 10 adults were selected by age and gender, ranging from 24 to 87
years. Subjects were asked to pour milk into a cup and remove money from a wallet
while being videotaped.
Statistically significant differences in age
1. prehension pattern frequency,
2. hand strength,
3. and performance time.
Hand function seemed to remain stable until age 65 years, . After age 75 years, age
differences in performance were most apparent.
Shiffman LM.
Am J Occup Ther. 1992 Sep;46(9):785-92

6. The effects of strength training on
finger strength and hand dexterity in
healthy elderly individuals
strength training-improve finger strength.
improve the hand function of less healthy elderly
subjects.
Journal of Applied Physiology October 2008 vol. 105
no. 4 1166-1178
Halla B. Olafsdottir, et al,

7. • N = 585
• Age 16 and
above
• 2 groups >60 and
<60
• N=34 vs n=551
THE EPIDEMIOLOGY AND DISTRIBUTION OF HAND
FRACTURES IN SINGAPORE
Jin Xi Lim, Jia Jun Justin Boey, Jun Hao Tan, Alvin Chin Kwong Tan,Rajaratnam Vaikunthan
1 Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828
2 National University of Singapore, Singapore

8. Gender
11
89
56
44
0
10
20
30
40
50
60
70
80
90
100
Female Male
Percentage
<60 >/= 60

9. Location/ circumstance of injury
9 8
51
19
2 7 4
71
3 12 6 0 0 9
0
10
20
30
40
50
60
70
80
Home Public Place Work RTA Assault/ Fight Sports Not recorded
Percentage
<60 >/= 60

10. Mechanism of Injury
3 3
38
8 5 1 9
33
0 3
21
3 15 0 3
52
0
10
20
30
40
50
60
Percentage
<60 >/= 60

11. No of Fractures
73
16 7 3 1
94
6 0 0 0
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 6
Percentage
<60 >/= 60

12. Open/ Closed injury
61
39
77
23
0
10
20
30
40
50
60
70
80
90
Closed Open
Percentage
<60
>/=60

13. Fracture distribution
<60 years old >/= 60 years old

14. DEMOGRAPHICS 40 cases
• GENDER
Male: 17 ( 41.4% )
Female: 23 ( 58.6% )
• AGE
Oldest: 101
Youngest: 60
Mean: 70.275
• RACE
Chinese: 28
Malay: 3
Indian: 9
• GAINFUL EMPLOYMENT
Yes: 4
No: 36
Gender
Male
Female
Race
Chinese
Malay
Indian
Mean 73.60
Median 73.00

15. DOMINANT HAND INJURY
• HANDEDNESS
Right: 29
Left: 0
Unknown: 11
• HAND INJURED
Dominant: 17
Non-Dominant: 12
Unknown: 11
Hand Injured
Dominant
Non-
Dominant
Unknown

16. GENESIS OF INJURY
• LOCATION INJURY SUSTAINED
Home/ Nursing Home: 25
Workplace: 4 (all those
gainfully employed)
Public Place: 5
Others: 6
• MECHANISM OF INJURY
Crush Injury: 8
Penentrating/Sharp Injury: 1
Blunt Trauma : 1
Hyperextension: 5
Fall/Axial Load: 1
Others/Unknown: 24

17. 0
5
10
15
20
25
30
CrushInjury
Penetrating/Shar…
Blunttrauma
Hyperextension
Fall/Axialload
Others/Unknown
Mechanism
Mechanism
Location
Home/Nu
rsing
Home
Workplac
e
Public
Place
Others

18. FRACTURE PATTERNS
• NUMBER OF FRACTURES
Single: 38
Multiple : 2 ( both 2 each )
• FINGER INVOLVED
Thumb: 5
Index: 4
Middle: 3
Ring: 6
Little: 16
Unknown: 6
• TYPE OF FRACTURE
Open: 8
Closed: 30
Unknown: 2
0
5
10
15
20
Finger
Finger
Type of Fracture
Open
Closed

19. MANAGEMENT
• Operative: 3
2 Plate & Screws
1 Interfragmentary screw
• Conservative: 37

21. # Metacarpal Base with extension to
Shaft

22. 5th Metacarpal Neck #

23. # Shaft of 5th Metacarpal

24. P1 Base # ring finger

25. P1 Base # ring finger – Post op

26. P1 Head intra-articular #

28. Tuft #s

29. Thumb P1 Base intra-articular #

30. • 12% had a superficial infection (all treated
with transverse pinning with wires left
exposed);
• 39% had some impairment in skin sensation;
29% reported cold intolerance; and
• 10% had other complications.
Surgical intervention - only when one is sure of giving
better results than conservative management

31. My view
• Treat as with all patients – implant evolution
• Discuss options and outcomes
• Manage physiological age not chronological
• Pre existing symptomatic OA – consider fusion
and replacement
• Manage osteoporosis
• High demand elderly ?

32. Thank you