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Metacarpal fracture
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- 2. History Case ผู้ป่วยหญิง อายุ40 ปี CC:โดนทาร้าย 3 hr pta
- 3. PI : 3hr pta ผู้ป่วยให้ประวัติว่าดื่มเหล้าผู้ป่วยไม่เมา ำา เหตุการณ์ได้หมด เกิดการทะเลาะวิวาท โดนทาร้ายด้วยแท่ง เหล็กที่มีตะขอฟาดเข้าที่แขนขวา มีอาการบวมมาก และมือซ้าย โดนตะขอเกี่ยวมือซ้าย มีแผลเปิด แขนขวาสามารถขยับหัวไหล่ ข้อศอก ข้อมือ นิ้วมือได้ดี แขนซ้าย ขยับข้อมือไม่ได้ ไม่ชา ไม่ อ่อนแรง ทั้ง 2 ข้าง ำึงมา รพ.
- 4. Past history -ไม่มีประวัติแพ้ยา แพ้อาหาร -เป็นHT มียาทานอยู่ -NPO time 18.30
- 5. Physical Examination V/S:BT 37degrees PR 100 /min RR 20 /min BP 137/73 mmHg GA:good conscious HEENT:no pale conjunctivae ,aniteric sclerae ,no wound Heart:WNL Lungs:WNL Abdomen:soft ,not tender Ext:Rt armSwelling tenderness at forearm ,LW 1 cm ,full ROM ,distal neurovascular intact Lt armswelling and tenderness at ulnar side ,limit ROM due to pain at wrist ,LW 2 cm at palmar side ,LW 1 cm at dorsal side
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- 9. Film:Left hand AP,Oblique
- 10. Film:Comminuted Fracture at5th metacarpal bone Lt hand Dx:Open fracture at fifth metacarpal bone Lt hand
- 11. Management Admit NPO Dressing wound Preop lab ,CXR ,EKG IV fluid:5%DN/2 1000 ml iv 80 ml/hr Cefazolin 1 g IV stat then q 6 hr Set or for Excisional debridement + K-wire
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- 16. concave onpalmar surface 1st, 4th, and 5th digits form mobile borders The second and third metacarpals are fixed rigidly at their bases, while the fourth and fifth carpometacarpal (CMC) joints are capable of at least 15° and 25° of motion three palmar and four dorsal interossei muscles arise from metacarpal shafts
- 17. Epidermology incidence metacarpalfractures account for 40% of all hand injuries demographics men aged 10-29 have highest incidence of metacarpal injuries location metacarpal neck is most common site of fracture fifth metacarpal is most commonly injured
- 18. Mechanism of injury direct blow to hand or rotational injury with axial load high energy injuries (ie. automobile) may result in multiple fractures
- 19. Management Depend onlocation ,acceptable angulation ,no degree of deformities Surgical indication Displaced Intraarticular frature Unstable diaphyseal fracture :long oblique ,spiral ,comminuted Rotation deformity Open fracture Tendon injury association Unaccept angulation Multiple fracture Cosmetic Fail reduction
- 20. Nonoperative management Immobilization indications must be stable pattern no rotational deformity acceptable angulation & shortening (see table) Acceptable Shaft angulation Shortening (mm) Acceptable neck angulation Index&long finger 10-20 5 10-20 Ring finger 30 5 40 Little finger 40 5 50
- 21. Metacarpal head fracture Undisplace ,Stable fracture -immobilization in save position Displaced fracture (Intraarticular fracture) -ORIF
- 22. Metacarpal neck fracture Nonoperative reduction and short arm AP slab acceptable degrees of apex dorsal angulation immobilize safe position include PIP joint Short arm AP slab for 3 weeks reduce using Jahss technique 90 degrees MCP flexion, dorsal pressure through proximal phalanx while stabilizing metacarpal shaft
- 23. Operative reductionand fixation indications unacceptable angulation (see above table) open fractures any malrotation intraarticular fractures Cosmetic Fail reduction
- 24. Metacarpal shaft fracture Nonoperative immobilization indications nondisplaced metacarpal neck fractures acceptable angulation (see above table) no malrotation shortening (aesthetic problem only) immobilize MCP joints in 70-90 degrees of flexion Short arm AP slab in safe position for 3 weeks
- 25. Operative ORIF indications open fractures unacceptable angulation any malrotation multiple fractures Cosmetic Fail reduction
- 26. Metacarpal base fracture Mostly nondisplaced Short arm AP slab in safe position and check rotation follow up 3 week
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