The document discusses managing complications from hand fractures and surgeries. It covers challenges like preventing tendon adhesions and angular deformities. Complications are discussed by site, including stiffness, malunion, and infection for bones and tendons. Treatment depends on the specific site of the nonunion or malunion, the nature of the deformity, any bone loss, and functional significance. The decision to operate involves balancing the morbidity of the existing condition with the risks of additional surgery.

1. MANAGING
COMPLICATIONS
DR JACQUELINE TAN
HEAD & SENIOR CONSULTANT
DEPT OF HAND & RECONSTRUCTIVE MICROSURGERY
SINGAPORE GENERAL HOSPITAL

2. CHALLENGES TO THE HAND SURGEON
Prevention of:
• Tendon adhesion
• Articular dysfunction
• Angular or rotational
deformity
• Infection
• When not to fix???

3. COMPLICATIONS BY SITE
Site Complications
Bone Nonunion/Malunion/Delayed union
Avascular necrosis, osteomyelitis, amputation
Soft Tissue Stiffness/motion loss, instability, laxity
Poor durability, lack of coverage
Contracture, flexion/extension loss
Tendon Adhesions, lag, tightness
Nerve Numbness, hypersensitivity, CRPS
Vascular Ischemia, congestion
Other Vibration and temperature sensitivitiy
Chrondrolysis, acute pain, joint laxity

4. COMPLICATIONS OF HAND FRACTURES
• Stiffness
• Malunion
• Non-union
• Tendon rupture
• Infection
• Fixation method

5. MALUNION
• Malunion is a common consequence of fractures in the hand (Barton 1988;
Green, 1986)
• Describes a fracture which has united but has done so incorrectly
• Types include:
Overlap & shortening
Angulation
Rotation

6. MALUNION
• The most common reasons are:
 Poor reduction of original fracture
 Poor holding of an originally well reduced fracture
 Soft tissue contracture
 Gradual collapse of fracture due to comminuted or osteoporotic bone
• May be apparent clinically, or only on x-ray
• Decision as to when to intervene and when to leave alone is often difficult. One must carefully
balance the morbidity of the malunion - functional and cosmetic - with the morbidity of operation

7. NON-UNION
• Defined as failure to achieve bony healing at a fracture site - the medullary cavity of the fragments
have closed with the fragments separate
• May be classifed as either hypertrophic or atrophic
• Hypertrophic non-unions are rare in the hand, most are atrophic & hypovascular
• The most common causes are:
 Infection
 Instability

8. METACARPALS

9. DORSAL ANGULATION & SHORTENING
• Prominence of metacarpal head in the palm -> pain on grasping
• Compensatory hyperextension at the MCPJ -> pseudoclawing
• Intrinsic muscles unable to accommodate metacarpal shortening – Weak grip, extension lag
• Average of 7o of extensor lag for every 2mm of metacarpal shortening
• Most authors quote between 3-5mm of shortening as maximum

10. ROTATIONAL ALIGNMENT
• 1o metacarpal shaft rotation produces 5o of fingertip rotation, causing 1.5cm
of digital overlap1
• Up to 10o malrotation is well-tolerated. Surgical intervention required if more
than this.2
1. Opgrande JD, Westphal SA. Fractures of the Hand. Orthop Clin N Amer 1983 14(4): 779-792.
2. Royle SG. Rotational Deformity Following Metacarpal Fracture. J Hand Surg (Br) 1990 15B: 124-125.

11. MALUNION
• If fracture line can be visualized and bone stock is satisfactory, osteotomy with
restitution of the articular surface is the optimum treatment
• Stabilisation with plate & screws appears to the most widely accepted
method of treatment
• Intraarticular malunions are rarely amenable to corrective osteotomy

14. NONUNION
• Uncommon
• Occurs after bone loss, osteomyelitis, inadequate immobilisation or
poor fixation

15. TREATMENT
• Jupiter and associates advised surgical intervention as early as 4 months
• Requires resection of the pseudoarthrosis, bone grafting and stable
internal fixation with K wires or plates & screws
• Rigid internal fixation not only allowed early active motion but also
permitted concomitant procedures such as capsulotomy & tenolysis

16. INFECTED NONUNIONS
• Management must be individualized
• First, all infected bone & fibrous tissue are debrided, followed by
skeletal stabilisation (external fixation) & appropriate skin coverage
• When there is no evidence of sepsis, delayed bone grafting & internal
fixation can be accomplished
• For persistent nonunions of border rays, esp those with associated
stiffness or contracture, ray amputation should be considered

17. PHALANGES

18. MALUNION
• Usually seen after oblique or spiral
fractures of proximal & middle
phalanges
• Best assessed by having patient make a
fist & looking for digital overlap
• Significant malrotation results in
functional impairment, pain from joint
malalignment & diminished grip
strength

19. MALUNION
• Surgical correction is technically difficult and demanding
• Choice of osteosynthesis varies from plates & screws to K-wires & intraosseous wiring
techniques (Lister, 1978)
• Correct contouring of plate is essential for fragments will be pulled out of their corrected
positions as the screws are inserted. 1mm of screw hole offset may translate into as much as
10deg of rotation (Buchler, 1996) & a second change at fixation is often impossible
• Intraosseous wiring is recommended as this technique provides a degree of malleability at
the osteotomy site for fine tuning of the correction whilst still providing firm enough fixation
for early mobilization

21. TREATMENT VARIABLES
• Location
• Complexity
• Nature of deformity
• Bone loss
• Functional significance

22. OSTEOTOMY
Indications
• Angulatory or rotatory deformity with or without stiffness
• Pain, weakness
Preoperative Evaluation
• Assess plane of deformity
• Assess integrity of soft tissue sleeve & flexor & extensor tendons
• Obtain AP, lateral & oblique radiographs
• Assess bone loss

23. ANGULATED MALUNIONS
• Can be volar or lateral
• Can be corrected by opening or closing wedge osteotomy
• Fixation is with Kirschner pins, plates & screws or interosseous wires
• If shortening is a concern, opening osteotomy with insertion of a
corticocancellous wedge-shaped graft is recommended

24. Closing wedge osteotomy

25. Lateral opening phalangeal osteotomy

26. MALUNITED CONDYLAR FRACTURES
• Problem of malunion leads to angulation of
digit
• Malunion alters mechanics of the finger
• Intra-articular osteotomy
• Difficult
• 76% success reported by Buchler et al JHS
Br 1996
• Condylar advancement osteotomy for
unicondylar malunion reported by Teoh et
al JHS Br 2002
Teoh et al JHS Br 2002

27. PHALANGEAL OSTEOTOMY
• Advantages
Corrects malunion at its site of origin
Allows for multiplanar correction
Permits concomitant soft tissue procedures such as tenolysis or capsulotomy
• Risks
Postoperative adhesions between dorsal apparatus & phalanx may result in
digital stiffness

28. PHALANGEAL OSTEOTOMY
Pearls
• Use plate & screw fixation whenever possible
• Maintain phalangeal length rather than shorten
• Consider other options when associated with joint stiffness, unstable soft tissue coverage, or
history of osteomyelitis
Pitfalls
• Inadequate correction
• Poor fixation precluding early ROM exercises
• Shortening of more than 3mm unacceptable

29. METACARPAL OSTEOTOMY
• Originally described by Weckesser & subsequently described by Pieron & Botelheiro
• Gross and Gelberman experimentally determined that correction of 18-19deg can be
obtained by osteotomy of IF, MF, RF & 20-30deg for LF
• Here larger cancellous surfaces are available for osteosynthesis & there is less risk to
soft tissues
• However, amount of rotational correction is limited to 25-30deg & multiplanar
correction is not possible

30. NONUNION
• Uncommon
• Predisposing factors include infection, bone loss & neurovascular injury
• Treatment include Kirschner pin fixation, plate fixation, with or without
bone grafting

31. NONUNION
• Key is to initiate active motion early (2-3wks after surgical fixation)
• Other important factors include method of fixation & surgical resection
of nonunion itself
• If a resultant gap produces unacceptable shortening, intercalated
corticocancellous bone grafting is indicated

32. Technique for treatment of atrophic non-union

33. SUMMARY
• Management depends on:
Site of fracture non union/malunion
Nature of deformity
Bone loss
Functional significance
• Decision as to when to intervene and when to leave alone is often
difficult. One must carefully balance the morbidity of malunion with the
morbidity of operation.