Metacarpal & Phalangeal Fractures pdf - D. Khalid

Orthopedic Surgery

Stage

Metacarpal & Phalangeal Fractures

Metacarpal fracture

Caused by blow, fall, or longitudinal force (boxers punch).

Site: base, shaft, neck.

Deformity:

1. Angular: {transverse#} not very marked, doesn’t interfere much

with function.

2. Rotational: {spiral #} serious, malrotation will result in overlap of

fingers when patient closes the fist.

Metacarpal shaft fracture



Transverse: caused by direct blow.



Spiral: caused by twisting or punching force.

Treatment :

Transverse #:

1. slight displacement; just crepe bandage.
2. Considerable displacement: closed reduction & plaster slab for 3 weeks.

If reduction is unstable, then open reduction & internal fixation by plate
& screws, or percutaneous k –wire across the fracture line.

Spiral #:

liable to rotate so treated by open reduction& internal fixation

Metacarpal neck (boxer #)



Usually the fifth finger.



Usually local swelling with flattening of the knuckle.



X-ray: transverse #, impacted with volar angulation of the

distal fragment.

Treatment:

Ringe & Littile finger

Up to 40 D angulation deformity can be accepted, apply gutter plaster with
MP joint flexed & IP joints extended for 2 weeks.

Index & middle finger,

no more than 20 D angulation can be accepted.



IF reduction is needed, try closed reduction under L.A followed by

immobilization in a gutter plaster.



For unstable frcactures do open reduction &internal fixation by K-

wires .

Metacarpal base #

Except 1st metacarpal (thumb), these are stable #, treated by volar slab,
extending from the forearm to PIP joint for 3 weeks. Just ensure that rotation is
corrected.

Displaced intraarticular # of the base of 4th &5th Metacarpal: these are
mobile joints, so joint incongruity will be painful, so do closed reduction
&percutaneous k-wire or compression screw.

Fracture of thumb metacarpal base

1. Impacted # of the MTC base.
2. Bennet fracture dislocation of carpometacarpal joint.
3. Rolando comminuted # of the base.

1. Impacted fracture:



Transverse # 6 mm distal to CMC joint.



TRT: <20-30 D angulation, apply thumb Spica for 2-3 weeks.

> 30 D, closed reduction & thumb spica.

2. Bennet fracture

Oblique fracture, extend into carpometacarpal (intraarticular) & unstable.

Treatment:



Try closed reduction &POP cast.



If failed,do closed reduction & percutaneous K wire fixation, or

open reduction & internal fixation by compression screw.

3. Rolando fracture:

Comminuted intra-articular # of the base of 1st metacarpal

Treatment:



closed reduction &k-wire fixation



external fixation for more sever comminution.

Fracture phalanges

Cause:

Direct trauma.

Fracture proximal & middle phalanges:



Transverse #: usually angulated.



Spiral #: rotation deformity.



Comminuted #: (tendon damage & skin loss).



Avulsion #: of small fragment of bone.



Intra-articular fracture:

Treatment:



Undisplaced #: functional splintage by strapping the

fractured finger to its neighbor (buddy strapping).



Displaced #: reduced; correct rotation & angulation. Apply

dorsal splint with MP joint in 80 D flexion & IP joint in
extension for 3 weeks.

Indication for internal fixation:

1. Closed reduction cannot be achieved.
2. Unstable #.
3. Intra-articular #.

Fracture distal phalanx:



# of the tuft: fingertip struck by hammer, or caught by a door,

the bone shattered.



Treatment: disregard the #, control swelling & regain

movement. Painful hematoma beneath finger nail should be
drained.

Mallet finger injury (baseball finger):

Cause:

  1. rupture of extensor tendon at or near its insertion at terminal
phalanx.
2. avulsion #of the base of terminal phalanx.

C/F: Terminal phalanx drops & patient unable to straighten it

Treatment:



Tendinous avulsion:

splint DIP joint in hyperextension,

using a special splint, constantly for 8 weeks, then only
at night for 4 weeks.



Bony avulsion:

also splint DIP joint in hyperextension

for 6 weeks. For large bony avulsion associated with
subluxation of DIP joint, fixation of the fragment with K
wire or a small screw.

Dislocations in the Hand

Carpo-metacarpal dislocation



Mostly in the thumb, it resembles Bennetts fracture

dislocation.



Treatment: closed reduction is easy, but unstable, so; fix
by k wire which is kept for 5 weeks but protective splint
should worn for 8 weeks (risk of instability).

Metacarpo-phalageal dislocation



Usually the thumb, sometimes the 5th finger.



The finger is suddenly forced into hyper extension.



TRT: trial of closed reduction (usually difficult to reduce). If

failed, then open reduction through dorsal approach.

Interphalangeal dislocation



Distal interphalangeal dislocation is rare.



Proximal interphalangeal dislocation is more common



Mechanism: hyperextension force.



TRT:

 closed reduction (easily done), strapping the finger to

its neighbor for few days.

 If there is # fragment which is big &associated with

dislocation, open reduction of the fragment &
fixation by small screw or k-wire.

Open hand injuries



Very common.



Types:

  1. Tidy or clean cuts
  2. Laceration
  3. Crushing or injection injuries
  4. Burns &finger bulb defects

Clinical assessment:



Mechanism: instrument; Sharp or blunt?? Clean or dirty??

Severity?



Position of the fingers: (flexed or extended??) at injury.



Timing:



Age: of the patient



Occupation:



Dominancy: right or left handed

Clinical examination



Skin: assess the degree of skin damage small wounds, be

alert!!, possibility of misdiagnosis



Circulation: careful evaluation of the state of hand

circulation, Perform (Allen test).



Nerve examination: assess function of the peripheral

nerves.



Tendon: assess the function of extensor tendons & long

flexor tendons.



Bones: any fractures

X-ray: AP, lateral & oblique view.

Primary treatment:



Preoperative care:



Treatment of pain & shock



Wound rinsed with plenty of normal saline



Antibiotics



Anti-tetanus &Anti gas gangrene prophylaxis



Wound dressed &hand splinted

Wound exploration:



Under G.A, skin debrided but here skin is very precious,

original wound is enlarged (must not cross skin creases)



Dead muscle excised, wound irrigated with saline



Further assessment of extent of injury.

Tissue repair:



# reduced & fixed by k-wire or external fixation.



Joint ligament & capsule: repaired



Artery& vein: repaired if the hand or finger is ischemic



Nerves: repaired (operating microscope)



Extensor tendon: repaired



Flexor tendon: repair is more challenging.



Closure: unless wound contaminated, skin is closed by

direct suture without tension or, if there is skin loss, by
skin grafting or local flaps.