Management of Intraarticular Hand Fractures

Management of Intraarticular Hand Fractures

Presentation: George MazisPresentation: George MazisResidentResident

1st Orthopaedic Department1st Orthopaedic Department““ATTIKON” Hospital ATTIKON” Hospital University of AthensUniversity of Athens

Essential for Reconstruction of

Hand Injuries

Understanding ofFunctional Anatomy

& Biomechanics

Anatomically complexAnatomically complexmechanical unitsmechanical units

HAND - WRIST

HAND - WRIST

Hand and wrist work in concert to optimize mobility and function

Bone & Joint Structure

• 3 arches of bones

• The arrangement of these bones form that are critical for successful object manipulation

Interphalangeal Joints

• The Proximal (PIP), Distal (DIP), and the IP joint of the thumb are all hinge joints

• The articular capsule made up of volar and collateral ligaments surround each IP joint

Metacarpophalangeal Joints

• Rounded distal heads of the metacarpals articulate with the concave proximal ends of the phalanges

• Reinforced by strong collateral ligaments

Carpometacarpal Joints

• CM of the thumb is a saddle joint

• CM of the four fingers gliding joints

Hand Function

• Power Grip: – ulnar digits– intrinsics

• Dexterity/ Fine Manipulation: – median innervated– radial sided digits

Management

"Hand fractures can be complicated by deformity from no treatment, stiffness from overtreatment, and both deformity and stiffness from poor treatment."

Alfred B. Swanson

Ideal treatment

Combination of:

• anatomic reduction • stable fixation of the fracture fragments• early mobilization to prevent joint stiffness

Intraarticular Fractures

• Fracture stabilization and postoperative rehabilitation must be designed to treat not only the fracture, but also concomitant injuries, such as extensor or flexor tendon injuries as well as neurovascular injuries

Physical Evaluation

Physical EvaluationAngulation

Physical EvaluationMalrotation

Physical Evaluation

Radiographic Evaluation

Standard posteroanterior, lateral, and oblique radiographs should be obtained for all hand fractures.


Depressed articular fractures can be difficult to appreciate on plain radiographs

• specific radiographs• traction radiographs • or CT scan can be useful


Brewerton view

Helpful in detailing the anatomy of fractures and chips of the metacarpal heads.


Traction radiographs:

PA and lateral radiographs applying traction to the injured digit(s)

Helpful in evaluating injuries when there is significant comminution of the fracture.

Intraarticular injuries

Intraarticular Fractures Base of the Distal Phalanx

“Mallet fractures”

“Pilon type fractures”

“Jersey Finger ”

Bony avulsion of FDP

http://www.eorif.com/WristHand/Phalanx%20distal%20class.html




• Nonoperative: - Minimally displaced #

→ 6-8 w extension splinting + 4 w night splinting

PIP SHOULD NOT BE IMMOBILIZED




• Operative: - Volar subluxation of distal phalanx - Dorsal fragment > 1/3 articular surface



Non-displaced: rare

Tendon forces usually displace fragments. Splint (Stack splint)



Displaced: typically severe injuries.

Treatment is dependent on the associated soft-tissue injury.

Varying combinations of the techniques desribed for volar base

and dorsal base fractures can be employed.



Volar plate arthroplasty

- Severely comminuted volar # - Chronic dorsal dislocations


“Jersey Finger ” Bony avulsion of FDP

Leddy and Packer Classification(1977)

Type I = tendon retracted to the palmType II = tendon retraced to level of the PIP joint.

Type IIIA = large bone fragment avulses and becomes caught at the entrance to the fourth annular pulley or the FDS chiasm. Type IIIB = distal phalanyx fracture combined with avulsion of

tendon from the fractured bone. Type IV = comminuted intraarticular fracture of the distal

phalanx.



Non-displaced: (rare) splint

(alumifoam or Stack splints) with DIP joint immobilized.



Displaced: ORIF.

Fragment fixation via suture, K- wires or mini-fragment screws as indicated.


Epiphyseal Fractures of the Distal Phalanx in skeletally immature patients

=> Open #

Intraarticular Fractures of the Middle and Proximal Phalanx

• Condylar Fractures

Condylar Fractures

Type I : stable fractures without displacementType II : unicondylar, unstable fracturesType III : bicondylar or comminuted fractures

LONDON CLASSIFICATION

Condylar Fractures

Class I : volar obliqueClass II : long sagittalClass III : dorsal coronal Class IV : volar coronal

Weis-Hastings classification for London I – II #

Condylar Fractures

Treatment

Nonoperative (3-4 w splint ): London I non displaced

BUT: High risk of displacement !!!

THEN → ORIF

Condylar Fractures

Operative

CRPP ORIF

Condylar Fractures

Rehabilitation

• Active exercises immediately if stable fixation is obtained with surgery

• In extremely comminuted cases dynamic traction splinting can be used ( for approximately 4 to 6 weeks) and then active exercises are begun.

Intraarticular Fractures Base of the Middle Phalanx

Volar Base Fractures

Most common

Hyperextension of PIP or axial loading to a flexed finger

Associated with dorsal dislocation



stable (IIIA) vs. unstable injuries (IIIB) :

- stable #: small fracture with less than 40% of the middle

phalanx base- unstable #: involves > 40% joint surface



Light (1981) described a dorsal V sign on a lateral radiograph that indicates PIP joint subluxation.

Articular surfaces are neither congruentnor parallel.



Non Operative Treatment:generally indicated when there isless than 40 % of the palmar articular surface

Radiographs are required todetermine the stable range of motion



Non Operative Treatment:Extension block splinting to prevent the digit fromextending past the safe zone

At least 10 deg more flexion


Operative Treatment:

Extension block pinning External fixation



Dynamic distraction external fixation



Volar plate arthroplasty


Any treatment selected must balance the forces tomaintain a concentric reduction!

Or else…

Chronic PIP Dorsal Dislocationslead to chronic volar plate laxity and hyperextension deformity


Dorsal Base Fractures

Avulsion of central slip

Usually the result of an anterior PIP joint dislocation


Dorsal Base Fractures

If displaced more than 2 mm,accurate reduction necessary to prevent extensor lag and boutonnière deformity

Intraarticular Base Fractures

Pilon fractures: comminuted, intra-articular fractures

Skeletal traction(hinged which spans the PIP joint to allowearly protected range of motion )

+ when necessary limited open reduction and cancellous bonegrafting

Intraarticular Base Fractures

Open Reduction and Internal Fixation

Complications of Intraarticular Fractures

• Malunion (Angulatory or rotatory deformity – Degenerative arthritis)

• Nonunion (rare…Infection, bone loss and vascular injury)

• Loss of Motion (Immobilization greater than 4 weeks )

• Infection• Flexor Tendon Rupture or

Entrapment

Intraarticular Fractures of the Thumb

Intra-articular fractures of the IP or MCP

→single fragment (sign of ligament or avulsion injury) → comminuted


Avulsion fractures of the dorsal base of the distal phalanx represent a mallet thumb.

Same treatment as any other digit


• Avulsion fractures of the volar lip of the base of the distal phalanx usually represent impaction fractures or, rarely, avulsion of FPL.


• Avulsion fractures from the ulnar base of the proximal phalanx

= > disruption of the ulnar collateral ligament

→ gamekeeper's or skier's thumb

• If the fragment is displaced more than 2 mm and the MCP joint is unstable to stress, stability needs to be surgically restored.


• If the fracture fragment is small or breaks during internal fixation, it can be removed and the ligament reinserted with a pullout wire or suture anchor.


Larger fragments :

• Kirschner pins

• Tension wire

• Lag screw

The repair is protected with a transarticular Kirschner pin


AFTERTREATMENT

Thumb spica cast immobilization for 4 to 6 weeks

Intraarticular Metacarpal Head Fractures

• Axial loading or direct

trauma (crush or clenched-fist injury)

• When an open wound is present a fight bite should be suspected


Radiographic evaluation • Posteroanterior, lateral, and oblique• Brewerton view to delineate collateral ligament avulsion

fractures • Skyline metacarpal view articular profile of the metacarpal

head after a clenched-fist injury• CT

Eyres KS, Allen TR Skyline view of the metacarpal head in the assessment of human fight bite injuries. J Hand Surg Br. 1993 Feb;18(1):43-4.


TREATMENTNonoperative:• Closed injury• No joint dislocation/subluxation• Articular involvement <20%• Articular stepoff <1 mm• Avulsion displacement <2 mm


TREATMENTOperative: External fixation• Open fractures• Infection• Significant comminution

Z. Dailiana MD, D. Agorastakis MD, S. Varitimidis MD, K. Bargiotas MD, N. Roidis MD and K.N. Malizos MD, Use of a Mini-External Fixator for the Treatment of Hand Fractures

The Journal of Hand Surgery, Volume 34, Issue 4, April 2009, Pages 630-636

Metacarpal Head fracture

Divide Extensor tendon at Sagittal

band


TREATMENTOperative:

ORIF


TREATMENT

Prosthetic arthroplasty

• comminuted intra-articular fracture associated with soft tissue injuries and metaphyseal compaction or bone loss

• for open nonsalvageable intra-articular fractures of the PIP and MCP joints

STEPHEN D. COOK, PH.D. et al. Long-Term Follow-up of Pyrolytic Carbon Metacarpophalangeal Implants* The Journal of Bone and Joint Surgery 81:635-48 (1999)

Intraarticular Metacarpal Base Fractures

Uncommon and underdiagnosed injuries.

Weakness of grip strength

and wrist extension,

decreased range of motion,

degenerative osteoarthritis,

tendon rupture.


Forced flexion of the wristwith simultaneousextension of the arm+ axial loading(like a punch or fall)

Associated fractures of thedistal carpus should be ruled out !!!


Tendon insertions of ECRL, ECRB and ECUcan lead toavulsion fractures ofsecond, third and fifthmetacarpal, respectively


• Relatively stable fractures because of dorsal and palmar carpometacarpal and interosseous ligaments

• However, stability decreases sequentially in a radial-to-ulnar direction


TREATMENT

Because of the rarity of occurrences of intra-articularfractures of the second through fifth metacarpal bases,there is no consensus regarding the optimal treatmentfor such injuries

Brandon D. Bushnell, MD, Reid W. Draeger, BS, Colin G.Crosby, MD, Donald K. Bynum, MD, ManagementOf Intra-Articular Metacarpal Base Fractures of the Second Through Fifth Metacarpals, J Hand Surg2008;33A:573–583


• If closed reduction is successful, percutaneous pinning may be sufficient.

• Open treatment may be necessary.

Intraarticular Thumb Metacarpal Base Fractures

• Bennett's fracture-subluxation: avulsion fracture of the beak

ligament insertion, with displacement of the metacarpal dorsoradially and proximally


Roberts view:

Helpful in more fully assessing the first metacarpal base.

Intraarticular Thumb Metacarpal Base Fractures

• Rolando's fracture: more complex injury with two

or more major articular fragments

Bennett's fracture-subluxation Mechanism of injury:thumb metacarpal is axially loaded and

partially flexed

Bennett's fracture-subluxation

The use of a cast that maintains reduction by pressure on the base of the metacarpal is unsatisfactory:

• Too much pressure causes skin necrosis• Τoo little pressure allows loss of reduction

Bennett's fracture-subluxation

Wagner technique of closed pinning of Bennett #

OPERATIVE MANAGEMENT OF BENNETT'S FRACTURE

INDICATIONS • Failed closed reduction (displacement or

stepoff greater than 1 to 2 mm) • Displaced Bennett fragment greater than

20% of joint surface

Treatments for Thumb Metacarpal Base Fractures

RELATIVE INDICATIONS TREATMENT Closed reduction/pin fixation

Open reduction /pin fixation

Screw fixation

Plate fixation

External fixation

If manipulation achieves anatomic reduction

A few fragments or significant comminutionOne large fragment

Buttressing comminuted fragments

Comminuted, unstable # with soft-tissue trauma

Treatments for Thumb Metacarpal Base Fractures

Rehabilitation

• Pins are removed at 4 to 6 weeks. • Cast immobilization should be maintained until pin

removal.• Immobilization should be maintained for an

additional 3 to 6 weeks with a removable splint • Progressive range-of-motion exercises is initiated. • Heavy gripping and pinching activities are avoided

for 3 months.

Management of Intraarticular Hand Fractures

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