Traumapedia and orthobullets Hand fractures and dislocations

DIP dislocations and fracture-dislocations

* Usually dorsal or lateral, volar dislocations are rare. often associated with open wounds presentation and xray same as PIP Treatment: closed reduction +/- splinting dorsal: longitudal traction, direct pressure on dorsal aspect, and then DIP flexion Volar: doesn't say dorsal splint in slight flexion x 2-3 weeks volar splint x 6 weeks tuft fracture has no specific treatment* *temporary splinting is ok operative open reduction +/- FDP repair if two reduction attempts fail. most common cause is volar plate interposition complications: mallet finger-from volar dislocations

seymour fracture

*it is a displaced distal phalangeal physeal fracture with a nailbed injury"

hamate complications

5th digit flexor tendon rupture symptomatic non union- can be treated with excision of the hook fragment ulnar neuropathy due to fracture displacement.

what is a orthogonal radiograph?

90 degrees from current view

Boutonniere deformity

A tear of the extensor tendon of the PIP joint, at the middle of the finger, and the DIP joint that controls the fingertip.

Bennet's Fracture /Rolandos

Bennets is one piece and rolandos is comminuted bennets- "Y" or "T" structures Xray is roberts view and orthogonal (AP/LAt) trx is Thumb Spica < 30° angulation and no displacement. Otherwise, surgery. Abductor policus longus can pull

Phalanx dislocation general info for DIP or PIP

Common. Volar plate under PIP and DIP prevents hyperextension. Elson test checks for integrity of central slip xrays: orthogonal, oblique, lateral, AP. V sign indicates subtle subluxation. classification and treatment: see next two flashcards for DIP and PIP fracture/dislocations and dislocations

PIP dislocations

Dorsal dislocations can lead to swan neck deformity. Volar dislocations can lead to a boutonnière deformity. classifications: 1) Dorsal a) Simple- middle phalanx remains in contact with condyles of the proximal phalanx Non op b) complex- will have a bayonet deformity. the base of the middle phalanx 2) Volar a) simple- dislocation without rotation, results from rupture of the central slip. Non-op b) rotatory- dislocation with rotation, results from rupture of one collateral ligament, the other remaining intact. on of the proximal phalangeal condyles buttonholes between the central slip and lateral band. 3) Lateral- rupture of one collateral ligament and at least partial avulsion of volar plate from middle phalanx. Treatments: Non-op- Closed reduction and buddy taping of simple dorsal and volar, lateral. Operative is if it can not be reduced, usually from volar plate or lateral band interposition. complications are PIP flexion contracture- usually with volar dislocations, hpysical therapy can help it. swan neck deformity secondary to volar plate injury, seen in dorsal locations extensor lag- seen in volar dislocations

metacarpal fractures assessment, mgmt

Fight wounds over MCP joint are open until proven otherwise. Dorsal wounds are almost always open fracture. Extensor tendon could be lacerated and retracted. assess rotation motor is typically ok, unless open frx- then check integrity of flexor..extensor tendons. neurovascular: dorsal wound could affect dorsal sensory branch or radial/ulnar nerve. Volar wounds can involve digital nerves. fight bite: irrigation. oral flora, abx are augmentin, or bactrim plus quinalone plus clindamycin in pcn allergic. hep B shot offered, plus accelerated course of hep b

Fracture treatment of metacarpal head:

Head: stable reductions get splint in protected position (0°, 40°, 20°) surgery for any small incongruity of articular surface (anything >1mm) or unstabel frx

MC Base fractures: reduce joint with axial traction and manual pressure

I need to review this more as it covers volar lip and dorsal lip. (traumapedia)

complications of lunate

Kienbock disease

frx treatment basics for metacarpal shaft

Neck: non-op with acceptable alignment: thumb <20° angulation (which direction though? 2nd and 3rd 15° angulation (again, direction? 4th and 5th- <45° angulation operative indications are unacceptable alignment and unstable reductions

Imaging for MC fractures

PA and lateral -ER (external rotation) oblique is best for 4th/5th CMC frx/dislocation -IR (internal rotation) oblique best for 2nd/3rd CMC fracture/dislocation -Brewerton best for metacarpal head -Roberts best for CMC fracture/dislocation CT for inconclusive xrays, multiple CMC dislocations/complex metacarpal fractures

Xray series for wrist

PA/Lat/oblique Scaphoid series: PA of wrist in ulnar deviation, and then again with 20-30° angle produces an even more true "en face" (face forward) view (scaphoid view) Roberts view (Jiu Jitsu on Robert's)

Acceptable shaft angulation, shortening, and neck angulation

Per orthobullets: 2nd and 3rd MC 10-20° angulation, 10-15° neck angulation 4th MC <30° shaft angle, 30-40° neck angle 5th MC <40° shaft, 50-60° neck no more than 2-5 MM shortening each MC Operative is open, intra-articular, rotational mal-alignment, multiple metacarpal shaft frx's. Traumapedia: Base of metacarpal 2, 3, 4 are often non-displaced, thus ok in volar resting splint. however, reverse bennets have MC pulled proximally by extensor carpii ulnaris, making it unstable.

pisiform frx treatment

Pisiform: dislocated or displaced fractures undergo closed reduction non-op- most frx, SAC or ulnar gutter operative: for persistant pain, may possibly excise

PIP fracture dislocations

Presentation and xrays are the same as PIP dislocations Volar lip fractures are the most common fracture pattern seen with dorsal dislocations. highly comminuted fracture, known as a pilon, may occur. articular involvment = stability <30% stable 30-50% tenuous >50% unstable treatment: non-op for <40% articular involvement extension block for volar and extension splint for dorsal must achieve adequate reduction

PIP-DIP-MCP-CMC say them out loud

Proximal Interphalengeal Distal interphalengeal metacarpophalengeal carpometacarpal

Dislocations of MCP (not fracture-dislocations)

Rare, < 1:100,000 annually exam: may have bayonet deformity (proximal phalanx dorsal to MC) Imaging: AP LATERAL, OBLIQUE- joint space widening suggets volar plate entrapment. Trx: closed reduction by dorsal pressure with wrist in flexion. don't pull, as volar plate could go into joint space, making it irreducible. Then buddy tape, early ROM. Instability keep in a splint for 3 weeks in 50° of flexion volar is rare and a bit different. look up before doing. surgery if sesamoid bone is inside MCP, thumb- spica splint with mcp in mild flexion for 3 weeks. most dislocations. complications: residual instability

How to reduce lunate dislocations/fractures

Reduction followed by surgery. Use a 10 lb weight, then once spasming subsides, dorsal force stabilizes lunate while volar pushes carpals into place. postreductions films to see Gilulas lines, intraosseous spaces, scapholunate and radiolunate andgles instability persisting after reduction means surgery needed.

Treatment of finger CMC dislocation-fractures

Reduction method: Longitudal traction with pressure at the base of the MC. Non-op for simple dislocation or minimally displaced fracture dislocations operative: preferred for most injuries *reverse bennets often requires an ORIF

Do they happen isolated?

Simple dislocations rare, most are fracture-dislocations

Mayfield classification (Mayfield is boxer and this is for wrist)

Starts by metacarpal 1 (thumb) and goes counter-clockwise, to the head first, this is progressive injury that occurs in following stages: Stage 1: Scapholunate disassociation. For dynamic instability: if static xrays are ok- may do cast and f/u in 6-8 weeks. If static Xrays NOT ok, surgery. Terry Thomas sign is >2mm space if non-static then must have surgery to achieve appropriate reduction Stage 2: midcarpal/capitolunate Stage 3: Lunotriquetal dissassociation: splint 6-8 weeks, possibly surgery Stage IV: radiolunate (lunate dislocation, not peri-lunate disassociation, like the other) complicationsa re median neuropathy with mayfield IV

Swanson, Szabo, and Anderson EBP for open frx treatment

Type I: clean without contamination -primary internal fixation and immediate wound closure has no increase in infection Type II: contaminated open wounds, treatment delay >24hrs, significant systemic illness (Diabetes, RA, asthma, Hepatitis, etc) has 14% infection rate, 10 times more than type 1. primary internal fixation not associated with increased infection risk.

Gamekeeper's/Skier's Thumb

Ulnar collateral ligament injury of thumb-> instability of MCP joint. Presentation- decrease in ability to pinch and grasp Skier's thumb: acute condition Gamekeeper's: chronic hyperabduction injury Mech: forced abduction of thumb (UCL functions to resist vs valgus forces) Stenar lesion: UCL pulls outside adductor aponeurosis imaging: xray PA/Lateral/oblique -stress views are controversial but may aid in bony lesion MRI can aid in dx IF exam equivocal ultrasound can be used. treatment immobilization for 4-6 weeks thumb spica. operative if >15° side to side variation or 30-35° joint space opening (ask how to assess this) Or if a stenar lesion is present **RCL (Radial collateral ligament) treatment is the same. so rare to injure this though.i

image section of traumapedia on carpals

a bit detailed not prioritized. go back later for it.

terms to use when describing hand fractures

amongst others, state if its articular or not, the deformity name, stability, and the direction of the dislocation

metacarpal head fractures- when to do surgery

anatomic reduction and fixation for displacement >1mm Comminuted also if there is articular involvement of finger or volar plate entrapment that can not be fixed.

complication of triquetrum

arhtritis and ulnar carpal instability form a non/mal union

trapezoid complications

arthritis to fusion or arthroplasty

scapholunate angle

between 30-60° 45° is norm.

pisiform complications

calcific tendinitis post-traumatic arhtritis ulnar neuropathy from subluxation of the pisiform

extensor tendon injury

caused by laceration, trauma, or overuse. 8 zones, see ortho bullets if I run into this. in general, <50% laceration of any zone is non-surgical.

Proximal and middle phalanges head fx treatmen

check with PA's and ortho bullets. traumapedica seems to state < 1 mm displacement to do nothing with- except a splint I assume

CRPP

closed reduction percutaneous pinning

complications from CMC disloc/fractures

compartment syndrome very rare 2nd and 3rd: Arthrodesis can be done for arthritis 3rd: deep palmer arterial arch at risk 5th/ reverse bennets: ulnar nerve at risk

treatment of lunate fx

dislocated or displaced frractures- closed reduction non-op- most lunate fractures heal well with

hamate treatment

dislocated or displaced frx reduction non-op : Sac or splint 4-6 weeks

triquetrum fracture treatment

dislocation/fracture undergoes closed reduction. non-op SAC or ulnar gutter splint 4-6 weeks op: displaced fx (ORIF)

Intraarticular DIP frx mgmt

dorsal lip: Mallet finger risk, so full time extension for 6-8 weeks appropriate in most fractures -involvement of >25% of surface of joint can be CRPP or ORIF Volar lip fx: Jersey finger- (FDP rupture/avulsion most common in ring finger) ORIF is prefferred for this fx. CR and extension block pinning can also be done for smaller frags

Phalanx fractures

exam: look for open wounds ASSESS ROTATION assess for numbness indicating digital nerve injury assess for digital artery injury via doppler distal phalanx fractures ( esp comminuted) have nailbed injuries. closed reduction followed by a finger splint, only very very wide displacement could use a pinning Imaging: PA/lat/oblique -proximal phalanx- will be apex volar due to proximal fragment pulled into flexion by interossei and distal fragment pulled into extension by central slip. -middle phalanx- -apex volar angulation if distal to FDS insertion -apex dorsal if proximal to FDS insertion. treatment: buddy tape or splint -extra articular <10° angulation <2 mm shortening no rotational deformity -non-displaced intra articular frx is ok too everything else is CRPP or ORIF

DIstal Phalanc fx treatment

extra articular comminuted tend to have nailbed injuries closed reduction with finger splint ok. wide displacement can had IM pinning nailbed injury: evacuate subungal hematoma via trephination if nail avulsed, cleansed and used as biologic dressing suture nailbed lacerations with 7-0 chromic under magnification

Trapezium frx treatment

first reduce non-op: thumb spica for non displaced op: articular frx, comminuted or displaced

Radiocarpal dislocation

full dislocation of all carpals from radius. This is a more serious trauma and requires surgery. radiocarpal fractures: loss of 30% of wrist ROM is typical some may need fusion in life later

Swan neck deformity

hyperextension of PIP joint and flexion of DIP joint

Thumb CMC dislocation

is rare bc usually it is a fracture- but if it is truly clean it should be stable post reduction, no need for surgery. If ligamentous injury, ask ortho what their decision making is.

Gilulas lines

lack of concentric lines suggests instability

Complications of scaphoid frx

mal union or non-union is 5-25% -occurs most often with proximal frx and smoking scaphoid non union advanced collapse (SNAC) degenerative change in radio-scaphoid joint, then lunocapitate joint Preisers disease: osteonecrosis of the scaphoid- usually with proximal pole frx, early ORIF and immobilization key to avoid

Proximal and middle phalanges extraarticular fx treatment

middle phalanx fracture at the base angle dorsal, neck fractures angle volar due to FDS. Closed reducation with finger trap traction. acceptable alignment is no rotational deformity and angulation <10° (again which direction- varus/valgus or also dorsal/volar?) operative is for anything unstable or not aligned

treatment of radiocarpal fracture/dislocations

operative generally preferred, but closed reduction with cast has shown good results.

capitate complications

osteonecrosis- there is single vessel blood supply, may need autogenous bone graft post-traumatic arthritis

most common wrist dislocation

peri-lunate dislocation

trapezium complications

postraumatic arthritis leading to fusion or arthroplasty

Compartment syndrome

pressure >15-20 warrants release of all compartments and transverse carpal ligament release

Scaphoid fracture presentation, x-rays, treatment

proximal (20%) Middle 75% distal 5% Most common carpal bone frx DX on xray ok, but CT or MRI meeded for confirmation sometimes. EXAM: snuffbox, scaphoid tubercle tender volarly X-rays: neutral PA, lateral, semi-pronated 45° oblique Scaphoid: 30° wrist extension, 20° ulnar deviation. CT: best for progression from nonunion to union after surgery. Bone scan for occult frx in acute setting MRI: most sensitive dx for occult fractures <24 hours, gives ligament injuries also. Can see vascularity of proximal pole, best seen on t1. Stability: no step off in any plane Treatment: unstable: displacement > 1 mm, scapholunate angle > 60°, radiolunate angle >15 majority are stable, non-displaced. Thumb spica CAST- 4-8 weeks, with regular x-rays to monitor progress of healing. 90% union rate in scaphoid with <1mm displacement if high level of suspicion, immoblize in thumb spica and see in 2-3 weeks. surgery if >1 mm displacementpossibly if it is proximal pole fractures.

Reverse Bennett's

radial fragment remains reduced while remainder of the MC is pulled proximally by the extensor carpi ulnaris

Digital Collateral ligament injury

radial or ulnar collarteral ligaments injured. clinical diagnosis with MRI possibly for confirmation. rare, usually from a "jammed finger" non-op treatment with buddy splinting 3 weeks for partial tear and 6 weeks for total tear.

robert view xray

really shows trapezius-MCP joint well

general fracture basics hand

reduce with a hematoma block or digital block reducations can usually be achieved with longitudal traction and pressure to reduce the deformity. Stable fractures in acceptable alignment are generally non-op treatment. fingers: buddy tape with finger splint distal, middle, proximal phalanx metacarpal forearm based splint (+ buddy tape??) maintain splint in protected position (intrinsic plus) 0° pip/dipflexion 70° mcp flexion, 20° wrist extension (POF) this minimizes stiffness thumb fractures get a Spica uninvolved joints receive early ROM early radiographic f/u required to identify any displacement early xrays to catch any displacement. unstable frx needs surgery, so splint then surgery

Proximal and middle phalanges base fx treatment

reduce with axial traction and manual pressure Volar lip fx: if articular involvement is <30% then use an extension block splinting (dorsal spint with 20° flexion allows flexion but prevents extensions) dorsal lip frx: consider a central slip avulsion frx frx with <1mm displacement may have splint in extension (like a boutenniere deofrmity) >1mm is ORIF highly comminuted frx can be treated with dnamic traction: k wires and rubber bands.

Capitate treatment

reduce. non-op- SAC splint 4-6 weeks Operative: fractures that remain displaced

brewerton view xray

shows distal mcp visual surface (metacarpal head)

Carpals dislocations and fracture easily confused with

sprains

distal and thumb interphalangeal

stable reductions can begin active motion immediately unstable immobilized in splint 2-3 weeks, 20° flexion

frx treatment basics for all metacarpal bases

thumb: extraarticular alignment not as crucial since CMC joint moves well.- closed reduction and thumb spica intraarticular: must align to minimize arthrosis (bennets and rolandos get CRPP or ORIF) Base of 2nd, 3rd, 4th are gneerally minimally displaced, so do a volar resting splint followed by early ROM. Reverse bennets - MC is being pulled proximally by extensor carpi ulnaris (ECU) radiographs fracture is best visualized with a 30° pronated view. often requires ORIF with Lag screws

Jersey finger

traumatic flexor tendon injury caused by FDP tearing off base of phalanx. exam shows finger in slight extension compared to other fingers at DIP joint. Xray of bone fragment may or may not be seen. This is a surgical case only in a splint if there is a dislocation.

Treatment of scaphoid fracture

trial of immobilization for 1-2 weeks if clinical suspicion but negative radio graphs -short arm thumb spica splint or cast in acute setting non-op- for non-displaced fracture, particularly of the distal pole and waist. -long or short arm cast with thumb spica in neutral posiiton -maintained for 4-8 weeks - interval imaging required to monitor for displacement - healing rate: distal 100% middle 80% proximal 60% operative: displaced fractures (>1mm) non-displaced waist fx in high demand patients

Thumb x-rays

true AP, oblique, lateral robert view: true AP with hand in IR, dorsum of thumb on the plate. (this is what I want to do to Robert's hand- Jiu Jitsu style!) brewerton view: dorsal digits on the plate, MCP flexed to 45°- visualizes distal MCP visual surface- (a brewer holds a cup up in the air)

Nail bed injuries

watch out if there was an open fracture under the nailbed

Kienbock's disease

when blood supply to the lunate is stopped and osteonecrosis occurs. Cause is unknown, some people have 1 instead of 2 arteries to lunate. often people present thinking they have a sprained wrist. fracture or dislocation is risk for keinbock disease early on pain and swelling can be managed with aspirin or ibuprofen, splinting for 2-3 weeks may help. revascularization is possible, and can occur in stage 1 and 2. leveling procedure if it is caused by discrepancy in radius and ulna lengths proximal row carpectomy wrist fusion