fractures and dislocations of hand

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A brief overview of various fractures and dislocations seen in hand.

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  • 1. Fractures And Dislocations of Hand Dr Aftab Alam

2. Basic AnatomyBones 3. Lumbricals and interossei 4. Blood supply 5. MR Angiogram of hand 6. Principles of Management -Mechanism of injury should be assessed regarding magitude , direction, point of application. -Fracture reduction, reduction maneuvres should not cause additional trauma and should be gentle. -Complete neurovascular examination should be done. -Injuries to tendons should be addressed. -Splints should immobilize minimum no. of joints and allow unrestricted motion at other joints. -Total duration of immobilization should rarely exceed 4 weeks. -Plain radiographs , atleast 2 projections centered at level of interest, oblique views may show displacements not evident on other views. 7. Injuries of the Thumb 8. First CMC joint - Most important Injuries (# SL DL) cause limitation of motion pain & weaknessBennett Fracture Bennett , Irish , 1882 Intraarticular # through base of first MC Shaft dislocated laterally due to pull of Abductor Pollicis Longus Medial fragment remains in place due to Volar Oblique Lig. Reduction easy but difficult to maintain. Closed Pinning Open fixation with K wires / 2- 2.7 mm screw 9. Wagner Tech for closed pinning 10. Postoperative Care Cast for 4 wks If screw fixation is used active ROM with intermittent splinting at 2 wks. Complications Malunion with CMC arthritis (1-3mm tolerated) Reduction not to be attempted after 6 wks Corrective Osteotomy by Giachino Arthritis Arthrodesis /Arthroplasty 11. Rolando Fracture Comminuted First Metacarpal Base # Presents as Y or T Pattern Differs from Bennette that usually no diaphyseal displacement Likely for Posttraumatic arthritis accurate reduction Fixed with small wires placed under the subchondral bone supplemented with a larger transarticular / transmetacarpal pinning. TBW with Ex Fix T plate 12. If reduction and fixation achieved well results are excellent. 13. Thumb Carpometacarpal Joint Dislocation Rare Injury Reported cases mostly Dorsal dislocations Dorsoradial & Volar Ob Lig most imp in preventing dislocation Should be reduced and immobilized early for 4-6 wk. If unstable OR and pinning with DR lig repair, immobilize for 46wk. Recurrent dislocation warrants ligament repair and immobilization. 14. Thumb immobilizer 15. Thumb Metacarpophalangeal Fractures Usually involve ulnar margin of proximal phalynx due to UCL avulsion Small frag/ chronic instability -> arthrosesAssociated injuries - avulsion # , dorsal capsular rupture , volar plate tears. 19. Plane Xray if 30-40 deg- functional deficit (pc) may result - consider percutaneous pin fixation. 30 deg of angulation results in loss of 22% of finger ROM AP view -little or no angulation should be accepted -indicates mal-rotation of the digit 36. Casting Buddy taping should always be done irrespective of method of casting. This prevents malrotation. 37. Bouquet Pinning of Metacarpal Neck Fracture Care should be taken to protect wrist extensors tendons by giving an incision and partially elevating them Sharp tip is cut off , bent about 3mm from leading end. Enter the canal at most acute angle possible Put several k wires through the # site Goal is to tension the wires off the intact proximal cortex and enter the distal fragment in various locations, creating a bouquet effect. 38. Operative treatment can be done with K wires 39. Indications for plating of MC shaft #s Multiple fractures with gross displacement or additional soft tissue injury Displaced diaphyseal transverse, short oblique, or short spiral fractures Comminuted intraarticular and periarticular fractures Comminuted fractures with shortening or malrotation or both Fractures with substance loss or segmental defects. 40. Metacarpal Head Fractures Intraarticular , often of 4th and 5th MC heads Occurs during fist fight,hitting opponents teeth 41. IM K wire fixation of 4th MC shaft 42. Tech for percutaneous pinning 43. Tech for ORIF of MC shaft # 44. Plating for MC shaft 45. Multiple #s treated with plating 46. Ex Fix for 5th MC shaft 47. MC shaft # fixed with Interfragmantary screws 48. Fracture of the Middle or Proximal Phalanx Direct blow over dorsum Palmer angulation with clawing 49. Pratts method ORIF 50. Proximal Interphalangeal Joint FractureDislocation Always an unstable dorsal displacement of the middle phalanx caused by disruption of the attachment of the volar fibrocartilaginous plate. If single VOLAR fragment with >50% jt space ORIF --