Difference between revisions of "Hand and finger fractures"

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==Background==
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[[File:Hand bones.svg|thumb|Hand bones]]
*Splinting is used in initial immobilization of, and often is definitive tx for, metacarpal fractures
 
*Maintenance of MCP joint in flexion is important to avoid immobility contractures of  collateral ligaments
 
  
==Thumb Fracture==
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==Types==
===Classification===
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{{Hand and finger fractures DDX}}
* Type I (Bennett's Fx)
 
** Fx-dislocation of the base of the metacarpal (intraarticular)
 
* Type II (Rolando's Fx)
 
** Comminuted version of a Bennett's fracture (intraarticular)
 
* Type III
 
** Extraarticular (transverse or oblique)
 
* Type IV
 
** Extraarticular pediatric fx involving the proximal physis
 
===Diagnosis===
 
*Examination
 
** Important to distinguish tenderness at base of 1st MC from injury to scaphoid, trapezium, or distal radius
 
** If pain or ecchymosis occurs more distally at the MCP (particularly on the ulnar side) consider ulnar collateral ligament injury (Game Keeper's Thumb)
 
* Imaging
 
** AP, lateral, oblique
 
===Treatment===
 
* Splinting
 
** Type I, II - Thumb-spica with the IP joint free and wrist in 30 deg of extension
 
** Type III - Short arm thumb-spica extening to the IP joint and wrist in 30 deg of extension
 
* RICE
 
** Significant swelling or overly aggressive icing to radial side of thumb may result in temporary palsy to the superficial radial nerve (numbness over the dorsum of the thumb)
 
* Reduction
 
** Indicated for:
 
*** Angulated extraarticular fx if clinician is comfortable with the procedure
 
===Disposition===
 
* Refer within 3-5 days:
 
** All intraarticular fractures warrant referral (most require sx)
 
** Extraarticular fractures that cannot be adequately reduced
 
  
==Non-Thumb Metacarpal Head Fracture==
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==Differential Diagnosis==
*Intra-articular Fx
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{{Hand and finger injury DDX}}
*Examination
 
**Swelling, decreased ROM, and TTP of MCP joint
 
**Assess for rotational alignment (rotational malalignment is not tolerated)
 
**Assess for skin integrity (r/o fight bite)
 
*Imaging
 
**AP, lateral, oblique
 
***Angulation assessed on lateral view
 
**Consider "Brewerton" view if collateral ligament avulsion fx suspected
 
*Treatment
 
**Ulnar or radial gutter splint
 
***MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
 
*Dispo
 
**Almost always refer b/c are intraarticular and typically comminuted
 
**Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises
 
 
 
==Non-Thumb Metacarpal Neck Fracture==
 
*Examination
 
**TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
 
**Loss of the normal knuckle contour
 
***Due to dorsal angulation of fracture apex due to pull of the interosseous muscles
 
**Assess angulation
 
***Head-to-neck angle of the metacarpals is normally 15 degrees
 
****Fracture angulation = measured angle minus 15 deg
 
***Angle toleration (below which there is no adverse functional outcome)
 
****2nd MC < 10 deg
 
****3rd MC < 20 deg
 
****4th MC < 30 deg
 
****5th MC < 30 deg
 
**Assess rotational alignment
 
**Assess extensor apparatus
 
**Assess skin integrity
 
*Treatment
 
**Gutter splint
 
***MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
 
**Acute reduction indicated:
 
***Pseudoclawing
 
***Significantly angulated 4th or 5th MC fx
 
*Dispo
 
**Refer for:
 
***Comminution
 
***Rotational malalignment
 
 
 
==Non-Thumb Metacarpal Shaft Fracture==
 
* Examination
 
** TTP along affected metacarpal
 
** Flexion at MCP is difficult
 
** Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
 
** Assess angulation
 
*** >10 deg in 2nd and 3rd and >20 deg in 4th and 5th metacarpal shaft fractures requires reduction
 
** Assess rotational alignment
 
* Imaging
 
** Oblique fx are more prone to shorten and rotate
 
** Transverse fx generally stable (particularly isolated 3rd or 4th MC shaft fx)
 
* Treatment
 
** Gutter splint
 
** Acute reduction indicated if there is pseudo-clawing or significant angulation
 
*** Closed reduction generally corrects angulation but typically does not restore length
 
* Dispo
 
** Refer:
 
*** Malrotation
 
*** Comminution
 
*** Shortening > 5mm (refer all shortening if not familiar with fx management)
 
*** 2 or more metacarpal fractures
 
*** Unacceptable angulation
 
*** Long oblique fractres
 
 
 
==Non-Thumb Metacarpal Base Fracture==
 
* Examination
 
** Movement at the wrist elicits pain
 
** Assess for ulnar deficits (finger abduction/adduction)
 
** Assess for rotational alignment
 
* Imaging
 
** AP, lateral, oblique
 
** 30 deg obliques pronated and supinated if usual films unable to visualize the MC bases
 
** Consider CT if index of suspicion high for occult fx despite "negative" plain films
 
* Treatment
 
** Dorsal and volar splints with the wrist in 30 deg of extension and MCP joints free
 
* Dispo
 
** Refer for:
 
*** Intraarticular fx
 
*** Extraarticular fx with malrotation
 
*** Dislocation of metacarpal base CMC joint;
 
*** Ulnar nerve injury
 
*** 5th metacarpal base fx (typically require sx)
 
  
 
==See Also==
 
==See Also==
 
*[[Fractures (Main)]]
 
*[[Fractures (Main)]]
*[[Finger (Phalanx) Fracture]]
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*[[Hand Diagnoses (Main)]]
 
 
==Source==
 
UpToDate
 
  
[[Category:Ortho]]
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==References==
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<references/>
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[[Category:Orthopedics]]

Latest revision as of 01:13, 24 July 2017