Difference between revisions of "Hand and finger fractures"

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===Background===
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[[File:Hand bones.svg|thumb|Hand bones]]
  
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==Types==
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{{Hand and finger fractures DDX}}
  
* Splinting is used in the initial immobilization of, and often is the definitive treatment for, metacarpal fractures
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==Differential Diagnosis==
* Maintenance of the MCP joint in flexion is important to avoid immobility contractures of the collateral ligaments
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{{Hand and finger injury DDX}}
=== ===
 
  
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==See Also==
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*[[Fractures (Main)]]
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*[[Hand Diagnoses (Main)]]
  
===Thumb metacarpal Fx===
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==References==
 
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<references/>
 
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[[Category:Orthopedics]]
* Classification
 
* 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
 
* 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 30º of extension
 
* Type III - Short arm thumb-spica extening to the IP joint and wrist in 30º 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 
 
* Dispo
 
* Refer within 3-5 days:
 
* All intraarticular fractures warrant referral (most require sx)
 
* Extraarticular fractures that cannot be adequately reduced
 
=== ===
 
 
 
 
 
===Non-Thumb Metacarpal Head Fx===
 
 
 
 
 
* Intra-articular Fx
 
* 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 70-90º flexion, wrist in 20-30º extension, PIP and DIP joints in 5-10º 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 Fx===
 
 
 
 
 
* 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 15º
 
* Angle toleration (below which there is no adverse functional outcome)
 
* 2nd MC < 10º
 
* 3rd MC < 20º
 
* 4th MC < 30º
 
* 5th MC < 30º
 
* Assess rotational alignment
 
* Assess extensor apparatus
 
* Assess skin integrity
 
* Treatment
 
* Gutter splint
 
* MCP joints in 70-90º flexion, wrist in 20-30º extension, PIP and DIP joints in 5-10º of flexion
 
* Acute reduction indicated:
 
* Pseudoclawing
 
* Significantly angulated 4th or 5th MC fx
 
* Dispo
 
* Refer for:
 
* Comminution
 
* Rotational malalignment
 
 
 
 
===Non-Thumb Metacarpal Shaft Fx===
 
 
 
 
 
* 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
 
* >10º in 2nd and 3rd and >20º 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 Fx===
 
 
 
 
 
* Examination
 
* Movement at the wrist elicits pain
 
* Assess for ulnar deficits (finger abduction/adduction)
 
* Assess for rotational alignment
 
* Imaging
 
* AP, lateral, oblique
 
* 30º 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 30º of extension and MCP joints free
 
* Dispo
 
* Refer for:
 
* Intraarticular fx
 
* Etraarticular fx with malrotation
 
* Dislocation of metacarpal base CMC joint;
 
* Ulnar nerve injury
 
* 5th metacarpal base fx (typically require sx)
 
==Source==
 
 
 
 
 
UpToDate
 
 
 
 
 
 
 
 
 
[[Category:Ortho]]
 

Latest revision as of 01:13, 24 July 2017