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
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*Maintenance of MCP joint in flexion is important to avoid immobility contractures of  collateral ligaments
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==Thumb Fracture==
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==Types==
===Classification===
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{{Hand and finger fractures DDX}}
* Type I (Bennett's Fx)
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** Fx-dislocation of the base of the metacarpal (intraarticular)
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* Type II (Rolando's Fx)
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** Comminuted version of a Bennett's fracture (intraarticular)
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* Type III
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** Extraarticular (transverse or oblique)
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* Type IV
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** Extraarticular pediatric fx involving the proximal physis
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===Diagnosis===
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*Examination
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** Important to distinguish tenderness at base of 1st MC from injury to scaphoid, trapezium, or distal radius
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** If pain or ecchymosis occurs more distally at the MCP (particularly on the ulnar side) consider ulnar collateral ligament injury (Game Keeper's Thumb)
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* Imaging
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** AP, lateral, oblique
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===Treatment===
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* Splinting
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** Type I, II - Thumb-spica with the IP joint free and wrist in 30 deg of extension
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** Type III - Short arm thumb-spica extening to the IP joint and wrist in 30 deg of extension
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* RICE
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** 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)
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* Reduction
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** Indicated for:
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*** Angulated extraarticular fx if clinician is comfortable with the procedure
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===Disposition===
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* Refer within 3-5 days:
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** All intraarticular fractures warrant referral (most require sx)
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** Extraarticular fractures that cannot be adequately reduced
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==Non-Thumb Metacarpal Head Fracture==
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==Differential Diagnosis==
*Intra-articular Fx
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{{Hand and finger injury DDX}}
*Examination
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**Swelling, decreased ROM, and TTP of MCP joint
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**Assess for rotational alignment (rotational malalignment is not tolerated)
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**Assess for skin integrity (r/o fight bite)
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*Imaging
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**AP, lateral, oblique
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***Angulation assessed on lateral view
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**Consider "Brewerton" view if collateral ligament avulsion fx suspected
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*Treatment
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**Ulnar or radial gutter splint
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***MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
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*Dispo
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**Almost always refer b/c are intraarticular and typically comminuted
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**Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises
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==Non-Thumb Metacarpal Neck Fracture==
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*Examination
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**TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
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**Loss of the normal knuckle contour
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***Due to dorsal angulation of fracture apex due to pull of the interosseous muscles
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**Assess angulation
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***Head-to-neck angle of the metacarpals is normally 15 degrees
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****Fracture angulation = measured angle minus 15 deg
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***Angle toleration (below which there is no adverse functional outcome)
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****2nd MC < 10 deg
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****3rd MC < 20 deg
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****4th MC < 30 deg
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****5th MC < 30 deg
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**Assess rotational alignment
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**Assess extensor apparatus
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**Assess skin integrity
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*Treatment
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**Gutter splint
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***MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
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**Acute reduction indicated:
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***Pseudoclawing
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***Significantly angulated 4th or 5th MC fx
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*Dispo
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**Refer for:
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***Comminution
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***Rotational malalignment
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==Non-Thumb Metacarpal Shaft Fracture==
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* Examination
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** TTP along affected metacarpal
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** Flexion at MCP is difficult
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** Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
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** Assess angulation
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*** >10 deg in 2nd and 3rd and >20 deg in 4th and 5th metacarpal shaft fractures requires reduction
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** Assess rotational alignment
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* Imaging
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** Oblique fx are more prone to shorten and rotate
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** Transverse fx generally stable (particularly isolated 3rd or 4th MC shaft fx)
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* Treatment
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** Gutter splint
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** Acute reduction indicated if there is pseudo-clawing or significant angulation
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*** Closed reduction generally corrects angulation but typically does not restore length
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* Dispo
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** Refer:
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*** Malrotation
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*** Comminution
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*** Shortening > 5mm (refer all shortening if not familiar with fx management)
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*** 2 or more metacarpal fractures
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*** Unacceptable angulation
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*** Long oblique fractres
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==Non-Thumb Metacarpal Base Fracture==
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* Examination
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** Movement at the wrist elicits pain
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** Assess for ulnar deficits (finger abduction/adduction)
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** Assess for rotational alignment
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* Imaging
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** AP, lateral, oblique
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** 30 deg obliques pronated and supinated if usual films unable to visualize the MC bases
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** Consider CT if index of suspicion high for occult fx despite "negative" plain films
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* Treatment
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** Dorsal and volar splints with the wrist in 30 deg of extension and MCP joints free
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* Dispo
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** Refer for:
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*** Intraarticular fx
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*** Extraarticular fx with malrotation
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*** Dislocation of metacarpal base CMC joint;
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*** Ulnar nerve injury
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*** 5th metacarpal base fx (typically require sx)
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==See Also==
 
==See Also==
 
*[[Fractures (Main)]]
 
*[[Fractures (Main)]]
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*[[Hand Diagnoses (Main)]]
  
==Source==
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==References==
UpToDate
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<references/>
 
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[[Category:Orthopedics]]
[[Category:Ortho]]
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Latest revision as of 01:13, 24 July 2017

Hand bones

Types

Hand and Finger Fractures

Differential Diagnosis

Hand and finger injuries

See Also

References