Difference between revisions of "Hand and finger fractures"

(Replaced content with "==DDX== *Thumb Fracture *Non-Thumb Metacarpal Fracture ==See Also== *Fractures (Main) *Finger (Phalanx) Fracture ==Source== UpToDate Category:Ortho")
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*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]]
*[[Thumb Fracture]]
*[[Non-Thumb Metacarpal Fracture]]
*[[Non-Thumb Metacarpal Fracture]]
==Non-Thumb Metacarpal Head Fracture==
*Intra-articular Fx
**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)
**AP, lateral, oblique
***Angulation assessed on lateral view
**Consider "Brewerton" view if collateral ligament avulsion fx suspected
**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
**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==
**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
**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:
***Significantly angulated 4th or 5th MC fx
**Refer for:
***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==

Revision as of 06:04, 4 January 2014