Difference between revisions of "Hand and finger fractures"

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(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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==Background==
 
*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
 
 
 
==DDX==
 
==DDX==
 
*[[Thumb Fracture]]
 
*[[Thumb Fracture]]
 
*[[Non-Thumb Metacarpal Fracture]]
 
*[[Non-Thumb Metacarpal Fracture]]
  
==Non-Thumb Metacarpal Head Fracture==
 
*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 70-90 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==

Revision as of 06:04, 4 January 2014

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