Difference between revisions of "Hand and finger fractures"

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===Background===
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==Background==
 
+
 
* Splinting is used in the initial immobilization of, and often is the definitive treatment for, metacarpal fractures
 
* Splinting is used in the initial immobilization of, and often is the definitive treatment for, metacarpal fractures
 
* Maintenance of the MCP joint in flexion is important to avoid immobility contractures of the collateral ligaments
 
* Maintenance of the MCP joint in flexion is important to avoid immobility contractures of the collateral ligaments
  
======
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==Thumb metacarpal Fx==
 
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===<u>Thumb</u> metacarpal Fx===
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+
 
* Classification
 
* Classification
 
** Type I (Bennett's Fx)
 
** Type I (Bennett's Fx)
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* Treatment
 
* Treatment
 
** Splinting
 
** Splinting
*** Type I, II - Thumb-spica with the IP joint free and wrist in 30� of extension
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*** 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� of extension
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*** Type III - Short arm thumb-spica extening to the IP joint and wrist in 30 deg of extension
 
** RICE
 
** 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)
 
*** 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
 
** Reduction
 
*** Indicated for:
 
*** Indicated for:
**** Angulated extraarticular fx if clinician is comfortable with the procedure�
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**** Angulated extraarticular fx if clinician is comfortable with the procedure
 
* Dispo
 
* Dispo
 
** Refer within 3-5 days:
 
** Refer within 3-5 days:
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*** Extraarticular fractures that cannot be adequately reduced
 
*** Extraarticular fractures that cannot be adequately reduced
  
======
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==Non-Thumb Metacarpal Head Fx==
 
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===Non-Thumb Metacarpal Head Fx===
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+
 
* Intra-articular Fx
 
* Intra-articular Fx
 
* Examination
 
* Examination
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* Treatment
 
* Treatment
 
** Ulnar or radial gutter splint
 
** Ulnar or radial gutter splint
*** MCP joints in 70-90� flexion, wrist in 20-30� extension, PIP and DIP joints in 5-10� of flexion
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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
 
* Dispo
 
* Dispo
 
** Almost always refer b/c are intraarticular and typically comminuted
 
** Almost always refer b/c are intraarticular and typically comminuted
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===Non-Thumb Metacarpal Neck Fx===
 
===Non-Thumb Metacarpal Neck Fx===
 
 
* Examination
 
* Examination
 
** TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
 
** TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
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** Assess angulation
 
** Assess angulation
 
*** Head-to-neck angle of the metacarpals is normally 15 degrees
 
*** Head-to-neck angle of the metacarpals is normally 15 degrees
**** Fracture angulation = measured angle minus 15�
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**** Fracture angulation = measured angle minus 15 deg
 
*** Angle toleration (below which there is no adverse functional outcome)
 
*** Angle toleration (below which there is no adverse functional outcome)
**** 2nd MC < 10��
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**** 2nd MC < 10 deg
**** 3rd MC < 20�
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**** 3rd MC < 20 deg
**** 4th MC < 30�
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**** 4th MC < 30 deg
**** 5th MC < 30��
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**** 5th MC < 30 deg
 
** Assess rotational alignment
 
** Assess rotational alignment
 
** Assess extensor apparatus
 
** Assess extensor apparatus
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* Treatment
 
* Treatment
 
** Gutter splint
 
** Gutter splint
*** MCP joints in 70-90� flexion, wrist in 20-30� extension, PIP and DIP joints in 5-10� of flexion
+
*** 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:
 
** Acute reduction indicated:
 
*** Pseudoclawing
 
*** Pseudoclawing
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** Refer for:
 
** Refer for:
 
*** Comminution
 
*** Comminution
*** Rotational malalignment�
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*** Rotational malalignment
 
+
===Non-Thumb Metacarpal Shaft Fx===
+
  
 +
==Non-Thumb Metacarpal Shaft Fx==
 
* Examination
 
* Examination
 
** TTP along affected metacarpal
 
** TTP along affected metacarpal
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** Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
 
** Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
 
** Assess angulation
 
** Assess angulation
*** >10� in 2nd and 3rd and >20� in 4th and 5th metacarpal shaft fractures requires reduction
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*** >10 deg in 2nd and 3rd and >20 deg in 4th and 5th metacarpal shaft fractures requires reduction
 
** Assess rotational alignment
 
** Assess rotational alignment
 
* Imaging
 
* Imaging
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*** Long oblique fractres
 
*** Long oblique fractres
  
===Non-Thumb Metacarpal Base Fx===
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==Non-Thumb Metacarpal Base Fx==
 
+
 
* Examination
 
* Examination
 
** Movement at the wrist elicits pain
 
** Movement at the wrist elicits pain
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* Imaging
 
* Imaging
 
** AP, lateral, oblique
 
** AP, lateral, oblique
** 30� obliques pronated and supinated if usual films unable to visualize the MC bases
+
** 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
 
** Consider CT if index of suspicion high for occult fx despite "negative" plain films
 
* Treatment
 
* Treatment
** Dorsal and volar splints with the wrist in 30� of extension and MCP joints free
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** Dorsal and volar splints with the wrist in 30 deg of extension and MCP joints free
 
* Dispo
 
* Dispo
 
** Refer for:
 
** Refer for:
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==Source==
 
==Source==
 
 
UpToDate
 
UpToDate
  
 
[[Category:Ortho]]
 
[[Category:Ortho]]

Revision as of 21:49, 8 April 2011

Background

  • Splinting is used in the initial immobilization of, and often is the definitive treatment for, metacarpal fractures
  • Maintenance of the MCP joint in flexion is important to avoid immobility contractures of the collateral ligaments

Thumb metacarpal Fx

  • 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 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
  • 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 70-90 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 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 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 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
      • >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 Fx

  • 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
      • Etraarticular fx with malrotation
      • Dislocation of metacarpal base CMC joint;
      • Ulnar nerve injury
      • 5th metacarpal base fx (typically require sx)

Source

UpToDate