Hand and finger fractures: Difference between revisions
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==Thumb Fracture== | ==Thumb Fracture== | ||
===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 | ===Diagnosis=== | ||
*Examination | |||
** Important to distinguish tenderness at base of 1st MC from injury to scaphoid, trapezium, or distal radius | ** 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) | ** 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 | * Imaging | ||
** AP, lateral, oblique | ** 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 Fracture== | ==Non-Thumb Metacarpal Head Fracture== | ||
* Intra-articular Fx | *Intra-articular Fx | ||
* Examination | *Examination | ||
** Swelling, decreased ROM, and TTP of MCP joint | **Swelling, decreased ROM, and TTP of MCP joint | ||
** Assess for rotational alignment (rotational malalignment is not tolerated) | **Assess for rotational alignment (rotational malalignment is not tolerated) | ||
** Assess for skin integrity (r/o fight bite) | **Assess for skin integrity (r/o fight bite) | ||
* Imaging | *Imaging | ||
** AP, lateral, oblique | **AP, lateral, oblique | ||
*** Angulation assessed on lateral view | ***Angulation assessed on lateral view | ||
** Consider "Brewerton" view if collateral ligament avulsion fx suspected | **Consider "Brewerton" view if collateral ligament avulsion fx suspected | ||
* Treatment | *Treatment | ||
** Ulnar or radial gutter splint | **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 | ***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 | ||
** Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises | **Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises | ||
==Non-Thumb Metacarpal Neck Fracture== | ==Non-Thumb Metacarpal Neck Fracture== | ||
* 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 | ||
** Loss of the normal knuckle contour | **Loss of the normal knuckle contour | ||
*** Due to dorsal angulation of fracture apex due to pull of the interosseous muscles | ***Due to dorsal angulation of fracture apex due to pull of the interosseous muscles | ||
** 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 deg | ****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 deg | ****2nd MC < 10 deg | ||
**** 3rd MC < 20 deg | ****3rd MC < 20 deg | ||
**** 4th MC < 30 deg | ****4th MC < 30 deg | ||
**** 5th MC < 30 deg | ****5th MC < 30 deg | ||
** Assess rotational alignment | **Assess rotational alignment | ||
** Assess extensor apparatus | **Assess extensor apparatus | ||
** Assess skin integrity | **Assess skin integrity | ||
* Treatment | *Treatment | ||
** Gutter splint | **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 | ***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 | ||
*** Significantly angulated 4th or 5th MC fx | ***Significantly angulated 4th or 5th MC fx | ||
* Dispo | *Dispo | ||
** Refer for: | **Refer for: | ||
*** Comminution | ***Comminution | ||
*** Rotational malalignment | ***Rotational malalignment | ||
==Non-Thumb Metacarpal Shaft Fracture== | ==Non-Thumb Metacarpal Shaft Fracture== |
Revision as of 02:27, 27 September 2011
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
Thumb Fracture
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
Diagnosis
- 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
- Indicated for:
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 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
- AP, lateral, oblique
- 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
- Ulnar or radial gutter splint
- 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
- Head-to-neck angle of the metacarpals is normally 15 degrees
- 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
- Gutter splint
- Dispo
- Refer for:
- Comminution
- Rotational malalignment
- Refer for:
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
- Refer:
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
- Etraarticular fx with malrotation
- Dislocation of metacarpal base CMC joint;
- Ulnar nerve injury
- 5th metacarpal base fx (typically require sx)
- Refer for:
Source
UpToDate