Académique Documents
Professionnel Documents
Culture Documents
• EPIDEMIOLOGY
• Metacarpal and phalangeal fractures are common, comprising 10% of all
fractures; >50% of these are work related.
• The 1998 United States National Hospital Ambulatory Medical Care
Survey found phalangeal (23%) and metacarpal (18%) fractures to be the
second and third most common hand and forearm fractures following
radius fractures. They constitute anywhere from 1.5% to 28% of all
emergency department visits, depending on survey methods.
• Location: Border digits are most commonly involved with approximate
incidence as follows:
• Distal phalanx (45%)
• Metacarpal (30%)
• Proximal phalanx (15%)
• Middle phalanx (10%)
• Male-to-female ratios run from 1.8:1 to 5.4:1, with higher ratios seen
in the age groups associated with the greatest incidence (sports
injuries in the early third decade and workplace injuries in the fifth
decade).
• ANATOMY
• Metacarpals
• They are bowed, concave on palmar surface.
• They form the longitudinal and transverse arches of the hand.
• The index and long finger carpometacarpal articulation is rigid.
• The ring and small finger carpometacarpal articulation is flexible.
• Three palmar and four dorsal interosseous muscles arise from
metacarpal shafts and flex the metacarpophalangeal (MCP) joints.
• These muscles create deforming forces in the case of metacarpal
fractures, typically flexing the fracture (apex dorsal angulation).
• Phalanges
• Proximal phalanx fractures usually angulate into extension (apex volar).
• The proximal fragment is flexed by the interossei.
• The distal fragment is extended by the central slip.
• Middle phalanx fractures are unpredictable.
• Distal phalanx fractures usually result from crush injuries and are
comminuted tuft fractures.
• MECHANISM OF INJURY
• A high degree of variation in mechanism of injury accounts for the broad
spectrum of patterns seen in skeletal trauma sustained by the hand.
• Axial load or “jamming―injuries are frequently sustained during ball sports
or sudden reaches made during everyday activities such as to catch a falling
object. Patterns frequently resulting from this mechanism are shearing articular
fractures or metaphyseal compression fractures.
• Axial loading along the upper extremity must also make one suspicious of
associated injuries to the carpus, forearm, elbow, and shoulder girdle.
• Diaphyseal fractures and joint dislocations usually require a bending component
in the mechanism of injury, which can occur during ball handling sports or when
the hand is trapped by an object and is unable to move with the rest of the arm.
• Individual digits can easily be caught in clothing, furniture, or workplace
equipment to sustain torsional mechanisms of injury, resulting in spiral fractures
or more complex dislocation patterns.
• Industrial settings or other environments with heavy objects and high forces lead
to crushing mechanisms that combine bending, shearing, and torsion to produce
unique patterns of skeletal injury and associated soft tissue damage.
• CLINICAL EVALUATION
• History: a careful history is essential as it may influence treatment.
This should include the patient’s:
• Age
• Hand dominance
• Occupation
• Systemic illnesses
• Mechanism of injury: crush, direct trauma, twist, tear, laceration, etc.
• Time of injury (for open fractures)
• Exposure to contamination: barnyard, brackish water, animal/human bite
• Treatment provided: cleansing, antiseptic, bandage, tourniquet
• Financial issues: workers’ compensation
• Physical examination includes:
• Digital viability (capillary refill should be <2 seconds).
• Neurologic status (documented by two-point discrimination [normal is 6 mm]
and individual muscle testing).
• Rotational and angulatory deformity.
• Range of motion (documented by goniometer).
• Malrotation at one bone segment is best represented by the alignment of the
next more distal segment. This alignment is best demonstrated when the
intervening joint is flexed to 90 degrees. Comparing nail plate alignment is an
inadequate method of evaluating rotation.
• RADIOGRAPHIC EVALUATION
• Posteroanterior, lateral, and oblique radiographs of the affected digit
or hand should be obtained. Injured digits should be viewed
individually, when possible, to minimize overlap of other digits over
the area of interest.
• CLASSIFICATION
• Descriptive
• Open versus closed injury (see later)
• Bone involved
• Location within bone
• Fracture pattern: comminuted, transverse, spiral, vertical split
• Presence or absence of displacement
• Presence or absence of deformity (rotation and/or angulation)
• Extraarticular versus intraarticular fracture
• Stable versus unstable
• Open Fractures
• Swanson, Szabo, and Anderson
• Type I: Clean wound without significant contamination or delay in treatment and no systemic illness
• Type II: One or more of the following:
• Contamination with gross dirt/debris, human or animal bite, warm lake/river injury, barnyard injury
• Delay in treatment >24 hours
• Significant systemic illness, such as diabetes, hypertension, rheumatoid arthritis, hepatitis, or asthma
• Rate of infection: Type I injuries (1.4%)
• Type II injuries (14%)
• Neither primary internal fixation nor immediate wound closure is associated with increased risk of infection in type I
injuries. Primary internal fixation is not associated with increased risk of infection in type II injuries.
• Primary wound closure is appropriate for type I injuries, with delayed closure appropriate for type II injuries.
• TREATMENT: GENERAL PRINCIPLES
• “Fight-bite―injuries: Any short, curved laceration overlying a
joint in the hand, particularly the metacarpal-phalangeal joint, must
be suspected of having been caused by a tooth. These injuries must
be assumed to be contaminated with oral flora and should be
addressed with broad-spectrum antibiotics (need anaerobic
coverage).
• Animal bites: Antibiotic coverage is needed for Pasterella and
Eikenella.
• There are essentially five major treatment alternatives:
• Immediate motion.
• P.260
• Temporary splinting.
• Closed reduction and internal fixation (CRIF).
• Open reduction and internal fixation (ORIF).
• Immediate reconstruction.
• The general advantages of entirely nonoperative treatment are lower cost and avoidance of the risks and complications associated with
surgery and anesthesia. The disadvantage is that stability is less assured than with some form of operative fixation.
• CRIF is expected to prevent overt deformity but not to achieve an anatomically perfect reduction. Pin tract infection is the prime
complication that should be mentioned to patients in association with CRIF.
• Open treatments are considered to add the morbidity of surgical tissue trauma, titrated against the presumed advantages of the most
anatomic and stable reduction.
• Critical elements in selecting between nonoperative and operative treatment are the assessments of rotational malalignment and stability.
• If carefully sought, rotational discrepancy is relatively easy to determine.
• Defining stability is somewhat more difficult. Some authors have used what seems to be the very reasonable criterion of maintenance of
fracture reduction when the adjacent joints are taken through at least 30% of their normal motion.
• Contraction of soft tissues begins approximately 72 hours following injury. Motion should be instituted by this time for all joints stable
enough to tolerate rehabilitation.
• General indications for surgery include:
• Open fractures.
• Unstable fractures.
• Irreducible fractures.
• Multiple fractures.
• Fractures with bone loss.
• Fractures with tendon lacerations.
• Treatment of stable fractures:
• Buddy taping or splinting is performed, with repeat radiographs in 1 week.
• Initially unstable fractures that are reduced and then converted to a stable
position: External immobilization (cast, cast with outrigger splint, gutter
splint, or anterior-posterior splints) or percutaneous pinning prevents
displacement and permits earlier mobilization.
• Treatment of unstable fractures:
• Unstable fractures that are irreducible by closed means or
exhibit continued instability despite closed treatment require
closed reduction or ORIF, including Kirschner wire fixation,
interosseous wiring, tension band technique, interfragmentary
screws alone, or plates and screws.
• Fractures with segmental bone loss
• These continue to be problematic. The primary treatment
should be directed to the soft tissues, maintaining length with
Kirschner wires or external fixation.
• MANAGEMENT OF SPECIFIC FRACTURE PATTERNS
• Metacarpals
• Metacarpal Head
• Fractures include:
• Epiphyseal fractures.
• Collateral ligament avulsion fractures.
• Oblique, vertical, and horizontal head fractures.
• Comminuted fractures.
• Boxer’s fractures with joint extension.
• Fractures associated with bone loss.
• Most require anatomic reduction (if possible) to reestablish joint congruity and to minimize posttraumatic arthrosis.
• Stable reductions of fractures may be splinted in the “protected position,―consisting of metacarpal-phalangeal flexion >70
degrees to minimize joint stiffness (Fig. 24.1).
• Percutaneous pinning may be necessary to maintain reduction; severe comminution may necessitate the use of minicondylar plate
fixation or external fixation with distraction.
• Early range of motion is essential.
• Metacarpal Neck
• Fractures result from direct trauma with volar comminution and dorsal apex angulation. Most of these fractures can
often be reduced closed, but maintenance of reduction may be difficult
Left: The collateral ligaments of the metacarpophalangeal
joints are relaxed in extension, permitting lateral motion,
but they become taut when the joint is fully flexed. This
occurs because of the unique shape of the metacarpal
head, which acts as a cam. Right: The distance from the
pivot point of the metacarpal to the phalanx in extension is
less than the distance in flexion, so the collateral ligament
is tight when the joint is flexed
Reduction of metacarpal fractures can be accomplished
by using the digit to control the distal fragment, but the
proximal interphalangeal joint should be extended rather
than flexed.
• The degree of acceptable deformity varies according to the metacarpal
injured:
• Less than 10-degree angulation for the second and third metacarpals.
• Less than 30- to 40-degree angulation for the fourth and fifth metacarpals.
• Unstable fractures require operative intervention with either percutaneous
pins (may be intramedullary or transverse into the adjacent metacarpal) or
plate fixation.
• Metacarpal Shaft
• Nondisplaced or minimally displaced fractures can be reduced and
splinted in the protected position.
• Operative indications include rotational deformity, dorsal angulation >10
degrees for second and third metacarpals, and >40 degrees for fourth and
fifth metacarpals.
• P.263
• Ten degrees of malrotation (which risks as much as 2 cm of overlap
at the digital tip) should represent the upper tolerable limit.
• Operative fixation may be achieved with either closed reduction and
percutaneous pinning (intramedullary or transverse into the adjacent
metacarpal) or open reduction and plate fixation.
• Metacarpal Base
• FINGERS
• Fractures of the base of the second, third, and fourth fingers are
generally minimally displaced and are associated with ligament
avulsion. Treatment is by splinting and early motion in most cases.
• The reverse Bennett fracture is a fracture-dislocation of the base of
the fifth metacarpal/hamate.
• The metacarpal is displaced proximally by the pull of the extensor
carpi ulnaris.
• The degree of displacement is best ascertained via radiograph with
the hand pronated 30 degrees from a fully supinated
(anteroposterior) position.
• This fracture often requires surgical intervention with ORIF.
• THUMB
• Extraarticular fractures: These are usually transverse or oblique.
Most can be held by closed reduction and casting, but some
unstable fractures require closed reduction and percutaneous
pinning. The basal joint of the thumb is quite forgiving, and an
anatomic reduction of an angulated shaft fracture is not essential.
• Intraarticular fractures
The most recognized patterns of thumb metacarpal base
intraarticular fractures are (A) the partial articular Bennett
fracture and (B) the complete articular Rolando fracture.
Displacement of Bennett fractures is driven primarily by
the abductor pollicis longus and the adductor pollicis
resulting in flexion, supination, and proximal migration
• Type I: Bennett fracture: fracture line separates major part of
metacarpal from volar lip fragment, producing a disruption of the first
carpometacarpal (CMC) joint; first metacarpal is pulled proximally by
the abductor pollicis longus.
• Type II: Rolando fracture: requires greater force than a Bennett
fracture; presently used to describe a comminuted Bennett fracture,
a “Y―or “T―fracture, or a fracture with dorsal and palmar
fragments.
• The need for fixation with a Kirschner wire should be based on the
assessment of stability, and it is not necessarily required for all open
dislocations.
• The duration of pinning should not be >4 weeks, and the wire may
be left through the skin for easy removal.
• COMPLICATIONS
• Malunion: Angulation can disturb intrinsic balance and also can result in prominence of
metacarpal heads in the palm with pain on gripping. Rotational or angulatory deformities,
especially of the second and third metacarpals, may result in functional and cosmetic
disturbances, emphasizing the need to maintain as near anatomic relationships as
possible.
• Nonunion: This is uncommon, but it may occur with extensive soft tissue injury and bone
loss, as well as with open fractures with gross contamination and infection. It may
necessitate debridement, bone grafting, or flap coverage.
• Infection: Grossly contaminated wounds require meticulous debridement and appropriate
antibiotics depending on the injury setting (e.g., barnyard contamination, brackish water,
bite wounds), local wound care with debridement as necessary, and possible delayed
closure.
• Metacarpal-phalangeal joint extension contracture: This may result if splinting is not in the
protected position (i.e., MCP joints at >70 degree) owing to soft tissue contracture.
• Loss of motion: This is secondary to tendon adherence, especially at the level of the PIP
joint.
• Posttraumatic osteoarthritis: This may result from a failure to restore articular congruity.