Hand intra articular fractures

by Dr Andrew Chin

1. Intra-articular fractures of the Hand
KTPH Hand Fracture fixation Course
31 May to 1 June 2019
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Andrew YH Chin
Department of Hand and Reconstructive Microsurgery
Singapore General Hospital

2. What is an intraarticular fracture? What is an intraarticular fracture?
Fracture with joint surface involvementFracture with joint surface involvement
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3. Bane of intra-articular fractureBane of intra-articular fracture
Loss of ligament Loss of ligament
restraintsrestraints
Loss of tendon Loss of tendon
attachmentattachment
Loss of structural Loss of structural
stabilitystability

DeformityDeformity

SubluxationSubluxation
Loss of cartilageLoss of cartilage
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4. Indications for operative treatmentIndications for operative treatment
Anatomically unstableAnatomically unstable
Functionally unstableFunctionally unstable
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5. Aims of operative treatment
Accurate reductionAccurate reduction
Stable fixationStable fixation
Early motionEarly motion
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6. Planning for fixation
Location of fracture fragmentsLocation of fracture fragments

Determines the surgical approachDetermines the surgical approach
Size & character of the fracture Size & character of the fracture
fragmentsfragments

Determines the fixation strategy Determines the fixation strategy
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7. Treatment options (fixation strategy)
Depends on size & Depends on size &
character of the fracture character of the fracture
fragmentsfragments

Sizable fragment (>5mm)Sizable fragment (>5mm)
1.5mm screws possible1.5mm screws possible

Small fragment (<5mm)Small fragment (<5mm)
Wiring or K-wireWiring or K-wire
1.3 & 1.0mm screws1.3 & 1.0mm screws
Hook plateHook plate

ComminutionComminution
External fixation assistedExternal fixation assisted
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8. Treatment options (large fragment)
(>5mm) 1.5mm implants
Bicondylar P1 fracture, fixation with Bicondylar P1 fracture, fixation with
3x1.5mm interfragmentary screws3x1.5mm interfragmentary screws
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9. Treatment options (large fragment)Treatment options (large fragment)
(>5mm) 1.5mm implants (>5mm) 1.5mm implants
Split basal P1 fracture, fixation with Split basal P1 fracture, fixation with
1.5mm condylar plate1.5mm condylar plate
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10. Treatment options (large fragment)
(>5mm) with shaft extension
Lateral “bracing” plating with 1.3mm implant
P1 comminuted fracture of the thumb, fixation with P1 comminuted fracture of the thumb, fixation with
radially placed 1.3mm plate & screwsradially placed 1.3mm plate & screws
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11. Treatment options (small fragment)
(<5mm) 1.3mm implants
Baseball fracture of ring finger, Combined dorsal & Baseball fracture of ring finger, Combined dorsal &
palmar approach, fixation with 2x1.3mm palmar approach, fixation with 2x1.3mm
interfragmentary screwsinterfragmentary screws
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12. Treatment options (small avulsion fragment)
(<5mm) wiring/K-wire
Collateral ligament avulsion of PIP joint, Collateral ligament avulsion of PIP joint,
fixation with tension band techniquefixation with tension band technique
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13. Treatment options (small avulsion fragment)
(<5mm) 1.3 mm “hook plate”
Mallet avulsion fracture fixation 1.3 mm Mallet avulsion fracture fixation 1.3 mm
“hook plate” and immediate motion“hook plate” and immediate motion
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14. Treatment options (intraarticular fragment)
(5mm) intraarticular fragment
5th MC condyle fracture, Intraarticular 5th MC condyle fracture, Intraarticular
fixation with 1.5mm screwfixation with 1.5mm screw
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15. Treatment options (comminution)
Ext fix assist, bone grafting and minimal
internal fixation
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Comminuted P1 base fracture, neutralizing Comminuted P1 base fracture, neutralizing
distraction with ext fix, bone grafting and minimal distraction with ext fix, bone grafting and minimal
fixationfixation

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Comminuted P1 base fracture, neutralizing distraction with ext fix, bone grafting Comminuted P1 base fracture, neutralizing distraction with ext fix, bone grafting
and minimal fixationand minimal fixation

17. Treatment options (comminution)
Ext fix assist, bone grafting and minimal
internal fixation
Comminuted P2 base, Suzuki traction, bone Comminuted P2 base, Suzuki traction, bone
grafting & 1.3mm hook plate fixationgrafting & 1.3mm hook plate fixation
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18. Treatment options (Bennett’s)
(5mm) 1.5 mm implants
Radiopalmar curving incision Radiopalmar curving incision
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19. Treatment options (Rolando’s)
(5mm) 1.5 mm implants
Radiopalmar curving incision Radiopalmar curving incision
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20. Treatment options (Reverse Bennett’s)
(<5mm) K-wires
Indirect fixation with 1.25mm k-wiresIndirect fixation with 1.25mm k-wires
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21. Summary
Operative treatment is indicated if the fracture Operative treatment is indicated if the fracture
is anatomically and functionally unstableis anatomically and functionally unstable
The aims of surgery is accurate reduction, The aims of surgery is accurate reduction,
stable fixation and early motionstable fixation and early motion
The fixation strategy is dependent on size and The fixation strategy is dependent on size and
character of the fracture fragmentcharacter of the fracture fragment
Comminuted fractures can be successfully Comminuted fractures can be successfully
treated with ext fix assist, bone grafting and treated with ext fix assist, bone grafting and
minimal fixationminimal fixation
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22. Acknowledgement
Prof Teoh Lam Chuan Prof Teoh Lam Chuan

for the illustrations, case pictures and x raysfor the illustrations, case pictures and x rays
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