Phalangeal fractures of hand

ANATOMY
Meatcarpophalangeal joint- Condyloid joints
ROM at MCPJ- flexion and extension of the digits, as well as a very small degree of abduction and adduction when the digits are extended.
• Phalanges - has a base, shaft, neck and head that is formed from two condyles.

• PIPJ, DIPJ - Hinge joints,
ROM at PIP and DIP joint : flexion and extension.
VERDAN’S ZONES OF HANDS
VOLAR PLATE
Vinculum breve and Vinculum longum
MECHANISMS OF INJURY

1. PHALANGEAL FRACTURES and DISLOCATONS Presenter : Dr Darshan K S(2 nd year post graduate) Moderator : Dr P AGNESH Assistant professor of orthopaedics Unit Chief : Dr G Ramesh Professor of Orthopaedics

2. ANATOMY Meatcarpophalangeal joint- Condyloid joints ROM at MCPJ- flexion and extension of the digits, as well as a very small degree of abduction and adduction when the digits are extended. • Phalanges - has a base, shaft, neck and head that is formed from two condyles. • PIPJ, DIPJ - Hinge joints, ROM at PIP and DIP joint : flexion and extension.

3. VERDAN’S ZONES OF HANDS

4. The joint capsule is reinforced on its volar aspect by the thickened ligament known as the VOLAR PLATE that prevents hyperextension of the joint

5. Vinculum breve and Vinculum longum are known to serve as transport and conduction pathways to the intravaginal segments of flexor tendons. T he Vinculum breve is regarded as essential for maintaining the tendons at work. In contrast, the significance of Vinculum longum will be variable for the microcirculation of intravaginal segments of the flexor tendons individually

6. 1. Axial load or “jamming” injuries , – shearing articular fractures or metaphyseal compression fractures. – catching a falling object 2. Bending – Diaphyseal fractures and joint dislocations – ball-handling sports or when the hand is trapped. 3. Torsional – Spiral fractures – Individual digits can easily be caught in clothing, furniture, or workplace equipment 4. Crushing – Bending + shearing + torsion. – with significant soft tissue injury MECHANISMS OF INJURY

7. Associated injuries Open injuries – Need for prophylactic antibiotics ? Previous standard administration of Ceftriaxone is no longer implacable due to MRSA dominating community acquired infection profile.( clinda,vanco ) Continuation of antibiotics beyond 24 hours.? Soft tissue reconstruction and use of flap essential for overlying skeletal injury. Tendons. Eg : Terminal tendon rupture a/w DIP, Central slip rupture a/w PIP. Nerves and vessels Massive hand trauma. Bone loss

8. FUNCTIONAL STABILITY • Fractures as functionally stable - if patients could actively move the adjacent joint more than 30% of the expected range while the alignment of fracture remained within acceptable range. • Unstable fracture - If the patient was not able to move the adjacent joint more than 30% of the expected range or movement resulted in malalignment.

9. DISTAL PHALANX FRACTURES Terminal point of contact . Therefore experiences stress loading forces. • Soft tissue injury is of greater significance • Hematoma can be seen beneath the nail plate- nail bed injury • Mechanism – crushing. • Radiographs - isolated views of the injured digit.

10. The proximal part of the pulp is thicker and more mobile than the distal pulp. The proximal portion of a tuft fracture may become entrapped in the septae of the pulp and prove irreducible. The dorsal surface of the distal phalanx is the direct support for the germinal matrix and sterile matrix of the nail. The bone volarly and the nail plate dorsally create a three-layered sandwich with the matrix in the middle

11. ASSOCIATED INJURIES : – Nailbed lacerations – Nail plate avulsion – Skin lacerations – Subungal hematoma

12. PATHOANATOMY • Shaft fracture – Transverse fracture – Longitudinal Tuft fracture (associated with nail bed fracture and open fracture) Dorsal Base (Mallet finger) Volar base ( Type III Jersey finger) Salter-Harris • The two mechanisms . – sudden axial load (as in ball sports) – crush injury

13. Crush fractures of the tuft are often stable. Majority of bone flakes at the volar base P3 are FDP tendon ruptures. Dorsal base IA # with shearing force will have intra articular extension(>20%) and should be distinguished from avulsion fracture.

14. MALLET FINGER Doyle’s classification for Mallet Finger Classification : TYPE 1 : Closed/blunt trauma No fracture, loss of tendon continuity with or without a small avulsion fracture (full extension or hyperextension in the DIP joint). Maintain for 8 weeks, Use for 2-6 weeks n ightime . M olded polythene (Stack) or aluminum splint .

15. TYPE 2 : Lacerations at or proximal to distal interphalangeal joint with loss of tendon continuity. (SUPERFICIAL SOFT TISSUE INJURY) Direct repair of the extensor tendon can be done by tendon suture repair and Kirschner wire fixation of the distal interphalangeal joint in full extension.

16. TYPE 3 : Deep abrasion with loss of skin ,subcutaneous cover and tendon substance. (DEEP SOFT TISSUE INJURY) Require soft-tissue coverage and pinning of the distal interphalangeal joint and possible primary arthrodesis.

17. Type 4: 4A , transphyseal fracture in children. 4 B , hyperflexion injury with fracture of articular surface of 20% to 50%. 4C , hyperextension injury with fracture of the articular surface usually greater than 50% with early or late volar subluxation of the distal phalanx.

18. C losed reduction with Extension Block Pinning • 6 Weeks: Remove kwire , wean from splint use • 3 Months: Resume full activities. Assess ROM. EXTENSION BLOCK PINNING

19. OPEN REDUCTION AND FIXATION WITH A PULL-OUT WIRE AND TRANSARTICULAR KIRSCHNER WIRE

20. JERSEY FINGER (FLEXOR TENDON AVULSION) Type I- Vincula ruptured with tendon retracted to the palm. Leads to disruption of the vascular supply. Able to fully flex PIP j oint .(If FDS intact) – Exploration and Primary repair within 10 days

21. TYPE 2 : FDP retracts to level of PIP joint. Unable to flex D IP and PIP joint. Primary repair as soon as possible. Primary repair may still be possible several weeks.

22. TYPE 3: Large avulsion fracture limits retraction to the level of the DIP joint Repair of fracture fragment (6 weeks)

23. TYPE 4 : Osseous fragment and simultaneous avulsion of the tendon from the fracture fragment  (" Double avulsion ” with subsequent retraction of the tendon usually into palm) If tendon separated from fracture fragment, first fix fracture via ORIF then reattach tendon as for Type I/II injuries

24. ANCHOR SUTURE TECHNIQUE DORSAL BUTTON TECHNIQUE

25. Jersey Finger Follow-up Care Splint for 4-6 weeks • Begin passive flexion exercises at one week • Remove suture/button at 4 weeks and begin protected active motion • Continue activity limitations for 12 weeks.

26. TUFT FRACTURES Splinted in a simple aluminum and foam splint. When the seal of the nail plate with the hyponychium has been broken and the tuft fracture is displaced, this represents an open fracture, that should be treated on the day of injury with debridement followed by direct nail matrix repair. K-wires for 4 to 6 weeks .

27. SHAFT FRACTURES Splinted with stack/ aluminium splints for undisplaced fractures. Headless screws Kirshner wire fixation.

28. Middle Phalanx (P2) Fractures • Head, neck, shaft, and base. Intra-articular fractures that occur at the base of the middle phalanx are m ost functionally devastating of all fractures. • T he most technically difficult to treat.

29. Unicondylar or bicondylar fractures of the head. • Partial articular fractures – Dorsal base – Volar base – Lateral base Complete articular fractures – “ pilon ” fractures. “ – Unstable in every direction including axially.

30. • Static Splinting. – Comminution with no significant displacement. • Dynamic Extension Block Splinting. – Volar base of P2 - less than 40% of the articular surface. • Condylar fractures – CRIF- converging or diverging k wires. • Unstable shaft fractures – CRIF – K wiring – ORIF – Lag screw fixation – if rotational instability. – Plate and screw fixation – if axial instability. Middle Phalanx Fracture- Treatment Options

31. Extension block splinting Diverging and converging k- wires

32. Temporary Transarticular Pinning for Partial Articular Base Fractures. • Volar Base Fractures – CRIF /ORIF • Pilon fractures. – Highly unstable,stiffness of PIPJ. – Dynamic traction / dorsal spring mechanism. – The general principle is to establish a foundation at the center of rotation in the head of Proximal phalanx. – traction (adjustable or elastic) is applied along the axis of P2 to hold the metaphyseal component of the fracture out to length.

33. Volar base fracture fixation Strategies for PILON fracture fixation

34. Custom hook plate for dorsal base fratcures Lag screw fixation for dorsal base fracture

35. External fixation frame

36. HINGED EXTERNAL FIXATOR

37. PROXIMAL PHALANGES FRACTURES • Head - Intraarticular fractures – partial or complete articular • Neck - extra-articular fractures – (extreme PIPJ limitation) • Base - extra-articular and intra-articular. • Shaft -extra-articular fractures – transverse, short oblique, long oblique, or spiral

38. PATHO ANATOMY • Sheet-like extensor mechanism with a complex array of decussating collagen fibers.

39. P 1 – Treatment options • Non operative . – Stable proximal fractures, Transverse shaft. – Dorsal splinting with the MP joint in flexion. – discontinued at 3 weeks, followed by AROM . – Stable + undisplaced – immediate AROM with buddy strapping. – Weekly follow up. Ball and bandage tech for base of proximal phalanx • Operative – CRIF/ORIF

40. Closed Reduction + Internal Fixation • Reducible but unstable isolated fractures. • For long oblique and spiral fractures – three K-wires- perpendicular to the fracture • For neck fractures- – retrograde pinning may be necessary • For short oblique and transverse fractures, – longitudinal K-wires .

41. Open Reduction and Internal Fixation • Indications : – Open fractures – multiple fractures – intra-articular fractures with displacement – Spiral fractures • lag screws • to achieve precise control over rotation.

42. Postoperative Care – P 1 fracture • Non operative – Restrict splinting to 3 weeks followed by AROM. • CRIF – pin removal at 3 weeks start AROM. ORIF – AROM should begin within 72 hours of surgery and edema control

43. DISLOCATIONS AT INTERPHALANGEAL JOINT

44. Interphalangeal joint dislocations often cannot be reduced with closed techniques. Entrapment of the lateral band around the head of the proximal phalanx may block reduction, and open reduction may be necessary.

45. SAFE CORRIDORS IN FINGERS It is the area where k – wire can be passed with minimal soft tissue trauma and without damaging vital structures like extensor expansion, neurovascular structures and flexor tendons. This allows relatively pain free active range of movements and prevent stiffness.

46. SAFE CORRIDOR IN HAND

47. Paediatric mallet finger Pediatric mallet fingers or Seymour fractures should be treated with closed reduction and splinting of the distal interphalangeal joint in neutral or slight extension for 4 weeks. Open reduction and Kirschner wire fixation of the epiphyseal fragment is indicated if closed reduction cannot be obtained. Remove the k wire within 2 weeks and start early mobilization if the k wire is inserted through the epiphysis.

48. ROCK WOOD AND GREENS, FRACTURES IN ADULTS – 8 th edition. Charles M Court Brown James D Heckman Margaret M Mcqueen William M Ricci Paul Tornetta • Campbell’s Operative Orthopaedics , 14 th edition. Fredrick M Azar James H Beaty A O principles of fracture management K wiring principles and techniques C REX

49. THANK YOU

50. MCP dislocation of thumb T humb is second most common digit involved M ECHANISM OF INJURY U sually a fall on outstretched hand leading to hyperextension of MCP joint leads to avulsion of the volar plate from metacarpal neck Associated conditions M etacarpal and phalanx fractures of the base of proximal phalanx or metacarpal head seen in up to 50%

51. Simple (subluxation) : No interposition of volar plate and/or sesamoid Base of proximal phalanx remains in contact with the metacarpal head. COMPLEX :Interposition of volar plate and/or sesamoidsMetacarpal head becomes entrapped by     -displaced natatory ligaments distally     -superficial transverse metacarpal ligament proximally

52. C omplex dislocation - joint space widening may indicate interposition of volar plate . E ntrapment of sesamoid in MCP joint is diagnostic of complex dislocation Radiograph findings:

53. Closed Reduction: D orsal dislocation r eduction technique: A pply direct pressure over dorsal aspect of proximal phalanx with the wrist in flexion to take tension off the intrinsic and extrinsic flexors.   A void longitudinal traction during closed reduction as it may pull volar plate into joint and convert to irreducible immobilization. Early ROM and dorsal blocking splint following successful reduction

54. Complications Stiffness Malunion Non union Tendon rupture Hypersentivity syndrome Post traumatic Arthritis Premature physeal closure in paediatric age groups