Let's begin with your first talk. Today we'll speak, or this morning, on phalangeal and metacarpal fracture management. So as a means of introduction, really the hand is quite an elegant appendage for our body. And it is really the most common injury of the skeletal system is fractures of the hand and wrist. And so our patient's function is very dependent on effective treatment for those types of injuries. And so hopefully we can share some things for you. Now, this is a fairly straightforward talk. But some of the more common questions that you will likely even see on your test will be included within this talk. And hopefully that will help you then later in your exam. So initial assessment, when we look at patients with these types of injuries, we look at the mechanism. What's involved? Is there a crush injury? Is it a sharp injury? Is there contamination potentially of the soft tissue? It's important to know the handedness of our patient. Are they right-hand dominant, left-hand dominant? Where is that fracture located? What is their vocation? Are they a musician? Do they spend the majority of their free time playing an instrument? That can often impact how we're going to end up treating patients with a particular injury of their hand. And do they have associated medical problems? We all know that diabetes and smoking can adversely impact the healing of an injury. So initial assessment, physical exam, we look for any malalignment of the digits. There's an obvious photograph there on the right-hand side showing scissoring of the ring finger. We look for swelling in their extremity. We look at their circulatory status. Do they have adequate cap refill? I will tell you oftentimes there are more severe injuries that you're assessing potentially in the ER or even in your office. And just be sure that, you know, you don't get sort of taken in by the severity of an injury. Go back to the standards of your physical exam. Clean, dried blood from the fingertips so that you can assess circulatory status. You don't want to be surprised if you ultimately need to take something to the OR that you've missed something that you otherwise would need to fix. Do a thorough neurologic exam. Tenderness. Palpate around the entire hand. Don't just once again get caught up in looking at the injury potentially that is so obvious. Palpate around the hand. Maybe they have an associated thumb injury that you ideally don't want to miss at the time of performing a surgery, such as a collateral ligament injury, for instance. So, x-rays are critical. You want a good quality film. If it's inadequate, send the patient back. Be sure that you get perfect films. Oftentimes, the tech doesn't get such a perfect lateral, for instance, if you're assessing a condylar fracture. And it's important just to be diligent in getting the appropriate films. So, the personality of the fracture. We often hear that in orthopedics. Is it an open or closed type fracture? Are there single fractures or multiple injuries to the digit? Is there comminution? Comminution can either be stable or unstable. It often does reflect, however, that there's more injury at hand, such as soft tissue injury, that we may ultimately also need to address at the same time of skeletal stabilization. Obviously, the location of that fracture, is it involving the shaft, the articular surface, or is it a periarticular fracture, which may alter how we're going to end up treating that particular injury? So, in looking at phalangeal fractures, I thought it would make sense to start at the distal phalanx and work our way up. So, the distal phalanx, often we see crush mechanisms. Workers in an industrial setting, maybe with punches and dies, that end up crushing the fingertip or car doors, a frequent type of injury that we see. We need to look for whether there's nail bed disruption. There is some controversy whether or not we need to decompress a subungal hematoma. I will say that I have a low threshold. If there's 100% involvement, obviously we know that there is likely a laceration involving the nail bed, and then the standard teaching is to remove that nail plate and perform a laceration repair, in addition to whatever skeletal stabilization we may need to do. Here you see in a picture on the right that the base of the nail bed will often extrude and flip over the eponychium, and so that will warrant intervention on our part to ensure that the patient has the best outcome by fixing that. So, often for non-displaced distal phalanx fractures, closed treatment is appropriate. I will often splint those patients for four weeks. Occasionally, pin fixation is necessary. If the injury involves relatively significant displacement at the shaft, then a pin will make sense, and that would involve performing a reduction and then usually pinning through the DIP joint. You need to tell your patients these injuries can often be painful, and even for many months. Often they have sensitivity even to exposure to cold, and if you reassure them that, and they expect it, it will make life a little better for you even in treating that patient over time. I don't often send patients to therapy for this type of injury, but if you already anticipate that they're having some difficulty with sensory function, then sending them to a trained therapist is often helpful to desensitize. The other thing is these fractures don't always unite, and I will tell patients early on, we don't have to become so fixated on the X-ray. If it's a comminuted distal tuft fracture, typically it won't require any intervention, even if there's a non-union. If there's a stable fibrous non-union, it doesn't necessarily mean you need to do anything about it, but if it's painful, excision is an option. So moving up the digit, bony mallet injuries, very common injury we see actually here in Chicago. Chicagoans love to play 16-inch softball. It's a hard, large softball, and I see a lot of bony mallet injuries. These most often can be treated closed with a splint distally, and it's kind of dealer's choice, but the bottom line is that you want to leave the PIP joint free, provided there's no associated swung neck deformity, and put the distal phalanx in a bit of hyperextension. So in the case, though, where we see a subluxated distal phalanx, where the articular involvement of that bony fragment is over 30% of the articular surface, the profundus is pulling that distal fragment into a subluxed position, and that we definitely need to address. And simple splinting is usually not sufficient for that, and that's where there's a surgical indication to fix that particular bony mallet. And there are various techniques. One is extension block pinning, where you can keep the fracture closed and use a technique where you put a dorsal K-wire in, use it as a block after flexing the tip of the digit into hyperflexion, use a K-wire dorsally, and then put the finger back up into full extension and put a K-wire down, crossing the DIP joint. That should usually be sufficient. I would caution you about trying to do an ORIF of these small fracture fragments. The skin is very unforgiving there, and those fragments are so small. Ideally, you try to do that in a closed technique. Moving up the digit, this is something you will likely see on the training exam, a Seymour fracture. Hopefully, you're not seeing more of these. It's an open Salter-Harris Type 1 fracture, where in a child with open physis, they have a fracture at the physis with incarcerated nail bed. And I have a picture of that in the next slide, where you can see they are at risk. This is an open fracture, considered open fracture, and they are at risk of infection. So it's really something we shouldn't miss. You can see that the eponychium is enlarged, and the base of the nail has flipped up because of the displacement at the growth plate. And here you can see on the right, on the lateral, that there is incongruity and displacement at the physis. So that requires open reduction, taking off the nail plate, making relaxing incisions on the radionulnar aspect of the eponychium, opening it up, and taking that incarcerated germinal matrix from the physis. It is interposed at the physis. And on this view, you see on the left, intraoperatively, the open incision dorsally, accentuating the fracture, and then ultimately performing a reduction after removing the incarcerated tissue and keeping a K-wire in there for about four weeks. So moving on now up the phalangeal shaft, proximal and middle phalangeal fractures are common. Displacement will often depend on the mechanism of injury, whether there's comminution, and truthfully, the tendon forces that are at play here on the digit. In the proximal phalanx, often we see apex volar angulation, which is typical. Here you see that the interosseous proximally will pull the proximal fragment into flexion, and the central slip remains inserted distally on the middle phalanx, and it will hyperextend at the PIP joint. And so you see that apex volar angulation. Here's a nice cadaver dissection showing the intricacy of the extensor mechanism, the terminal tendon on your right, and then the central slip there just below the hemostat on the right-hand side of that hemostat. So in the middle phalanx, it can be a bit different. We know that there's a more broad insertion of the FDS at the volar portion of the middle phalanx, and angulation will be dependent on the site of the fracture. In base fractures, we often see an apex dorsal where the FDS insertion is just distal to that fracture line and then pulls the middle phalanx into flexion. In neck fractures, now the FDS is pulling the more proximal fragment into flexion, and then once again, it is all relative to the position of the FDS insertion. We may see some differences with more advanced injuries and crush injuries. Now I mentioned earlier about on physical exam looking for malrotation or scissoring. It's critical. First thing I ask for patients is can you make a fist, and even if they can't, you can at least get a gestalt feeling for whether or not they have some even subtle malrotation of their digits. There's no one fixed point, but when they make a fist, the nail plate should all point towards the scaphoid tubercle. And you can even do the tenodesis effect intraoperatively and compare oftentimes when you're fixing a fracture maybe on the right hand and you're uncertain as to their cascade, you can use the tenodesis effect and look at their left hand. There can be, and there is, natural variation due to asymmetry of condyles, and so definitely you want to compare to the contralateral arm when you have any question on malrotation. Malrotation is often due to a twisting mechanism. It's often associated with an oblique fracture, which is typically unstable. And treatment for a phalangeal fracture that is nondisplaced, such as what you see on the right, typically just can involve body taping and early active motion. However, that must be a stable fracture with no angulation or malrotation. You can attempt to treat an unstable fracture closed after an adequate reduction, but that obviously will require frequent follow-up with radiographs to confirm there's been no displacement. Here's a case shared by a colleague with me who's a young female. She had a left ring finger deformity when her finger was caught and twisted in a dog leash. And I think I showed this picture earlier, but you see significant malrotation of her ring finger. I would have probably been more prone to intervening surgically, but my colleague treated this patient with a closed reduction. And you see the proximal phalanx oblique fracture there on the left. Performed a closed reduction and ulnar-gutter splinting with early motion when there was confirmed stability and then body taping to the small finger and achieved a good outcome. So this particular fracture, I probably would have a low threshold to treating even with K-wire fixation, and we'll talk about some of those fixation options yet. But you can treat fractures in a closed fashion if you achieve a good reduction. Now, we haven't talked yet about the various options in fracture fixation, but Peter Stern did a nice review on complications and range of motion in fixation with plate and screws, both with phalanx fractures and metacarpals. And it's just nice to see, or not necessarily nice to see, but it points out that in phalangeal fractures fixed with plates and screws, there's a very high complication rate and risk of lack of motion in the final outcome. So the bottom line is be very careful in using that plate and screw technique in phalangeal fractures. We know that metacarpal fractures have a better outcome with that technique. So, interspersed in this talk, I have some of the common questions that you may see on the exam. Here's a 35-year-old female that presented with a small finger deformity, shown on the right. X-rays revealed a rotational malunion of the metacarpal shaft. So what is the expected mean correction in deviation of the fingertip with a one-millimeter derotation of the metacarpal when performing osteotomy? You'll likely see this type of question. Mike, is there a means where they're answering questions? Okay. Okay. So I don't know if anyone is willing to give an answer. No? Okay. So in the interest of time, we'll move on. But the preferred response there is A, one centimeter. So the rule of thumb there is a one-millimeter derotational osteotomy correction at the metacarpal will result in one centimeter of correction of malrotation at the tip of the digit. So, in phalangeal fracture malunions, you can perform a correction with osteotomy at the metacarpal. It's a common question in the SAE. So, again, continuing onward with phalangeal fractures, closed manipulation and pinning is often a preferred technique in that it really minimizes soft tissue disruption. I showed you Peter Stern's article. If we can get away with minimal soft tissue disruption, you'll come ahead in fracture fixation for fingers. The PIP joint, truthfully, is the predictor of success. I tell patients that joint cannot take a joke. When it is injured, it will swell and want to become stiff. So adding insult with surgery anywhere around the PIP joint is really fraught often with difficulty in achieving outcomes with good motion. So you want to introduce pins away from the PIP joint and you should avoid violating that joint. There is a technique in proximal phalanx fractures where you can pin through the metacarpal head. We know that with hyperflexion of the proximal phalanx for a base fracture, you will achieve a reduction and a good technique and one available to you is to pin through the metacarpal head. Now, there's a theoretical risk of potential infection there and even joint infection. I've personally not seen that and I think it's a technique you might want to include in your armamentarium. So with ORIF, if we choose to do that technique, the critical advantage there is that hopefully you've achieved a stable fixation where now you can engage active range of motion, early motion in your patient. You do pay a price with the soft tissues, as I mentioned earlier. And your options, you know, once again, even with ORIF, include K-wires, 90-90 wiring, or screw and plate fixation. Interfragmentary screws are appealing for long oblique fractures where the length of the fracture is more than two times the diaphysial width. That's kind of a rule of thumb. Here you see on the left side the radiograph showing a comminuted fracture at the base of the small finger in the proximal phalanx and there's a technique in using plate and screw fixation where the approach is at the mid-axial line on the proximal phalanx and avoids disruption or involvement of the extensor tendon, which can also become scarred with fracture fixation on the digits. Here's a radiograph of interfrag screw fixation. So ligament avulsion fractures, another variety that we see in the digits, often these are small fragments at the base of the proximal phalanx. If it's non-displaced, typically buddy taping is sufficient to achieve union and minimize disruption for the patient. In larger fragments where there may be articular step-off and they are displaced, that warrants fracture fixation. So you see the radiograph on the left. That's a small finger basilar fracture through the inter-articular portion of that proximal phalanx, and that warrants fracture fixation given the amount of displacement that is involved. And a singular screw there is sufficient as long as you're capturing the opposite cortex of that phalanx. Condylar fractures also are now inter-articular fractures of the digit. There can be varus or valgus force as the reason for the injury. These are obviously inter-articular, and you will see digital angulation, not necessarily maybe mal-rotation, but angulation deformity with these injuries. These typically demand ORIF and are challenging fractures to fix. There is a technique. My preference is to perform a dorsal exposure for a comminuted condylar fracture where you can create a window between the central slip and the lateral bands and perform arthrotomy and be sure that you have an adequate reduction of the articular surface. You can use K-wires or even compression screws for these types of injuries. Here you see an example of a singular screw achieving fixation for that unicondylar fracture fragment. So now moving up to the metacarpals. These, truthfully, are miniature long bones. They have an arch in the long axis and are concave on the volar surface. We need to keep that in mind when we're performing fixation. They are frequently comminuted and sometimes difficult to fix. Distraction is an option in those comminuted fractures. I have a picture there of a technique that I don't personally use. I think that's more for historical purposes. I think patients probably wouldn't tolerate that nowadays. And early motion is the key in treating these fractures to avoid the inevitable stiffness that can occur if we're not moving the patients early on. Now, usually there is dorsal angulation or apex dorsal with the distal fragment volarly angulated due to the intrinsic and extrinsic pull of the tendons across the fracture. There's a 10, 20, 30, and 40 degree rule. And that means 10 degrees of angulation is tolerated at the index finger, 20 at the middle, 30 at the ring, and 40 is the rule of thumb in the small finger. We allow and will accept more angular deformity in the ulnar digits because of that mobility that we have at our CMC joints in that location. And so that mobility will help compensate for that angular deformity. And I've tolerated even more than 40 degrees and have patients with fine outcomes, as long as there's no malrotation or scissoring of the digit. So here's an exam question from 2011. Ideal management of an isolated fracture of the small finger metacarpal neck with 40 degrees of apex dorsal angulation and no rotational deformity is... Do we have any takers on this one? What's that? D. D is correct. Excellent. So there's really no published evidence yet that operative treatment of a small finger metacarpal neck fracture without any rotational deformity improves the functional outcome. And so you will likely see a question like this when you're taking the exam. So for close treatment, I will typically have patients wear an intrinsic plus either cast or splint, typically for three to four weeks, and then have that cast removed and allow early active range of motion with further protection for more vigorous activities. Indications for operative fixation for metacarpals are unstable fractures, significant angular deformity, any malrotation that we appreciate, particularly on the physical exam, multiple fractures of the metacarpals is also an indication for surgical intervention, and also open injuries. Our treatment options include K-wires, screws, plates, intramedullary nails, interosseous wiring, and external fixation. It really, I believe, comes down to also what works well in your hands and what you feel comfortable with. Knowing some of the shortcomings and the potential issues with some of the fracture fixation techniques. So with K-wires, we obviously will avoid the extensor mechanism and can often even allow for early range of motion despite the indwelling K-wire. So here you see K-wire fixation used for a transverse fracture where you can place those K-wires both distal and proximal to the shaft fracture, pinning it and supporting it to the ring finger metacarpal. It leaves the extensor mechanism undisturbed and can allow for early motion. Screw fixation is often used for long oblique fractures. I had some examples even in the phalanx, the proximal phalanx with screw fixation for long oblique fractures, and you use those when the fracture length is twice the diameter of the diaphysis. Blades are typically reserved for transverse fractures, multiple fractures, even open injuries with minimal contamination. However, we know that this can cause extensor adhesions and patients have minimal soft tissue coverage over the dorsum of the hand and we know that that's a potential issue, so I will even counsel patients, potentially we may need to remove that hardware in the future. So here you see examples of multiple fractures of the metacarpals and using dorsal plate fixation. The benefit there is that we can allow that patient to move early on. Here's an example of using, on the left you see, it's hard to see on the AP radiograph of the middle finger metacarpal fracture, but there's a spiral oblique fracture and both of these were treated with interphrag screws. So now there's a technique of bouquet pinning for metacarpal neck fractures. There are people who are very facile with this. I don't personally use it as that often, but it is an appealing type of technique where you can create intramedullary stacking of nails and achieve a reduction of a metacarpal neck fracture. So here you see you're essentially filling the canal. You put a little bend on the distal tip of that K wire and there are even vendors that have specific instrumentation for this technique that make it even simpler, but often that hardware will need to come out if it's prominent proximally. Border digits are appealing in doing this, and here you see a technique done on the index finger with the bouquet pinning. So there are mixed techniques. Here's a 29-year-old unemployed male who had a hand deformity following an altercation, and that's a pretty significant deformity. Multiple fractures, index, middle finger, and you see various techniques in the index using a plate on the side of the proximal phalanx, another plate dorsally with a sort of Y configuration, and various manufacturers have those types of options available to you. You see that that's a comminuted fracture at the base of the middle phalanx, and that requires additional screw fixation in that location, so that's the type of plate system that you would want in that location. And then you see K wire fixation for the ulnar fractures. So let's move on now to finish up at the thumb. Metacarpal base fractures are Bennett's fractures. It can be either extra-articular or intra-articular fractures. The traditional Bennett's fracture is intra-articular, and we know the deforming forces involve the APL, the adductor pollicis, and the thenar musculature. Intra-articular fractures in this location require pin fixation due to the instability that is associated here. What's involved is the anterior oblique ligament is still attached to that intra-articular fracture fragment, and you will not achieve any motion or be able to typically achieve a closed reduction of that fracture. The reduction maneuver includes distraction, pronation of the thumb, palmar abduction while placing a dorsal pressure against the metacarpal base. And I go into those specifics because that's a typical question that you will see on the exam. Here you see a singular K-wire fixation either crossing the thumb metacarpal into the index once you have a stable reduction or even achieving fixation right to that small fracture fragment. Here you see a commented fracture fixed with multiple headless screws. That obviously required open reduction. And so looking at the 2010 exam, 26-year-old man has the injury shown in the X-ray. That's a Bennett's fracture. In order to have minimum long-term post-operative pain and the best possible function, recommended treatment should include A, open reduction and plate fixation, B, open and closed reduction with metacarpal fixation, C, closed reduction by thumb pronation and thumb spike at cast application, D, excision of the fragment and reconstruction of the vulnar beak ligament, E, arthroscopically assisted reduction of the fracture. I think we can cross out a few of those as really non-indicated. Any takers on that? So the preferred response there is B. So going back. That was the open or closed reduction and metacarpal fixation. So obviously the reduction maneuver needs to be performed, and then whether you keep it closed with percutaneous pinning or perform an open reduction, the key there is achieving stability of that fracture complex. Now looking at the self-exam, there's, I think, a couple more questions I noticed in the more recent exams that I went through. In 2015, here again, the proper reduction maneuver for the fracture shown in Figure 1 consists of external pressure over the metacarpal base, traction, and palmar abduction alone, palmar abduction and pronation, palmar abduction and supination. D is palmar abduction and pronation. E, palmar abduction and supination. So this is just another example of that same question. That's D, palmar abduction and pronation. So the Rolando's fracture is a comminuted fracture at the base of the thumb. That definitely warrants typically a fixation technique. You can use T-plates, even K-wire fixation, whatever is necessary to achieve an articular reduction to minimize long-term possibility of post-traumatic arthritis. Here you see use of a plate and fixed angle screws. Here's another technique in a similar fracture. This is not my patient. It's shared by a colleague. But even external fixation stabilizing that joint, spanning it, and performing K-wire fixation. Here's a picture of that particular patient. So fractures of the hand in conclusion. Treatment is driven by displacement or rotation of the finger. Closed methods that allow protected motion are ideal to minimize soft tissue disruption. Surgical treatment is hopefully performed with limited open methods, although when necessary, don't be shy regarding your exposure. You need to achieve an articular reduction if that's your goal of the surgery. And rigid internal fixation will provide greater ability to obtain a superior reduction and hopefully avoid any possible morbidity. So thank you for your attention. Thank you.

hand fractures

management

phalangeal fractures

metacarpal fractures

assessment

treatment

fracture location