Closed Fracture Right Neck Humerus

A. INTRODUCTION

The proximal humerus consists of the articular surface of the shoulder joint

and the attachments of the rotator cuff to the greater and lesser tuberosities. Most

of the blood supply to the humeral head comes from the anterior humeral

circumflex branch of the axillary artery. More than 90% of proximal humeral

fractures result from a low-energy fall directly onto the shoulder. Patients with

osteoporotic bone are at the highest risk. In nonosteoporotic patients, fractures

result from high-energy trauma. Neer’s classification divides the proximal

humerus into 4 parts (1):

i. Articular surface

ii. Greater tuberosity

iii. Lesser tuberosity

iv. Surgical neck (the border between the round proximal metaphysis

and the diaphyseal portion of the bone)

v. Fractures are classified as having 1–4 parts, based on the number

of fragments, with a fragment defined as a part if it is displaced >1

cm and/or angulated >45°.

B. EPIDEMIOLOGY

Proximal humerus fractures comprise 4% to 5% of all fractures and represent

the most common humerus fracture (45%). The increased incidence in the older

population is thought to be related to osteoporosis. Risk for a proximal humeral

fracture increases with age, peaking in the 9th decade. The 2:1 female-to-male

ratio is likely related to issues of bone density.(1,2)

C. ANATOMY

The shoulder has the greatest range of motion of any articulation in the body;

this is due to the shallow glenoid fossa that is only 25% the size of the humeral

head and the fact that the major contributor to stability is not bone, but a soft

tissue envelope composed of muscle, capsule, and ligaments.The proximal

humerus is retroverted 35 to 40 degrees relative to the epicondylar axis. The four

osseous segments (Neer) are the humeral head, the lesser tuberosity, the greater

tuberosity, and the humeral shaft.(2)

Deforming muscular forces on the osseous segments : the greater tuberosity is

displaced superiorly and posteriorly by the supraspinatus and external rotators, the

lesser tuberosity is displaced medially by the subscapularis, the humeral shaft is

displaced medially by the pectoralis major, the deltoid insertion causes abduction

of the proximal fragment. The neurovascular supply are from: (2,3)

a. The major blood supply is from the anterior and posterior humeral

circumflex arteries.

b. The arcuate artery is a continuation of the ascending branch of the anterior

humeral circumflex. It enters the bicipital groove and supplies most of the

humeral head. Small contributions to the humeral head blood supply arise

from the posterior humeral circumflex, reaching the humeral head via

tendo-osseous anastomoses through the rotator cuff. Fractures of the

anatomic neck are uncommon, but they have a poor prognosis because of

the precarious vascular supply to the humeral head.

c. The axillary nerve courses just anteroinferior to the glenohumeral joint,

traversing the quadrangular space. It is at particular risk for traction injury

owing to its relative rigid fixation at the posterior cord and deltoid, as well

as its proximity to the inferior capsule where it is susceptible to injury

during anterior dislocation and anterior fracture-dislocation.

Picture 11. Anatomy of Humerus(3)

Picture 12. Anatomy of Proximal Humeral Vascular(4)

D. ETIOPATHOMECHANISM

Most common is a fall onto an outstretched upper extremity from a standing

height, typically in an older, osteoporotic woman. Younger patients typically

present with proximal humeral fractures following high-energy trauma, such as a

motor vehicle accident. These usually represent more severe fractures and

dislocations, with significant associated soft tissue disruption and multiple

injuries. Less common mechanisms include:(2)

a. Excessive shoulder abduction in an individual with osteoporosis, in which

the greater tuberosity prevents further rotation.

b. Direct trauma, usually associated with greater tuberosity fractures.

c. Electrical shock or seizure.

d. Pathologic processes: malignant or benign processes in the proximal

humerus.

Associated condition that may bring into proximal humeral fracture such as

dislocation of the glenohumeral joint, complete rotator cuff tears occur in 20% of

cases, particularly greater tuberosity fractures, axillary and suprascapular nerve

injury, vascular injury to axillary vessels or their branches, especially in the

presence of atherosclerosis.(1)

Classification

The most commonly used classification system for proximal humeral fractures

is that of Neer. Although limited reliability, reproducibility among observers, and

consistency by the same observer at different times have been cited as limitations

of the Neer system, it remains useful in guiding treatment. Classification is based

on the four-part anatomy of the proximal humerus: the humeral head, the lesser

and greater tuberosities, and the proximal humeral shaft. The criterion for

displacement is greater than 1 cm of separation of part or angulation of 45

degrees. Displaced three-part and four-part fractures markedly alter the articular

congruity of the glenohumeral joint and have the highest likelihood of disrupting

the major blood supply to the proximal humerus. Osteonecrosis is most likely

after displaced four-part fractures.(4)

Picture 13. Neer’s Classification of Proximal Humeral Fracture(4)

E. CLINICAL FEATURES

Patients typically present with the upper extremity held closely to the chest by

the contralateral hand, with pain, swelling, tenderness, painful range of motion,

and variable crepitus. Chest wall and flank ecchymosis may be present and should

be differentiated from thoracic injury. A careful neurovascular examination is

essential, with particular attention to axillary nerve function. This may be assessed

by the presence of sensation on the lateral aspect of the proximal arm overlying

the deltoid. Motor testing is usually not possible at this stage because of pain.

Inferior translation of the distal fragment may result from deltoid atony; this

usually resolves by 4 weeks after fracture, but if it persists, it must be

differentiated from a true axillary nerve injury.(2)

F. DIAGNOSTIC TEST

Trauma series, consisting of AP and lateral views in the scapular plane as well

as an axillary view. Axillary is the best view for evaluation of glenoid articular

fractures and dislocations, but it may be difficult to obtain because of

pain.Velpeau axillary: If a standard axillary cannot be obtained because of pain or

fear of fracture displacement, the patient may be left in the sling and leaned

obliquely backward 45 degrees over the cassette. The beam is directed caudally,

orthogonal to the cassette, resulting in an axillary view with magnification.

Computed tomography is helpful in evaluating articular involvement, degree of

fracture displacement, impression fractures, and glenoid rim fractures. Magnetic

resonance imaging is generally not indicated for fracture management, but it may

be used to assess rotator cuff integrity.(2)

Picture 14. X-Rays provide information about the position of the main fracture

lines and areas of articular surface depression()

Picture 13. X-Ray of Proximal Humeral Fractures(5)

Picture 14. CT Scan of Proximal Humeral Fractures(5)

G. TREATMENT

1. Minimally displaced fractures(2)

a. Up to 85% of proximal humerus fractures are minimally displaced or

nondisplaced.

b. Sling immobilization or swathe for comfort.

c. Frequent radiographic follow-up is important to detect loss of fracture

reduction.

d. Early shoulder motion may be instituted at 7 to 10 days if the patient

has a stable or impacted fracture.

e. Pendulum exercises are instructed initially followed by passive range-

of-motion exercises.

f. At 6 weeks, active range-of-motion exercises are started.

g. Resistive exercises are started at 12 weeks

2. Two-part(5,6)

Repair of the displaced tuberosity with sutures or tension band wiring; surgical

neck fractures can normally be managed nonoperatively. Unstable,

unimpacted fractures may be treated with closed reduction with percutaneous

pinning (CRPP). Immediate physical therapy during nonoperative

management results in faster recovery.

Surgical neck fracture. The fragments are gently manipulated into

alignment and the arm is immobilized in a sling for about four weeks or until

the fracture feels stable and the x-ray shows some signs of healing. Elbow and

hand exercises are encouraged throughout this period; shoulder exercises are

commenced at about four weeks. The results of conservative treatment are

generally satisfactory, considering that most of these patients are over 65 and

do not demand perfect function. However, if the fracture cannot be reduced

closed or if the fracture is very unstable after closed reduction, then fixation is

required. Options include percutaneous pins, bone sutures, intramedullary pins

with tension band wiring or a locked intramedullary nail. Plate fixation

requires a wider exposure and the newer locking plates offer a stable fixation

without the need for extensive periosteal stripping.

Greater tuberosity fractures Fracture of the greater tuberosity is often

associated with anterior dislocation and it reduces to a good position when the

shoulder is relocated. If it does not reduce, the fragment can be re-attached

through a small incision with interosseous sutures or, in young hard bone,

cancellous screws.

Anatomical neck fractures These are very rare. In young patients the

fracture should be fixed with a screw. In older patients prosthetic replacement

(hemiarthroplasty) is preferable because of the high risk of avascular necrosis

of the humeral head.

3. Three-part(5,6)

These usually involve displacement of the surgical neck and the greater

tuberosity; they are extremely difficult to reduce closed. In active individuals

this injury is best managed by open reduction and internal fixation. There is

little evidence that one technique is better than another although the newer

implants with locked plating and nailing are biomechanically superiorin

osteoporotic bone.

-Open reduction with internal fixation (ORIF) for young patients, with repair

of the tuberosities or rotator cuff

-Hemiarthroplasty for older patients, with repair of the rotato cuff/ tuberosities

4. Four-parts(5,6)

The surgical neck and both tuberosities are displaced. These are severe injuries

with a high risk of complications, such as vascular injury, brachial plexus

damage, injuries of the chest wall and (later) avascular necrosis of the humeral

head. The x-ray diagnosis is difficult (how many fragments are there, and are

they displaced?). Often the most one can say is that there are ‘multiple

displaced fragments’, sometimes together with glenohumeral dislocation. In

young patients an attempt should be made at reconstruction. In older patients,

closed treatment and attempts at open reduction and fixation can result in

continuing pain and stiffness and additional surgical treatment can

compromise the blood supply still further. If the fracture pattern is such that

the blood-supply is likely to be compromised, or that reconstruction and

internal fixation will be extremely difficult, then the treatment of choice is

prosthetic replacement of the proximal humerus. The results of

hemiarthroplasty are somewhat unpredictable. Anatomical reduction, fixation

and healing of the tuberosities are prerequisites for a satisfactory outcome;

even then, secondary displacement of the tuberosities may result in a poor

functional outcome. In addition the prosthetic implant should be perfectly

positioned. Be warned – these are operations for the expert.

Picture 15. Treatment of Proximal Humeral frcatures(5)

H. COMPLICATIONS(2)

Vascular injury: This is infrequent (5% to 6%); the axillary artery is the most common

site (proximal to anterior circumflex artery). The incidence is increased in older

individuals with atherosclerosis because of the loss of vessel wall elasticity.

Neural injury

o Brachial plexus injury: This is infrequent (6%).

o Axillary nerve injury: This is particularly vulnerable with anterior fracture-

dislocation because the nerve courses on the inferior capsule and is prone to

traction injury or laceration. Complete axillary nerve injuries that do not

improve within 2 to 3 months may require electromyographic evaluation and

exploration.

Chest injury: Intrathoracic dislocation may occur with surgical neck fracture-

dislocations; pneumothorax and hemothorax must be ruled out in the appropriate

clinical setting.

Myositis ossificans: This is uncommon and is associated with chronic unreduced

fracture-dislocations and repeated attempts at closed reduction.

Shoulder stiffness: It may be minimized with an aggressive, supervised physical

therapy regimen and may require open lysis of adhesions for recalcitrant cases.

Osteonecrosis: This may complicate 3% to 14% of three-part proximal humeral

fractures, 13% to 34% of four-part fractures, and a high rate of anatomic neck

fractures.

Nonunion: This occurs particularly in displaced two-part surgical neck fractures with

soft tissue interposition. Other causes include excessive traction, severe fracture

displacement, systemic disease, poor bone quality, inadequate fixation, and infection.

It may be addressed with ORIF with or without bone graft or prosthetic replacement.

Malunion: This occurs after inadequate closed reduction or failed ORIF and may

result in impingement of the greater tuberosity on the acromion, with subsequent

restriction of shoulder motion.

Open Fracture 1/3 Distal Right Radius Grade IIIA

A. INTRODUCTION

Open fractures are defined as situations in which the fracture site communicates

with the outside environment; the bone does not need to protrude from the skin for the

injury to be an open fracture, any full-thickness skin laceration in the zone of fracture

injury is considered an open fracture. Open fractures can be classified by the Gustilo-

Anderson system:(6)

o Type I: Low-energy fracture with a clean wound <1 cm long

o Type II: Low- to medium-energy fracture with a laceration >1 cm long but

without extensive soft-tissue damage

o Type III:

High-energy fracture

Segmental fractures, gunshot injuries

More extensive soft-tissue devitalization than in type II

Type IIIA: Adequate soft-tissue coverage of bone

Type IIIB: Inadequate soft-tissue coverage of bone, fractures that need

rotational or free flap coverage

Type IIIC: Fracture with an arterial injury

Forearm fractures involve the bones of the forearm (the radius and ulna), and

sometimes the fractures are associated with elbow and wrist injuries. In addition to the

bone injury, soft-tissue injuries may include compartment syndrome, neurapraxia, and

vascular damage. Adults are more susceptible than children to more severe injuries

and also require a more exact reduction because they have less potential for bony

remodeling, and the fractures have no innate stability. Children <12 years old do not

require anatomic reduction of forearm fractures. Classification:(6)

o Multiple classification schemes

o Important factors include:

Fracture location

Fracture configuration

Presence of any radioulnar or radiohumeral articular involvement

Isolated ulna shaft fractures are called night stick fractures because

they often are caused by blunt trauma.

EPIDEMIOLOGY

Forearm fractures are more common in men than women; secondary to the

higher incidence in men of motor vehicle accidents, contact athletic participation,

altercations, and falls from a height. The ratio of open fractures to closed fractures is

higher for the forearm than for any other bone except the tibia.(2)

ANATOMY

The forearm acts as a ring; a fracture that shortens either the radius or the ulna

results either in a fracture or a dislocation of the other forearm bone at the proximal or

distal radioulnar joint. Nightstick injuries are an exception. The ulna, which is

relatively straight, acts as an axis around which the laterally bowed radius rotates in

supination and pronation. A loss of supination and pronation may result from radial

shaft fractures in which the lateral curvature has not been restored. The interosseous

membrane occupies the space between the radius and ulna. The central band is

approximately 3.5 cm wide running obliquely from its proximal origin on the radius

to its distal insertion on the ulna. Sectioning of the central band alone reduces stability

by 71%. Fracture location dictates deforming forces:

o Radial fractures distal to the supinator muscle insertion but proximal to the

pronator teres insertion tend to result in supination of the proximal fragment

owing to unopposed pull of the supinator and biceps brachii muscles.

o Radial fractures distal to the supinator and pronator teres muscles tend to

result in neutral rotational alignment of the proximal fragment.(2)

Picture 16. Anatomy of Radial and Ulna(3)

Picture 17. Anatomy of The Muscles at Forearm(3)

ETIOPATHOMECHANISM

These are most commonly associated with motor vehicle accidents, although

they are also commonly caused by direct trauma (while protecting one’s head),

gunshot wounds, and falls either from a height or during athletic competition

Pathologic fractures are uncommon. Treatment of open fractures is based on

preventing infection and stabilizing the injured bone. Infection is promoted by

bacterial contamination of wound, devitalized muscle and bone, dead space, and

foreign material.(2,6)

Picture 18. Mechanism of Injury of Forearm(3)

Picture 19. Gustilo and Anderson’s Classification of Open Fracture(6)

Classification:(6)

Type I: no periosteal stripping, minimum soft tissue damage, small

skin wound (1 cm)

Type II:little periosteal stripping, moderate muscle damage, skin

wound (1-10 cm)

Type IIIA—contaminated wound (high-energy gunshot wound, farm

injury, shotgun) or extensive periosteal stripping with large skin

wound (>10 cm)

Type IIIB—same as IIIA but will require flap coverage

Type IIIC—same as IIIA but with vascular injury that requires repair

CLINICAL FEATURES

Patients typically present with gross deformity of the involved forearm, pain,

swelling, and loss of hand and forearm function. A careful neurovascular

examination is essential, with assessment of radial and ulnar pulses, as well as

median, radial, and ulnar nerve function. One must carefully assess open wounds

because the ulna border is subcutaneous, and even superficial wounds can expose

the bone. Excruciating, unremitting pain, tense forearm compartments, or pain on

passive stretch of the fingers should raise suspicions of impending or present

compartment syndrome. Compartment pressure monitoring should be performed,

with emergency fasciotomy indicated for diagnosed compartment syndrome.(2)

Physical Exam(6)

The physician must diagnose the open fracture and then follow a general

fracture physical examination.

Diagnosing an open fracture:

o Bone protruding from skin (not required)

o Fat or blood oozing from a laceration

Laceration in the zone of injury, which can be large in high-energy

fractures

General examination for fractures:

Palpate joint above and below injury as well as every other joint in

body.

o Assess vascular viability of limb and damaged soft tissues.

Pulses or arterial brachial indices

Color and capillary refill of contused skin and muscle

o Presence or absence of:

Periosteal stripping

Gross contamination with foreign material

Compartment syndrome

o Neurologic motor and sensory examinations

DIAGNOSTIC TEST

Anteroposterior (AP) and lateral views of the forearm should be obtained, with

oblique views obtained as necessary for further fracture definition. Radiographic

evaluation should include the ipsilateral wrist and elbow to rule out the presence

of associated fracture or dislocation. The radial head must be aligned with the

capitellum on all views. CT scan is indicated for some fracture patterns but should

not delay surgical debridement and stabilization.(2,6)

TREATMENT(5)

Antibiotics. The wound should be kept covered until the patient

reaches the operating theatre. In most cases co-amoxiclav or cefuroxime (or

clindamycin if penicillin allergy is an issue) is given as soon as possible,

often in the Accident and Emergency department. At the time of

debridement, gentamicin is added to a second dose of the first antibiotic.

Both antibiotics provide prophylaxis against the majority of Gram-positive

and Gramnegative bacteria that may have entered the wound at the time of

injury. Only co-amoxiclav or cefuroxime (or clindamycin) is continued

thereafter; as wounds of Gustilo grade I fractures can be closed at the time of

debridement, antibiotic prophylaxis need not be for more than 24 hours.

With Gustilo grade II and IIIA fractures, some surgeons prefer to delay

closure after a ‘second look’ procedure. Delayed cover is also usually

practised in most cases of Grade IIIB and IIIC injuries. As the wounds have

now been present in a hospital environment for some time, and there are data

to indicate infections after such open fractures are caused mostly by

hospital-acquired bacteria and not seeded at the time of injury, gentamicin

and vancomycin (or teicoplanin) are given at the time of definitive wound

cover. These antibiotics are effective against methicillin-resistant

Staphylococcus aureus and Pseudomonas, both of which are near the top of

the league table of responsible bacteria. The total period of antibiotic use for

these fractures should notbe greater than 72 hours.

Debridement. The operation aims to render the wound free of foreign

material and of dead tissue, leaving a clean surgical field and tissues with a

good blood supply throughout. Under general anaesthesia the patient’s

clothing is removed, while an assistant maintains traction on the injured limb

and holds it still. The dressing previously applied to the wound is replaced

by a sterile pad and the surrounding skin is cleaned. The pad is then taken

off and the wound is irrigated thoroughly with copious amounts of

physiological saline. The wound is covered again and the patient’s limb then

prepped and draped for surgery. Many surgeons prefer to use a tourniquet as

this provides a bloodless field. However this induces ischaemia in an already

badly injured leg and can make it difficult to recognize which structures are

devitalized. A compromise is to apply the tourniquet but not to inflate it

during the debridement unless absolutely necessary. Because open fractures

are often high-energy injuries with severe tissue damage, the operation

should be performed by someone skilled in dealing with both skeletal and

soft tissues; ideally this will be a joint effort by orthopaedic and plastic

surgeons.

We generally prefer not to use internal fixation initially in type III open

fractures of the forearm. We believe that complications are fewer if the

wound is initially cared for with irrigation and débridement. This allows the

wound either to reveal itself infected or to heal. If the wound is clean at 5 to

7 days, the appropriate internal fixation can be performed. Anderson et al.

reported experience in treating open fractures with this delayed method of

open reduction and internal fixation using the compression plate. No

infections occurred in 38 open fractures treated in this manner. In many type

I and type II wounds, internal fixation can be performed primarily without

wound healing problems, but we believe it is safer to delay the fixation in

type III wounds in most cases. In single-bone fractures of the forearm, a cast

that is windowed over the open wound provides sufficient external fixation

until the wound has healed and internal fixation can be inserted. Shortening

from overriding of single-bone fractures resulting from delay in inserting

internal fixation is not a problem. To prevent shortening in both-bone

fractures associated with open wounds, pins through the proximal ulna and

through the bases of the second and third metacarpals can be used to apply

traction and restore length. The pins are incorporated in a plaster cast that

can be windowed appropriately to treat and inspect the wounds. External

fixation devices also are satisfactory for reduction and skeletal fixation when

extensive soft-tissue wounds require procedures such as skin grafting, and

we have had excellent experience with them. If the soft-tissue wound is

massive, making skin grafting and reconstructive procedures inevitable, and

these procedures are not manageable through a window in a traction type of

cast, an intramedullary nail in the ulna can be used to stabilize the forearm.

Skin grafting and similar procedures on the soft tissues are almost

impossible to carry out unless the forearm is stabilized by either external or

internal means. The technique for the traction cast is described in the next

section.

Current treatment trends favor immediate open reduction and internal

fixation of all open forearm fractures. Duncan et al. reported 90% acceptable

results in 103 Gustilo type I, type II, or type IIIA open diaphyseal forearm

fractures treated with immediate débridement and compression plate and

screw fixation. Their results with type IIIB and type IIIC injuries were poor,

however. Jones reported 55 good results in a small series of type IIIB and

type IIIC injuries treated in a similar fashion. Two of three patients with type

IIIC injuries had poor results after immediate débridement and compression

plate and screw fixation. Immediate open reduction and internal fixation of

type I and type II open diaphyseal forearm fractures is appropriate if

thorough débridement is performed. Treatment of type III injuries should be

individualized, with consideration given to the mechanism and force of

injury, associated injuries, and the condition of the patient before and after

injury. We continue to delay open reduction and internal fixation until there

is no evidence of infection. In a critically injured patient, multiple returns to

the operating room may not be possible, and early definitive treatment may

be necessary.

Picture 20. Treatment for Radial Fracture (6)

COMPLICATIONS(2)

Nonunion and malunion: These are uncommon, most often related to infection and

errors of surgical technique. Patients may require removal of hardware, bone grafting,

and repeat internal fixation.

Infection: The incidence is only 3% with open reduction and internal fixation. It

necessitates surgical drainage, debridement, copious irrigation, wound cultures, and

antibiotics. If internal fixation is found to be stable, it does not necessarily need to be

removed because most fractures will unite despite infection. Massive infections with

severe soft tissue and osseous compromise may necessitate external fixation with

wounds left open and serial debridements.

Neurovascular injury: This is uncommon, associated with gunshot injury or iatrogenic

causes. Nerve palsies can generally be observed for 3 months, with surgical

exploration indicated for failure of return of nerve function. Injuries to the radial or

ulnar arteries may be addressed with simple ligation if the other vessel is patent.

Volkmann ischemia: This devastating complication follows compartment syndrome.

Clinical suspicion should be followed by compartment pressure monitoring with

emergency fasciotomy if a compartment syndrome is diagnosed.

Posttraumatic radioulnar synostosis: This is uncommon (3% to 9% incidence); the

risk increases with massive crush injuries or closed head injury. It may necessitate

surgical excision if functional limitations of supination and pronation result, although

a nonarticular synostosis excision is rarely successful in the proximal forearm.

Postoperative low-dose radiation may decrease the incidence of recurrence.

Closed Fracture Right Base Metacarpal Little Finger

A. INTRODUCTION

A fracture of the metacarpal bone, the small tubular bone in the hand..

Metacarpal fractures are classified according to their anatomic location (at the

head, neck, shaft, or base). Metacarpal fractures of the thumb are classified into 4

patterns (some eponymous), according to whether they are intra-articular or extra-

articular and by the amount of comminution. The Bennett fracture has a volar lip

fragment of variable size at the CMC joint, and the remainder of the base is

displaced from the joint. The Rolando fracture is a Y-shaped intra-articular

fracture.(1)

Bora and Didizian called attention to a potentially disabling intraarticular

fracture at the base of the fifth metacarpal. If the injury is not reduced properly, a

malunion may result in weakness of grip and a painful joint. The joint consists of

the base of the fifth metacarpal articulating with the hamate and the adjoining

fourth metacarpal. The extensor carpi ulnaris tendon attaches proximally to the

fifth metacarpal dorsal base. The joint permits approximately 30 degrees of

normal flexion and extension and the rotation necessary in grasp and in palmar

cupping. This displaced intraarticular fracture might be compared with a Bennett

fracture because the pull of the extensor carpi ulnaris has a great tendency to

displace the metacarpal shaft proximally, similar to the thumb metacarpal

displacement in a Bennett fracture by the abductor pollicis longus.(4)

B. 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).(2)

C. ANATOMY

\

Picture 21. Anatomy of Hand (3)

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).

o The proximal fragment is flexed by the interossei.

o 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.(2)

D. ETIOPATHOMECHANISM(2)

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 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.

E. CLINICAL FEATURES(2)

o History: a careful history is essential as it may influence treatment. This

should include the patient: 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 bit, treatment provided: cleansing, antiseptic,

bandage, tourniquet, financial issues: workers compensation.

o 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.

F. DIAGNOSTIC TEST

In addition to the routine anteroposterior and lateral views, a radiograph

should be made with 30 degrees of pronation to give a better view of the

articular surface for accurate diagnosis.

Picture 22. AP, Oblique, and Lateral View of Hand(4)

G. TREATMENT

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.

o The metacarpal is displaced proximally by the pull of the extensor carpi

ulnaris.

o The degree of displacement is best ascertained via radiograph with the hand

pronated 30 degrees from a fully supinated (anteroposterior) position.

o This fracture often requires surgical intervention with ORIF.(2)

A. 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.(2)

DRUJ Disruption

A. INTRODUCTION

B. EPIDEMIOLOGY

C. ANATOMY

D. ETIOPATHOMECHANISM

E. CLINICAL FEATURES

F. DIAGNOSTIC TEST

G. TREATMENT

H. COMPLICATIONS

REFFERENCES

1. Frassica, Frank J, Paul DS, John HW. The 5-Minute Orthopaedic Consult. 2nd ed.

New York: Lippincott Williams & Wilkins; 2007. p. 401-2.

2. Koval Keneath J. Zuckerman Joseph D. Handbook of fracture, 3nd edition. New

York: Lippincott Williams & Wilkins; 2006. p. 166-171.

3. Thompson JC. Leg and Knee. Netter Concise Orthopaedic Anatomy. 2nd ed.

Saunders Elsevier. p. 84, 111, 141, 163.

4. Canale Terry, et all. Campbell’s Operative Orthopaedics. Eleventh Edition.

Philadelphia : Mosby Elsevier. 2007.

5. Solomon L, Warwick D, Nayagam S. Principle of Fracture. Apley's System of

Orthopaedics and Fractures. 9th ed. London: Hodder Arnold; 2010. p. 726-7, 744-

7.

6. Miller MD, Stephen RT, Jennifer AH. Review of Orthopaedics. 6th ed. Elsevier

Saunders. 2012. p. 701,9-11.