IC24-L: Errors, Complications and Complaints: Strategies ...

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IC24-L: Errors, Complications and Complaints:

Strategies to Handle Difficult Problems

Moderator(s): Sonu A. Jain, MD

Faculty: Jesse B. Jupiter, MD, Peter J. Stern, MD, Loree K. Kalliainen, MD, MA, FACS and Harry A. Hoyen,

MD

Session Handouts

76th Annual Meeting of the ASSH

September 30 – October 2, 2021

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

mailto:[email protected]

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Errors,Complications,and ComplaintsStrategies to handle difficult situations

Jesse B Jupiter MDHansjorg Wyss/AO ProfessorHarvard Medical School

Jesse B. Jupiter M.D.Orthopaedic Hand Service

Massachusetts General Hospital

Disclosures

Consultant AO Foundation; Trimed; OHKStock OHKReviewer/Editor Elsevier;Springer;AO FoundationResearch Support AO Foundation;MaterializeTextbook AO Foundation; Elsevier

Disclosures found in websites AAOS; ASSH; ASES;OTA;AAHS;Harvard Medical School; Partners HealthSystems

Assessment of Complications of Distal Radius FracturesMcKay, MacDermid, Roth et al J Hand Surg 2001

• Evaluated incidence and types of complications in consecutive cohort

• Developed “check list” with classification and severity

• Evaluated difference in physician-reported vs patient reported

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McKay et al J Hand Surg 2001

• Physician-reported in 235 pts -27%

• Patient-reported in 207 pts-- 21%

• Suggested patients more focused on symptoms rather than diagnoses

McKay et al J Hand Surg 2001Classification and rating of complication

• Mild—symptoms caused by the fx (or rx) but resolved with no treatment (1pt)

• Moderate-- required specific treatment such as therapy or splint (2 pts)

• Severe– required surgical treatment (3 pts)

McKay et al J Hand Surg 2001complexity of evaluation-ex median nerve

• Can be preexisting condition

• Can occur acutely with fracture

• Can be the result of intraoperative rx

• Can occur with increased postop swelling

• Can be later due to malunion

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Rozental and Blazar J Hand Surg 2006

• 41 patients dorsally displaced fxs

• 9 physician-reported complications

4 loss of reduction-2 lunate facet

3 tendon irritation—h/w removal

1 wound dihiscence

1 mcp stiffness

• Overall high degree of pt satisfaction with DASH avg 14

1. LOSS OF REDUCTION

2. DELAYED UNION AND NONUNION

3. MALUNION

4. DISTAL RADIOULNAR JOINT

5. INFECTION

COMPLICATIONS(osteoarticular)

• Carpal ligaments

• Carpal fractures

• Nerves

• Tendons

• Combined soft tissues

• Vascular, compartment syndrome

ASSOCIATED LESIONS COMPLICATIONS

Carpal instability

Nonunion, malalignment

Neuropathy

Tendinitis, ruptures

Multifactorialfunctional deficit

RSD, Complex RegionalPain syndrome

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comminuted volar shearing fractureLOSS OF REDUCTION

intra-operative fluoroscopy

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(beware of the volar-ulnar fragment !!!)

5 weeks post-op

Choon-lai Toh, JB Jupiter, DL Fernandez, T Fellman

J Bone Joint Surg 78A: 1996

Unstable volarly displaced fractures of the distal radius

A: Anterior shear radial styloid 2

B: Anteriormargina(Shear) 4

C: Two-part anterior marginal 22

D: Comminuted anterior marginal 18

Fernandez classification (48)

A B C D

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7 m post-op

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6 m post-op

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LOSS OF FIXATION OF THE VOLAR LUNATE FACET FRAGMENT IN

FRACTURES OF THE DISTAL PART OF THE RADIUS

Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DLJBJS 86 A: 1900-1908, 2004

7 patients, average follow up 24 months after surgery

AO classification: 1 B3.2, 6 B3.3

4 had repeat ORIF

1 had a radiocarpal arthrodesis

2 had no further treatment

RESULTS (average 2 years after surgery)

6 patients returned to previous level of function

Average wrist extension 48° (75% of uninjured side)

Average wrist flexion 37° (64% of uninjured side)

4 patients had repeat ORIF with good maintenanceof reduction and carpal alignment

2 patients declined further treatment had tolerablesymptoms despite carpal subluxation

1 patient had a successful RSL arthrodesis

Loss of Reduction-strategies

• Placement of distal screws under the subchondral bone

• Understand articular fxpattern

• Alternative methods for fixation of small lunate facet fx

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Biomechanics of Angular Stable Volar Plate Fixation--Evidence

• Drobetz et al JHS 2006—rigidity of plate systems higher where distal screws placed close to subchondral bone

• Leung et al JHS 2003—similar observations

Loss of Reduction-strategies


• Understand articular fxpattern—CT scan


Arc of curve of articular surface

Standard lateral 10 degree lateral

Radial styloid

“Teardrop”

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Courtesy of David Nelson M.D.

minimally displaced palmar avulsionfractures are dangerous and should be fixed

post-op 2 years post-op

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RADIOCARPAL FX-DISLOCATION

• Complex injury

• Ulno and radiocarpalligaments avulsed

• Ulnar styloid fracture common

• Carpus displaces dorsally

• Fracture of dorsal rim of distal radius

Loss of Reduction--Strategies


• Understand articular fx pattern


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POSSIBLE CAUSES

-over-distraction of fracture line with external fixation

-failure to graft large defects in comminuted fractures

-extensive devascularisation during initial ORIF

-unstable construct and cast-free aftertreament

-inadequate period of immobilisation

DELAYED UNION AND NON-UNION

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atrophic nonunion after prolonged period of external fixation

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NONUNION OF THE DISTAL RADIUS

TYPES: -fibrous „stable“ nonunion-synovial „mobile“ non-union

delayed union: lack of radiographic signs of healing after 4 monthsNon-union: fractures failed to heal 6 months after injury

PROBLEMS: -small osteopenic distal fragment

-wrist and distal radioulnar jointcapsular contracture

-soft tissue contracture (brachioradialis)

-significant shortening (DRUJ disruption)

Strategies(1)Wrist arthrodesis

• 12 ununited fractures of the distal radius• ORIF not feasible• Distal fragment too small and osteopenic• Poor results commonplace• Multiple surgeries to achieve fusion• Wrist and digit stiffness• Sensory abnormalities

Segalman & Clark, ASSH 1994

-correction of deformity : -axial realigment-restoration of radial length

-soft tissue release : -dorsal wrist capsulotomy(if necessary) -DRUJ capsulotomy

-tenotomy brachioradialis

-internal fixation and and autologous bone grafting (iliac crest)

-additional DRUJ procedure if realignment not possible:-ulnar shortening-ulnar head prosthesis-ulnar head resection (older age group)

Fernandez DL, Ring D, Jupiter JB: Surgical management of delayedunion and nonunion of distal radius fractures J Hand Surg:26A:201-209 ,2001

Strategies. (2 internal fixation)

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ORIF of Un-united Fractures of the Distal Radius:Does the Size of the Distal Fragment Affect the Result?

Prommersberger KJ, Fernandez DL, Ring D, Jupiter JB2000

-13 patients with a distal fragment with more than 5mm ofsubchondral bone supporting the articular surface

-10 patients with an un-united fracture with a distal fragmentsmaller than 5mm

INDEPENDENT OF THE SIZE OF THE DISTAL FRAGMENT ALL

PATIENTS HAD AN ATTEMPT TO OBTAIN UNION WITH

INTERNAL FIXATION AND AUTOLOGOUS BONE GRAFTING

IN ORDER TO REALIGN THE WRIST PRESERVING SOME MOTION

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RESULTS

AVERAGE FOLLOW-UP : -large fragment group 22 months-small fragment group 30 months

SOLID UNION WAS ACHIEVED IN 22 PATIENTS

1 PERSISTENT NON-UNION IN THE LARGE FRAGMENTGROUP WAS SALVAGED WITH A WRIST ARTHODESIS

AT LATE FOLLOW-UP THER WERE NO SIGNIFICANTDIFFERENCES IN THE CLINICAL AND RADIOLOGICAL

OUTCOME OF BOTH GROUPSforearm rotation F/E arc grip force

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3. MALUNION


Intraarticular Malunion Of The Distal Radius

Decision making and surgical techniques

Jesse B. Jupiter M.D.

Retrospective study 43 fxs in 40 pts—mean age 27.6 yrs

• Pts rx’d at MGH 1970-1981

• 21 cast

• 17 pins & plaster

• 3 ORIF

• 2 Ext fix

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Mean follow-up—6.7 yrs

• 26% excellent

• 35% good

• 33% fair

• 6% poor

Paul Curtis ed JBJS. “where were these patients treated? certainly not MGH

> 2 mm Residual Step Off

100% Post-traumatic Arthritis

Articular Congruity Restored

100% Excellent (11% arthritis)

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INTRA-ARTICULAR MALUNION

-joint surface disruption-articular incongruity (RC-DRUJ)-carpal malalignment-radio-carpal subluxation

Osteotomy of Articular Malunion

Small articular fragments

• Is it technically feasible?

• Will the fragments heal?

• What is the risk of osteonecrosis?

Indications—prerequisites

• Chronology

• Fracture pattern

• Articular status

STRATEGIES

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Preoperative assessment

• Xrays

• CT and 3-D CT

• Arthroscopy

• Virtual planning

Recommendations

• Well defined articular deformity

• Good hand function

• Minimal cartilage injury

• Timing may not be so critical

Contraindications

• Severe cartilage damage• Radiographic arthrosis• Chronic synovitis• CRPS with contractures• Fixed carpal malaligment with complex fx pattern

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International Series

Massachusetts General HospitalBoston, Massachusetts, USA

Klinik fur HandchirurgieBadneristaat, Germany

Instituto Jaime Slullitel Trauma CenterRosario, Argentina

26 Patients, 3 Centers

JBJS AM 2005

• Mean follow-up: 22 (14 - 36) months

• All osteotomies healed

• Implant removal: 14 cases

• Good or excellent result

• Radiographic (Lidstrom): 23 cases

• Clinical (Fernandez): 22 cases

Results

• DRUJ arthritis: 1 (Darrach)

• Moderate RC arthritis: 1

• EPL tendon rupture: 1

• CRPS: 1

Complications

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The Problem-combined intra and extraarticular malunion

• 63 year old-failed k-wire fixation

• 4 months after intraarticular fracture

• Limited and painful motion

• Active club tennis player

• Dominant limb

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Jupiter J B et al. Computer generatedBone models in planning corrective Osteotomy. J Hand Surg Am 1992.

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Surgical Technique

Intra-Articular Malunion

Surgical Technique

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Surgical Technique

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Surgical Technique

Surgical Technique

Eleven years FU

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3. MALUNION

4. DISTAL RADIOULNAR JOINT


Three basic conditions:

1) Painful non-union of the ulnar styloid (no instability)

2) Capsular retraction (pronatory contracture)

3) Radio-ulnar impingement (following resection of the

ulnar head or unstable Sauve-Kapandji stumps)

Less frequent problems:

(these findings may present isolated or combined!!)

Incongruency, impaction and instability.

INCONGRUITYExtra-articular: abnormal orien-

tation of the joint surfaces due

to metaphyseal deformity of the

radius, ulna or both.

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INCONGRUITYIntra-articular: following fractures

entering the sigmoid notch, ulnar

head or both.

Ulnocarpal arthritis secondary

to chronic ulnar impaction.

(post-traumatic radial shortening)

INCONGRUITY--Strategies

A) Extra-articular: reorient sigmoid notch withRADIAL OSTEOTOMY

B)Intra-articular (Post-traumatic arthrosis): depending on the severity ofdegenerative changes, age, hand dominance, occupation

- RESECTION ARTHROPLASTY

- SAUVE-KAPANDJI PROCEDURE

- PROSTHETIC REPLACEMENT

C) Combined (Extra- and intra-articular):

RADIAL OSTETOMY and DRUJ PROCEDURE as in B)

EXTRA-ARTICULARINCONGRUITY OF THE DRUJ:

Reorient sigmoid notch to ulnarhead with radial ostetotomy

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3 years post-op

RESECTION ARTHROPLASTY-StrategiesPartial ulnar head resection (Bowers, Watson)

INDICATIONS:

LOW FUNCTIONAL WRIST DEMAND

Elderly patients, non-dominant hand, light manual activities

PRE-REQUISITES: neutral ulnar variance,otherwise ulnar shortening necessary to preventstylo-carpal impingement

To avoid late radio-ulnar impingement a voluminoussoft tissue interposition is mandatory: ECU anchovyand pronator quadratus!!

modified Bowers procedure with ECU “anchovy“ and pronator quadratus interposition

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trans-osseous fixation of thecapsulo-retinacular flap to thedorsal ridge of sigmoid notch

A B

C C

D

Clenched fist x-ray 4,2 years post-op

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RESECTION ARTHROPLASTY--StrategiesTotal ulnar head resection (Darrach procedure)

Severe degenerative changes in the elderly

Technical details: sub-capital osteotomy (at neck level),and re-center(dorsalize) the sheath of ECU (dynamic stabilizer)

17 years post- op 17.1.96

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ULNO-CARPAL ABUTMENT

IMPACTIONAbnormal contact of two bony surfaces

due to radial shortening (synonyms: ulno-carpal abutment or impingement syndrome

IMPACTION or ULNAR ABUTMENT: Strategiesulnar shortening OT

-decompresses ulnar compartment-tightens ulno-carpal ligaments-controls instability

Pre-requisites: well oriented sigmoidnotch, no step-offs, no degenerativechanges

Tolat and Stanley classification

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IMPACTION: restore radio-ulnar index or ulnar variance to normal

-ulnar shortening ostetotomy-radial lenghthening osteotomy-both radius + ulna OT combined-epiphysiodesis, Ilizarov (child)-Wafer procedure

PREOPERATIVE PLANNING:determination of ulnar variance with comparative X-rays (Palmer)

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B

PREOPERATIVE PLANNING:

distal radial mal-union with significantshortening and dorsal tilt

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1.6 years post-op

INSTABILITYLoss of ligament support: rupture or avulsion of the TFC,capsular ligaments, secondary stabilizers (ECU sheath,

pronator quadratus, interosseous membrane).

IMAGING

-CT-Scans

-MRI

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WRIST ARTHROSCOPY

Best diagnostic tool forassessment of TFCC

pathology

INSTABILITY: open or arthroscopic TFC re-attachment---Strategies

-proximal re-insertion ofulnar styloid non-union-capsulodesis

-ulnar shortening osteotomy

-other ligament reconstructions

malunion of the distal radius withdistal radioulnar joint instability

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• Carpal ligaments


• Nerves

• Tendons




Carpal instability


Neuropathy

Tendinitis, ruptures



Carpal Ligament injury with distal radius fractureTreat or Not??

OBJECTIVES• Pathoanatomy of intraarticular fractures with intercarpal soft tissue injury

• Best evidence re decision making -----

• When not to treat

• When to treat

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• When to treat

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• When to treat

Case Study 02 - 62 y

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Surgical SideSurgical Side Contralateral SideContralateral Side



The patient has similar image on the contralateral sideORIF of the distal radius fracture was performed, no repair of the ligament.

The patient has similar image on the contralateral sideORIF of the distal radius fracture was performed, no repair of the ligament.


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16w



PRE

PRE


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The patient has NO similar image on the contralateral sideORIF of the distal radius fracture was performed, no repair of the ligament.

The patient has NO similar image on the contralateral sideORIF of the distal radius fracture was performed, no repair of the ligament.

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26w


• Carpal Ligaments


• Nerves

• Tendons




Carpal instability


Neuropathy

Tendinitis; rupture



Recent studies have reported an incidence of FPL rupture of from 2% to12%.Drobetz and Kutscha-Lissberg reported adhesion of flexor tendons

requiring tenolysis in one patient. Arora et al reported flexor tenosynovitis in 9 of 141 patients; all 9 patients were treated with hardware removal. In addition to FPL rupture, rupture and inflammation of the flexor digitorum profundus to the index

finger have been noted

Flexor Tendon Problems after Volar Plate Fixationof Distal Radius Fractures

Mehdi N. Adham & Margaret PorembskiHAND 1558-9447 (Print) 1558-9455 (Online) 2009

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Volar plates:‘Low risk of soft tissue

irritation’

Nunley JA, Rowan PR. Delayed rupture of the flexor pollicis longustendon after inappropriate placement of the pi plate on the volarsurface of the distal radius. J Hand Surg Am. 1999 Nov;24(6):1279-80.

Bell JS, Wollstein R, Citron ND. Rupture of flexor pollicis longustendon: a complication of volar plating of the distal radius. J Bone Joint Surg Br. 1998 Mar;80(2):225-6.

Lugger LJ, Pechlaner S. [Tendon rupture as a complication after osteosynthesis of distal radius] Unfallchirurgie. 1984 Oct;10(5):266-70.

Flexor tendon ruptures (hardware) Literature prior to 2000 (1980-

1999)

Ateschrang A, Stuby F, Werdin F, Schaller HE, Weise K, Albrecht D. [Flexor tendon irritations after locked plate fixation of the distal radius with the 3.5 mm T-plate: identification of risk factors] Z Orthop Unfall. 2010 May;148(3):319-25. Epub 2010 Jun 18.

Valbuena SE, Cogswell LK, Baraziol R, Valenti P. Rupture of flexor tendon following volar plate of distal radius fracture. Report of five cases. ChirMain. 2010 Apr;29(2):109-13.

Lifchez SD. Flexor pollicis longus tendon rupture after volar plating of a distal radius fracture.Plast Reconstr Surg. 2010 Jan;125(1):21e-23e.

Ishii T, Ikeda M, Kobayashi Y, Mochida J, Oka Y. Flexor digitorum profundustendon rupture associated with distal radius fracture malunion: a case report. Hand Surg. 2009;14(1):35-8.

Berglund LM, Messer TM. Complications of volar plate fixation for managing distal radius fractures.

Flexor tendon ruptures (hardware)Literature after 2000 (2002 – 2010)

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Arora R, Lutz M, Zimmermann R, Krappinger D, Gabl M, Pechlaner S. [Limits of palmar locking-plate osteosynthesis of unstable distal radius fractures] Handchir Mikrochir Plast Chir. 2007 Feb;39(1):34-41.

Koo SC, Ho ST. Delayed rupture of flexor pollicis longus tendon after volarplating of the distal radius. Hand Surg. 2006;11(1-2):67-70.

Hohendorff B, Kurzen P, Boss A. [Flexor tendon rupture after palmarosteosynthesis using a multidirectional fixed-angle plate] Unfallchirurg. 2006 Nov;109(11):995-7.

Cognet JM, Dujardin C, Popescu A, Gouzou S, Simon P. Rupture of the flexor tendons on an anterior plate for distal radial fracture: four cases and a review of the literature]. Rev Chir Orthop Reparatrice Appar Mot. 2005 Sep;91(5):476-81.

Kato N, Nemoto K, Arino H, Ichikawa T, Fujikawa K. Ruptures of flexor tendons at the wrist as a complication of fracture of the distal radius. Scand J PlastReconstr Surg Hand Surg. 2002;36(4):245-8.

Flexor tendon ruptures (hardware)Literature after 2000 (2002 – 2010) 4

ASSH questionnaire 595/3022 responded

199 (33%) had at least one flexor tendon ruptureFlexor pollicis longus most common 254 (75%)

Majority of plates removed were distal to watershed line 355 (44%)

Flexor tendon ruptures

Causative factors

• Hardware design

• Distal positioning

• Soft tissue coverage

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---------------------------------------------------------------------

-----------------------------

----------------------------------------------------------------

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Courtesy of David Nelson M.D.

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(A) (B) (C) Grade-1 prominence

(volar to critical line, proximal to volar rim)

Grade-0 prominence

(dorsal to critical line)

Grade-2 prominence

(volar to critical line,at volar rim)

J Bone Joint Surg Am. 2011 Feb 16;93(4):328-35. doi: 10.2106/JBJS.J.00193. Epub 2011 Jan 14.

Volar locking plate implant prominence and flexor tendon rupture.

Soong M1, Earp BE, Bishop G, Leung A, Blazar P.

23-DS-832 | Symptomatic Flexor Tendon Rupture at 29 weeks / 60y | FULL

23-DC-889 | Symptomatic Flexor Tendon Rupture at 80 weeks / 80y | FULL

23-DU-968 | Non-symptomatic Flexor Tendon Rupture at 251 weeks / 60y | FULL

23-DS-148 | Symptomatic Flexor Tendon Rupture at 116 weeks / 55y | FULL

23-VC-502 | Non-symptomatic Partial Flexor Tendon Rupture at 168 weeks / 60y | PARTIAL

We found 5 cases of Distal Radius Fractures with Flexor Tendon Rupture (4 full and 1 partial)

out of 186 Distal Radius-Fracture cases in the ICUC® App.

Cases ID’s:

Soong criteria measured on plain X-rays and on CT scan.

Post Series Case | Symptomatic Partial Flexor Tendon Rupture at 44 weeks / 60y | PARTIAL

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23-DS-832 | Symptomatic Flexor Tendon Rupture at 29 weeks / 60y

We found 5 cases of Distal Radius Fractures with Flexor Tendon Rupture (4 full and 1 partial)

out of 186 Distal Radius-Fracture cases in the ICUC® App.

Cases ID’s:

.

14w | Soong 2 26w | Soong 2 29w | Flexor Tendon Rupture

26w 80w | Flexor Tendon Rupture79w

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26w | Volar tilt -6º 80w | Flexor Tendon Rupture79w | Volar tilt -2º

40w | Soong 2 44w | Partial Flexor Tendon Rupture23w | Soong 1

Partial Rupture of Flexor Pollicis Longus tendonand the void space between the plate and the bone is shown by the scissors.

The plate is off the bone at surgery even if it is not so clear in the X-rays.

Partial Rupture of Flexor Pollicis Longus tendonand the void space between the plate and the bone is shown by the scissors.

The plate is off the bone at surgery even if it is not so clear in the X-rays.

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After 20 weeks, a distal radius fracture is probably

healed,

in order to minimize the flexor tendons rupture risk:

•Should protruding plates be removed, even if non-

symptomatic?

•Should even slightly or not protruding plates be

removed, if symptomatic?

•Should every plate be removed in younger patients?

Plate removal in Order to Minimize Flexor Tendon Rupture Risk

Strategies

J Am Acad Orthop Surg, Vol 17, No 6, June 2009, 369-377.

Complications of Volar Plate Fixation for Managing Distal RadiusFractures

Lisa M. Berglund, MD and Terry M. Messer, MD

Benson et al evaluated the third extensor compartment through a limited dorsal incision in a clinical study of 10 patients. The authors identified postreduction bone spurs, dorsal gapping at the fracture site, and prominent screw tips as potential causes of EPL rupture.

Lateral radiograph of a patient who presented with an

extensor pollicis longus rupture 8 months after volar fixed-angle plating of a distal radius fracture.

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Clement et al. Morphometric analysis of Lister’s tubercle JHS 2008

• Studied 100 cadavers

• Height between Lister’s tubercle and depth of groove of EPL varied 4-10 mm

• Recommend down sizing screw lengths

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STRATEGIES

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THANK YOU !!

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Errors, Complications, Complaints

in Hand Fracture Surgery

Peter J. Stern, MDNo ConflictsASSH A.M. 2021San Francisco, CA

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REMEMBER“ Hand fractures can be complicated by

deformity from no treatment, stiffness from over treatment, and both deformity and stiffness from poor treatment….”

Swanson,A. Ortho Clin N.A, 1970

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Spiral & oblique phalangeal fractures must be checked for malrotation

Assess active synchronous composite digital flexion w/ or w/o a metacarpal block

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Fractures of the base of the proximal phalanx (meta-diaphyseal junction)…..

….. difficult to assess sagittal plane angulation on AP & lat.views. Oblique views + clinical assessment (for pseudo-clawing) are important in determining treatment

Faruqui, Stern, Kiefhaber. JHS, 2012

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Condylar fractures of the head of P1 or P2 are usually unstable…..

……..If managed non-operatively, close follow-up with serial radiographs are mandatory.

Weiss A-PC and Hastings HH II, Distal Unicondylar Fx.s of P-1, J. Hand Surg, 1993

Condyle Flipped 180o

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Corollary: Condylar fractures

Single pin or screw fixation of condylar fractures is inadequate.

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Plate fixation of phalangeal shaft fractures (flexor tendon zone II)……

…….is sexy but may not be all its cracked up to be.

After tenolysis

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8 weeks60 y/o farmer, corn auger, open shaft fx.s P-1 (2-5)

Corollary: Percutaneous fixation of unstable phalangeal shaft fractures…..

…….is not sexy but often does the trick.

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Direct dorsal plating of phalangeal fractures can be risky………..

….....Screws that inadvertently penetrate the volar cortex can impair flexor tendon excursion or cause flexor tendon rupture

Rupture FDS & FDP

Honeycutt et al. JHS, 2017

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No Heroics: Gun shot injuries that ‘take out’ the metacarpal head and base of proximal phalanx of the border digits should strongly be considered for amputation. Salvage is a multi-step process that often results in short, stiff, and painful finger.

38 y/o male accidental low caliber GSW dominant handPMHx: CAD, multiple stents, HTNSocial: on SS disability, takes care of quadriplegic wife (also on SS disability), smoke 1 p.p.d.

Profundus appears intactEIP, EDC outSensibility diminishedDigit warm, pink

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No Heroics: Gun shot injuries that ‘take out’ the metacarpal head and base of proximal phalanx of the border digits should strongly be considered for amputation. Salvage is a multi-step process

that often results in short, stiff, and painful finger.

38 y/o male accidental low caliber GSW dominant handPMHx: CAD, multiple stents, HTNSocial: on SS disability, takes care of quadriplegic wife (also on SS disability), smoke 1 p.p.d.

Profundus appears intactEIP, EDC outSensibility diminishedDigit warm, pink

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Two Weeks Postoperatively

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EXTERNAL FIXATION of comminuted open fractures of the phalanges (and metacarpals) is frequently the

better part of valor.

Ashmead D IV et al. JHS, 1992

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Phalangeal shortening is poorly tolerated and is under-rated. Metacarpal shortening (up to 5 mm) is

over-rated and generally well tolerated

• There is a linear relationship b/t P-1 shortening and PIPJ extensor lag.

• For each mm of shortening 10° PIPJextensor lag

Vahey, Hastings, Wegner: J Hand Surg, 1998

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………. Allows for intraoperative assessment of rotationby having the patient actively make a fist.

Consider WALANT (w/ or w/o sedation) for fixation of phalangeal fractures…………………

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Quote from a highly respected A.O. surgeon and friend: regarding K-pins: “Pins penetrate, incinerate, irritate and

incarcerate” BUT in my opinion pin fixation is not a sign of weakness; they are forgiving, versatile, and minimize soft

tissue damage.

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Interfragmentary fixation of spiral phalangeal & metacarpal fractures:

• Don’t forget to countersink• Lagging can be dangerous• Upon insertion: if there is resistance on the

far cortex: STOP• Close the periosteum when

possible

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MANAGEMENT OF INFECTED FRACTURES

• Eliminate sepsis– Debride, cultures, antibiotics– Remove implants (especially if loose)

• Secure union ( staged procedure)– Ex. Fix. + PMM spacer– bone graft + stabilization (Masquelet)

• Regain function

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Six months later

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OSTEOMYELITIS OF THE TUBULAR BONES OF THE HAND

v 46 metacarpal & phalangeal osteomyelitisvMost frequent cause: post-traumaticvCultures: often mixed (35%) or gram positive

(35%)vOverall amputation rate: 39%vDelay > 6 mos. : 86% amputation ratev> 3 procedures: 75% amputation rate

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OSTEOMYELITIS: One, two, three strikes and you’re out……..

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AND FINALLY

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Even the worst looking X-rays may produce aSatisfactory result

Courtesy: Wm. Burkhalter

“It seems that skeletal stability and not skeletal rigidity is necessary for functional use.” 1989

Treat the patientNot the fracture

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THANK YOU

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IC24-L: Errors, Complications and Complaints: Strategies ...

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