Managing hand fractures Vaikunthan Rajaratnam Summary: healing process after trauma I: Inflammation II: Soft callus III: Hard callus III: Bone remodelling Personality of hand fractures •osteology of hand, •principles of management of hand fractures, •evaluation of fractures – clinical and investigations ( xrays, views, CT scan, bone scan, ultrasound, MRI, arthroscopy) •Classification of common hand fractures •Goals of management Complete or incomplete break in the continuity of bone or cartilage Can occur in any type or shape of bone Fractures are caused by forces acting on bone which are higher than the ones the bone is able to take Types of forces: compression, traction, torsion, impaction, avulsion Types of fractures: complete/incomplete, open/closed, intra-/extraarticular, transversal, oblique, spiral, segmental, comminuted, pathological and fatigue fractures What is a Fracture? Why classify fractures? •Classification or description of fractures is only used when the classification or description is useful in providing treatment or outcomes Types of classifications •Anatomic description •AO classification •Salter-Harris classification •Gustillo open fracture classification •Fracture specific classifications Anatomic description -Type •Type is the over all fracture pattern •Examples are: Simple, spiral, segmental Anatomic description of fractures •Described in specific order •Type •Comminution •Location •Displacement Anatomic description -Location •Location is the anatomic location of the fracture usually described by giving the bone involved and location on the bone •Examples are: distal radial shaft, proximal 1/3 humeral shaft, intra-articular distal tibial Anatomic description -Communition •Comminution is the measure of the number of pieces of broken bone that there are. •Examples are: non-comminuted or mildly comminuted or severely comminuted Anatomic description -Displacement •Displacement is the amount the pieces of a fracture have moved from their normal location •Can be displaced or non-displaced •Subdivided into 3 sub-categories: translation, angulation, and shortening Displacement -Translation •Translation is sideways motion of the fracture -usually described as a percentage of movement when compared to the diameter of the bone. Displacement -Angulation •Angulation is the amount of bend at a fracture described in degrees. Also described with respect to the apex of the angle. Displacement -Shortening •Shortening is the amount a fracture is collapsed expressed in centimeters. Sometimes called bayonette apposition. Anatomic description •Simple, transverse, non-communited midshaft radial and ulnar fracture with 30 degrees apex radial angulation. Anatomic description •Simple, transverse, non-communited distal radial and ulnar fracture with 100% radial translation, 45 degrees apex ulnar angulation and 2 cm of shortening. AO Fracture Classification Bone segments . AO Fracture Classification Fracture types AO Classification -Type A •Type A fracture are extra-artucular •1 -Avulsion fracture •2 -Complete fracture •3 -Comminuted fracture AO Classification -Type B •Type B fracture are intra-artucular single condyle fractures •1 -Simple •2 -Crush/depression •3 -Comminuted -split depression AO Classification -Type C •Type C fractures are intra-artucular both condyle fractures •1 -Simple •2 -Crush/depression •3 -Comminuted -split depression Gustillo classification •The Gustillo classification is used to classify open fracture -ones in which the skin has been disrupted •Three grades that try to quantify the amount of soft tissue damage associated with the fracture Open fractures -grade 1 •wound less than 1 cm w/minimal soft tissue injury •wound bed is clean •bone injury is simple w/minimal comminution •w/IM nailing, average time to union is 21-28 weeks Open fractures -grade 2 •wound is greater than 1 cm w/moderate soft tissue injury •wound bed is moderately contaminated •fracture contains moderate comminution •w/IM nailing, average time to union is 26-28 weeks Open fractures -grade 3A •wound greater than 10 cm w/crushed tissue and contamination •soft tissue coverage of bone is usually possible •w/IM nailing, average time to union is 30-35 weeks Open fractures -grade 3B •wound greater than 10 cm w/crushed tissue and contamination •soft tissue is inadequate and requires regional or free flap •w/IM nailing, average time to union is 30-35 weeks Open fractures -grade 3C •is fracture in which there is a major vascular injury requiring repair for limb salvage •fractures can be classified using the MESS •in some cases it will be necessary to consider BKA following tibial fracture Complex intra articular fractures around PIPJ •Principles of ligamentotaxis •Dynamic external fixator principles •The Suzuki frame »indications »the design »the techniques »complications »alternative management Traction To achieve reduction, traction is normally applied in the long axis of the limb. This works only when the fragments are still connected to some soft tissues = Ligamentotaxis Some form of traction is best for indirect reduction Dynamic external fixator principles •Proximal and distal anchor •Longitudinal distraction •2 types – static and dynamic •Connection allowing mobilisation Design – unilateral and bilateral Introduction •Proximal interphalangeal joint (PIPJ) fractures –Can predispose to chronic pain, joint stiffness –Various treatment options: •extension block splinting1 •open reduction and internal fixation2 •closed reduction and percutaneous fixation3 •Capsuloligamentotaxis. . . Hynes-Giddins Dynamic External Fixator (HG-DEF)4 •Modified the ‘pins and rubbers traction system’ advocated by Suzuki et al5 •Simple, effective construct –Performed under LA –2 K-wires (1.1mm) –Mean finger PIPJ flexion at 6/52 reported as 12-880 (9 patients) Modified Hynes Giddins Dynamic External Fixator (dorsal and lateral views) Methods Anteroposterior and lateral views of the construct used to determine the forces applied by the dynamic external fixator Results Force against displacement for constructs on models under compression0102030405060-7-6-5-4-3-2-101Displacement (mm)Force (N)6.5 mm5.5mm4.5mm repeat3.5mm2.5mm1.5mmLinear (6.5 mm)Linear (5.5mm)Conclusion Linear correlation between force and displacement (δD ‘Loading’ the construct stores potential energy within it which has the effect of exerting an outward force. It is this force that tends to distract the fracture in vivo. The larger the difference in distance between the resting and ‘loaded’ frame, the greater the distracting force applied. Suzuki Frame Indication –Communited fractures –Intra articular fractures of the concave component Principle -accurate central position of proximal anchor – parallel and symmetrical frame –Flexible secure connection of both wires References 1.Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint of the fingers: a preliminary report of a new treatment technique. J Hand Surg [Am] 1978;3-4:386-9. 2.Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint. Treatment with the force couple splint. Clin Orthop Relat Res 1987-214:101-12. 3.Deshmukh SC, Kumar D, Mathur K, Thomas B. Complex fracture-dislocation of the proximal interphalangeal joint of the hand. Results of a modified pins and rubbers traction system. J Bone Joint Surg Br 2004;86-3:406-12. 4.Hynes MC, Giddins GE. Dynamic external fixation for pilon fractures of the interphalangeal joints. J Hand Surg [Br] 2001;26-2:122-4. 5.Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for treatment of comminuted intraarticular fractures and fracture-dislocations in the hand. J Hand Surg [Br] 1994;19-1:98-107. 6.Cheema M, Mangat K, Holbrook N, Rajaratnam V. A biomechanical analysis of distraction force in modified hynes-Giddins dynamic external fixator. Ann Plast Surg. 2007 Sep;59(3):300-1. 7.Theivendran K, Pollock J, Rajaratnam V., Proximal interphalangeal joint fractures of the hand: treatment with an external dynamic traction device. Ann Plast Surg. 2007 Jun;58(6):625-9 Managing complications •Infections, stiffness, mal union, non union, implant failure and tendon rupture •Diagnosing, prevention and treatment, •Tenolysis and arthrolysis •Post operative therapy • Infections •Not common as other areas •Prophylaxis – thorough debridement, A/B, gentle tissue handling, vascular tissue cover (flaps) • early detection stiffness •Adhesions •Flexor tendon injury •Oedema •Collateral ligament contracture •Intra particular fibrosis mal union •Inadequate reduction •Inadequate plate contouring •Implant failure non union •Bone loss •Avascularity •Abnormal mobility at fracture site •Infection •poor bone contact •malnutrition •peripheral neuropathy, •advising smoking cessation, •avoiding NSAIDs implant failure •Mechanical instability •Overuse •Technical errors •Over manipulation of plates •Infection tendon rupture •Anatomy •Drilling •Osteotomy •Screw protrusion Tenolysis and arthrolysis •Extensor •Flexor •Arthrolysis •Adequacy of procedure •Post op theraphy -analgesia Other techniques of fracture fixations and General conservative management of hand fractures •K wire fixations •external fixators •types of fractures suitable for conservative treatment •principles of non operative treatment 5 days post op What would your treatment be? What would your treatment be? Rolando