Neal test - Slideshare

1. Thumb Metacarpal Fractures
Alan M. Hirahara, M.D.

2. Fracture Classification
Intra-articular
I - Bennett Fx
II - Rolando Fx
Extra-articular
IIIA - Transverse
IIIB - Oblique
IV - Children’s physeal

3. Bennett’s Fracture
• Fracture-dislocation
• First described by Bennett in 1882
• Mechanism of injury
– Axial blow directed against the partially flexed
metacarpal
– Commonly sustained in fistfights

4. Bennett’s Fracture
• Fracture line separates
major part of MC from
small volar lip
fragment, producing
disruption of CMC
joint

5. Bennett’s Fracture
• Avulsion rather than pure dislocation
secondary to strength of anterior oblique
ligament (AOL), which anchors volar lip of
MC to tubercle of trapezium

6. Bennett’s Fracture
• Primary variables • Associated injuries
– Size of volar lip – Trapezium fractures
fragment – Rupture of MP joint
– Amount of collateral ligaments
displacement of shaft

7. Deformity
• Primary forces
– Base of MC pulled
dorsally & radially by
AbdPL
– Distal attachment of
adductor levers base
further dorsally

8. Treatment
• Closed Reduction • Open Reduction,
Internal Fixation
• Percutaneous Pin – Herbert screw
– AO screw
Fixation
– Trans-meta
– Trapezium-MC • External Fixator
– Intramedullary

9. Treatment
• Accept 2 mm displacement
– Criteria not well established
– OKU Hand & Campbell’s - Accepts 1-3 mm
• 4 weeks thumb spica cast

10. Bennett Fx - Options

11. Bennett Fx - CRPP 1

12. Bennett Fx - CRPP 2

13. Bennett Fx - CRPP 3

14. Bennett Fx - CRPP 4

15. Bennett Fx - ORIF

16. Rolando’s Fracture
• Rolando described fracture in 1910
– Volar lip fragment & large dorsal fragment,
resulting in Y- or T-shaped intra-articular
fracture
– Commonly severe comminution
• Least common of adult thumb MC fx
• Prognosis - Poor

17. Rolando Fx - Xray 1

18. Rolando Fx - Xray 2

19. Treatment
• ORIF only attempted if volar & dorsal
components are single large fragments
• Traction
• External Fixation
• Limited immobilization with early attempt
at remolding via mobilization

20. Rolando Fx - ORExFix 1

21. Rolando Fx - ORExFix 2

22. Rolando Fx - Ex Fix

23. Rolando Fx - ORIF

24. Extra-articular Fractures
• Most frequent fracture in thumb metacarpal
• Surgery rarely indicated
• Closed manipulation under regional or local
anesthesia
• Spica cast x 4 weeks

25. Extra-articular Fx - Xray

26. Extra-articular Fractures
• Avoid hyperextension of MP joint
• Failure to achieve exact alignment not an
indication for open reduction
• Can accept 20-30° of residual angulation,
without detectable limitation of motion
• Oblique type
– With marked vertical inclination, percutaneous
pinning may be necessary

27. Extra-articular Fx - CRPP