Bone healing and hand fractures
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Bone healing and hand fractures
- 1. Bone Healing & Hand Fractures Sreedharan Sechachalam TTSH Hand
- 23. • Absolute stability – Primary bone healing • Relative stability – Secondary bone healing
- 26. Hand Fractures
- 27. Clinical assessment • Concomitant fractures • Range of motion • Malrotation • Shortening
- 29. Anatomy- Phalanx • 3 phalanges per finger: – Proximal, middle and distal • Gross anatomy – Tubular bone with well defined medullary canal – Base, shaft, neck and head/ tuft – P1 longest and largest – P1:P2 ratio 2-1.3:1 – P3shortest and smallest – P1 length: MF>RF>IF>LF – Tendon insertions
- 30. Fractures- Proximal Phalanx • Apex/volar angulation • Intrinsics flex proximal fragment • Central slip extends distal fragment • Angulation shortens fragment • Progressive PIPJ extension lag • Pseudoclaw
- 31. Fractures- Middle Phalanx • Dependent on location – Central slip/ FDS insertions – Proximal to FDS: apex dorsal – Midshaft: dorsally or volar – Distal to FDS: apex volar
- 32. Fracture- Distal Phalanx • Base, shaft, tuft • Significant soft tissue injury • Insertion of flexor/ extensor tendons at base of distal phalanx
- 33. Metacarpal fractures • Base, Shaft, Neck, Head • Increasing angulation tolerated with ulnar sided fractures
- 34. Fracture character and fixation techniques • Size of the fragment • Fracture personality
- 35. Fractures of the Thumb
- 36. Bennett Fracture • Metacarpal shaft displaced radially, proximally and dorsally with supination by the pull of AbdPL, AddPL • Unstable fracture
- 37. Comminuted Fractures of Metacarpal Base • 1910: Silvio Rolando described 3 cases of a Y-pattern fracture of the MC base • Definition of Rolando fracture: – Y or T- pattern fractures that include the volar- ulnar Bennett fragment + dorsoradial fragment • Rolando fracture loosely used to describe all comminuted fractures of the metacarpal base • Mechanism of injury: Axial loading • Compared to Bennett fracture, more difficult to treat, worse outcome Carlsen BT, Moran SL. Thumb trauma. JHSA 2009.
- 38. Thumb Metacarpal Shaft Fractures • Uncommon – Force directed to shaft often transferred to base • Such fractures occur at the metaphyseal-diaphyseal junction (epibasal fractures) • Displaced with apex dorsal angulation due to pull of adductor pollicis, FPB, abductor pollicis brevis Carlsen BT, Moran SL. Thumb trauma. JHSA 2009.
- 39. end
Hinweis der Redaktion
- Proximal and middle phalanx similar internal structure Distal phalanx is markedly different Base Flares out from the shaft. Concave palmar surface Shaft Smooth, convex dorsally and concave palmarly. Narrow from proximal to distal Head 2 condyles Articular surface extends palmarly Tuft Similar to that of the proximal phalanx Shorter Ratio of proximal : middle phalanx 2:1 to 1.3 : 1 The EDC and the IF and LF proprius joints the extensor expansion at the MCP joint. Tendons are maintain over the apex of the MCPJ by a substantial dorsal sling of transverse fiber, the sagittal band. Distal to MCPJ, the extensor tendon divides into 3 components: central slip which inserts into the base of the middle phalanx, and 2 lateral slips that joint he lateral bands at the distal aspect of the proximal phalanx. ( conjoint tendons) Tendons of the dorsal component of the DI passes almost direct over the axis of rotation of the joint and thus may extends, flex or abduct the phalanx; it’s angle of attack is 0-5 degree The palmar component of the dorsal and palmar interossei attack the joint well below the axis and thus are capable of flexing the MCPJ more strongly as well as extending the IPJ Each lumbrical approaches the MCP palmar to the transverse MC ligament and its mechanically best suited to initiate flexion of the MCP. Palmar interosseous inserts into the ulnar of IF and radial of MF, RF
- Surgical anatomy of the hand and upper extremities Fractures of the proximal phalanx normally exhibit a apex/volar angulation Intrinsics flex proximal fragment Distal fragment extended by attachment of of central slip to dorsal lip of middle phalanx MA of rotational axis of ext > flex tendons As the palmar angulation shortens the proximal fragment, the reserve length is used till saggital bands tighten. (Sagittal band is the dorsal sling of transverse fibres which invest the tendon dorsally and pass palmarly to each side of the MCPJ, attaching to the palmar plate an the metacarpal ligament.) Extensor mechanism has 2-6mm of reserve length before sagittal bands tighten and produce progressive extensor lag at PIPJ (12degrees per mm of bone tendon discrepancy) Progressive ext lag at PIPJ= ACCORDIAN LIKE COLLAPSE Pseudoclaw develops
- Proximal to insertion of FDS, the distal fragment is flexed resulting in dorsal angulation Midshaft Dorsal or volar Distal to FDS Proximal fragment flexed, distal extended by terminal tendon
- Significant soft tissue injury Primary concern is soft tissue repair Base of distal phalanx fractures evaluated for avulsion of insertion of flexor/ extensor tendons The distal phalanx is divided into three anatomical parts: proximally, the metaphysis (base), followed by the diaphysis (“shaft”), and finally the ungual tuberosity (“tuft”). The base of the distal phalanx has a prominent dorsal crest at the insertion of the extensor tendon. The tendon is also adherent to the distal interphalangeal (DIP) joint capsule. On the palmar surface is the insertion of the flexor digitorum profundus tendon. This is also adherent to the volar plate. The flexor tendon inserts into the whole width of the base of the distal phalanx. The volar plate is very flexible, allowing hyperextension of the DIP joint and pulp-to-pulp pinch. The vascularity of the extensor tendons is more precarious than that of the flexor tendons. This prolongs extensor tendon healing time.
- 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). The border digits- unstable fractures. Inside 2 digits are stable.
- The size of the fragment determines the type and size of implant suitable for the fixation The fracture character guides the fixation technique. Size of the fracture fragment should be more than 3x the size of the screw diameter before ascrew can be used without shattering the fragment Plate fixation, ideal 6 cortices purchase proximal and distal to the fragments Interosseous wiring ( Gingrass and Lister) requires less bone volume and may be more suitable in periarticular fractures