Fractures of the Metacarpals and Phalanges PDF

► Fractures of the metacarpals and phalanges ► History and clinical assessment ► Fractures of the small bones of the hand are very common injuries. ► Many of these injuries are comparatively minor and a very satisfactory result can be expected from non-operative treatment. ► However, mismanagement...

► Fractures of the metacarpals and phalanges ► History and clinical assessment ► Fractures of the small bones of the hand are very common injuries. ► Many of these injuries are comparatively minor and a very satisfactory result can be expected from non-operative treatment. ► However, mismanagement can result in disabling deformity and stiffness. ► A careful history is the first step, taking note of hand dominance and occupation. ► Mechanism of injury may be of considerable significance, particularly with industrial injuries, where there may be crushing or penetrating trauma that will influence management decisions. ► Radiographs are not a good guide to the extent of rotational or angular deformity. ► In most injured hands the patient will hold the fingers in an extended position.. Flexion of the fingers is necessary to judge the degree of angular and rotational deformity. ► In the flexed position, the middle and distal phalanges should point towards the scaphoid region of the wrist. ► Injuries sustained as a consequence of penetrating trauma may result in tendon or nerve injury and clinical assessment should evaluate these structures also. DX: ► Most hand fractures can be diagnosed without difficulty with radiographs. ► These need to include AP, oblique and true lateral views for a full assessment of the extent of injury and the need for treatment ► Management of metacarpal and phalangeal shaft fractures: ► Most of these fractures heal reliably and quickly and non-operative treatment in some form of splintage is the treatment of choice for the majority. ► The position of immobilization is important. In a position of extension the collateral ligaments of the metacarpophalangeal (MCP) joints are at their shortest length. If immobilized in this position, stiffness is the usual result, and may be very difficult to overcome.. ► The correct position of immobilization is with the MCP joints flexed to 90° with the interphalangeal joints in full extension. ► In the case of the thumb, it should be immobilized in abduction and palmar opposition to minimize stiffness due to adduction contracture. ► If you keep the hand in such position is called ( position of safety) or the (functional position). ► Fractures with angulation or rotation can be manipulated and reduced under anaesthesia. ► A splint or short cast can then be applied. Immobilization for 2-3 weeks is more than adequate for most stable metacarpal and phalangeal shaft fractures ► Unstable and intra-articular fractures Intra-articular fractures, as described elsewhere, usually require surgical treatment. ► Angulation of more than 10° in any plane or rotational deformity causing overlapping of the fingers in flexion may require operative treatment if a stable reduction cannot be maintained by closed reduction and splintage. ► The exception to this rule is a fracture of the neck of the little finger metacarpal, where up to 45° of sagittal displacement can be accepted. ► ► Usually Kirschner wires are used for fixation. ► Screws and plates are available for use in small bones and are most suitable for use in intra-articular injuries. ► Mini-external fixators are occasionally used in the hand, most useful in high-energy injuries with comminution. In children ► Greenstick and physeal injuries of the phalanges and metacarpals are seen, as well as complete fractures. ► The same principles of management in the adults apply to children and these injuries heal rapidly. ► It is essential that any rotational malalignment is corrected as this does not remodel. ► Plates are rarely used in the child's hand as most fixations can be achieved with wires.