Hand CASE 1
CASE 1
A 28-year-old, right-hand-dominant male caught big air going off a jump while snowboarding for the first time. He landed awkwardly on his non-dominant left hand and immediately developed pain.
Radiographs were obtained at the slope side indicating multiple fractures in the hand (Fig. 4–1A and B).
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Figure 4–1 A–B
He was then splinted and presented to your office on the fourth day after injury.
The most appropriate management at this time for this injury would be:
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Short-arm splint for 6 weeks
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Short-arm cast in intrinsic plus position for 6 weeks
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Long-arm cast in intrinsic plus position for 6 weeks
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Open reduction, internal fixation of all fractures
Discussion
The correct answer is (D). This patient has suffered multiple displaced metacarpal
fractures in contiguous digits. The most appropriate treatment would be an open reduction and internal fixation in order to give the patient an earlier, rehabilitative start.
The reasons for open treatment of these contiguous fractures include which of the following?
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Restoration of anatomy
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Decompression of the interosseous muscles
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Restoration of longitudinal length of metacarpals and the length–tension relationships of the intrinsic musculature
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Restoration of the transverse arch of the hand
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All of the above
Discussion
The correct answer is (E). The metacarpals in the hand have longitudinal arches and are arranged in the transverse arch such that the first metacarpal lies slightly volar to the second metacarpal with the apex of the arch forming at the level of the third metacarpal. In addition, the space between the metacarpals is occupied by the interossei, both the volar and dorsal. Displacement of multiple metacarpal fractures are associated with a significant degree of soft tissue swelling and are especially associated with high-energy injuries such as this one. Internal fixation of these contiguous, multiple metacarpal fractures allows for: restoration of both longitudinal and transverse arches; decompression of the interosei to reduce swelling; restoration of longitudinal length and thereby the length-tension relationship of the intrinsic muscles; and restoration of the skeletal stability which allows for early rehabilitation of the hand, optimizing his functional outcome.
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Figure 4–1 C
Basic requirements for fixation of a tubular bone shaft fracture in the hand using only interfragmentary screws include which of the following?
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Length of the fracture should be more than twice the diameter of the bone at the central part of the fracture.
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The amount of bone available around the head of the screw should be at least three times the size of the screw being utilized.
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The screws must follow the spiral of the fracture.
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All of the above.
Discussion
The correct answer is (D). When fixing fractures with interfragmentary screws only, it is critical that they be stable enough for early motion. Interfragmentary screws, when utilized appropriately, produce interfragmentary compression thereby obviating the need for plate neutralization. To do so, the length of the fracture should be more than twice the diameter of the bone in the middle of the fracture. Furthermore, screws should be placed in the part of the bone where the amount of bone available around the screw head is three times the size of the screw head. This
allows one to exert compression from the screw head during interfragmentary compression without splitting of the bone from tightening the screw. In most instances, interfragmentary screws are suitable for either long, oblique fractures, fulfilling the criteria described above, or for spiral fractures. Therefore, interfragmentary screws, which are usually placed perpendicular to the fracture line, follow the line of the spiral. Short, oblique fractures and transverse fractures are not suited for just interfragmentary screw fixation and usually require the use of a neutralization plate.
Which of the following are possible complications of such an injury and of the surgical procedure utilized for this patient?
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Stiffness of the interphalangeal joints
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Problems due to soft tissue irritation from the hardware
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Extensive tendon irritation
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Stiffness of the metacarpophalangeal joints
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All of the above
Discussion
The correct answer is (E). Multiple metacarpal fractures as mentioned above are high-energy injuries. Every effort should be made to fix them if they are displaced and to start early rehabilitation. Failure to do so is likely to cause stiffness of the small joints in the hand. This can occur not only due to the injury itself but from: the edema of the intrinsics; the resulting atony from the injury; the loss of the length–tension relationships of the intrinsics; as well as the stiffness that can occur from swelling, bleeding, and lack of use should these fractures be treated nonoperatively. Early rehabilitation after stable internal fixation allows for the treating surgeon to minimize all of these possibilities. Plates placed over the hand, especially the metacarpals, are known to cause difficulties with tendon irritation. It is therefore critical that, after placing the plate over the dorsal aspect of the metacarpal, every effort is made to cover the metacarpal with surrounding soft tissue, namely the interosseous fascia so as to insert a layer of soft tissue between the plate and the overlying extensor mechanism. Furthermore, plates placed very distally on the metacarpals are likely to interfere with the metacarpophalangeal joint capsule causing pain and resulting in stiffness. In some studies, problems associated with symptomatic hardware after metacarpal fracture fixation are as high as 40%. However, while tendon irritation associated with metacarpal plating remains a problem, routine removal of metacarpal plates, if asymptomatic, is not
recommended.
Objectives: Did you learn...?
Treat for multiple metacarpal fractures?
Identify reasons for open reduction and internal fixation? Identify complications of open reduction and internal fixation?