hand fractures

BENNETT’S FRACTUREDr. Lokesh Sharoff

• Irish surgeon Edward Bennett in 1882

• Base of 1st MC # intra-articular #s

Mechanism of injury

Axial blow directed against

partially flexed MC Usually in fist fighters

ANATOMY

• Base of MC pulled radially & dorsally by APL while the distal attachment of the adductor levers pulls the base further dorsally

• Avulsion # :Smaller volar lip fragment remains attached to the AOL that anchors the fragment to tubercle of trapezium

VARIABLES

• Two primry variables

• Size of the volar lip fragment

• Amt of displacement of shaft

Clinical features

• H/o injury / blow

• Swelling and pain in the carpometacarpal region

• Painful and restricted movement at the first carpometacarpal joint. Pain on gripping, dorsiflexion, etc.

• Thumb appears shortened.

Normal ROM of 1st CMC

-Flexion –Extension Arc of 50*

-Abduction-Adduction arc of 40*

-Pronation-Supination arc of 15*

DIAGNOSIS

• Intra articular status

• AP & Oblique

• Billing & Gedda’s lateral view

Billings and Gedda view

• True lateral view (by Billing and Gedda's technique) hand pronated by 15-20° on the cassette and the tube is directed obliquely 15° distal to proximal, centering at the carpometacarpal joint.

• Characteristic fracture is seen.

ASSOCIATIONS

- # Trapezium- Ulnar collateral ligament injury

Treatment options

- C.R.- CRIF- ORIF

CR - Indications

- Undisplaced- Minimally displaced - Old age with medical co-morbidities

CR- Method

- By giving a cast and leaving the IP joint free for 6 weeks.

- In 1st CMC joint- loss of stability is more of a complication than stiffness.

CRIF - Indications

- Pure #s in which reduction can be achieved with no dislocation

CRIF - method

- Manual traction is giving by acting against the muscle forces and direct pressure over the base of 1st MC- K-wire is passed – transfixed to carpus

Open reduction - Indications

- # dislocations - Open #s- Failed CR- Tissue interposition - Late unreduced dislocation

ORIF - method

- Without ligament reconstruction- With ligament reconstruction- WAGNER technique –split FCR tendon

TREATMENT cont’d

• Check X rayIf >3mm incongruity in joint go for ORIF

• ORIF :with cortical screws probably the best

• Technically more demanding, more secure & active range of motion

POST OP Tt

• Thumb spica cast x 4wks

• 10 th day S/R & window for pintract care

COMPLICATIONS

• Malunionrec/persistent subluxation of trapezio MC jt

• CLINKSCALES closing wedge osteotomy

ROLANDO FRACTURE

• ROLANDO 1910• TYPE 2 THUMB MC #• BENNETT’S # + LARGE DORSAL

FRAGMNT• #BASE OF 1ST MC WITH Y/T SHAPED

INTRA ARTICULAR FRAGMENT• PROBABLY A COMMINUTED

BENNETT’S FRACTURE

• A difficult # to treat but least common among adult thumb MC #

• ORIF attempted only if single large dorsal & volar fragments

• ORIF of comminuted #s ----experienced surg in AO techniques

• Traction& Ex fix are reasonable alternatives• If joint surface incongrous on check x ray immobilise

the thumb for a minimal period & early active motion to remold badly distorted articular surface

GAME KEEPER’S THUMB

• C/c laxity of UCL without h/o trauma as occupational deformity in British game keepers

• MC among Skiers due to fall on an outstretched handA/c UCL injurySkier’s thumb

• MOI: valgus or abdn force probably combined with hyper extension

• UCL,dorsal capsule,ulnar aspect of volar plate& occasionally rent in adductor aponeurosis with avulsion #s of its insertion on the volar base of prox phalanx

• Stener lesion : in total tear of UCL addr aponeurosis interposed; prevents adequate healing

• CLINICAL FEATURES: Painful swollen MP joint, max tenderness ulnar aspect.

• Differentiate partial & total tear difficult but important.

DIAGNOSIS• Stener lesion : tender at ucl just prox to MP jnt• Valgus stress at MCP in flexion & ext and compare amt of

radial deviation with opposite side under LA/Wrist block.• VST with radiological support >5-15deg +ve[in 30*

flexion]• Difficult to suspect & diagnose when asso with prox

phalax#• Routine x ray before VST to r/o a]shear # .rad side of head

of MC b]prox phalanx, ulnar aspect of base

DIAGNOSIS cont’d

• MRI: 100% sensitive to stener lesion

• USG : Skilled person can detect stener lesion

DIFFERENTIAL DIAGNOSIS

- Boxers knuckle – it is a dorsal tear in the capsule of the MCP joint.- Sesamoid # - to take oblique views

Indications

- Non-operative -RCL Injuries- Volar or dorsal Subuluxation

- Boxers knuckle -Sesamoid # -Partial ucl injuries

Indications

-Operative -Steners lesion -Unreduced dislocation -Failed conservative rx -Complete lig mid-substance tear -Complete tear with bony avulsion

TREATMENT

-Partial tearsWell molded thumb spica cast in slight flexion of MP jt x3-4 wks

- then , 2 weeks arom - then 2 weeks passive rom

SURGICAL Tt- Collateral lig injuries 1- Mid substance tear 2-Tear at the distal ends

SURGICAL Tt

- Ligament tear asso. With bony fragments

1- If fragment too small

2- if large bony fragment

SURGICAL Tt

- Ligament tear with osteochondral fragment

1-if Fragment very small 2-if fragment is large3-if fixation is not possible in a fragment

POST OP Tt• Removable thumb spica brace or splint x 3-

4 wks ,ROM EXERCISES

• Rmove pull out sutures& K wire 4-6 wks

• REPAIR OF OLD UCL INJURIES:

• Using EPB tendon,addr pollicis[Neviaser et al]palmaris longus TG

• Avulsion #s to be treated if >25% of articular surface involved.

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