hand fractures
TRANSCRIPT
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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