Complications of Hand Fractures and Their Prevention

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Presentation transcript:

Complications of Hand Fractures and Their Prevention Andrew D. Markiewitz, MD Hand Clinics Volume 29, Issue 4, Pages 601-620 (November 2013) DOI: 10.1016/j.hcl.2013.08.012 Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 1 Individuals can adapt to minor metacarpal deformities because of carpometacarpal motion. However, significant flexion deformities or rotation may need a corrective osteotomy. (A) Fifth metacarpal deformity. (B) Clinical tenodesis showing scissoring; (C, D) osteotomy and fixation; (E) scissoring corrected. (Courtesy of P.J. Stern, MD, Cincinnati, OH.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 2 Intra-articular malunion of the metacarpal head suspected on plain radiographs and caused by failure of therapy. (A, B) Plain radiographs. (C, D) CT evaluation showing the step-off on the lateral view. (E) Intraoperative view showing step-off. (F, G) Reduction and fixation with 2 screws that avoid impingement. (Courtesy of T.R. Kiefhaber, MD, Cincinnati, OH.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 3 Rotation; the width of the proximal and distal fragments do not match. (A) Posteroanterior view. (B) Oblique view with evidence of rotation despite fixation. (C) Lateral view with good articular profile. (D) Clinical view with obvious rotation. (Courtesy of P.J. Stern, MD, Cincinnati, OH.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 4 Surgery to correct rotation done at the site of malunion with takedown of prior hardware and application of new fixation allowing early rehabilitation. Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 5 (A) Proximal phalanx fracture with malalignment (B) lateral view of malalignment. (C) Osteotomy and fixation with screws. (D) Lateral view of reduced fracture. (E) Clinical views of osteotomy. Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 6 Near amputation with significant open injuries leading to K-wire fixation. Although healed, a malunion resulted. Surgery to correct the malunion led to a nonunion. Plate fixation required a second surgery with bone grafting and a bone stimulator to get union. (A) Initial reduction. (B) Healed malunion in extension. (C) After osteotomy. (D) Nonunion with bone graft. (E) Union after bone stimulation. Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 6 Near amputation with significant open injuries leading to K-wire fixation. Although healed, a malunion resulted. Surgery to correct the malunion led to a nonunion. Plate fixation required a second surgery with bone grafting and a bone stimulator to get union. (A) Initial reduction. (B) Healed malunion in extension. (C) After osteotomy. (D) Nonunion with bone graft. (E) Union after bone stimulation. Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 7 (A) Preoperative films of a proximal phalanx malunion. (B) Postoperative films after reduction and fixation with crossed K wires. (Courtesy of P.J. Stern, MD, Cincinnati, OH.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 8 Phalangeal malunion requiring osteotomy and fixation. (A) Anteroposterior (AP) view not revealing joint abnormality. (B) Lateral view showing deformity. (C) AP view showing osteotomy and correction with divergent K wires to prevent rotation. (D) Lateral view showing restoration of alignment. (Courtesy of P.J. Stern, MD, Cincinnati, OH.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 9 (A) An intra-articular phalanx fracture with malunion and angulation. (B) Scissoring. (C) Intraoperative view as the fracture line is identified and recreated while being fixed with screws. (D) Motion improvement. (Courtesy of P.J. Stern, MD, Cincinnati, OH.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 10 (A) Rollover injury with open metacarpal fracture in a smoker. (B) After irrigation and debridement of devitalized tissue. (C) After antibiotic treatment of osteomyelitis, showing nonunion. (D) Bone graft and provisional fixation after infection has been cleared. (E) Fixation. (F, G) Healed construct. (Courtesy of P.J. Stern.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 11 Extensor tenolysis. (Data from Creighton JJ Jr, Steichen JB. Complications in phalangeal and metacarpal fracture management: results of extensor tenolysis. Hand Clin 1994; 10(1):112.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 12 The balance between bone length and position affects tendon function. Thus allowing a phalanx to heal in distraction leads to stiffness. (A) Position of initial immobilization after K wires were removed at another facility. (B) Phalanx has healed but the patient is stiff on presentation 1 year later, requiring a tenolysis that allowed full motion. Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 13 (A, B) Fixed head of a proximal phalanx. (C) Collapse secondary to infection. (D, E) An arthrodesis for stable thumb. (Courtesy of P.J. Stern, MD, Cincinnati, OH.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions

Fig. 14 Therapy and splinting allow patients to focus their efforts on rebalancing joint forces as well as avoiding being placed in an unacceptable position. (A, B) Resting hand splint to keep balance while doing therapy out of splint. (C) MP flexion splint blocking the MCP joint but allowing full PIP and DIP motion. (D) Figure-of-eight or dorsal blocking splints at the PIP help restore MP and DIP balance. (Courtesy of O.T. Robert Schneider, CHT, Cincinnati, OH.) Hand Clinics 2013 29, 601-620DOI: (10.1016/j.hcl.2013.08.012) Copyright © 2013 Elsevier Inc. Terms and Conditions