152-手部骨折(英文)

Phalanges
• Proximal phalanx fractures usually angulate into extension (apex volar).
– Proximal fragment flexed by interossei – Distal fragment extended by central slip.
MC Fractures: Indications for Surgery
• More angulation of metacarpal fractures is acceptable is acceptable in the ring and small fingers than in the index and long fingers.
Muscular Anatomy
• Three palmar and four dorsal interosseous muscles arise from MC shafts and flex the MCP joints • These muscle create deforming forces in the case of MC fractures, typically flexing the fracture (apex dorsal angulation).
General Indications for Surgery
• • • • • • Open fractures Unstable fractures Irreducible fractures Multiple fractures Fractures with bone loss Fractures with tendon lacerations
Metacarpals
• Bowed, concave on palmar surface • Form the longitudinal and transverse arches of the hand. • Index and long finger carpo-metacarpal articulation is rigid. • Ring and small finger carpo-metacarpal articulation is flexible.
• Plate fixation
– Multiple fractures – Bone loss – Should be placed dorsally and prebent
Spiral MC Fractures
பைடு நூலகம்
• Result from twisting injury. • Often associated with rotational deformity
Fractures of the Hand
Andrew H. Schmidt, MD
Created March 2004
Anatomy and Function of the Hand
• The metacarpals and phalanges function as a jointed lever system that balance the forces of the flexor and extensor tendons. • Fractures of these bones disrupt this mechanism, and can impair hand function.
Phalanx Fractures: Surgical Options
• Unstable transverse fractures may be reduced closed and pinned percutaneously. • K-wires may be crossed or inserted antegrade or retrograde (through a flexed MCP or IP joint respectively) • ORIF of unstable and irreducible fractures may be performed through a dorsal or midaxial (preferred) incision. • Long oblique fractures (length at least twice the diameter of the bone) can be treated with interfragmentary lag screws.
• Transverse fractures usually stable and are immobilized in the intrinsic plus position (70-90 degrees MCP joint flexion and IP joints extended) for 1-3 weeks. • Spiral fractures unstable and should be stabilized.
Nonoperative Treatment
• Brief immobilization in intrinsic plus position. • Early movement • Protective splints or “buddy-taping”.
General Principles of Surgical Treatment
Surgical Techniques
• Pinning to adjacent metacarpal - useful to maintain length. • Internal Fixation
– Screws alone for long fractures – Plates for short fractures
• Incisions must be carefully placed • Soft tissues must be handled atraumatically. • Fixation must be adequate.
Metacarpal Fractures
• Minimally displaced or angulated fractures can be treated nonoperatively • Displacement of more than 5 mm, unacceptable angulation, or clinical malrotation are indications for intervention.
• Middle phalanx fractures unpredictable. • Distal phalanx fractures usually result from crush injuries and are comminuted tuft fractures.
Evaluation of Hand Fractures
• Physical examination reveals swelling, deformity. • Assess all musculotendinous units that traverse the injured area. • Standard x-rays: AP, lateral, oblique. • CT/ MRI not usually needed. • Be sure to assess malrotation by asking patient to make a fist.
Fixation of Spiral MC Fractures
• Interfragmentary lag screws
– 2.7 mm in adults – 2.0 mm in adolescents, small statured people – 2-3 screws used
Middle and Proximal Phalangeal Fractures
Distal Phalanx Fractures
• Rarely require surgery. • When needed, retrograde K-wires preferred.
Outcomes
• Results variable and related to type of injury and treatment. • Dabezies and Schutte, J Hand Surg 11:283, 1986: ROM > 90% of normal in MC and phalangeal fractures treated with ORIF. • Pun et al, J Hand Surg 16:113, 1991:Only 26% of patients regained adequate ROM after ORIF.
• Make incisions away from extensor tendons. • Plates require contouring to maintain the arch of the hand.
Transverse MC Fractures
• Usually due to a direct blow. • Typically apex dorsal angulation and increased palmar displacement of MC head. Less angulation tolerated in midshaft fractures compared to neck fractures • Effects of dorsal angulation
Principles and Goals of Fracture Treatment
• Optimum treatment determined by severity of bone and soft tissue injury. • Most fractures can be treated by immobilization or protective splinting.
Complications
• • • • Infection Soft Tissue scarring - Stiffness Nonunion Malunion
Return to Upper Extremity Index
– Weak grip – MCP hyperextension – Decreased PIP extension
Fixation of Transverse MC Fractures
• Percutanous pinning
– Crossed pins – Transmetacarpal pinning
– General rule: 10-15 degrees more angulation than the normal CMC joint motion of the involved digit is acceptable. – Index and long fingers = 10-15 degrees angulation – Ring finger = 30-35 degrees. – Small finger = up to 50 degrees.