Professional Documents
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COMPLICATIONS OF HAND
FRACTURES AND POST
FIXATION REHABILITATION OF
THE HAND
Christian Dumontier MD, PhD
- De Putter CE et al. Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. J
Bone Joint Surg Am 2012;94(9):e56.
- Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg 2001;26:908
15.
- Feehan LM, Sheps LM, Samuel B. Incidence and demographics of hand fractures in British Columbia, Canada: a population-based study. J
Hand Surg 2006;31:106874.
COMPLICATIONS OF HAND FRACTURES
DEPEND OF
sharp vs crushing
injury;
low vs high-energy
injury,
COMPLICATIONS OF HAND FRACTURES
DEPEND OF
Type of fracture
(transverse, oblique,
comminutive)
COMPLICATIONS OF HAND FRACTURES
DEPEND OF
Type of fracture
(transverse, oblique,
comminutive)
Type of bone
(metacarpals vs phalanx)
COMPLICATIONS OF HAND FRACTURES
DEPEND OF
As plastic surgeons we
are aware that there are
many envelopes around
the hand bones !!!.
COMPLICATIONS OF HAND FRACTURES
DEPEND OF
Patient characteristics
(age, activity level,
occupation, and
vocational interests)
Smoking (X 9 nonunion
rate)
Puckett BN et al. Remodeling potential of phalangeal distal condylar malunions in children. J Hand Surg 2012;37:3441.
COMPLICATIONS
Complications and
outcome depends of the
initial injury +++
Complications and
outcome depends of the
initial injury +++
NONUNION
NON UNION
A nonunion can be atrophic or hypertrophic.
Barton NJ: Fractures of the shafts of the phalanges of the hand. Hand 11:119-33, 1979
Borgeskov S: Conservative therapy for fractures of the phalanges and metacarpals. Acta Chir Scand 133:123- 30, 1967
Van Oosterom FJ et al. Treatment of phalangeal fractures in severely injured hands. J Hand Surg Br. 2001;26(2):108-111.
NON UNION
Most nonunions in the hand are atrophic and
associated with bone loss or
infection.
Smoking
Jupiter JB et al. The management of delayed union and nonunion of the metacarpals and phalanges. J Hand Surg l0A:457-66, 1985
Crossed K-wires for neck fracture ending as a non-union
DIAGNOSIS OF NONUNION CAN BE
CHALLENGING
Meta: 6 weeks
Ring D. Malunion and nonunion of the metacarpals and phalanges. Instr Course Lect 2006;55: 1218.
TREATMENT OF ATROPHIC NONUNION
Amputation or arthrodesis
are useful treatment
options, especially if the
associated soft tissue
components are
compromised
Ring D. Malunion and nonunion of the metacarpals and phalanges. Instr Course Lect 2006;55: 1218.
DISTAL PHALANX NONUNION
Asymptomatic nonunion of the distal
phalanx tuft does not require
intervention;
Kim J et al. Correction of Distal Phalangeal Nonunion Using Peg Bone Graft. J Hand Surg Am. 2014;39(2):249-255
DISTAL PHALANX NONUNION
Ito et al. in 6 patients used a palmar midline incision and cancellous and
cortical bone graft from the olecranon.
- Ozcelik IB, Kabakas F, Mersa B, Purisa H, Sezer I, Erturer E. Treatment nonunion of the distal phalanx with olecranon bone graft. J Hand Surg Eur Vol.
2009;34(5):638-642
- Itoh Y, Uchinishi K, Oka Y. Treatment of pseudoarthrosis of the distal phalanx with the palmar midline approach. J Hand Surg Am. 1983;8(1):80-84.
- Botelheiro JC. Treatment of pseudarthrosis of the distal phalanx with a compression screw. J Hand Surg Br. 1995;20(5):618-619.
- Jupiter JB, Koniuch MP, Smith RJ. The management of delayed union and nonunion of the metacarpals and phalanges. J Hand Surg Am. 1985;10(4):457-466.
- Chim H, Teoh LC, Yong FC. Open reduction and interfragmentary screw fixation for symptomatic nonunion of distal phalangeal fractures. J Hand Surg Eur
Vol. 2008;33(1):71-76.
DISTAL PHALANX NONUNION
Kim performed grafts using
bone pegs in 13 patients.
Kim J, Ki SH, Cho Y. Correction of Distal Phalangeal Nonunion Using Peg Bone Graft. J Hand Surg Am. 2014;39(2):249-255
ATROPHIC NONUNION AND
POTENTIAL INFECTION ?
MALUNION
Deformities caused by malunions range from the mild,
aesthetically displeasing to the severe and functionally
disabling. This includes muscle fatigue, cramping,
pseudoclaw deformity, deformity, and prominent
metacarpal heads in the palm.
Seitz WH Jr, Froimson AI. Management of malunited fractures of the metacarpal and phalangeal shafts. Hand Clin 1988;4(3):52936.
PRINCIPLES OF SURGICAL TREATMENT FOR
ROTATIONAL DEFORMITIES
Birndorf MS et al. Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. PRS 1997; 99:1079-1085
FIFTH METACARPAL NECK
DISPLACEMENT/ MALUNION
Shortening can be
functionally tolerated but
leaves the patient with the
disappearance of
prominence of metacarpal
head
Shortening is appreciated by drawing Chmell line on plain X-rays.
Usually the deep intermetacarpal ligaments prevent greater than 3 to 4
mm of metacarpal shortening
METACARPAL SHAFT MALUNION AND
TOLERANCE
Meunier
Shor et al found that metacarpal shortening affected strength, with 2
mm oftshortening
ening producing a minimal 8% loss of power and 10 mm of
less ta 45% loss of power from the dorsal interossei.
shortening producing han 4-
5 mm
sigand
Low et al. found that flexion is uforces
nifiextension s u were diminished with
c an
shortening of more than 3 mm or dorsal a
ce angulationllygreater
withothan 30
ut an
Strauch et al. found 7 of extensor lag with every 2 mm of metacarpal
y
shortening, possibly affecting flexor power.
- Meunier MJ, Hentzen E, Ryan M, et al. Predicted effects of metacarpal shortening on interosseous muscle function. J Hand Surg 1998;29(4):
68993.
- Low CK, Wong HC, Low YP, et al. A cadaver study of the effects of dorsal angulation and shortening of the metacarpal shaft on the
extension and flexion ratios of the index and small fingers. J Hand Surg 1995; 20(5):60913.
- Strauch RJ, Rosenwasser MP, Lunt JG. Metacarpal shaft fractures: the effect of shortening on the extensor mechanism. J Hand Surg 1998;23:
51923.
- Wills J et al. The effect of metacarpal shortening on digital flexion force. J Hand Surg Eur. 2013, 38: 66772.
AT THE FINGER (P1) LEVEL
Proximal phalangeal
fractures typically produce
a volar apex angulation
because of tension on the
central slip distally and the
lumbrical proximally.
BIOMECHANICAL CONSEQUENCES (AT THE FINGER LEVEL)
- Coonrad RW, Pohlman MH. Impacted fractures in the proximal phalanx of the finger. J Bone Joint Surg Am 1969;51(7):12916
- Vahey JW, Wegner DA, Hastings H III. Effect of proximal phalangeal fracture deformity on extensor tendon function. J Hand Surg 1998;23:673
81.
Minor complication with extensor lag due to malunion
ASSOCIATED LESIONS ARE DETRIMENTAL (AT THE
FINGER LEVEL)
- Botte MJ, Davis JL, Rose BA, et al. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. Clin Orthop
Relat Res 1992;(276):194201.
- Buchler U, Gupta A, Ruf S. Corrective osteotomy for post-traumatic malunion of the phalanges in the hand. J Hand Surg 1996;21(1):3342.
AT THE FINGER (P2) LEVEL
Middle phalangeal
malunions are apex dorsal if
the fracture is proximal to
the FDS insertion and apex
volar if the fracture is distal
to the FDS insertion. Apex
volar angulation affect
flexor tendon
biomechanics.
SURGICAL PRINCIPLES AT FINGER LEVEL
Trumble T, Gilbert M. In situ osteotomy for extra articular malunion of the proximal phalanx. J Hand Surg 1998;23:8216.
STAGE SURGERY ?
Established intra-
articular malunions
are very challenging
to treat.
In situ osteotomy is
most often used -
stiffness is a
common outcome.
2 months post-trauma !!!
CT scan
MALUNIONS
Freeland and Lindley presented options for malunion management of
8
Articular incongruity,
Rotation > 10
Freeland A, Lindley SG. Malunions of the finger metacarpals and phalanges. Hand Clin 2006;22(3): 4155.
STIFNESS
Stiffness is not only the most common complication
encountered, but it is also unfortunately the most difficult
to treat.
STIFFNESS IS THE MOST FREQUENT
COMPLICATION (AND THE MOST
DIFFICULT TO TREAT)
Due to the injury
Open fractures
Soft tissue scarring affects hand function more than fracture healing
Faruqui S, Stern PJ, Kiefhaber TR. Percutaneous pinning of fractures in the proximal third of the proximal phalanx: complications and
outcomes. J Hand Surg 2012;37(7):13428.
STIFFNESS IS THE MOST
FREQUENT COMPLICATION
Due to the injury
Type of fixation ?
DOES THE TYPE OF FIXATION HAS ANY
INFLUENCE ON THE POST-OP STIFFNESS ?
A few studies have raised concerns about the possibly higher rates of complications
of plate fixation.
52% complication rate in 64 # treated with plates (CPRS, Total ROM < 180,
infection, delayed union/nonunion, implant failure) - Kurzen
64% complication rate with plates (extensor lag > 35, ROM < 180, infection,
plate prominence, tendon rupture) - Page
Kurzen P et al. Complications after plate fixation of phalangeal fractures. J Trauma. 2006; 60(4):841843
Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal
fractures. J Hand Surg Am. 1998; 23(5):827832.
Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat
Res 2006;445:13345.
DOES THE TYPE OF FIXATION HAS ANY
INFLUENCE ON THE POST-OP STIFFNESS ?
608 patients out of 749 had satisfactory results with therapy and only 61
of the 141 unsatisfied patients had surgery.
Skin and soft tissue envelope should be mature and supple, and the fracture
consolidated before any surgical procedure.
Young VL, Wray RC Jr, Weeks PM. The surgical management of stiff joints in the hand. Plast Reconstr Surg 1978;62(6):83541.
EXTENSOR TENOLYSIS +/- ARTHROLYSIS
Various techniques described. Stage
surgery with manual testing
between stages:
Creighton JJ Jr, Steichen JB. Complications in phalangeal and metacarpal fracture management. Results of extensor tenolysis. Hand Clin 1994;
10(1):1116.
FLEXOR TENOLYSIS +/- ARTHROLYSIS
INFECTION
INFECTION
Reilly KE, Linz JC, Stern PJ, et al. Osteomyelitis of the tubular bones of the hand. J Hand Surg Am 1997;22(4):6449
INFECTION (NOT ALWAYS A COMPLICATION
BUT A RESULT) IS SECONDARY TO:
2011 review of 145 cases showed a 1.4% infection rate, with a high proportion (91 out
5
A 2006 review of bone grafting for open fractures of the hand found a 0% infection
rate
A 2010 retrospective review of 432 metacarpal and phalanx fractures requiring ORIF
found no significant difference in infection rates between the open (133 fractures) and
closed (299 fractures) injury groups.
- Duncan RW, Freeland AE, Jabaley ME, et al. Open hand fractures: an analysis of the recovery of active motion and of complications. J
Hand Surg 1993; 18(3):38794.
- Capo JT, Hall M, Nourbakhsh A, et al. Initial management of open hand fractures in an emergency department. Am J Orthop
2011;40(12):E2438.
- Saint-Cyr M, Gupta A. Primary internal fixation and bone grafting for open fractures of the hand. Hand Clin 2006;22(3):31727.
- Bannasch H, Heermann AK, Iblher N, et al. Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and
outcome analysis show no increase of complications in the treatment of open compared with closed fractures. J Trauma 2010;68(3):
6248.
PREVENTION OF
INFECTION
Gonzalez MH, Bach HG, Elhassan BT, et al. Management of open hand fractures. J Am Soc Surg Hand 2003;3(4):20818.
Metcalfe D. et al. .Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg. 2016;41E(4):423-30
DIAGNOSIS OF INFECTION IS NOT ALWAYS EASY
Definitive diagnosis is made with cultures obtained from a bone biopsy.
Radiographs are initially normal, but may reveal sequestrum and involucrum in
chronic cases.
Hardware loosening
SURGICAL PRINCIPLES
Remove the hardware if the fracture is healed
Case Pr Obert
Masquelets technique:
Resection of infected tissue
Cement to fill the defect
Stabilisation
At two months, open the capsule, remove the cement, fill with
cancellous bone
Postop D 15 D 30
2 Months 2 Years
PAIN
PAIN
Acute pain represents the normal response of the body to injury.
Injury alters the perception of self and may be a major factor in the
patients ability to recover. It is desirable to avoid the cycle of pain,
swelling, disuse, and stiffness that can occur with even minor injuries.
DaCruz DJ, Slade RJ, Malone W. Fractures of the distal phalanges. J Hand Surg Br. 1988;13(3):350-352
POST-TRAUMATIC ARTHRITIS
POST-TRAUMATIC ARTHRITIS
Can be the result of intra-articular malunion or chondral injury
from the moment of impaction
REHABILITATION OF HAND FRACTURES
Edema postures the hand into wrist flexion, MP joint extension, IP joint flexion, and thumb adduction. Functional
splinting place the hand in a resting position that will avoid this deformed posturing.
Ice can be performed with the use of large bags of frozen peas and is effective even over a splint or cast.
The greatest reduction in swelling is obtained with the hand supported in elevation overnight. +++
Early mobilization to promote venous return via muscle contraction is advocated in stable fractures.
Having the patient adduct the fingers tightly and maintain this tension while flexing at the MP joint enhance both
intrinsic muscle pumping and achieve the desired joint positions of full MP flexion and IP extension.
Double buddy straps, protect fracture alignment and encourage mobility of the injured digit.
Patients are also instructed in shoulder and elbow ROM exercise in elevation to facilitate proximal muscle pumping.
Night
SPLINTING
AK-wires removal 4-6 weeks. Adjust the splint for proper fit for continued
fracture protection for another 2 weeks. AROM exercises are performed hourly.
Callus is considered clinically stiff enough for free active motion but is not
stable enough to bear a functional load, which occurs after 6 to 8 weeks.
Micks JE, Reswick JB. Confirmation of differential load- ing of lateral and central fibers of the extensor tendon. J Hand Surg [Am].
1981;6:462-467.
FLEXOR TENDON
GLIDING: FDP
Try to increase selective gliding
of flexor tendons between the
FDP and FDS
PREVENTION FOR EXTRA-ARTICULAR #
Early motion +++. Do not hesitate to start early mobilisation. Bob Beasley is
quoted as saying For every nonunion, the hand surgeon sees a thousand stiff
joints.
Hardy MA. Principles of Metacarpal and Phalangeal Fracture Management: A Review of Rehabilitation Concepts. J Orthop Sports Phys Ther
2004;34:781-799
PREVENTION FOR ARTICULAR #
Articular fractures should be reduced to anatomic or near-anatomic alignment to prevent
joint pain, loss of motion, and accelerated degenerative changes
Fractures that involve more than 15% to 25% of the articular surface benefit from
articular reduction.
Early motion should be started. Weiss shown no difference in ROM for proximal phalanx
fractures with K-wire fixation when motion was initiated between 1 to 21 days but
significant loss of mobility if motion was delayed after 21 days
- Seno N, Hashizume H, Inoue H, et al. Fractures of the base of the middle phalanx of the finger. Classification, management and long-term
results. J Bone Joint Surg Br 1997;79(5):75863.
- Weiss AP, Hastings H, 2nd. Distal unicondylar fractures of the proximal phalanx. J Hand Surg [Am]. 1993;18:594-599.
REFERENCES