IC 30: Tips and Tricks for Management of Hand Fractures-Simple to Complex Moderator(s): Randip R. Bindra, FRCS, MCh Orth Faculty: Andrea Atzei, MD, Donald H. Lalonde, MD, David S. Ruch, MD Session Handouts Friday, September 14, 2018 73RD ANNUAL MEETING OF THE ASSH SEPTEMBER 13 15, 2018 BOSTON, MA 822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: meetings@assh.org All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.
Handout for Lalonde talk at finger fracture course IC30 The following is a power point presentation with videos and case studies to show early protected movement with K wired finger fractures. These should be treated just like flexor tendons for the same reason. A stiff finger is a useless finger. http://www.mediafire.com/file/2w8hul6d6evg2dl/3_pain_guided_early_motion_with_k- Wired_20.wmv/file If patients come in with a full range of motion and no scissoring with non articular fractures, please don t screw them up with surgery. Spiral metacarpals do not get decrease in power if the bones heal in a shortened position. Reference 1) Jones NF, Jupiter JB, Lalonde DH. Common fractures and dislocations of the hand. Plast Reconstr Surg; 2012;130(5):722e. 2) Gregory S, Lalonde DH, Leung LT, Minimally invasive finger fracture management, wide-awake closed reduction, k-wire fixation and early protective movement. Hand Clin: 2014 Feb;30(1):7-15. 3) MacDonald B, Higgins A, Kean S, Smith C, Lalonde DH. Long-term follow-up of unoperated, nonscissoring spiral metacarpal fractures. Plast Surg: 2014:22(4)254.
9/07/2017 DISCLOSURES Unusual approaches for uncommon hand fractures Randy Bindra, MD FRCS Professor of Orthopaedic Surgery Gold Coast University Hospital Australia Consultant/paid speaker for Acumed LLC Integra LifeSciences Actelion Pharmaceuticals Objectives Discuss complex fracture patterns Unconventional approaches Surgical techniques and tips Right hand crush Comminuted index P1 Middle PIP dislocation Depressed fracture thumb P1 base 1
9/07/2017 Sink screw beneath collateral Rolando Fracture 2
9/07/2017 Metacarpal compression fractures Metacarpal compression fractures 3
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9/07/2017 Volar lateral corner: Lateral instability Locking buttress plate 6 week old injury 6
9/07/2017 Open Reduction Technique: Lateral Technique: Lateral Open Reduction Right hand crush Comminuted index P1 Middle PIP dislocation Depressed fracture thumb P1 base 7
9/07/2017 CONCLUSION Key: Restore joint alignment Evaluate x-rays carefully/ct if required Know your anatomy direct approach Early rehabilitation 8
Tips and Tricks: PIP Fracture Dislocations David S Ruch, MD Chief of Division of Hand Surgery Professor and Vice Chairman Department of Orthopedic Surgery Duke University Medical Center Introduction Hand fractures can be complicated by deformity from no treatment, stiffness from overtreatment, and both deformity and stiffness from poor treatment A. Swanson 1970 Introduction Anatomy Goals of treatment
Treatment options Articular Fractures Dorsal fx/dislocation Volar fx/dislocation Lateral shear fx Pilon fx Condylar and bicondylar fx of P1 Dorsal fracture dislocation < 30% of articular surface extension block splint >40% - unstable Surgery-many options Key: Congruent reduction Cadaver Studies Cut saggital plane Not a true injury pattern
Fail to take into account impaction Intra-Articular Base P1/P2 Fractures But even with less than 20% - look dorsal! Radiographic Outcome Clinical outcome volar lip fracture / subluxation Closed Pinning articular surface and neutralize the joint Case example
Secondary subluxation V sign 18 yo 5 weeks unable to flex >40 Volar approach- collaterals? Elevate and buttress volar lip Reduce shotgun outcome Open reduction internal fixation (ORIF) with transverse volar plating for unstable proximal interphalangeal (PIP) fracture dislocation Ruch, DS Aldridge, JM Richard, MJ Matson, AS Hand 2018 10 patients average age of 29 years old surgery at 24d (range 2-52) average of 53% of articular involvement encountered at time of surgery.
At 3.5 months ave PIP arc 65 degrees 7.3 months with 10/10 patients having no signs of clinical subluxation and an average PIP arc of motion of 75. Note of caution FDS attaches here and shotgun approach displaces fragment Old school Treat like central slip Screws rarely engage consider anchors Intra-Articular Base P1/P2 Fractures Massive bone loss or delayed with no cartilage
hemihamate autograft for comminuted volar lip fx shotgun approach Middle Phalanx hemihamate autograft for comminuted volar lip fx shotgun approach Middle Phalanx hemihamate autograft for comminuted volar lip fx shotgun approach Middle Phalanx hemihamate autograft for comminuted volar lip fx graft harvest Middle Phalanx hemihamate autograft for comminuted volar lip fx graft fixation with 1.3mm screw
Middle Phalanx hemihamate autograft for comminuted volar lip fx graft fixation with 1.3mm screws Middle Phalanx hemihamate autograft for comminuted volar lip fx graft fixation with 1.3mm screws ORIF indications >40% articular surface PILON type with depression Dorsal and Volar and Impaction= Pilon External fixation may be best Intra-Articular Base P1/P2 Fractures
Pilon Fractures of the PIP Joint Stern, Roman et al JHS 1991 compared splinting, ORIF and Traction Splinting: 100% major pain 50% arthrodesis ORIF 7 of 9 major pain 1 arthrodesis Traction: reduction not anatomic 4 of 7 pain free all acceptable ROM External Fixation- Pilon type Schenck dynamic external fixator device
options Intra-Articular Base P1/P2 Fractures Volar lateral compression P2 Volar lateral compression P2 Volar lateral compression P2 Volar lateral compression P2 20 y female at 3months post injury
Cover plate Plate wraps around corner Immediate motion Unicondylar Fractures Type I- nondisplaced unicondylar 70-80% will displace Close follow up vs. Perc fixation Proximal Phalanx
unicondylar fracture treated with lag screw Type II- displaced unicondylar First try percutaneous with two laterally wires or small screws If can t get reduction, open Approach Head of middle phalanx-lat to terminal extensor tendon Head of proximal phalanx between central slip and lateral band Intra-Articular Head & Condylar Fx Take away points approach chamay
Take away points Two screws May not be enough Type III-Bicondylar Requires open reduction Fixation begins with lag screw fixation of one condyle to other Then plate fixation of condyle to shaft Proximal Phalanx bicondylar fracture treated with lag screw and crossed pinning conclusions The reputation of a surgeon may stand as much in jeopardy from a phalangeal fracture as from any fracture of the femur
Charnley, 1974 Thank You J.