Wrist and hand fractures

Among them we include:
 * fractures of the os scaphoid;


 * luxation of the carpal bones;


 * metacarpal fractures;


 * dislocation of the metacarpophalangeal joints;


 * fractures of finger joints.

Fractures of the os scaphoid

 * It is caused by direct force during dorsiflexion of the hand.

Classification

 * Fracture of the tuberculum scaphoid (distal pole) – an extra-articular fracture that heals well.


 * Break-off of the proximal end - poor vascular supply - heals with a flap or avascular necrosis.


 * Fracture of the body - the most common, according to Russ it is divided into:
 * Horizontally inclined
 * Transverse (stable);
 * tertically slanted.

Clinical picture and diagnosis

 * Clinically, there is tenderness on palpation in the foveola radialis and on pressure on the long axis of the thumb.
 * X-ray AP, L i in dorsiflexion and ulnar duction (navicular quartet).
 * The fracture may not be visible immediately after the injury (if the pain continues with a negative finding (diagnosed as wrist distortion), we repeat the X-ray after 2-3 weeks of immobilization).
 * The most reliable diagnosis is CT.

Conservative

 * For non-dislocated fractures, immobilisation with a circular cast from the elbow to the heads of the metacarpals, including the thumb (wrist in ulnar adduction, thumb in abduction) for at least 6 weeks.


 * Then X-ray – if the fracture is not healed, immobilisation should be extended to 8-12 weeks.

Surgical

 * In fractures of the proximal pole and middle part;


 * Osteosynthesis with a Herbert screw.

Complications

 * Avascular necrosis of the fragment


 * Hip joint - We treat hip joint surgically - compression osteosynthesis, cortico-spongiograft from the iliac blade or palliative resection. Styloideus radii (relieves pain);


 * Arthrosis of the radiocarpal joint.

Wrist Distortion

 * Denotes an injury mechanism (indirect) in which painful distension of the capsule and collateral ligaments occurs (clinically, pain, palpable findings on the bones and their ligaments).


 * Fracture of the carpal bones must be ruled out on the X-ray (it may not be immediately apparent, therefore plaster fixation is indicated for more significant physical findings), otherwise the joint must be immobilized and cooled.


 * After a week, a control X-ray is performed to definitively rule out/confirm a fracture.

Wrist dislocation

 * There is a dislocation of the carpal bones with rupture of the ligaments, it may be associated with a fracture of the scaphoid or proc. ulna styloid.


 * On the X-ray, it is manifested by the expansion of joint spaces above 2 mm.


 * Treatment with traction repositioning and plaster fixation for 6 weeks.


 * Unstable dislocations and fractures solved by osteosynthesis, instabilities based on fibrous injuries require ligament reconstruction.


 * Isolated os lunate dislocation':
 * Extrusion of the lunate ventrally (most often) or dorsally (rarely), by severing the ligaments, the lunate is deprived of contact with the radius, it can be combined with a fracture of the os scaphoid (De Quervain's fracture).


 * Perilunate luxation of the carpus':
 * The connection of the lunate with the radius is preserved, the distal row of carpal bones luxates backwards, the proc may be broken off at the same time. ulna styloid.


 * Transscapho-perilunate dislocation':
 * Perilunate dislocation associated with a scaphoid fracture.


 * Peritriquertro-lunate dislocation.
 * Isolated os hamatum dislocation.


 * Radiocarpal luxation':
 * shearing forces causing ruptures of the radiocarpal ligaments, fractures of the proc. styloideus radii or ulnae, marginal fractures of the radius (reverse Barton).

Clinical picture and diagnosis

 * Pain, pathological contour of the wrist, restriction of movement;


 * Os lunate can press on the median nerve - pain in the innervation area;


 * On the X-ray in the AP, the trapezoidal shape of the lunate is changed to a triangular one, LAT empty concavity of the lunate (in case of ossis lunati dislocation, the radius axis – capitatum axis is preserved and the lunate is luxated volarly, rarely dorsally, in perilunate dislocation the radius – os lunatum axis is preserved and the rest the carpus is luxated dorsally).

Treatment

 * It consists in immediate reposition (after 24 hours it is necessary to operate) - in short-term general or block anesthesia (brachial plexus block).
 * Reposition by hyperextension and traction, then converting into flexion and pushing the lunate back to its original position.


 * If the reposition is not stable, the lunate is transfixed with a K-wire, the os scaphoid fracture is best fixed with a compression screw.

Metacarpal fractures

 * They are caused by direct force on the dorsum of the hand, axial force (blow with a fist), open fractures in cutting wounds.

Classification by localization

 * base fractures;


 * diaphyseal fractures (according to the fracture line – spiral, oblique, transverse, comminutive);


 * subcapital fractures;
 * head fractures (intra-articular);

Boxer's fracture - subcapital fracture of the V. metacarpal.

Bennett's fracture - fracture of the base of the first metacarpal with dislocation in the carpometacarpal joint (pull m. abductor pollicis longus).

Rolland's fracture - a Y-shaped fracture of the base of the first metacarpal.

Clinical picture and diagnosis

 * pain, swelling, hematoma;


 * X-ray (appropriate oblique projections - overlapping metacarpals).

Conservative

 * for non-dislocated or well-replaced fractures;


 * the rotational deviation of the metacarpal axes is important (it cannot be seen on an X-ray) – the nails must be level when the fingers are flexed;


 * immobilization with plaster, metacarpophalangeal joints in flexion (release of collateral ligaments in case of subcapital fractures);


 * fractures in the area of ​​the base of the 1st metacarpal are repaired by traction in semi-abduction and opposition, in this position they are also plastered.

Surgical

 * irreparable, unstable and intra-articular fractures (K-wires, screws, plates);


 * for comminuted fractures, external mini-fixator, suture of torn ligaments.

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