HAND
( any hand- atls, crossmatch, consent on neurovascular injury, hand
dominance, occupation, neurovascular status)
thumb amputation, multifinger amputation for replantation; steps; soft tissue
cover
little finger amputation ; zone II flexor injury pg 198 greens with digital nerve
injury.
mallet finger pg 168 Greens
swan neck deformity; boutenniere deformity
Seymour # Pg 259 Greens, oblique #; oblique # distal phalanx?
Spiral fracture treatment with lag screw. What is lag screw?
(The name lag screw derives from their original use in securing barrel staves, also
known as lags. A lag screw is used to compress fracture fragments. It is threaded into
the opposite cortex, and slides through a hole in the near cortex. Tightening the screw
presses the screw head against the near cortex, compressing the fracture fragments.
Optimally, a lag screw should be perpendicular to the fracture plane.)
PIPJ dislocation (no fracture): management
Metacarpal # with scissorsing
salter harris #, Pg 1505
Boxer’s #
bennet # Pg 283, rolando#
Thumb:
UCL injury, skiers thumb, stener lesion step in operative treatment; game
keeper thumb, page 604 operative
zone II flexor tendon injury;
extensor tendon injury;
Digital nerve repair. Nerve repair consent graft, physiology types, repair
methods growth/day/month.Pg1035 Greens
Defect volar aspect finger staged reconstruction?
Mucous cyst or ganglion, grab 8 pg 3015 recurrence 0.6% to 40%
Giant cell tumor of tendon sheath recurrence, 9-27% hand Pg 2168
Greens, Pg 2181 Greens . grabb 8th pg 3016
Extensor brevis manus
Pilomatrixoma .grabb 8th pg 887calcifying epithelioma of malherbe (10yr
female painless slow growing nodule yellow white chalky exudates
calcification on imaging)
Glomus tumor recurrence 3.9% Pg 2210 Greens. grabb 8th pg 3051
carpal tunnel syndrome Pg 978.Greens
Proximal phalanx (0.08 inch = 2 mm)
(0.7, 0.9 mm) k wires, Lag screw (2, 1.5, 1.3 mm) (0.035, 0.045 inch.
Remove k-wire after 3-4 weeks. Kirschner wire fixation has been reported
to result in an 18% complication rate.
Metacarpal
Cerclage or interosseous wiring (stainless steel wire 24, 25, 26 gauge)
Intermedullary steinmann pins (0.8mm)
Flexor tendon post op therapy:
METACARPAL HEAD #
1. Closed Intra articular, non-comminuted ( two part coronal, sagittal,
oblique) more than 25% of the articular surface or exhibit greater than
1 mm of articular step-off
ORIF with headless screw
(k-wire is less rigid and delay mobilization of joint)
2. Open Intra articular, non-comminuted
Clenched fist injury, oral contamination, wound left open, irrigation
and debridement, internal fixation is delayed till wound shows no sign
of infection.
3. Closed Intra articular, Comminuted
Multiple k-wire
If still there is unstable reduction then immobilize for 2-3 weeks with
MP joint flexed 70degree followed by intense range of motion
exercises
4. Closed Intra articular, Comminuted and associated comminuted
fractures of the adjacent base of proximal phalanx
Skeletal traction or external fixation
5. Open intra articular, comminuted, with bone loss
Prosthetic arthroplasty (Contraindications- (a) head of index finger as
shear stresses from pinch results in implant failure. (b) inadequate
soft tissue coverage.(c) excessive metacarpal bone loss
Complications of intra articular metacarpal head fracture
1. Stiffness (delayed tenolysis, capsulotomy)
2. Avascular necrosis
MP arthrodesis is a salvage procedure with risk of excessive
shortening or non-union.
METACARPAL NECK #
1. If no pseudo clawing on attempted digital extension (compensatory
hyperextension of the MP joint and flexion of the PIP joint caused
by excessive metacarpal neck flexion)
Functional brace, forearm based dorsal ulnar gutter splint, wrist 30
degree extension, MP joint 70 degree flexion. Buddy taping
Active range of motion. Splint for 2 weeks
2. If there is pseudo clawing or rotational deformity
Appropriate anesthesia followed by closed reduction (Jahss
maneuver).
Radiograph (Angulation acceptable, index and middle finger-<15,
ring finger-30-40, little finger-50-60 degrees and < 40 in case of
athletes and carpenters)
If stable reduction: forearm based ulnar gutter plaster 2 weeks.
Wrist 30 degree extension, Mp joint maximally flexed, PIP joints
extended), after 2 weeks active range of motion and intermittent
splinting. Return to sports at 4 to 6 weeks
If unstable reduction: percutaneously inserted retrograde crossed
Kirschner pins or antegrade intramedullary fixation,
percutaneously inserted in transverse fashion
3. If ORIF: crossed Kirschner pins, dorsal tension band wire with a
supplemental Kirschner pin, laterally applied mini- condylar plate
4. Immobilization in an ulnar gutter splint for 2-3 weeks. After 1 week
repeat x-ray if fracture is aligned then starts protected active range
of motion exercises.
5. Edema control with elastic garment
