Wrist and hand fractures
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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);
- vertically slanted.
Clinical picture and diagnosis
- Clinically, there is tenderness on palpation in the foveola radialis and on pressure in 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.
Treatment
Conservative
- For non-dislocated fractures, immobilization 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, immobilization should be extended to 8-12 weeks.
Operational
- 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.
Luxation of carpal bones
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
- X-ray (appropriate oblique projections - overlapping metacarpals).
Treatment
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.
Operational
- irreparable, unstable and intra-articular fractures (K-wires, screws, plates);
- for comminuted fractures, external mini-fixator, suture of torn ligaments.
