J Korean Fract Soc.  2016 Apr;29(2):143-159. 10.12671/jkfs.2016.29.2.143.

Current Concepts of Fractures and Dislocation of the Hand

• Yoon YC
• Baek JR

• KMID: 2162017
• DOI: http://doi.org/10.12671/jkfs.2016.29.2.143

Abstract

Fractures and dislocation of the hand is a body injury involving complex structures and multiple functions, which frequently occur as they represent 10%-30% of all fractures. Such fractures and dislocation of the hand should be treated in the context of stability and flexibility; and tailored treatment is required in order to achieve the most optimal functional performance in each patient since deformation may occur if not treated, stiffness may occur with unnecessarily excessive treatment, and both deformation and stiffness may occur coincidently with inappropriate treatment. Stable injuries can be fixed with splintage whereas surgery is actively considered for unstable injuries. In addition, surgeons should keep in mind that as the surgical intervention is done aggressively, aggressive rehabilitation must be followed in correspondence with the surgical intervention. Successful outcome requires effort to prevent any potential complication including nerve hypersensitivity and infection. Finally, it is also important that the patient to know that swelling, stiffness, and pain may last for a long period of time until the recovery of fractures and dislocation of the hand.

Keyword

Finger injury; Fracture; Dislocation; Complication

MeSH Terms

Dislocations*
Finger Injuries
Hand*
Humans
Hypersensitivity
Pliability
Rehabilitation

Figure

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  Fig. 1 (A) The rotational deformity of the 4th finger nail plate was noted. (B) The deformity was aggravated with finger flexion.

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  Fig. 2 (A) We cannot see the specific fracture line on plain X-ray postero-anterior view. (B) The hamated fracture line was observed on a computed tomography imaging (arrow).

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  Fig. 3 (A) Damaged skin and soft tissue of the left hand was observed. (B) The reversed flow radial forearm flap was harvested. (C) Five months after flap surgery.

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  Fig. 4 Various treatments for distal phalangeal fractures. (A-C) Distal phalangeal fracture with nail bed injury. After closed reduction and K-wire fixation, the nail bed was repaired. Finally, the nail was reinserted and tied. (D, E) The avulsed fragment of the distal phalanx base dorsal aspect was noted. Extension block K-wiring was used. (F, G) Flexor digitorum profundus avulsion fracture at the distal phalanx was observed. Open reduction and hook plate fixation was performed.

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  Fig. 5 Various situations and treatment of middle, proximal phalangeal fracture. (A) Due to interaction of flexor digitorum superficialis (FDS) and extensor tendon central slip, dorsal angulation deformity was made at the middle phalangeal base fracture. (B) Because of traction of FDS, volar angulation was made at the middle phalangeal neck fracture. (C, D) Angulated and comminuted fracture of the proximal phalanx. Complete union was achieved with open reduction and plate fixation. (E-H) Crush injury at the middle phalanx. An open comminuted fracture and a severely damaged, dirty wound was observed. After dirty and devitalized tissue was debrided, temporary K-wire fixation was performed. At 2nd stage operation, auto iliac bone block graft and plate fixation was performed. A flap was required for skin coverage.

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  Fig. 6 Example of metacarpal fracture treatments. (A, B) A proximal phalanx collateral ligament avulsion fracture was observed. Closed reduction and K-wire fixation was performed. (C, D) A displaced, comminuted 2nd metacarpal head fracture. One headless screw and 1 miniscrew were used for fixation. (E, F) Multiple metacarpal neck fractures. Intramedullary nailing was performed at the 2, 3, and 5th metacarpal neck fracture. (G, H) Angulated and comminuted 5th metacarpal neck fracture. Intramedullary nailing with bouquet technique was performed. (I, J) Angulated and comminuted 5th metacarpal neck fracture. Transverse K-wire fixation was performed to the adjacent intact 4th metacarpal bone shaft. (K, L) Multiple metacarpal shaft fractures were noted. Plate fixation for the 2nd metacarpal bone, 3 lag screws for the 3rd metacarpal bone, and intramedullary nailing for the 4th metacarpal bone were used for each fracture. (M, N) Multiple comminuted metacarpal fractures. Complete union was achieved by locking plate.

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  Fig. 7 Various treatments of 1st metacarpal fractures. (A, B) A comminuted fracture of the 1st metacarpal shaft. Bony union was observed with plate fixation. (C, D) A 1st metacarpal base intraarticular fracture (Bennett fracture) was observed on a computed tomography image. After achieving satisfactory reduction with closed method, K-wire fixation was performed. (E, F) A 1st metacarpal base intraarticular comminuted fracture. Closed reduction was attempted, but failed. Therefore, open reduction and 2 screws fixation were performed. (G, H) A 1st metacarpal base intraarticular comminuted fracture. Comminution is very severe. We tried with limited minimal open reduction to achieve joint congruency and additional K-wire fixation and external fixation was applied.

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  Fig. 8 (A) Proximal interphalangeal joint flexion, distal interphalangeal joint joint hyperextension deformity (buttonhole deformity). (B) Severe valgus instability was checked on physical examination, which indicates a complete radial collateral ligament tear. (C-E) Second metacarpophalangeal joint dorsal dislocation was observed on imaging study. In the operating room, metacarpal head buttonholes into the palm (Kaplan deformity) was observed. The volar plate is interposed between the base of the proximal phalanx and metacarpal head. Lumbricalis is on the radial side, flexor tendon is on the ulnar side of the protruded metacarpal head. (F) Interposition of the adductor aponeurosis between the distal site of attachment of the ruptured ligament and the detached ligament, thus preventing ligamentous healing and restoration of joint stability. In this situation, only operative intervention will allow apposition and healing of the ligament in an anatomic position (arrow).

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