Fractures, Dislocations, and Ligamentous Injuries of The Hand and Wrist

Open Fractures and Dislocations

Open fractures and dislocations require wound debridement and irrigation and then reduction. If an open dislocation is self-reduced and a contaminant is suspected, redislocation and wound cleansing should be done. Finger motion should begin as soon as soft-tissue healing and fracture and joint stability permit. Fixation should permit wound inspection or dressing changes without loss of fracture alignment.

Severely traumatized hands commonly are accompanied by soft-tissue defects, and additional incisions are usually unnecessary to access the fracture. Fractures should be fixed under direct vision or percutaneously, and segmental defects of tubular bones may be held to length by wire spacers or rods to prevent collapse while the wound is healing ( Fig. 67.4 ). Massive trauma to the hand may require extensive reconstructive efforts to restore bony integrity ( Fig. 67.5 ).

Judgment is required to determine whether the wound is sufficiently clean to permit primary closure or whether it should be left open for repeat debridement and irrigation. Loose skin-edge approximation is recommended because soft-tissue edema over the next 48 hours will further increase tension on the traumatized tissues and possibly compromise otherwise viable flaps. At 48 hours, the wound can be reevaluated in the operating room and plans made at that time for closure. The goal is to close the wound within the first 4 to 5 days before granulation tissues form and contractures develop. Exposed tendons without their paratenon or sheath soon necrose without appropriate coverage (see Chapter 65 for a discussion of methods of and indications for skin closure). We no longer routinely culture acute open hand injuries in the emergency department. Thorough irrigation and debridement usually are adequate for primary fracture treatment. Routine use of antibiotics for fresh injuries probably is not necessary; however, when essential tissue has borderline viability and contamination remains after irrigation and debridement, antibiotic use is justified.

Basic Fracture Techniques

Physician judgment is required to form logical treatment plans including, when applicable, suitable internal and external fracture fixation implants. Plating of small tubular bones, especially of the phalanges, can cause skin sloughs, tendon adherence or ruptures, joint contractures, and other complications. External fixation pins can impinge on tendons or ligaments and interfere with motion. Percutaneously placed pins may damage nerves, and tendons or ligaments may be tethered as well.

Rarely is more fixation needed than that afforded by external splinting, Kirschner wires, and minifragment screws. Unstable, long, oblique, or spiral fractures may be best treated with interfragmentary screw fixation alone, although a variety of fixation techniques may be indicated ( Fig. 67.6 ).

The same instruments used in handling the soft tissues can be used to manipulate the bones; a straight Kocher clamp, hemostat, or towel clip is usually sufficient to reduce provisionally metacarpal or phalangeal shaft fractures before fracture fixation. Kirschner wires sharpened on both ends permit antegrade and retrograde drilling when necessary. A small hand-held power Kirschner-wire driver or drill without a cumbersome air supply line aids in accurate in-plane placement. A trocar-pointed wire has greater initial holding power than either a diamond or diagonally cut wire; in addition, initial bone engagement and placement at an acute angle are easier with a trocar-pointed wire. The Kirschner wire should project as short a distance as possible to prevent pin bending during insertion. After insertion, the wires may be cut off flat and the ends left protruding or left beneath the skin. Kirschner wires usually can be removed under local anesthesia, using a pointed extractor with grooved, corrugated, and parallel jaws. A diamond or carbide-tipped needle holder likewise is useful for gripping and removing small Kirschner wires.

Regardless of the method chosen for fracture fixation, the fractured bone ends should be in close approximation or apposition to promote healing. Sometimes a second wire is needed, however, to control rotation. When possible, the fractured finger should be flexed fully at the metacarpophalangeal, proximal and distal interphalangeal joints and compared with the adjacent uninjured finger or fingers before definitive rotational control is achieved, especially if there are doubts regarding correct fracture rotational alignment.

Outpatient surgery center services are usually selected when wounds are grossly contaminated or when fractures require implants other than Kirschner wires. In addition, young children and patients with medical conditions requiring cardiovascular monitoring should be treated at a surgical center. Wide-awake local anesthesia with no tourniquet (WALANT) can be incorporated in the office setting for less complex fractures that can be treated with Kirschner wires. Patients with Raynaud or Berger disease and patients with other epinephrine-intolerant conditions are not candidates for WALANT procedures. The WALANT technique uses a 30-gauge needle to liberally infiltrate in a tumescent fashion the region to be operated, including the subperiosteal regions of the fractures to be treated ( Fig. 67.7 ). A 10 mL syringe is filled with 10 mL of 1% lidocaine with 1:100,000 epinephrine, after which an additional 1 mL of 8.4% sodium bicarbonate is drawn into the same syringe (a typical 10 mL syringe can hold 11 mL of solution). The addition of 8.4% sodium bicarbonate to the 1% lidocaine with 1:100,000 epinephrine in a 1:10 ratio normalizes the lidocaine pH of 4.2, thus reducing the burning sensation associated with local anesthetic infiltration. Simple procedures may require 10 to 20 mL of this solution; however, 50 mL of this mixture is permissible in an average 70 kg (155 lb) man, assuming 7 mg/kg maximum dosage of lidocaine.

Bennett Fracture

In 1882, Bennett, an Irish surgeon, described an intraarticular fracture through the base of the first metacarpal in which the shaft is laterally dislocated by the unopposed pull of the abductor pollicis longus ( Fig. 67.8 ). The medial projection of the thumb metacarpal base on which the volar oblique ligament attaches remains in place. Reduction by traction is easy but is difficult to maintain. The use of a cast that maintains reduction by pressure on the base of the metacarpal also often is unsatisfactory because immobilization is incomplete and verification of alignment by radiographs through the overlying cast is difficult. Too much pressure may cause skin necrosis, and too little allows loss of reduction. Some controversy surrounds the acceptable limits of displacement. Articular incongruity of 1 to 3 mm seems to be well tolerated, provided that union and joint stability are achieved. The technique of closed pinning described by Wagner ( Figs. 67.9 and 67.10 ) is preferred, but should reduction be unsatisfactory, open reduction is indicated ( Fig. 67.11 ). Long-term patient-reported outcomes following displaced Bennett fractures treated by closed reduction and Kirschner wire fixation show excellent functional results according to Middleton et al. At a mean follow-up of 11.5 years the 62 patients in this study had a high level of patient satisfaction and none required a revision or salvage procedure.

Open reduction and direct exposure of the thumb basal joint may be required when adequate reduction cannot be achieved by closed or percutaneous fragment manipulation techniques. We have found that thumb metacarpal base fractures and the trapeziometacarpal joint are best seen through a Wagner type approach ( Fig. 67.11 ). The volar capsule (between the abductor pollicis longus tendon and beak ligament) is structurally unimportant and can be reflected off the metacarpal base for joint exposure.

Complications

Malunion with persistent subluxation may progress to painful carpometacarpal joint arthritis. Reduction should not be attempted after 6 weeks. For a malunion that is recognized before degenerative changes are noted, an intraarticular osteotomy through an extended Wagner approach may be warranted ( Fig. 67.11 ). When degenerative arthritis has developed, arthrodesis or arthroplasty is advised.

Rolando Fracture (Comminuted First Metacarpal Base) and Other Fractures Involving the First Carpometacarpal Joint

In 1910, Rolando described a Y-shaped fracture involving the thumb metacarpal base that usually does not result in diaphyseal displacement as in a Bennett fracture. We have found that in most Rolando-type fractures the joint surface fragments can be reasonably well fixed with the use of small wires placed directly under the subchondral bone and supplemented with a larger transarticular and occasionally transmetacarpal pinning ( Fig. 67.15 ). Because of the likelihood of posttraumatic arthritis after these fractures or after intraarticular trapezial fractures, accurate reduction is important. Many fractures can be reduced by traction and held by open or closed pinning. Open reduction and fixation with a minifragment T-plate may be plausible if the articular fragments are of sufficient size (Technique 67.4).

The combination of tension band wiring and an external fixator can result in an acceptable reduction. The external fixator is used to align the comminuted fragments and to restore length, and tension band wiring provides stability ( Fig. 67.16 ). If the fracture is stable, the external fixator can be removed; if not, the fixator should remain in place for 8 weeks.

Severely comminuted fractures may require a combination of external fixation, limited internal fixation, and bone grafting. This technique showed good results despite persistent joint irregularities. Although the quality of reduction does not correlate with the late occurrence of symptoms and osteoarthritic changes, it is recommended that the joint articulation be restored to as close to normal as possible.

Thumb Carpometacarpal Joint Dislocation

Dislocation of the thumb carpometacarpal joint is a rare injury, and all those reported have been dorsal dislocations. Based on cadaver studies, the dorsoradial ligament and the volar oblique ligament are the most important ligaments in preventing dislocation. When this injury occurs without fracture and is recognized early, the dislocation should be reduced and the joint immobilized for 4 to 6 weeks to prevent recurrence. Careful assessment of joint stability immediately after reduction is advised. Dislocations reduced on the day of injury may be stable immediately after reduction, and cast immobilization can be sufficient to maintain reduction and prevent long-term instability. Open reduction and pinning with repair of the dorsoradial ligament is necessary to ensure better joint stability if the joint is unstable after reduction. Immobilization for 6 weeks is indicated after the repair. If reduction is delayed beyond 3 weeks, ligament reconstruction is advised.

In idiopathic or traumatic recurrent thumb carpometacarpal joint dislocation or subluxation, intermetacarpal ligament reconstruction may be indicated. The operation is most helpful when the joint is unstable and painful and when degeneration of its articular surfaces is minimal. This procedure should not be done solely to relieve symptoms or subluxations of this joint from osteoarthritis.

Thumb Metacarpophalangeal Fractures and Dislocations

Fractures around the thumb metacarpophalangeal joint usually involve the ulnar margins of the proximal phalanx from ulnar collateral ligament avulsion injuries. When the fragment is small and displaced less than 2 to 3 mm, the injury does not require surgery. Biplanar films should always be taken before evaluating joint stability. Displaced fractures of this sort are treated similarly to ulnar collateral ligament injuries. Impaction fractures with less than 20 degrees of dorsal angulation or joint separation less than 2 mm often can be treated nonoperatively. Angulated and displaced fractures probably are best treated operatively ( Fig. 67.20 ).

Dislocation of any of the metacarpophalangeal joints is possible from hyperextension injuries, but dorsal dislocation of the thumb metacarpophalangeal joint is the most common type of metacarpophalangeal dislocation injury ( Fig. 67.21 ). These injuries are classified as simple (reducible using closed technique) or complex (irreducible with closed technique). Simple dislocations manifest with hyperextension deformity at the metacarpophalangeal joint, whereas complex dislocations show more parallelism between the proximal phalanx and the metacarpal. The volar plate, sesamoids, or flexor tendon may become entrapped, preventing reduction. Early closed reduction may be easy, provided that the thumb is maintained in adduction to relax its intrinsic muscles. In one method, minimal if any tension is used, the metacarpophalangeal joint is hyperextended, and the examiner uses his or her thumb to push forward the proximal end of the proximal phalanx over the end of the metacarpal head. This tends to diminish the buttonhole effect on the metacarpal neck that traction accentuates. Flexing the thumb interphalangeal joint also can help to relax the flexor pollicis longus. After reduction, the collateral ligaments should be checked for stability. Rarely is collateral instability found with pure dorsal dislocations. The thumb should be immobilized in 20 degrees of flexion for 4 weeks. If this method is unsuccessful, repeated attempts are contraindicated; open reduction should be done to disengage the metacarpal head from a buttonhole slit in the volar capsule and the flexor pollicis brevis muscle. A volar-radial or a dorsal approach can be used. In 1876, Farabeuf recommended a dorsal surgical approach for irreducible dislocations of the thumb metacarpophalangeal joint. The dorsal approach provides access to the dorsally displaced volar plate, which is the main obstacle to reduction and is tethered tightly over the metacarpal head and neck. The volar plate, a fibrocartilaginous structure similar in appearance to articular cartilage, is divided longitudinally so that it slips around the metacarpal head and permits reduction of the proximal phalangeal base. Motion is started within a few days of surgery.

Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Rupture

Injury to the thumb metacarpophalangeal joint ulnar collateral ligament is commonly referred to as gamekeeper thumb or skier’s thumb , although the original “gamekeeper” description (Campbell, 1955) referred to an attritional ulnar collateral ligament injury. Snow skiing accidents and falls on an outstretched hand with forceful radial and palmar abduction of the thumb are the usual causes. Changes in ski pole design have not been shown to reduce the incidence of this injury. Patients commonly report pain, swelling, and ecchymosis around the metacarpophalangeal joint. Tenderness is greatest over the ulnar aspect of the joint but often is not localized. Differentiating between an incomplete and complete ulnar collateral ligament rupture is necessary because incomplete ruptures are treated nonoperatively and complete ruptures usually require surgery. Stener described the anatomic pathology found in 39 complete ruptures of the ulnar collateral ligament of the thumb. In 25 of the 39 patients, he found the adductor aponeurosis interposed between the ruptured ulnar collateral ligament and its site of insertion on the base of the proximal phalanx. On clinical examination, a prominent lump can be palpated that represents the ulnar collateral ligament being proximally and superficially displaced by the adductor aponeurosis. Pathologic rotation of the thumb also may be evident. If left uncorrected, this lesion prevents proper healing and leads to chronic instability and subsequent arthrosis. Other injuries associated with tears of the ulnar collateral ligament include avulsion fractures, dorsal capsular tears, and volar plate tears. The following protocol is recommended to differentiate between complete and incomplete tears.

Plain radiographs should be obtained prior to any stress examinations. A minimally displaced (<2 mm) avulsion fracture signifies a complete avulsion without a Stener lesion. This fracture usually heals with casting. To prevent the development of a Stener lesion, the joint should not be stressed. If a Salter-Harris type I or type II fracture is present in a child, stress films are contraindicated.

After plain radiographs have been reviewed, anteroposterior stress radiographs can be obtained of both thumbs for comparison purposes. A local anesthetic may be necessary. The surgeon can stress the joint while obtaining the radiographs, but this may be awkward, especially when the surgeon wears lead gloves. It may be easier to tape the tips of both thumbs together and have the patient actively abduct both thumbs over a roll of tape placed as a fulcrum between the thumb metacarpophalangeal joints while the anteroposterior radiograph is taken. As an alternative, both thumbs can be held together at the interphalangeal joint level with a rubber band, and an image can be obtained while the patient tries to separate the hands ( Fig. 67.22 ). An injured thumb that shows more than 30 degrees of instability compared with the uninjured side indicates a complete rupture. Ultrasonography, arthrography, and MRI also have been used successfully to distinguish complete from incomplete tears; moreover, ulnar collateral ligament retraction more than 3 mm and interposed soft tissue are reasonable guides to surgical intervention ( Figs. 67.23 to 67.26 ). Incomplete ruptures of the ulnar collateral ligament of the thumb are common and require only proper protection for restoration of function, although pain and swelling may persist for several months. A thumb spica cast or functional brace is recommended for 4 to 6 weeks.

Acute complete rupture of the ulnar collateral ligament should be surgically repaired ( Fig. 67.27 ). If the diagnosis is delayed for 1 month or longer, fibrosis makes ligament identification and repair more difficult, although repair can be done by dissecting out the ligament from within the fibrotic mass and reattaching it appropriately ( Fig. 67.28 ). The detached tendinous insertion of the adductor muscle can be advanced and reattached to furnish a dynamic reinforcement. If the repair is done several months after the injury, a graft can be used to replace the ligament. The graft can be box-like with a strip of fascia or palmaris longus tendon passed through the proximal and distal attachments of the ligament, or the extensor pollicis brevis tendon, either split or in total, can be threaded through bone and attached by pull-out sutures to reconstruct the ligament. Arthrodesis of the metacarpophalangeal joint may be indicated when arthritic changes within the joint or global joint instability is present.

Chronic Ulnar Collateral Ligament Reconstruction

Procedures designed to restore range of motion and stability for chronic ulnar collateral ligament injuries are numerous. Stability at long-term follow-up has been associated with “anatomic repairs” in which the graft is directed to reconstruct both proper and accessory ulnar collateral ligament limbs. We favor more anatomic type repairs such as those described by Glickel et al., Jobe, and others. Tendon anchor systems such as suture anchors and tenodesis screws are preferred by some for early construct stability; however, the adjunct provisional metacarpophalangeal joint stabilization in 20 degrees of flexion with Kirschner wires probably is sufficient during the graft incorporation period. A palmaris longus graft is preferred; if the palmaris longus is absent, common alternative autogenous sources include a portion of the flexor carpi radialis or a toe extensor tendon.

Radial Collateral Ligament Injuries

Although radial collateral ligament injuries occur less frequently than ulnar collateral ligament injuries, improper treatment can lead to chronic painful instabilities, especially during activities requiring “push off.” No lesions comparable to that described by Stener exist; if proper protection is provided, adequate healing of the ligament should occur. Incomplete tears and tears not associated with volar or rotational subluxation can be treated in a cast for 4 to 6 weeks. Complete tears, particularly if rotational and with volar subluxation after casting, should be treated with direct ligament repair. Chronic instability should be treated with open repair, radial collateral ligament reefing, supplemental palmaris longus tendon graft, or advancement of the abductor pollicis brevis.

Carpometacarpal Fracture-Dislocations

Fracture-dislocation of the metacarpal bases often is not recognized because of swelling and metacarpal overlap on lateral plain films. The fifth metacarpal base is most commonly dorsally displaced, and concomitant fourth metacarpal base involvement is frequent; however, all four metacarpals may be dislocated dorsally or volarly. A true lateral radiograph is needed for accurate diagnosis because swelling can obscure the deformity ( Fig. 67.33 ). The loss of parallel joint surfaces at the carpometacarpal articulations in a posteroanterior radiograph is indicative of this injury ( Fig. 67.34 ). Sometimes a CT scan is beneficial to determine the extent of joint surface involvement and to guide appropriate intervention. When the injury is seen early, manual reduction is easy, but Kirschner wire fixation usually is necessary to prevent redislocation. Open reduction and pinning are useful in patients in whom closed reduction is unsuccessful. Excellent long-term results can be achieved with open reduction and internal fixation because better reduction can be obtained and transfixing of the tendons and nerves avoided. When seen late, the injury requires open reduction, and sometimes the proximal end of the metacarpal must be resected and the carpometacarpal joint treated by either fusion or interposition arthroplasty.

Intraarticular Fracture of the Fifth Metacarpal Base

Bora and Didizian called attention to a potentially disabling intraarticular fracture at the base of the fifth metacarpal ( Fig. 67.35 ). If the injury is not reduced properly, a malunion may result in weakness of grip and a painful joint. The joint consists of the fifth metacarpal base articulating with the hamate and the adjoining fourth metacarpal. The extensor carpi ulnaris tendon attaches proximally to the fifth metacarpal dorsal base. The joint permits approximately 30 degrees of normal flexion and extension and the rotation necessary in grasp and palmar cupping. This displaced intraarticular fracture might be compared with a Bennett fracture because the pull of the extensor carpi ulnaris has a great tendency to displace the metacarpal shaft proximally, similar to the thumb metacarpal displacement in a Bennett fracture by the abductor pollicis longus. In addition to the routine anteroposterior and lateral views, a radiograph should be made with 30 degrees of pronation to give a better view of the articular surface for accurate diagnosis. This fracture often can be reduced by traction and percutaneous pinning and is then protected by a cast. Fractures that are not recognized early and are healing in a displaced position may benefit from correction osteotomy of the malunion or resection arthroplasty ( Fig. 67.36 ) or fusion.