Differential Indication

In this chapter, the most common fracture types in the hand and the current surgical treatment options are presented in tabular form. The first set of tables ( ▶ Table 5.1, ▶ Table 5.2, ▶ Table 5.3, ▶ Table 5.4) shows fractures of the distal phalanx, followed by fractures of the middle and proximal phalanges ( ▶ Table 5.5, ▶ Table 5.6, ▶ Table 5.7, ▶ Table 5.8, ▶ Table 5.9), of the metacarpals ( ▶ Table 5.10, ▶ Table 5.11, ▶ Table 5.12, ▶ Table 5.13, ▶ Table 5.14, ▶ Table 5.15), and of the proximal ( ▶ Table 5.16, ▶ Table 5.17, ▶ Table 5.18, ▶ Table 5.19) and distal ( ▶ Table 5.20, ▶ Table 5.21, ▶ Table 5.22) carpal bones.

AO code A brief explanation of the AO coding is as follows:

According to the general principles of the AO Foundation, fractures are coded according to their location and morphology. The first four numbers define the location, followed, after a hyphen, by a letter and number, which describe the fracture type.

First number: 7 (identifies the hand as the location of the fracture)
The second number identifies the finger:
- Thumb 1
- Index finger 2
- Middle finger 3
- Ring finger 4
- Little finger 5
The third number defines the finger bone:
- Metacarpal 0
- Proximal phalanx 1
- Middle phalanx 2
- Distal phalanx 3

In the wrist, the second number codes the proximal (6) and distal (7) row and the third number identifies the individual carpal bones from radial to ulnar:

Scaphoid 61
Lunate 62
Triquetrum 63
Pisiform 64
Trapezium 71
Trapezoid 72
Capitate 73
Hamate 74
The fourth number, separated by a period, identifies the location within the bone:
- Proximal 1
- Diaphyseal, shaft 2
- Distal 3

A letter and a further number, separated from the first three numbers by a hyphen, describes the fracture type:

Carpus:
- A1: avulsion, A2: chip, A3: comminuted
- With reference to the forearm axis: B1: transverse, B2: spiral, B3: parallel
- With regard to the number of fragments: C1: with a third fragment, C2: multiple fragments, C3: comminuted
Metacarpal, proximal phalanx, middle phalanx, distal phalanx:
- A = diaphyseal: 1 simple, 2: with a third fragment, 3: multifragmentary
- B = metaphyseal: 1 simple, 2: with a third fragment, 3: multifragmentary
- C = intra-articular fracture: 1: unicondylar, 2: bicondylar, 3: multifragmentary, depression
  
  Additional Information
  
  The author would like to emphasize that the listed operation methods represent a treatment possibility only if surgery is indicated. The limiting factors are defined in Chapter ▶ 4.3 and Chapter ▶ 4.4.
  
  Moreover, ▶ Fig. 1.1 shows an algorithm for deciding on therapy.
  
  The radiographs show only the variety of fracture geometries and fracture types. Each must be considered individually to establish which of the possible treatment options may be appropriate.

5.2 Distal Phalanx Fractures

5.2.1 Fractures of the Distal Phalanx, Distal

**Table 5.1** Distal phalanx fractures, distal
Fracture type	Surgical management	Procedure reference
Simple ( ▶ Fig. 5.1) AO: 7 1 to 5 3.3-A1	Conservative: Splinting by nail plate, possibly artificial nail/silicone film and/or external splint	Artificial nail, see Chapter ▶ 10.13.2, ▶ Fig. 10.33
Complex ( ▶ Fig. 5.2) AO: 7 1 to 5 3.3-A3		Artificial nail, see Chapter ▶ 10.13.2, ▶ Fig. 10.33

Fig. 5.1 Distal phalanx fracture, distal, simple. Right fifth finger, X-ray in two planes (a,b).

Fig. 5.2 Distal phalanx fracture, distal, complex and intra-articular longitudinal fracture. Right thumb, X-ray in two planes (a,b).

5.2.2 Fractures of the Distal Phalanx Shaft

**Table 5.2** Distal phalanx shaft fractures
Fracture type	Surgical management	Procedure reference
Simple transverse ( ▶ Fig. 5.3) AO: 7 1 to 5 3.2-A1	Conservative: Splinting by nail plate, possibly artificial nail and/or external splint
Simple spiral, longitudinal ( ▶ Fig. 5.4) AO: 7 1 to 5 3.2-A1/A2
Complex ( ▶ Fig. 5.5) AO: 7 1 to 5 3.2-A3	Percutaneous Kirschner wire occasionally	See Chapter ▶ 10.13.2

Fig. 5.3 Distal phalanx shaft fracture, transverse. Right fifth finger, X-ray in two planes (a,b).

Fig. 5.4 Distal phalanx shaft fracture, longitudinal. Left third finger, X-ray in two planes (a,b), see also Fig. 5.2.

Fig. 5.5 Distal phalanx shaft fracture of the thumb, complex.

Fig. 5.6 Extra-articular distal phalanx fracture, proximal.

5.2.3 Extra-articular Fractures of the Distal Phalanx, Proximal

**Table 5.3** Proximal extra-articular distal phalanx fractures
Fracture type	Surgical management	Procedure reference
Proximal extra-articular ( ▶ Fig. 5.6) AO: 7 1 to 5 3.2-B1/B2	Conservative: External splinting, percutaneous Kirschner wire occasionally	See Chapter ▶ 10.13.2

5.2.4 Intra-articular Fractures of the Distal Phalanx, Proximal

**Table 5.4** Proximal intra-articular distal phalanx fractures
Fracture type	Surgical management	Procedure reference
Dorsal border AO: 7 1 to 5 3.1-C1 Type I: small fragment without significant joint involvement / bony extensor tendon avulsion ( ▶ Fig. 5.7a) Type II: fragment < 50% of the lateral joint line, joint congruent	Conservative: External splinting, e.g., stack splint
	Refixation: Lengemann suture	See Chapter ▶ 10.6.1
	With supporting tube
	Ender/Hintringer method	See Chapter ▶ 10.13.3
	Retrograde Kirschner wire	See Chapter ▶ 10.13.5
	Ishiguro operation	See Chapter ▶ 10.13.6
Type III: fragment size at least 50% of the lateral joint line; intra-articular fracture with subluxation, especially in hyperextension ( ▶ Fig. 5.7b)	Screw (Kirschner wire)	See Chapter ▶ 10.4.1
		See Chapter ▶ 10.13.3
	Tension band wiring	See Chapter ▶ 10.13.1
	Hooked/pronged plate	See Chapter ▶ 10.17.1 Caution: nail matrix
Lateral border AO: 7 1 to 5 3.1-C1	Conservative: External splinting, e.g., stack splint	See Chapter ▶ 10.13.2
	Refixation: Percutaneous Kirschner wire	See Chapter ▶ 10.13.2
	Lengemann suture	See Chapter ▶ 10.16
	Ender/Hintringer method	See Chapter ▶ 10.13.3
	Screw	See Chapter ▶ 10.4.1
Palmar border ( ▶ Fig. 5.8) AO: 7 1 to 5 3.1-C1	Ender/Hintringer method	See Chapter ▶ 10.13.3
	Lengemann suture	See Chapter ▶ 10.16
	Screw	See Chapter ▶ 10.4.1
Depression AO: 7 1 to 5 3.1-C3	Elevation and Kirschner wire support (see depressed fracture of base of middle phalanx)	See Chapter ▶ 10.13.4
Complex ( ▶ Fig. 5.9) AO: 7 1 to 5 3.1-C3	External fixator joint -bridging from dorsolateral, lateral	See Chapter ▶ 10.12.3

Fig. 5.7 Intra-articular distal phalanx fractures, proximal. Dorsal border. (a) Without dislocation, type I. (b) With minimal palmar subluxation, type II to III.

Fig. 5.8 Intra-articular distal phalanx fracture, proximal. Palmar border with dorsal dislocation, type II to III.

Fig. 5.9 Intra-articular distal phalanx fracture of the thumb, proximal, complex. Depression, posterolateral border.

5.3 Middle Phalanx and Proximal Phalanx Fractures

5.3.1 Intra-articular Fractures of the Middle/Proximal Phalanx, Distal

**Table 5.5** Distal intra-articular middle/proximal phalanx fractures
Fracture type	Surgical management	Procedure reference
Monocondylar ( ▶ Fig. 5.10) AO: 7 1 to 5 1/2.3-C1	Percutaneous Kirschner wire	See Chapter ▶ 10.13.2
	Lag screw, correct size	See Chapter ▶ 10.4.1
	Combination of lag screw and neutralization plate	See Chapter ▶ 10.5.1
Bicondylar ( ▶ Fig. 5.11) AO: 7 1 to 5 1/2.3-C2	Percutaneous Kirschner wire	See Chapter ▶ 10.13.2
	Lag screws, correct size	See Chapter ▶ 10.4.1
	Combination of lag screw and Kirschner wire	See Chapter ▶ 10.4.1, Chapter ▶ 10.13.2
Complex ( ▶ Fig. 5.12) AO: 7 1 to 5 1/2.3-C3	External fixator from dorsolateral, lateral	See Chapter ▶ 10.12.3

Fig. 5.10 Intra-articular proximal phalanx fracture, distal. X-ray in two planes (a,b).

Fig. 5.11 Intra-articular proximal phalanx fracture, distal, bicondylar with misalignment.

Fig. 5.12 Intra-articular proximal phalanx fracture, distal, complex. X-ray in two planes (a,b).

5.3.2 Extra-articular Fractures of the Middle/Proximal Phalanx, Distal

**Table 5.6** Distal extra-articular middle/proximal phalanx fractures
Fracture type	Surgical management	Procedure reference
Transverse AO: 7 1 to 5 1/2.3-B1	Percutaneous Kirschner wire	See Chapter ▶ 10.13.2
	Wire suture	See Chapter ▶ 10.2.1
	Intramedullary pinning, antegrade or retrograde	See Chapter ▶ 10.11.2, Chapter ▶ 10.11.3
	T-plate, H-plate	See Chapter ▶ 10.7.1
	Fixed-angle locking plate, correct size, possibly hybrid plate after interfragmentary compression	See Chapter ▶ 10.8.2 See Chapter ▶ 10.7.1
	Condylar plate, interfragmentary compression, possibly hybrid plate	See Chapter ▶ 10.9.1 See Chapter ▶ 10.7.1
Spiral ( ▶ Fig. 5.13) AO: 7 1 to 5 1/2.3-B1	Percutaneous Kirschner wire	See Chapter ▶ 10.13.2
	Lag screw(s), correct size	See Chapter ▶ 10.4.1
	Combination of lag screw and neutralization plate	See Chapter ▶ 10.5.1
Complex ( ▶ Fig. 5.14) AO: 7 1 to 5 1/2.3-B3	Fixed-angle locking plate	See Chapter ▶ 10.8.2
	External fixator	See Chapter ▶ 10.12.2, Chapter ▶ 10.12.3

Fig. 5.13 Extra-articular proximal phalanx fracture, distal, spiral. Left middle finger.

Fig. 5.14 Extra-articular middle phalanx fracture, distal, complex. X-ray in two planes (a,b).

5.3.3 Fractures of the Middle/Proximal Phalanx Shaft

**Table 5.7** Middle/proximal phalanx shaft fractures
Fracture type	Surgical management	Procedure reference
Transverse ( ▶ Fig. 5.15) AO: 7 1 to 5 1/2.2-A1	Wire suture (possibly with Kirschner wire)	See Chapter ▶ 10.2.1
	Tension band wiring	See Chapter ▶ 10.3.1
	Interfragmentary compression (straight plate, L-plate, H-plate, correct size)	See Chapter ▶ 10.7.1
	Fixed-angle locking plate/hybrid plate after interfragmentary compression	See Chapter ▶ 10.8.2
	Intramedullary pinning antegrade (retrograde)	See Chapter ▶ 10.11.2
	Compression wire fixation	See Chapter ▶ 10.10.3
Spiral ( ▶ Fig. 5.16) AO: 7 1 to 5 1/2.2-A1	Lag screws, correct size	See Chapter ▶ 10.4.1
Spiral ( ▶ Fig. 5.16) AO: 7 1 to 5 1/2.2-A1	Combination of lag screw and neutralization plate	See Chapter ▶ 10.5.1
Complex ( ▶ Fig. 5.17 and ▶ Fig. 5.18) AO: 7 1 to 5 1/2.2-A3 Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Nonoperative Fracture Management Biology of Fracture Healing Further Reading Implants and Instruments Surgical Fracture Management Surgical Procedures Stay updated, free articles. Join our Telegram channel Tags: Osteosynthesis of the Hand Jul 19, 2018 \| Posted by admin in ORTHOPEDIC \| Comments Off on Differential Indication Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access