Surgical Fracture Management

4.1 Atraumatic Technique

Due to technical improvements in the materials used for internal fixation, the trend is toward surgical management of hand fractures (fingers and wrist), provided that this confers an advantage in subsequent treatment.

If surgical treatment of hand fractures is to have a better functional prognosis than nonoperative treatment, however, several important conditions must be met:

A well-established operating team
A surgeon experienced in hand surgery
Instruments and implants of appropriate size
Postoperative management by staff with specialist hand management skills

Note

Surgical management of a hand fracture is of benefit only if it achieves rigid fixation that allows early, active (protected) motion. In this case, functional postoperative physical therapy can begin immediately or a short time after the procedure. The goal is improvement of mobility, stability, and proprioception.

A further requirement is that adjacent structures in the hand that might be damaged by surgery are preserved by using atraumatic operation technique.

4.1.1 The Ten Commandments of Atraumatic Surgery

(after Nigst and Haussmann)

Thou shalt choose a functionally correct approach of adequate size.
Thou shalt know and identify the anatomy and proceed with dissection anatomically.
Thou shalt operate in a bloodless field using a tourniquet.
Thou shalt avoid all tissue distortion and therefore use sharp dissection and respect tissue planes.
Thou shalt not crush the tissue and thou shalt therefore use retaining sutures instead of retractors and sharp hooks instead of forceps.
Thou shalt use the finest possible instruments and sutures.
Thou shalt divide and crush blood vessels (including veins) as little as possible.
Thou shalt prevent tissue from drying out.
Thou shalt perform meticulous hemostasis (bipolar microthermy) and if in doubt apply a pressure dressing thyself.
Thou shalt make thyself as comfortable as possible at the operating table; do not hesitate to support thine arms and never look at the clock.

4.2 Common Injuries, Consequences of Trauma, Deformities

The more frequently occurring fractures can be explained by the type of force and by the anatomy. These largely determine the fracture type and deformity. An exact history of the accident and knowledge of anatomy are therefore highly important.

As mentioned in Chapter ▶ 1, fractures in adults often occur in the work setting. Fractures due to direct external force are usually combined with soft tissue injuries, thereby influencing the later functional result. For instance, this applies to saw injuries with open fractures, as seen in agriculture and forestry and among do-it-yourself enthusiasts and hobbyists. Shaft fractures, often comminuted, and intra-articular fractures result from blunt trauma.

4.2.1 Fractures of the Distal, Middle, and Proximal Phalanges

The typical fracture deformity in proximal extra-articular fractures of the middle phalanx can be explained by the anatomy. Owing to the pull of the superficial flexor tendon, the proximal fracture fragment is in flexed position while the distal middle phalanx fragment is pulled into extension by the extensor tendon apparatus with simultaneous flexion of the distal interphalangeal joint by the deep flexor tendon ( ▶ Fig. 4.1a).

If the fracture is proximal to the insertion of the superficial flexor tendon, the distal fragment and distal interphalangeal joint are drawn into flexion by the deep flexor tendon ( ▶ Fig. 4.1b).

Closed and open injuries of the distal phalanges, sometimes with soft tissue loss or amputation, result from saw injuries and trapping of the distal phalanges by heavy objects.

Other types of fractures occur during sporting activities, especially ball sports. Axial stresses and lateral impacts cause intra-articular condylar fractures, basal fractures, marginal avulsions, fractures with tendon avulsion, and bony palmar plate avulsions.

Fig. 4.1 Deformity due to proximal extra-articular fractures of the middle phalanx. FDS, flexor digitorum superficialis. (a) Fracture distal to the insertion of the superficial flexor tendon. (b) Fracture proximal to the insertion of the superficial flexor tendon.

Distal intra-articular fractures of the middle and proximal phalanges are often mono- or bicondylar fractures, which are associated with shortening and lateral deviation ( ▶ Fig. 4.2, ▶ Fig. 4.3).

Fig. 4.2 Deformity due to distal monocondylar fracture of the proximal phalanx. Schematic (a) and X-ray in two planes (b,c).

Fig. 4.3 Deformity due to distal bicondylar fracture of the proximal phalanx. Schematic (a) and X-ray (b).

Subcapital fractures of the phalanges tend to be hyperextended with lateral displacement ( ▶ Fig. 4.4).

Fig. 4.4 Deformity due to subcapital phalangeal fracture in both planes. Schematic (a) and X-ray of subcapital fracture of the proximal phalanx of the thumb, lateral view (b).

Long spiral fractures and torsional fractures have a considerable tendency to shortening and there is often a rotational deformity ( ▶ Fig. 4.5).

Fig. 4.5 Deformity due to long oblique fracture of the proximal phalanx. Schematic (a) and X-ray in one plane (b).

With proximal intra-articular fractures of the distal, middle, and proximal phalanges, depressed and comminuted basal fractures must be distinguished from intra-articular avulsions. Comminuted fractures of the base are characterized by shortening, a tendency to dislocation, radial/ulnar deviation and greater depression of the base on one side ( ▶ Fig. 4.6).

Fig. 4.6 Deformity due to depressed fracture of the base of the distal/middle/proximal phalanx. (a) Schematic. (b) Depressed fracture of the base of the proximal phalanx, lateral view. (c) Depressed fracture of the base of the middle phalanx, AP view. (d) Same patient as in (c), lateral view.

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