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MANAGEMENT OF THE

COMPLICATIONS OF HAND
FRACTURES AND POST
FIXATION REHABILITATION OF
THE HAND
Christian Dumontier MD, PhD

Presentations are available at www.diuchirurgiemain.org


Figures may belong to authors quoted in the references
Not a easy topic

It is when you go deep into things .that it becomes


complicated (JF Malgaigne (1806-1865), French
Surgeon, Treatise on fractures and luxations)
THE FRAMEWORK
Fractures of the metacarpals and phalanges > 40% of all
upper extremity fractures. Out of 1.5 million hand and
forearm fractures, 23% were phalangeal fractures
(Chung). 50% of 72,000 hand fractures were phalangeal
fractures (Feehan).

Complications can and do occur,

Lost productivity associated with phalangeal fractures


exceeds $2 billion per year

Hand fractures were the most expensive subgroup of all


fractures, resulting in an excess of $278 million in annual
costs and loss of productivity in the Netherlands.

- De Putter CE et al. Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. J
Bone Joint Surg Am 2012;94(9):e56.
- Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg 2001;26:908
15.
- Feehan LM, Sheps LM, Samuel B. Incidence and demographics of hand fractures in British Columbia, Canada: a population-based study. J
Hand Surg 2006;31:106874.
COMPLICATIONS OF HAND FRACTURES
DEPEND OF

The context of the injury


i.e.

sharp vs crushing
injury;

low vs high-energy
injury,
COMPLICATIONS OF HAND FRACTURES
DEPEND OF

Type of fracture
(transverse, oblique,
comminutive)
COMPLICATIONS OF HAND FRACTURES
DEPEND OF

Type of fracture
(transverse, oblique,
comminutive)

Type of bone
(metacarpals vs phalanx)
COMPLICATIONS OF HAND FRACTURES
DEPEND OF

Bone and soft-tissues


injuries

As plastic surgeons we
are aware that there are
many envelopes around
the hand bones !!!.
COMPLICATIONS OF HAND FRACTURES
DEPEND OF

Patient characteristics
(age, activity level,
occupation, and
vocational interests)

Smoking (X 9 nonunion
rate)

Patient implication in his/


her rehabilitation
COMPLICATIONS OF HAND FRACTURES
DEPEND OF

The type of treatment:


immobilisation vs surgery

The hardware used :

i.e. coaptive devices (External Fixators, Intramedullary Rods, K-wires, Pins,


Interosseous Wiring) hold the fracture ends together without compression
(secondary callus healing) vs rigid fixation (screws, plates, Tension Band Wiring,
90-90 Wiring) that immobilize and compress the fracture (primary healing).
FOR EXAMPLE
Complications are more frequent with phalangeal
fractures and open fractures.

Metacarpal fractures and closed fractures regained >


220 of TAM (76% vs 67%).

Only 11% of phalangeal and only 24% of open


fractures regained that degree of motion.
Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am
1998;23(5): 82732.
AGE OF PATIENT IS OF
PARAMOUNT IMPORTANCE

Puckett noted significant remodeling in children


(214 years) with distal condylar malunions of the
phalanges.

They found complete correction in the sagittal


plane and near-complete coronal plane correction.

Puckett BN et al. Remodeling potential of phalangeal distal condylar malunions in children. J Hand Surg 2012;37:3441.
COMPLICATIONS

Complications and
outcome depends of the
initial injury +++

It can also be a failure of


technique, failure of
rehabilitation, or failure
caused by patient disease.
WHAT ARE THE COMPLICATIONS WE MAY
ENCOUNTERED ?

Stiffness is the most


common complication,
followed by malunion,
posttraumatic arthritis,
nonunion, infection, and
chronic pain syndromes.

Complications and
outcome depends of the
initial injury +++
NONUNION


NON UNION
A nonunion can be atrophic or hypertrophic.

Hypertrophic nonunion needs stability to heal


inadequate initial treatment .

Atrophic nonunions require bone graft and a


healthy bed.

Rare (rich vascular network supplying the hand)


0.7% incidence in 148 fractures (Barton)

0.2% incidence among 485 (Borgerskov).

6% of surgically corrected phalanx fractures resulted in


nonunion (Van Oosterom).

Barton NJ: Fractures of the shafts of the phalanges of the hand. Hand 11:119-33, 1979
Borgeskov S: Conservative therapy for fractures of the phalanges and metacarpals. Acta Chir Scand 133:123- 30, 1967
Van Oosterom FJ et al. Treatment of phalangeal fractures in severely injured hands. J Hand Surg Br. 2001;26(2):108-111.
NON UNION
Most nonunions in the hand are atrophic and
associated with bone loss or
infection.

Usually seen in complex injuries (open


fractures and crush injuries) with concomitant
injuries to the nerves, blood vessels, and
tendons (15 cases out of 25 in Jupiters series).

Sequelae of operative treatment and vascular


insult during exposure and fracture fixation, or
malreduction of the fracture in a distracted
position.

Smoking

Jupiter JB et al. The management of delayed union and nonunion of the metacarpals and phalanges. J Hand Surg l0A:457-66, 1985
Crossed K-wires for neck fracture ending as a non-union
DIAGNOSIS OF NONUNION CAN BE
CHALLENGING

Delay for (radiographic) healing varies from bone to


bone:

Meta: 6 weeks

P1: 6-8 weeks

P2: 8-10 weeks

P3: 10-12 weeks

Radiolucent lines can be seen on radiographs for more


than a year in fractures that ultimately unite
radiographically

Factors such as pain, instability, deformity, and failure of


fixation should be considered along with the
radiographs
TREATMENT OF ATROPHIC NONUNION

Bone stimulator have thus


far not been shown to be
efficacious

Surgery (Revision ORIF +


Autologous bone graft)
improved alignment and
stability but resulted in
modest motion
improvement.

Ring D. Malunion and nonunion of the metacarpals and phalanges. Instr Course Lect 2006;55: 1218.
TREATMENT OF ATROPHIC NONUNION

ORIF with autologous bone graft +/- tenolysis and arthrolysis


for the coexisting stiffness in cases where the finger is
expected to be nearly fully functional after surgery.

All atrophic and nonviable bone must be resected until there


is bleeding bone.

Rigid fixation to provide added mechanical stability is


preferred when there is adequate soft-tissue
coverage.
TREATMENT OF ATROPHIC NONUNION

Amputation or arthrodesis
are useful treatment
options, especially if the
associated soft tissue
components are
compromised

Almost universally improves


finger function

Ring D. Malunion and nonunion of the metacarpals and phalanges. Instr Course Lect 2006;55: 1218.
DISTAL PHALANX NONUNION
Asymptomatic nonunion of the distal
phalanx tuft does not require
intervention;

Symptomatic nonunion of the tuft can be


treated by removing the bone fragment.

Nonunion of the distal phalanx neck and


shaft may causes functional limitation
such as pain upon motion or instability in
pinching and grasping objects.

Bone grafting on the tip of the


phalanx is prone to resorb

Kim J et al. Correction of Distal Phalangeal Nonunion Using Peg Bone Graft. J Hand Surg Am. 2014;39(2):249-255
DISTAL PHALANX NONUNION

Ozcelik et al used olecranon bone graft in 11 cases with K-wire fixation.


8

Access by midlateral incisions, and only cancellous bone was grafted. No


complications except a hematoma at the donor site.

Ito et al. in 6 patients used a palmar midline incision and cancellous and
cortical bone graft from the olecranon.

Botelheiro treated 5 cases of nonunion, employing compressive screws


10

using a fish mouth incision.

Jupiter et al managed 2 of 3 cases of distal phalanx nonunion by simple


11

removal of a distal fragment.

Chim et al treated 14 cases of distal phalanx nonunion by performing


12

open reduction and interfragmentary screw fixation using a dorsal


approach through the nailbed, and reported good functional results.

- Ozcelik IB, Kabakas F, Mersa B, Purisa H, Sezer I, Erturer E. Treatment nonunion of the distal phalanx with olecranon bone graft. J Hand Surg Eur Vol.
2009;34(5):638-642
- Itoh Y, Uchinishi K, Oka Y. Treatment of pseudoarthrosis of the distal phalanx with the palmar midline approach. J Hand Surg Am. 1983;8(1):80-84.
- Botelheiro JC. Treatment of pseudarthrosis of the distal phalanx with a compression screw. J Hand Surg Br. 1995;20(5):618-619.
- Jupiter JB, Koniuch MP, Smith RJ. The management of delayed union and nonunion of the metacarpals and phalanges. J Hand Surg Am. 1985;10(4):457-466.
- Chim H, Teoh LC, Yong FC. Open reduction and interfragmentary screw fixation for symptomatic nonunion of distal phalangeal fractures. J Hand Surg Eur
Vol. 2008;33(1):71-76.
DISTAL PHALANX NONUNION
Kim performed grafts using
bone pegs in 13 patients.

Fingertip incision with placement


of bone pegs through the canal.

All patients had successful union


of the distal phalanx without
serious complications

Range of motion improved


postoperatively.

Kim J, Ki SH, Cho Y. Correction of Distal Phalangeal Nonunion Using Peg Bone Graft. J Hand Surg Am. 2014;39(2):249-255
ATROPHIC NONUNION AND
POTENTIAL INFECTION ?

Preoperative white blood cell count, erythrocyte sedimentation


rate, and C-reactive protein

Intraoperative bone cultures should be obtained +++

Surgical principles include eradication of any residual infection,


debridement of nonviable bone, and stabilization of the fracture
segments.

Bone graft is required to achieve union which may require stage


surgery.
MALUNION


MALUNION
Deformities caused by malunions range from the mild,
aesthetically displeasing to the severe and functionally
disabling. This includes muscle fatigue, cramping,
pseudoclaw deformity, deformity, and prominent
metacarpal heads in the palm.

Less tolerance in shortening and angulation in index and


middle fingers (more fixed).

Malunions are caused by a combination of shortening,


malrotation, and angulation in the coronal and/or sagittal
plane, but one deformity usually
predominates.

Should (may) be corrected if there is a functional deficit


that is due to malunion (not to the injury or
other causes of failures)

Q ?: how much deformity can we accept ?


Freeland A, Lindley SG. Malunions of the finger metacarpals and phalanges. Hand Clin 2006;22(3): 4155.
ROTATIONAL DEFORMITIES

Are responsible for finger scissoring

The more proximal the fracture, the


more the angulation is amplified distally
(1 of rotation in the metacarpal results
in 5 in the fingertip)

10 of metacarpal rotation produces 2


cm of overlap at the fingertips.

Alignment should be checked with the


fingers extended as well as flexed (In
the uninjured hand, all nail plates are
coplanar both with the digits extended
and flexed.).

Seitz WH Jr, Froimson AI. Management of malunited fractures of the metacarpal and phalangeal shafts. Hand Clin 1988;4(3):52936.
PRINCIPLES OF SURGICAL TREATMENT FOR
ROTATIONAL DEFORMITIES

Freeland and Lindley noted that 1 mm of


metacarpal derotation corrects 1 cm of fingertip
overlap.

Gross and Gelberman found that metacarpal base


osteotomies can correct deformities in the index,
middle, and ring fingers of up to 20 and the small
finger up to 30.
- Freeland A, Lindley SG. Malunions of the finger metacarpals and phalanges. Hand Clin 2006;22(3): 34155.
- Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat Res 2006;445:13345
- Gross MS, Gelberman RH. Metacarpal rotational osteotomy. J Hand Surg 1985;10:1058.
PRINCIPLES OF SURGICAL
TREATMENT FOR Do
not
ROTATIONAL DEFORMITIES Har
m!
Respect soft tissues to minimize scarring, adhesions, and
contractures.

Metaphyseal-level osteotomies seem to heal better than


diaphyseal osteotomies (however performing the osteotomy
at the old fracture site has the advantages of restoring normal
anatomy without creating a zigzag deformity, giving access to
the soft tissues for concurrent tenolysis and capsulectomy, and
the ability to correct multiple deformities).
PRINCIPLES OF SURGICAL TREATMENT
FOR ROTATIONAL DEFORMITIES
Clinical tenodesis should be done
during initial fixation to avoid
basing reduction/rotation
confirmation on radiographs

Always control finger position in


full flexion - Eventually use a
longitudinal K-wire for transverse
osteotomy to control for rotation

Stable/rigid fixation allows early


therapy, minimizing stiffness. Use
adapted, low-profile plates
SURGICAL TECHNIQUES FOR
ROTATION DEFORMITIES CORRECTION

Transverse metacarpal osteotomy does not fully


correct scissoring from phalangeal malunions.

A step-cut osteotomy at the metacarpal level heals


well and is successful at derotating both metacarpal
and phalangeal malunions.
- Jawa A, Zucchini M, Lauri G, et al. Modified step-cut osteotomy for metacarpal and phalangeal rotational deformity. J Hand Surg
2009;34(2):33540.
- Manktelow RT, Mahoney JL. Step osteotomy: a precise rotation osteotomy to correct scissoring deformities of the fingers. Plast Reconstr
Surg 1981; 68(4):5716.
- Pichora DR, Meyer R, Masear VR. Rotational step-cut osteotomy for treatment of metacarpal and phalangeal malunions. J Hand Surg
1991;16(3):5515.
The direction of the proximal cut
will allow only one-way of rotation
ANGULATION DEFORMITY DEPENDS OF THE PULLING FORCES
ANGULATION DEFORMITY AT THE METACARPAL LEVEL

Due to the force of intrinsics and


extrinsic, shaft and neck # tend to
deform in flexion

Angulation < 10 is accepted for


M2M3 and up to 20 for M4M5 for
shaft fractures ( neck fractures)

Angulation leads to loss of flexor


tendon efficiency (excursion, load
and work requirements) as well as
loss of strength and range of
motion

Birndorf MS et al. Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. PRS 1997; 99:1079-1085
FIFTH METACARPAL NECK
DISPLACEMENT/ MALUNION

Biomechanical studies have shown that 30


angulation is a limit as beyond this threshold there
is a loss of flexor tendon efficiency (excursion,
load and work requirements) as well as loss of
strength and range of motion (30 of angulation
resulted in 92% of normal strength and 78% of
normal motion).
Ali A. et al. The biomechanical effects of angulated Boxers fractures. J Hand Surg 1999;24A:835-844
Birndorf MS et al. Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. PRS 1997; 99:1079-1085
HOWEVER
Prospective clinical series have shown no loss of
function or disability beyond 30 angulation and
no relationship between the presence of
symptoms and residual angulation
Braakman M, Oderwald EE, Haentjens MH. Functional taping of fractures of the 5th metacarpal results in a quicker recovery. Injury. 1998;
29(1):59.
Statius Muller MG, Poolman RW, von Hoogstraten MJ, Steller EP. Immediate mobilization gives good results in boxer's fractures with volar
angulation up to 70 degrees: a prospective randomized trial comparing immediate mobilization with cast immobilization. Arch Orthop Trauma
Surg. 2003; 123(10):534537.
McMahon PJ, Woods DA, Burge PD. Initial treatment of closed metacarpal fractures: a controlled comparison of compression glove and
splintage. J Hand Surg Br. 1994; 19(5):597600.
Hansen PB, Hansen TB. The treatment of fractures of the ring and little metacarpal necks: a prospective randomized study of three different
types of treatment. J Hand Surg Br. 1998; 23(2):245247.
Kuokkanen HO, Mulari-Keranen SK, Niskanen RO, Haapala JK, Korkala OL. Treatment of subcapital fractures of the fifth metacarpal bone: a
prospective randomised comparison between functional treatment and reposition and splinting. Scand J Plast Reconstr Surg Hand Surg. 1999;
33(3):315317.
Lowdon IM: Fractures of the metacarpal neck of the little finger, Injury 17:189-192, 1986.
Ozturk I, Erturer E, Sahin F, et al. Effects of fusion angle on functional results following non- operative treatment for fracture of the neck of the
fifth metacarpal. Injury. 2008; 39(12):1464 1466
5TH METACARPAL NECK FRACTURE
MALUNION

Due to the absence of correlation


between angulation and symptoms
and the characteristics of the
involved population

Except if there is a rotational


malunion

There is little if any indication for


surgical correction
SURGICAL PRINCIPLES FOR ANGULATION
DEFORMITY

Losing wedge osteotomies are easier and more reliable,


but they shorten the bone.

Opening wedge osteotomies are preferred when there is


also shortening

Cancellous grafts are adequate as long as the fixation is


robust.

Plates and screws are preferred


METACARPAL SHORTENING

Shortening can be
functionally tolerated but
leaves the patient with the
disappearance of
prominence of metacarpal
head
Shortening is appreciated by drawing Chmell line on plain X-rays.
Usually the deep intermetacarpal ligaments prevent greater than 3 to 4
mm of metacarpal shortening
METACARPAL SHAFT MALUNION AND
TOLERANCE

Meunier
Shor et al found that metacarpal shortening affected strength, with 2
mm oftshortening
ening producing a minimal 8% loss of power and 10 mm of
less ta 45% loss of power from the dorsal interossei.
shortening producing han 4-
5 mm
sigand
Low et al. found that flexion is uforces
nifiextension s u were diminished with
c an
shortening of more than 3 mm or dorsal a
ce angulationllygreater
withothan 30
ut an
Strauch et al. found 7 of extensor lag with every 2 mm of metacarpal
y
shortening, possibly affecting flexor power.
- Meunier MJ, Hentzen E, Ryan M, et al. Predicted effects of metacarpal shortening on interosseous muscle function. J Hand Surg 1998;29(4):
68993.
- Low CK, Wong HC, Low YP, et al. A cadaver study of the effects of dorsal angulation and shortening of the metacarpal shaft on the
extension and flexion ratios of the index and small fingers. J Hand Surg 1995; 20(5):60913.
- Strauch RJ, Rosenwasser MP, Lunt JG. Metacarpal shaft fractures: the effect of shortening on the extensor mechanism. J Hand Surg 1998;23:
51923.
- Wills J et al. The effect of metacarpal shortening on digital flexion force. J Hand Surg Eur. 2013, 38: 66772.
AT THE FINGER (P1) LEVEL

Proximal phalangeal
fractures typically produce
a volar apex angulation
because of tension on the
central slip distally and the
lumbrical proximally.
BIOMECHANICAL CONSEQUENCES (AT THE FINGER LEVEL)

Angulation leads to shortening, which affects position


and function and significant when > 15 .

Phalanx angulation > 25 in older children and adults


produced losses in both flexion and extension.

Shortening by 1 mm extensor lag at the PIP of 12.

If angulation from 16 to 46 , the PIP lags (in a


cadaver model) from 10 to 66.

Because of proclivity of PIP joint for stiffness, fixed


flexion contractures can rapidly develop.

- Coonrad RW, Pohlman MH. Impacted fractures in the proximal phalanx of the finger. J Bone Joint Surg Am 1969;51(7):12916
- Vahey JW, Wegner DA, Hastings H III. Effect of proximal phalangeal fracture deformity on extensor tendon function. J Hand Surg 1998;23:673
81.
Minor complication with extensor lag due to malunion
ASSOCIATED LESIONS ARE DETRIMENTAL (AT THE
FINGER LEVEL)

Adhesions amplifies the biomechanics consequences of malunion.

Patients with only bony involvement had a 96% rate of good to


excellent results. If other structures were involved, the success
rate decreased to 64%.

Buchler and colleagues found that 50% of corrective phalangeal


osteotomies required concurrent tenolysis (100% bone healing)

A prolonged flexion deformity of the PIP may lead to permanent


attenuation of the dorsal capsule and extensor slip

- Botte MJ, Davis JL, Rose BA, et al. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. Clin Orthop
Relat Res 1992;(276):194201.
- Buchler U, Gupta A, Ruf S. Corrective osteotomy for post-traumatic malunion of the phalanges in the hand. J Hand Surg 1996;21(1):3342.
AT THE FINGER (P2) LEVEL

Middle phalangeal
malunions are apex dorsal if
the fracture is proximal to
the FDS insertion and apex
volar if the fracture is distal
to the FDS insertion. Apex
volar angulation affect
flexor tendon
biomechanics.
SURGICAL PRINCIPLES AT FINGER LEVEL

Phalangeal malunions are best


treated at the level of the fracture
because of the benefit of being able
to concurrently perform
tenocapsulolysis and address the
source of the deformity.

PIP joint motion improved by 15 and


DIP joint motion by 10 .

Consideration may be given to


perform osteotomies at the proximal
phalanx base rather than close to the
PIP joint to lower the risk of
contracture.

Trumble T, Gilbert M. In situ osteotomy for extra articular malunion of the proximal phalanx. J Hand Surg 1998;23:8216.
STAGE SURGERY ?

Patients should be informed that surgery may be


done in stages:

Malunion correction first

Motion correction second.


ARTICULAR MALUNION

Established intra-
articular malunions
are very challenging
to treat.

In situ osteotomy is
most often used -
stiffness is a
common outcome.
2 months post-trauma !!!
CT scan
MALUNIONS
Freeland and Lindley presented options for malunion management of
8

the phalanges and metacarpals based on degree.

Surgery is frequently necessary in:

Middle and proximal phalanx sagittal angulation exceeding 15

Articular incongruity,

Metacarpal sagittal angulation > 30

Rotation > 10
Freeland A, Lindley SG. Malunions of the finger metacarpals and phalanges. Hand Clin 2006;22(3): 4155.
STIFNESS


Stiffness is not only the most common complication
encountered, but it is also unfortunately the most difficult
to treat.
STIFFNESS IS THE MOST FREQUENT
COMPLICATION (AND THE MOST
DIFFICULT TO TREAT)
Due to the injury

Crush injuries damage every structure from skin to bone.

Open fractures

Soft tissue scarring affects hand function more than fracture healing

Due to the fractured bone

Due to technical failures


STIFFNESS IS THE MOST
FREQUENT COMPLICATION
Due to the injury

Due to the fractured bone

Phalanx fractures, particularly those around the PIP


joint, are more predisposed to developing stiffness
than metacarpal fracture

Due to technical failures


STIFFNESS IS THE MOST
FREQUENT COMPLICATION

Extra-articular cross pinning or transarticular


pinning of proximal third phalangeal fractures had
equal results but nearly 30% of patients had a
fixed flexion contracture (at least 15) at the PIP
joint.

Faruqui S, Stern PJ, Kiefhaber TR. Percutaneous pinning of fractures in the proximal third of the proximal phalanx: complications and
outcomes. J Hand Surg 2012;37(7):13428.
STIFFNESS IS THE MOST
FREQUENT COMPLICATION
Due to the injury

Due to the fractured bone

Due to technical failures

Prolonged immobilisation (Phalanx fractures heal within 4 weeks,


although radiographic incorporation is delayed.)

Delayed motion (inadequate fixation, non-cooperative patient, post-op


swelling,)

Type of fixation ?
DOES THE TYPE OF FIXATION HAS ANY
INFLUENCE ON THE POST-OP STIFFNESS ?
A few studies have raised concerns about the possibly higher rates of complications
of plate fixation.

52% complication rate in 64 # treated with plates (CPRS, Total ROM < 180,
infection, delayed union/nonunion, implant failure) - Kurzen

64% complication rate with plates (extensor lag > 35, ROM < 180, infection,
plate prominence, tendon rupture) - Page

Similar results of ORIF with miniplates to K-wire fixation (Freeland). Authors


recommended excising the lateral band and oblique fibers of the extensor
mechanism on the same side.

Kurzen P et al. Complications after plate fixation of phalangeal fractures. J Trauma. 2006; 60(4):841843
Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal
fractures. J Hand Surg Am. 1998; 23(5):827832.
Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat
Res 2006;445:13345.
DOES THE TYPE OF FIXATION HAS ANY
INFLUENCE ON THE POST-OP STIFFNESS ?

K-wire fixation, while more biologically friendly, can


also have problems notably with infection and loss
of fixation

Kirschner wire fixation has known complications


up to 18%
DOES THE TYPE OF FIXATION HAS ANY
INFLUENCE ON THE POST-OP STIFFNESS ?

Screws proved superior to K-wire for


complications (7 vs 31%), shorter immobilisation
time (2 vs 4 weeks) and return to work (6,2 vs
10,1 wk off).

Literature trends are for better functional


outcomes and earlier finger mobilization for screw,
plate and pin fixation, in that order
MOTION VS IMMOBILISATION
Therapy can be advanced when tenderness starts to disappear. Motion
decreases patients swelling, Splinting is useful.

Early motion is better than immobilization in minimizing adhesions. However,


fracture fixation or healing must withstand loads.

As little as 1.7 mm of tendon excursion may decrease adhesions and


prevent stiffness. DIP blocking helps to mobilize the tendons at the PIP level

Immobilization for 4 weeks or greater is likely to result in stiffness

Extensor tendon adhesions are more common than flexor tendon


adhesions (surgical approach and plating are usually performed dorsally or
laterally).
EXAMINATION OF THE STIFF PATIENT

Stiffness in a central digit affects the hands function to


a larger degree.

Stiffness with both active and passive motion indicates


a capsular contracture, whereas stiffness with active
motion alone is caused by tendon adhesions to the
surrounding soft tissues, capsule, bone, or implants

X-rays are needed to rule out an articular involvement


INDICATION FOR SURGERY IN A STIFF PATIENT

The initial treatment is through intensive hand therapy with an


experienced therapist to gain as much motion as possible.

608 patients out of 749 had satisfactory results with therapy and only 61
of the 141 unsatisfied patients had surgery.

When motion has plateaued after at least 3 months following fracture


fixation and hand therapy, surgical treatment may be indicated.

Skin and soft tissue envelope should be mature and supple, and the fracture
consolidated before any surgical procedure.

Patient must be informed of the intensive postoperative rehabilitation and be


dedicated to participate.

Young VL, Wray RC Jr, Weeks PM. The surgical management of stiff joints in the hand. Plast Reconstr Surg 1978;62(6):83541.
EXTENSOR TENOLYSIS +/- ARTHROLYSIS
Various techniques described. Stage
surgery with manual testing
between stages:

Incision is dorsal, either


longitudinal or curvilinear

Release of the skin from the


extensor mechanism

Separation of the central slip,


lateral slip, and intrinsic apparatus
from each other and the
underlying bone and capsule
with blades or elevators.
EXTENSOR TENOLYSIS +/- ARTHROLYSIS
Dorsal capsulotomy if needed

Release of the collateral


ligaments (V resection,
complete release,)

Volar plate freeing if a cam


effect is observed during
testing (elevator)

Associated flexor tenolysis if


needed (at least, traction on
the flexors proximal to A1)
EXTENSOR TENOLYSIS +/-
ARTHROLYSIS

Creighton and Steichen achieved good outcomes 6

with increases in TAM of about 50 when tenolysis

alone was performed and 30 when tenolysis and


capsulotomy were performed.

Creighton JJ Jr, Steichen JB. Complications in phalangeal and metacarpal fracture management. Results of extensor tenolysis. Hand Clin 1994;
10(1):1116.
FLEXOR TENOLYSIS +/- ARTHROLYSIS

Various techniques: Staged surgery and


testing between stages

Volar approach (Brunner, hemi-


brunner,) from the distal palmar
crease to the distal finger crease.

The adhesions between the skin and


tendon sheath are released.

The tendon sheath is opened using


multiple transverse incisions, proximal
to the A2 pulley, distal to the A2 pulley,
through the middle of the A2 pulley if
necessary (idem for A4 pulley).
FLEXOR TENOLYSIS +/- ARTHROLYSIS

The flexor tendons are freed from


adhesions to each other and the
underlying capsule and bone using
curved blades, fine periosteal
elevators or the wire to cut
butter technique using large sutures.

If there is a persistent flexion


contracture, the checkrein ligaments,
accessory collateral ligaments, and the
volar aspect of the collateral
ligaments are sequentially released in
that order until the joint can be
adequately extended.
FLEXOR TENOLYSIS +/- ARTHROLYSIS

Yamazaki and colleague noted average improvement


in total active motion (TAM) of 107 and mostly
excellent and good clinical outcomes.

In Hahn and colleagues series 84% of fingers


achieved a mean postoperative TAM of 189 at a
mean follow-up of 10 months compared with a
preoperative TAM of 79 .
Yamazaki H, Kato H, Uchiyama S, et al. Results of tenolysis for flexor tendon adhesion after phalangeal fracture. J Hand Surg Eur Vol
2008;33(5):55760.
Hahn P, Krimmer H, Muller L, et al. Outcome of flexor tenolysis after injury in zone 2. Handchir Mikrochir Plast Chir 1996;28(4):198
203.
LAXITY IS A
VERY RARE
COMPLICATION


INFECTION


INFECTION

Open # are severe injury


(up to 39% amputation rate
reported after open fracture)

Patients who were diagnosed


or treated greater than 6
months after initial symptoms
or who underwent multiple
procedures had an
amputation rate of 86%.

Reilly KE, Linz JC, Stern PJ, et al. Osteomyelitis of the tubular bones of the hand. J Hand Surg Am 1997;22(4):6449
INFECTION (NOT ALWAYS A COMPLICATION
BUT A RESULT) IS SECONDARY TO:

The initial injury: infection rate of 0% for type 1 #, 9% for type


2, and 14% for type 3.

The fixation technique:

Surgery (Devitalization of the surrounding soft tissues and


periosteal stripping) may convert lower grade types to
higher grade injuries with dissection.

Kirschner wire fixation has known complications up to 18%


McClain RF, Steyers C, Stoddard M. Infections in open fractures of the hand. J Hand Surg 1991;16:10812.
HOWEVER, RECENT REVIEWS SUPPORT THAT
INFECTION ARE NOT SO FREQUENT
Infection rate of 6 per 171 fractures (3.5%), all in Gustilo- Anderson type III injuries.

2011 review of 145 cases showed a 1.4% infection rate, with a high proportion (91 out
5

of 145) of Gustilo-Anderson type III injuries.

A 2006 review of bone grafting for open fractures of the hand found a 0% infection
rate

A 2010 retrospective review of 432 metacarpal and phalanx fractures requiring ORIF
found no significant difference in infection rates between the open (133 fractures) and
closed (299 fractures) injury groups.

- Duncan RW, Freeland AE, Jabaley ME, et al. Open hand fractures: an analysis of the recovery of active motion and of complications. J
Hand Surg 1993; 18(3):38794.
- Capo JT, Hall M, Nourbakhsh A, et al. Initial management of open hand fractures in an emergency department. Am J Orthop
2011;40(12):E2438.
- Saint-Cyr M, Gupta A. Primary internal fixation and bone grafting for open fractures of the hand. Hand Clin 2006;22(3):31727.
- Bannasch H, Heermann AK, Iblher N, et al. Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and
outcome analysis show no increase of complications in the treatment of open compared with closed fractures. J Trauma 2010;68(3):
6248.
PREVENTION OF
INFECTION

Prompt and thorough irrigation and debridement


is the most important part of the treatment

Antibiotics has proven useless for open distal


phalanx fracture

Gonzalez MH, Bach HG, Elhassan BT, et al. Management of open hand fractures. J Am Soc Surg Hand 2003;3(4):20818.
Metcalfe D. et al. .Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg. 2016;41E(4):423-30
DIAGNOSIS OF INFECTION IS NOT ALWAYS EASY
Definitive diagnosis is made with cultures obtained from a bone biopsy.

Patients present with swelling, warmth, erythema, tenderness, loss of motion,


and sometimes a draining sinus tract.

Fevers usually absent

Inflammatory markers (CRP) are elevated although WBC may be normal or


elevated.

Radiographs are initially normal, but may reveal sequestrum and involucrum in
chronic cases.

Hardware loosening
SURGICAL PRINCIPLES
Remove the hardware if the fracture is healed

If the fracture has not yet united, the hardware


may be retained until union while the patient is
on chronic suppressive antibiotics.

When the hardware is loose, it should be


removed, and the fracture stabilized with
external fixation.

The dead space can be managed with antibiotic


impregnated cement spacers with external
fixation as needed for stability, and flaps can be
used for soft tissue coverage as necessary
46 years old male
1 month postop
Treatment ?

Case Pr Obert
Masquelets technique:
Resection of infected tissue
Cement to fill the defect
Stabilisation
At two months, open the capsule, remove the cement, fill with
cancellous bone
Postop D 15 D 30
2 Months 2 Years
PAIN


PAIN
Acute pain represents the normal response of the body to injury.

When it persists, causative issues need to be considered from nerve


injury, instability, or stiffness not to forget CRPS !

70% of 110 patients with distal phalanx # still complain at 6


months (chronic pain, cold hypersensitivity, numbness)

Injury alters the perception of self and may be a major factor in the
patients ability to recover. It is desirable to avoid the cycle of pain,
swelling, disuse, and stiffness that can occur with even minor injuries.

DaCruz DJ, Slade RJ, Malone W. Fractures of the distal phalanges. J Hand Surg Br. 1988;13(3):350-352
POST-TRAUMATIC ARTHRITIS


POST-TRAUMATIC ARTHRITIS
Can be the result of intra-articular malunion or chondral injury
from the moment of impaction

The treatment options depend on the patient, the deformity, the


involved joint, and they include osteotomies, various types of
arthroplasties, and arthrodeses or joint denervation.

Arthrodesis is preferred in the index finger because of the lateral


stress from pinch, whereas arthroplasty is generally preferred in
the other fingers to preserve motion and grip strength
PHYSICAL THERAPY


REHABILITATION OF HAND FRACTURES

Also we lack some evidence about the value of physical therapy,

It is probably of paramount importance when dealing with hand


fractures:

Prevention and treatment of edema

Early (protected) mobilisation

Training and coping with patients


REHABILITATION AFTER HAND #
Spl
i n
Is adaptative tin
g is
also
Treatment of edema par
to
f th
Early protected range of motion before e r bone healing
eha
bili
Early rehabilitation of soft-tissues tati
on
Active and resisted rehabilitation once bone healing is
strong enough
REHABILITATION DOES NOT CONCERN
ONLY THE BONE

It is a mistake to consider fracture healing apart from


soft tissue healing, because successful outcomes
require the return of functional integrity to both
tissues.

Soft tissue scarring affects hand function


more than fracture healing, which explains
why stiffness is the most frequent complication.
Physical therapy is
adapted to the
evolution of
fracture and soft-
tissue healing and
to treatment of
the fracture
One example of the adaptation of rehabilitation to the time elapsed
after fracture treatment
EDEMA CONTROL
Therapy works to control
edema.

Swelling prevents motion


and engenders stiffness: a
vicious cycle.

Edema management include


a warm-up to start therapy,
and a cool-down to prevent
rebound swelling + RICE
protocol + early mobilisation
EDEMA CONTROL
RICE : Rest, ice, compression, and elevation

Edema postures the hand into wrist flexion, MP joint extension, IP joint flexion, and thumb adduction. Functional
splinting place the hand in a resting position that will avoid this deformed posturing.

Ice can be performed with the use of large bags of frozen peas and is effective even over a splint or cast.

Coban (1 inch [2.5 cm] for fingers) provides effective compression.

The greatest reduction in swelling is obtained with the hand supported in elevation overnight. +++

Early mobilization to promote venous return via muscle contraction is advocated in stable fractures.

Having the patient adduct the fingers tightly and maintain this tension while flexing at the MP joint enhance both
intrinsic muscle pumping and achieve the desired joint positions of full MP flexion and IP extension.

Double buddy straps, protect fracture alignment and encourage mobility of the injured digit.

Patients are also instructed in shoulder and elbow ROM exercise in elevation to facilitate proximal muscle pumping.

Eccles MV. Hand volumetrics. Br J Phys Med. 1956;19:5-8.


EDEMA CONTROL: RICE
RICE : Rest, ice, compression, and elevation

Edema postures the hand into wrist flexion, MP joint


extension, IP joint flexion, and thumb adduction.
Functional splinting place the hand in a resting
position that will avoid this deformed posturing.

Ice can be performed with the use of large bags of


frozen peas and is effective even over a splint or cast.

Coban (1 inch [2.5 cm] for fingers) provides effective


compression.

The greatest reduction in swelling is obtained with


the hand supported in elevation overnight. +++

Eccles MV. Hand volumetrics. Br J Phys Med. 1956;19:5-8.


Day

Night
SPLINTING

Splinting limits joint stiffness,


which allows focused
therapy.

Static (early) then dynamic

Example of the splint used for


transverse # of first phalanx
This is not recommended

M5 neck fracture P1 fracture non displaced P2 fracture


MEDICAL TREATMENT

Theoretically interfering with bone growth, NSAID


can help limit scarring and stiffness (and pain)

Pain control helps to limit edema, and to start


early mobilisation
EARLY MOBILISATION
Hand fractures do not need to be
solidly united to start joint mobilization,
and most hand fractures treated closed
have healed sufficiently by 3 weeks to
begin gentle protected motion +++

No one should immobilise a fracture


more than 3-4 weeks +++

Early tendon gliding is mandatory (Both


soft-tissue and bone should heal
properly)
PHYSICAL THERAPY AFTER K-WIRE FIXATION

Postop period: splint, elevation, limit edema

1 week: removable splint in a functional, rehabilitation ready position. Start


protected AROM exercises.

AK-wires removal 4-6 weeks. Adjust the splint for proper fit for continued
fracture protection for another 2 weeks. AROM exercises are performed hourly.
Callus is considered clinically stiff enough for free active motion but is not
stable enough to bear a functional load, which occurs after 6 to 8 weeks.

Dynamic or serial static splints may be initiated after 6 to 8 weeks time.


Early strengthening exercises with light resistance can be initiated at 8 weeks, but
unrestricted return to sports and heavy work is delayed until after 10 weeks.
PHYSICAL THERAPY AFTER RIGID FIXATION

Postop period: splint, elevation, limit oedema. Full


AROM is the early goal as edema diminishes.

Dynamic splints may be used at 2 weeks for soft


tissue stretching,

Early strengthening exercises with light resistance can


be initiated at 6 weeks, but unrestricted return to
sports and heavy work is delayed until after 10
weeks.
EXTENSOR TENDON GLIDING
The hook fist posture is use for tendon
gliding in fractured metacarpals

Intrinsic plus position to gain extensor hood


glide over proximal phalanx (P1) fractures,

The central slip is responsible for initiating


extension from a fully flexed PIP joint position,
while the lateral bands (interossei and
lumbricals) achieve full terminal PIP extension.

Flexing the wrist may assist by the addition of


passive tenodesis action

Micks JE, Reswick JB. Confirmation of differential load- ing of lateral and central fibers of the extensor tendon. J Hand Surg [Am].
1981;6:462-467.
FLEXOR TENDON
GLIDING: FDP
Try to increase selective gliding
of flexor tendons between the
FDP and FDS

FDP tendon gliding is performed


by manually blocking the PIP
joint

To promote selective FDP flexor


tendon glide past the superficialis
tendon, claw fist posture of
MP extension with PIP and DIP
joint maximal flexion.
FLEXOR TENDON
GLIDING: FDS

FDS tendon blocking exercise


requires inhibition of the FDP
tendon of the same finger,

The sublimis fist maximally


glides the FDS tendon past
the FDP tendon with full MP
and PIP flexion and an
extended DIP joint.
Rehabilitation
will focus on the
most important
problem
PHALANGEAL VS METACARPAL FRACTURE

Phalangeal fractures are more unstable than metacarpal fractures


as they lack intrinsic muscle support and are adversely affected
by tension in the long finger tendons.

Phalangeal fractures respond more unfavorably to immobilization


than metacarpal fractures, with a predicted 84% return of
motion, compared to 96% return in metacarpal fractures.

In 19% of digital fractures, nonfractured neighboring fingers also


lose motion.
Do not harm !
Huffaker WH, Wray RC, Jr., Weeks PM. Factors influ- encing final range of motion in the fingers after fractures of the hand. Plast Reconstr Surg.
1979;63:82-87
PREVENTION OF
COMPLICATIONS


PREVENTION FOR EXTRA-ARTICULAR #

Restoration of critical anatomic relationships is more important than the


anatomic reduction of fracture fragments.

This means correction of clinically significant shortening, angulation, and rotation

This means prevention of infection, rigid fixation, early therapy, short


immobilization,Remember that 24% of digits that require release procedures
are noninjured, border digits that were included in the immobilization

Early motion +++. Do not hesitate to start early mobilisation. Bob Beasley is
quoted as saying For every nonunion, the hand surgeon sees a thousand stiff
joints.

Hardy MA. Principles of Metacarpal and Phalangeal Fracture Management: A Review of Rehabilitation Concepts. J Orthop Sports Phys Ther
2004;34:781-799
PREVENTION FOR ARTICULAR #
Articular fractures should be reduced to anatomic or near-anatomic alignment to prevent
joint pain, loss of motion, and accelerated degenerative changes

Articular step-offs of 1 mm or larger should be corrected. In 140 intra-articular middle


phalanx base fractures the presence of a residual articular step-off of 1 mm or more
was associated with poor clinical outcomes (Seno).

Fractures that involve more than 15% to 25% of the articular surface benefit from
articular reduction.

Persistent subluxation after reduction usually require operative management

Early motion should be started. Weiss shown no difference in ROM for proximal phalanx
fractures with K-wire fixation when motion was initiated between 1 to 21 days but
significant loss of mobility if motion was delayed after 21 days
- Seno N, Hashizume H, Inoue H, et al. Fractures of the base of the middle phalanx of the finger. Classification, management and long-term
results. J Bone Joint Surg Br 1997;79(5):75863.
- Weiss AP, Hastings H, 2nd. Distal unicondylar fractures of the proximal phalanx. J Hand Surg [Am]. 1993;18:594-599.
REFERENCES

Complications of Hand Fractures and Their Prevention. Andrew D.


Markiewitz, Hand Clin 29 (2013) 601620

Management of Complications with Hand Fractures. Varun K. Gajendran,


Vishal K. Gajendran, Kevin J. Malone. Hand Clin 31 (2015) 165177

Principles of Metacarpal and Phalangeal Fracture Management: A Review


of Rehabilitation Concepts. Maureen A. Hardy. Journal of Orthopaedic &
Sports Physical Therapy. 2004; 34 (12): 781-799
CONCLUSION
Complications are numerous
after hand fractures

Treatment is difficult and


sequelae frequent, indications
questionable

Stiffness is the most frequent,


due to bone AND soft-tissue
injuries

Prevention is the key

If you have certaintiesyou must be poorly informed