OSTEOSYNTHESIS OF THE

HAND
RIBKA THEODORA
 ANATOMY

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
FRACTURES
 INTRODUCTION

• GOALS
RESTORATION OF FUNCTION
EARLY MOTION STABILITY

• TREATMENTS
CONSERVATIVE, SURGICAL (PERCUTANEOUS PROCEDURES/ ORIF)
 INTRODUCTION
• Fractures of the metacarpals and phalanges  most common fractures of
the upper extremity

• Certain fractures  require operative fixation

• Selection of treatment, depends on:

• Fracture location (articular versus extraarticular)
• Fracture geometry (transverse, spiral or oblique, comminuted)
• Deformity (angular, rotational, shortening)
• Open or closed; osseous and soft tissue injuries are associated
• Additional  patient’s age, occupation, socioeconomic status; systemic
illnesses; the surgeon’s skill; and the patient’s compliance

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
 INDICATIONS

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
 FRACTURE HEALING

• THE HEALING PROCESS. THE NATURAL COURSE OF FRACTURE HEALING IS

SECONDARY AND INDIRECT VIA THE FRACTURE HEMATOMA TO CALLUS FORMATION.
• THIS HEALING PROCESS TAKES PLACE IN FOUR STAGES:
INFLAMMATORY PHASE
SOFT CALLUS PHASE (APPROXIMATELY 2–3 WEEKS)
HARD CALLUS PHASE (3–4 MONTHS)
REMODELING PHASE, CONSOLIDATION (MONTHS–YEARS)
Tissue destruction and Inflammation Callus Consolidation Remodelling
haematoma formation and cellular formation
proliferation
 FRACTURE HEALING

• MECHANOTRANSDUCTION LEADS TO THE NECESSARY MOLECULAR BIOLOGICAL

REACTION

MACRO- AND MICROARCHITECTURE

(TENSEGRITY THEORY)
OR
MOLECULAR AND MICROMOLECULAR STRUCTURES TO THE MACROMOLECULAR
REACTION (MECHANOSOME THEORY)
 FRACTURE HEALING

• MECHANOTRANSFER LEADS TO A MOLECULAR CHEMICAL REACTION ON

LOADING
- THE THREE-DIMENSIONAL NETWORK OF THE OSTEOCYTES MEDIATION
- THE HEALING PROCESS IS THEREBY INITIATED (MECHANOCOUPLING,
BIOCHEMICAL COUPLING, SIGNAL TRANSDUCTION FROM THE SENSOR CELLS TO
THE REACTIVE CELL, AND ITS RESPONSE—OSTEOBLASTS AND OSTEOCLASTS)
- REGULATED BY CYTOKINES, GROWTH FACTORS, HORMONES, AND MANY OTHER
BIOCHEMICAL MOLECULAR SUBSTANCES
 FRACTURE HEALING

• MESENCHYMAL CELLS FROM THE BONE MARROW, ALONG WITH INDUCED

ANGIOGENESIS, ALSO PLAY AN IMPORTANT PART IN THE HEALING PROCESS.

• INFLUENCING FACTORS :
- COMPRESSION FORCES HAVE A POSITIVE EFFEC
- CONTRAST, SHEAR, TORSIONAL, BENDING, AND TRANSVERSE FORCES DELAY
HEALING
 FRACTURE HEALING

• MECHANOBIOLOGICAL :
- WELL-DOSED INTERFRAGMENTARY MOVEMENT IN THE EARLY PHASE LEADS TO FASTER
FRACTURE HEALING
- HASTENS THE TRANSITION FROM SOFT CONNECTIVE TISSUE CALLUS TO BRIDGING
- SOLIDIFYING BONY CALLUS
• IN COMMINUTED FRACTURES, STRESS MOVEMENT IS DISTRIBUTED TO MANY FRACTURE
PLANES, SO THE INDIVIDUAL MOVEMENTS DIMINISH AT CELLULAR LEVEL. FOR THIS REASON,
STRESS MOVEMENTS ARE BETTER TOLERATED IN COMMINUTED FRACTURES (STRAIN
THEORY, PERREN 2008).
 FRACTURE HEALING

• THE CONSEQUENCE IS THAT PHALANGEAL FRACTURES CAN USUALLY BE

REGARDED CLINICALLY AS SUFFICIENTLY STABLE WITH EARLY MOTION AFTER
3 WEEKS DESPITE THE RADIOGRAPHIC ABSENCE OF CALLUS AND STILL-VISIBL
E FRACTURE GAP
• LONGER IMMOBILIZATION OF THESE FRACTURES IS NOT USUALLY INDICATED.
 NONOPERATIVE FRACTURE MANAGEMENT

• STABLE AND RELATIVELY STABLE FRACTURES IN THE HAND

• ESPECIALLY FOR FRACTURES OF THE PHALANGES
• TH/ EXTERNAL SPLINTING IN FUNCTIONAL INTRINSIC POSITION COMBINED WITH
PROTECTED MOBILIZATION
PRINCIPLES OF INTERNAL FIXATION AS APPLIED TOTHE
HAND AND WRIST

Nelligan. Plastic Surgery 4th Ed. 2018

PRINCIPLES OF UPPER EXTREMITY
SURGERY
Operative

• Safe duration of tourniquet-induced ischemia in the upper extremity  2 hours  can

be extended by releasing the tourniquet and then reinflating it after the blood supply has
had time to circulate

• Incisions should be longitudinal

• Incisions should not cross flexion creases

• Incisions should be long enough to do the job

• Work from normal to abnormal, known to unknown

• If it does not look right, it will not work right

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METHODS OF
FIXATION

Nelligan. Plastic Surgery 4th Ed. 2018

 METHODS OF FIXATION

• KIRSCHNER WIRES (K-WIRES)

Nelligan. Plastic Surgery 4th Ed. 2018

 21

Grabb and smith 7 ed

th

Campbell’s operative orthopaedics

MIDDLE AND PROXIMAL PHALANGES
FRACTURES
Nonarticular Fractures of the Phalanges

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
MIDDLE AND PROXIMAL PHALANGES
FRACTURES
MIDDLE PHALANX BASE ARTICULAR FRACTURES

Nelligan. Plastic Surgery 4th Ed. 2018

METHODS OF FIXATION
• TENSION BAND WIRING

Nelligan. Plastic Surgery 4th Ed. 2018

METHODS OF FIXATION

• EXTERNAL FIXATION

Nelligan. Plastic Surgery 4th Ed. 2018

 METHODS OF FIXATION

• INTERFRAGMENTARY LAG SCREWS

Nelligan. Plastic Surgery 4th Ed. 2018

METHODS OF FIXATION

• COMPRESSION PLATING

Nelligan. Plastic Surgery 4th Ed. 2018

MIDDLE AND PROXIMAL PHALANGES FRACTURES

• MINI SCREWS

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques: Hand And
Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018; Grabb And Smith’s
Plastic Surgery 8th Ed. 2020.
METACARPAL HEAD FRACTURES
Treatment  must be individualized

• Displaced ligament avulsion fractures and

osteochondral fractures  ORIF
(Kirschner wires or interfragmentary
screws)

• Comminuted articular fracture  most

difficult fracture to treat  if ORIF not
impossible  skeletal traction or joint
arthroplasty

• Noncomminuted, displaced fractures that

constitute >25% of the articular surface or
exhibit >1 mm of articular step-off 
treat  operatively

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL HEAD FRACTURES

• If Kirschner wires  fail to stabilize the fracture and maintain the reduction
 immobilization for 2-3 weeks with the MP joint flexed 70 degrees 
followed by intensive range-of-motion exercises

• Most common complication of articular metacarpal head fractures is stiffness

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL NECK FRACTURES
• Optimal treatment  controversy  nonoperative treatment to various
internal fixation techniques

• Factors must be considered: 

• Which metacarpal neck is fractured 
• The degree of angulation 
• Presence of a rotational deformity

• CMC joints have 20-30 degrees angulation  can be better compensated for
in the ring and small fingers  studies varies from <40 or <70 degree

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL NECK FRACTURES
Closed Reduction
• “Jahss position” (MP and PIP joints flexed 90 degrees)

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL NECK FRACTURES
Closed Reduction
• Foucher  use of “bouquet” osteosynthesis

• Percutaneous pins

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL NECK FRACTURES
Exposures
• For open plating:
• longitudinal incision is centered over the metacarpal neck
• incision is on the dorsum for the long and ring fingers. For the border digits—index and small
fingers—the incision is on the midlateral line and then curves dorsally at the
metacarpophalangeal joint

• For intramedullary pinning:

• incision is placed at the metacarpal base
• periosteum at the fracture site is elevated circumferentially to allow accurate reduction without
soft tissue interposition.

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL NECK FRACTURES
Open Reduction
• Jahss maneuver first for
reduction, then plating

• Angulation:
• >15 degrees 
unacceptable for index
and middle metacarpal
necks
• 30-40 degrees 
acceptable in ring finger
• 50-60 degrees 
acceptable in the small
finger

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL NECK FRACTURES
• Plate application  used as
a last resort  requires
more dissection  may
result in tendon adherence
and MP stiffness

• Postoperatively 
immobilized in an intrinsic-
plus position for 5-7 days

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL SHAFT
FRACTURES
• Broadly classifed into three types:
• Transverse
• Oblique/spiral
• Comminuted

• Reduction required:
• Angulation >30 degrees  in the small finger
• Angulation >20 degrees  in the ring finger
• Any angulation  in the middle and index fingers

• Acceptable shortening  2-5 mm

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
TREATMENT: THUMB
Bennet vs Rolando Fracture

Nelligan. Plastic Surgery 4th Ed. 2018

METACARPAL SHAFT
FRACTURES
Closed Reduction

Plaster Immobilization

• Used a short-arm cast

• Wrist in 30-40 degrees of
extension
• Dorsal extension block to
hold the MP joints flexed
80-90 degrees
• Interphalangeal (IP) joints
extended.
• Composite active MP and IP
flexion was initiated
• Cast was maintained for 4 weeks

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL SHAFT
FRACTURES
Closed Reduction

Percutaneous Pinning

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL SHAFT
FRACTURES
Closed Reduction
Percutaneous Pinning

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL SHAFT
FRACTURES
Open Reduction

Lag screws

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL SHAFT
FRACTURES
Open Reduction

Plate fixation

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
METACARPAL SHAFT
FRACTURES
Open Reduction
Plate fixation

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
FRACTURES OF THE THUMB
Rolando fracture

• Includes any comminuted articular fracture of the base of the thumb metacarpal

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
COMPLICATIONS
• Malunion
• Malrotation
• Angulation
• Shortening
• Nonunion  had not healed within 4 months of injury
• Loss of Motion
• Infection

Wolfe SW. Green’s Operative Hand Surgery, Seventh Edition. 2017; Yu. Hl. Atlas Of Hand Anatomy And Clinical Implications. 2004; Chung KC. Operative Techniques:
Hand And Wrist Surgery.2012; The Netter Collection Of Medical Illustrations Musculoskeletal System Part I—upper Limb 2nd Ed; Nelligan. Plastic Surgery 4th Ed. 2018;
Grabb And Smith’s Plastic Surgery 8th Ed. 2020.
TERIMA KASIH