When damaged severely as in crush injuries, the hand becomes flail and thus useless and repair of the skeleton has to be undertaken before soft tissue reconstruction proceeds. It is therefore essential that fracture fixation is adequately performed primarily and is strong enough to provide a stable scaffold to undertake further soft tissue repairs as well as undergo rehabilitation.
The upper extremity is blessed by a better blood supply and less infection. Whether to use plates, screws or Kirschner wires depends on the amount of contamination, bone loss, soft-tissue defect, tendon system and rigidity desired. Top left: the older miniplates. Left: the trilock mechanism—a neat way to get the screw head to lock in the plate.
Sometimes in severe comminution in the digits , closed pinning with cross K-wires has been found to be quite useful, since the intact periosteal sleeve provides support. Care should be taken in placement of these wires, which should preferably be buried under the skin and away from tendinous or ligamentous structures for ease of hand rehabilitation as well as reduction in infection rates especially in tropical climes.
They can be removed later if need be rather than earlier if they are subcutaneous. Severe damage to the DIPJs is fairly well tolerated by fusion, but with the advent of the miniscrew 1. PIPJs , however, are a different matter. Every effort should be made to salvage the PIPJ if feasible especially in a badly mutilated digit.
Stable fixation will allow early mobilization and achieve better results. MCPJs tolerate fusion to a better degree than PIPJs, but it is rarely required for they adapt quite well to marked degrees of malpositioning. Fractures of the neck of the fifth metacarpal deserve special mention because of the associated stiffness that develops in the MCP joint. Metacarpal diaphyseal fractures, on the other hand, may require either intramedullary fixation or plates and screws.
In stabilization of transverse or comminuted fractures, especially in multiple segments and multiple digits, however, rotation of digits should be given special attention. Axial and especially rotational malalignment is magnified from proximal to distal starting at the metacarpal level, thus plating is a better option and little added time is necessary. Prevention is the key, by checking rotation after the fixation. The present minihand plates are lower in profile, chamfered including the screws and even locking, causing little interference to the tendons and providing the required rigidity.
Fusion of a joint primarily has to be thought of carefully and prior discussion with the patient is essential. A: there is an avulsion fracture of the dorsal lip of the distal phalanx P3 and the DIP joint is subluxed volarly. B: a central 0. D: the approach is then made dorsally and the fracture fragment reduced to P3.
An incision made in the germinal matrix prevents it from being compressed. E: the holding screw is inserted. F: final picture. G: a severely crushed P3 with mallet deformity requiring bony stability was fixed with a 1. H: postoperative film. A: intra-articular fracture of the radial condyle of P1 of the left MF.
B, C: reduction and fixation with a 0. F, G: a year-old engineering student presented a month later with a volar lip fracture P2 and dorsal dislocation of his R ring finger.
H, I: through a volar approach, the two condylar fragments were reduced and held with K-wires before miniscrews were inserted. J: the volar plate was reattached with a bone anchor suture. A, B: a die-punch type of pylon injury to the base of the middle phalanx P2. The patient was not keen on surgery. C, D: overall view of the thermoplastic splint. E, F: close-up view.
A strap was glued to the dorsal nail plate and traction applied. A: intra-articular fractures of the bases of the fourth and fifth metacarpals.
C: a cannulated screw and K-wires were only possible for the fifth base due to extensive comminution. D: another patient with basal fracture dislocation of the fifth metacarpal and CMC joint. E: the basal K-wire was used to reduce the fracture fragment, but it started to push it away, so the proximal K-wire was used to maintain height as well as push the fifth metacarpal toward the fourth and hold it in place.
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