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Section I - Fractures of the first metacarpal
- from Chapter 6
-
- By Reinhard Meier, Hannover Medical School
- Peter V. Giannoudis, St James's University Hospital, Leeds, Hans-Christian Pape, University of Pittsburgh
-
- Book:
- Practical Procedures in Orthopaedic Trauma Surgery
- Published online:
- 05 February 2015
- Print publication:
- 14 December 2006, pp 98-103
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Summary
KIRSCHNER WIRE FIXATION OF BASAL FRACTURES OF THE FIRST METACARPAL
Indications
Fractures of the base of the first metacarpal tend to dislocate owing to forces from the tendons (e.g. abductor pollicis longus (APL) tendon in Bennett's fracture). Therefore operative treatment is necessary if stable retention cannot be achieved by casting. Closed reduction and internal K-wire fixation can be performed for:
(a) Fractures with small fragments.
(b) Fractures with good alignment after closed reduction but no stable retention without fracture fixation, in the absence of large impression defects.
Pre-operative planning
Clinical assessment
Pain and swelling localized to carpometacarpal joint I.
Assess and document neurovascular status of thumb.
Radiological assessment
Standard anteroposterior (AP) and lateral radiographs of the trapezium (Kapandji) obtained by placing the hand for a true lateral view, with abduction of the thumb and directing the imaging beam centred over the trapeziometacarpal joint.
Computed tomography helps to define the degree of comminution within a fracture, as well as suspected impaction of the articular surface.
Operative treatment
Anaesthesia
Brachial plexus block, intravenous regional anaesthesia or general anaesthesia.
Prophylactic antibiotic according to the local hospital protocol (e.g. 2nd generation cephalosporin).
Table and equipment
Hand surgery instrumentation set, K-wires: 1.2mm.
Radiolucent armtable.
Upper armtourniquet.
Image intensifier.
Table set up
The instrumentation is set up on the side of the operation.
Image intensifier is from the front side of the arm table.
Patient positioning
Supine, supinated armextended on armtable.
Fracture reduction
Gentle axial traction and pressure on the displaced fragment usually reduces displaced fractures.
Open anatomical reduction is indicated if closed reduction fails and/or stable reduction cannot be achieved.
Section II - Fractures of the metacarpals II–V
- from Chapter 6
-
- By Reinhard Meier, Hannover Medical School
- Peter V. Giannoudis, St James's University Hospital, Leeds, Hans-Christian Pape, University of Pittsburgh
-
- Book:
- Practical Procedures in Orthopaedic Trauma Surgery
- Published online:
- 05 February 2015
- Print publication:
- 14 December 2006, pp 104-108
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- Chapter
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Summary
OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF MIDSHAFT FRACTURES OF THE METACARPALS
Indications
Screw and plate fixation is used to stabilize:
(a) Fractures of 2 or more metacarpal bones.
(b) Fractures irreducible by closed reduction.
(c) Open/comminuted fractures.
(d) Fractures with rotational mal-alignment.
(e) Angulation of more than 30?.
(f) Fractures if early mobilization is required.
Pre-operative planning
Clinical assessment
Pain and swelling localized over the metacarpus.
Assess and document neurovascular status of hand.
Assess and document rotational alignment, axis and range of movement (ROM) of fingers.
Radiological assessment
Anteroposterior, lateral, and oblique views (Fig. 6.6).
A30° pronated lateral view for 2nd and 3rd metacarpal fractures and 30? supinated lateral view for 4th and 5th metacarpal fractures are helpful.
Anaesthesia
Brachial plexus block, intravenous regional anaesthesia or general anaesthesia.
At induction, administer prophylactic antibiotic as per local hospital protocol (e.g. 2nd generation cephalosporin).
Table and equipment
Hand surgery instrumentation set.
Hand small-fragment implant system.
A radiolucent armtable.
An upper armtourniquet.
An image intensifier.
Table set up
The instrumentation is set up on the side of the operation.
Image intensifier is fromthe front side of the armtable.
Check for adequate visualization in 2 planes prior to draping.
Patient positioning
Supine, supinated armextended on armtable.
Section I - Fractures of the proximal radius
- from Chapter 4
-
- By Reinhard Meier, Hannover Medical School
- Peter V. Giannoudis, St James's University Hospital, Leeds, Hans-Christian Pape, University of Pittsburgh
-
- Book:
- Practical Procedures in Orthopaedic Trauma Surgery
- Published online:
- 05 February 2015
- Print publication:
- 14 December 2006, pp 60-64
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Summary
OPEN REDUCTION AND INTERNAL FIXATION OF RADIAL HEAD FRACTURES
Indications
Open reduction and internal fixation (ORIF) for radial head fractures is used to stabilize displaced radial head fractures (Mason Type II) (Table 4.1).
Non-displaced fractures (Mason Type I) are managed with early motion. To facilitate immediate motion aspiration of the joint fluid (haematoma) is recommended. Comminutedanddisplaced fractures(Mason Type III and IV) are best treated with complete early excision.
Pre-operative planning
Clinical assessment
Pain localized in the affected elbow.
Obliterated contour of the skin in the intracondylar recess (‘soft spot’).
Assess and document neurovascular status of the arm.
Careful examination of ligament stability is mandatory.
Radiological assessment
Anteroposterior (AP) radiograph, a lateral view and a radial head view of the affected elbow (Fig. 4.1). A CT scan is helpful to demonstrate the exact fracture geometry. In children or in unclear situations (e.g. previous injury) the contralateral side should be evaluated.
Operative treatment
Anaesthesia
Regional and/or general anaesthesia.
At induction, administer prophylactic antibiotics according to local hospital protocol (e.g. 3rd generation cephalosporin).
Table and equipment
Small-fragment instrumentation set or Herbert screw set - ensure the availability of the complete set of small compression screws.
Radiolucent armtable.
Image intensifier. Check for adequate visualization in 2 planes prior to draping.
Table set up
The instrumentation is set up on the side of the operation.
Image intensifier is fromthe front side of the armtable.
Section III - Fractures of the distal radius
- from Chapter 4
-
- By Peter V. Giannoudis, St James's University Hospital, Leeds , Doug Campbell, St James’s University Hospital, Reinhard Meier, HannoverMedical School
- Peter V. Giannoudis, St James's University Hospital, Leeds, Hans-Christian Pape, University of Pittsburgh
-
- Book:
- Practical Procedures in Orthopaedic Trauma Surgery
- Published online:
- 05 February 2015
- Print publication:
- 14 December 2006, pp 76-89
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Summary
OPEN REDUCTION AND INTERNAL FIXATION (ORIF) FOR DISTAL RADIUS FRACTURES: VOLAR APPROACH
Indications
Displaced, irreducible extra-articular fractures (A3).
Unstable, partial intra-articular fractures (B1, B2, B3), or complete (C2, C3).
Fractures requiring bone grafting.
Palmarly displaced short oblique fractures.
Volar Barton's.
Fractures with primary instability.
Pre-operative planning
Clinical assessment
Mechanism of injury: grading from low- to highvelocity trauma.
Typical deformity, swelling, tenderness.
Evaluate neurovascular status of the hand.
Assess soft tissue damage.
Evaluate patient for age, hand dominance, occupation, and level of activity.
Check for associated ligamentous lesions of fractures of carpal bones.
Radiological assessment
High-quality anteroposterior and lateral radiographs (Fig. 4.37a,b).
Oblique films (45? pronated and supinated).
Assess degree of fragment displacement, quality of bone, whether the fracture is intra-articular or extraarticular, direction of displacement,metaphysealcomminution.
CT scan if the diagnosis is not clear in plain radiographs.
Timing of surgery
Immediatelywhenthefractureisopenorprimarycompression of the median nerve is present.
After 5-6 days if there is important soft tissue swelling (after reduction of the initial displacement and immobilization in a plaster splint).
Operative treatment
Anaesthesia
At induction, administration of prophylactic antibiotics as per local hospital protocol.
General anaesthesia is preferable. Avoid a regional anaesthetic/block in acute injuries as it masks symptoms indicating compartment syndrome in the immediate post-operative period.
Apply a tourniquet to the upper armif not contraindicated (situations in which the soft tissue envelope is extremely traumatized).
Table and equipment
AOsmall-fragmentset 3.5mmor Jupiter plating system (Fig. 4.38).
Standard osteosynthesis set as per local hospital protocol.
Fluoroscopy is necessary for intraoperative imaging.
Section III - Fractures of the phalanx
- from Chapter 6
-
- By Reinhard Meier, Hannover Medical School
- Peter V. Giannoudis, St James's University Hospital, Leeds, Hans-Christian Pape, University of Pittsburgh
-
- Book:
- Practical Procedures in Orthopaedic Trauma Surgery
- Published online:
- 05 February 2015
- Print publication:
- 14 December 2006, pp 109-114
-
- Chapter
- Export citation
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Summary
OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF CONDYLAR FRACTURES
Indications
Unstable dislocated intra-articular condylar fractures (Fig. 6.12).
Pre-operative planning
Clinical assessment
Local pain and swelling.
Assess and document neurovascular status of finger.
Assess and document axial or rotational dislocation.
Radiological assessment
Standard anteroposteriorandlateral radiographsofthe finger.
Operative treatment
Anaesthesia
Brachial plexus block, intravenous regional anaesthesia or general anaesthesia.
At induction, administer prophylactic antibiotic as per local hospital protocol (e.g. 3rd generation cephalosporin).
Table and equipment
Hand surgery instrumentation set.
Hand small-fragment implant system.
K-wires 1.0-1.2 mm.
A radiolucent armtable.
An upper armtourniquet.
An image intensifier.
Table set up
The instrumentation is set up on the side of the operation.
Image intensifier is fromthe front side of the armtable. Check for adequate visualization in 2 planes prior to draping.
Patient positioning
Supine, pronated armon armtable.
Draping, surgical approach and implant Positioning
Place tourniquet at upper arm.
Prepare the skin over elbow, forearm, wrist and hand with usual antiseptic solutions (aqueous/alcoholic povidone-iodine).
Apply adherent drape circularly above the elbow, so free motion of the elbow is possible.
Tourniquet after exsanguination.
Skin incision via a dorsal ‘S’ or ‘Z’ approach to the metacarpophalangeal or interphalangeal joint. In combined fractures the skin incision is via the wound.
Incision of the extensor tendons.
Open joint.
Reduce fracture under direct vision.
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