Hand clinics
-
Although complete collateral ligament tear and instability involving the metacarpophalangeal joints of the fingers, especially those on the radial aspect of the index finger, are rare, they may be underdiagnosed, underestimated, and potentially disabling. Awareness and suspicion of the injury, coupled with careful physical and imaging examinations, confirm the diagnosis and its extent. ⋯ Late ligament repair or reconstruction is typically slightly less reliable than acute repair, yet often improves outcomes. Arthritic joints may require reconstruction.
-
The surgeon treating traumatic injuries to the TMC joint should be aware of the fundamental misconceptions and pervasive axiomatic myths perpetuated in the medical literature: namely that the volar beak ligament is the prime stabilizer, that the dorsal ligament complex plays no significant role in TMC joint function, and that the APL is a deforming force in Bennett fractures. On the contrary, stability of the TMC joint in power pinch and power grasp depends on the TMC joint's two prime stabilizers, the volar beak of the thumb metacarpal and the dorsal radial ligament complex; and the APL is not a deforming force in a Bennett fracture. ⋯ Rolando multipart fractures of the thumb metacarpal into the TMC joint are best treated closed, with traction in opposition with pin fixation; pure dislocations of the TMC joint that tear the dorsal ligament complex and Bennett fractures with an associated dorsal ligament complex tear (as diagnosed by the screw-home-torque technique) require open reduction and dorsal ligament complex repair. The current literature is so replete with myths and folklore regarding the anatomy that a conscientious surgeon treating a traumatic dislocation or in-stability of the TMC joint should return to the cadaver room and carefully review and understand TMC joint anatomy.
-
Percutaneous K-wire fixation is still a useful technique for closed oblique phalangeal and meta-carpal fractures when an adequate closed reduction can be achieved. Lag screw fixation may be the best choice for open fixation of long oblique phalangeal and metacarpal fractures. For short oblique fractures, plating or tension band wiring is recommended. ⋯ Tension band wiring technique at the phalangeal location may reduce such complications. Overall, successful outcomes of treating phalangeal and metacarpal fractures require a clear appreciation of fracture anatomy and pattern. It is mandatory for the treating surgeon to be familiar with all the treatment techniques discussed in order to tailor a specific technique for a particular injury and patient type.
-
Comparative Study
The treatment of unstable metacarpal and phalangeal shaft fractures with flexible nonlocking and locking intramedullary nails.
Metacarpal and phalangeal shaft fracture fixation can be achieved by closed IM nailing. This technique provides sufficient stability to commence early unsupported joint motion and minimize soft-tissue irritation and scar formation. Stability is enhanced by proximal nail locking; a measure that extends the indications to spiral and comminuted fractures. The surgical technique is simple but requires attention to detail.
-
Scaphoid fractures in children are uncommon. A high index of suspicion is required in children when clinical signs and symptoms indicate a scaphoid fracture in a child. Radiographic evaluation with multiple views should be performed to assess for fracture. ⋯ Most scaphoid fractures can be treated with cast immobilization, which results in healing in the vas majority of cases. Scaphoid nonunion is usually the result of delayed presentation or missed diagnosis. Fortunately union can be achieved reliably with cast immobilization or surgical fixation.