Instructional course lectures
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Most fractures of the phalanges or metacarpals are amenable to closed treatment, with favorable outcomes. However, two groups of complex fractures are difficult to diagnose and treat. The first group includes unicondylar and bicondylar fractures, fracture-dislocations, and fracture-related instability of the proximal interphalangeal joint. ⋯ Some unstable fracture-dislocations are characterized by loss of the volar aspect of the articular surface of the base of the middle phalanx; they can be treated by using a sculpted osseous articular graft from the dorsal hamate. The second group includes displaced diaphyseal fractures associated with a soft-tissue injury, instability, or multiple fracturing. Articular fractures and fracture-dislocations at the base of the metacarpal also can be difficult to diagnose and treat.
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The thumb trapeziometacarpal joint is a saddle joint that is subject to high compressive forces during prehensile hand function. Fractures to the base of the thumb metacarpal occur commonly following axial load to a partially flexed thumb. Although reduction is easily performed, severe deforming forces act to displace the fractures into a varus and shortened position. ⋯ Most Bennett fractures can be treated with closed reduction with percutaneous Kirschner wire fixation. Fractures with large Bennett fragments and Rolando fractures should be treated with open reduction and internal fixation to allow anatomic reduction with rigid fixation and early range of motion. Comminuted intra-articular fractures are challenging injuries that are best treated with application of an external fixator with limited open reduction and internal fixation, followed by bone grafting of metaphyseal bone defects if necessary.