Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

FIGURE 74.2 Fracture site deformity is based on location of the fracture relative to the flexor and extensor tendons. A.
Metacarpal shaft fracture. B. Proximal phalanx fracture. C. Middle phalanx fracture proximal to flexor digitorum superficialis
insertion. D. Middle phalanx fracture distal to flexor digitorum superficialis insertion.
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Indications for Repair
The primary goals of hand fracture management are to restore anatomic relationships, provide fracture
stability with minimal soft tissue injury, and institute early motion. Whereas, most fractures can be
managed nonoperatively, surgery may be warranted in the following cases 7 :
Articular incongruity
Digital malrotation, shortening, or angulation
Multiple fractures
Open fractures
Fractures with soft tissue injury or bone loss
The amount of tolerable deformity varies by fracture location and pattern of injury.
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Fracture Repair Techniques
Fracture fixation options are dependent on fracture anatomy, associated injuries, and surgeon preference
and experience. In general, fixation options include Kirschner wires (K-wires), interosseous wiring,
compression screws, plating, and external fixation 8 (Table 74.1).
TABLE 74.1
Comparison of Hand Fracture Fixation Techniques
Technique
Advantages
Disadvantages
K-wires
Easily removed, low cost, limited soft tissue damage
Need for additional immobilization, pin tract migration/infection,
lack of compression at fracture site
Compression
screws
Rigid fixation, limited periosteal stripping needed
Technically demanding
Interosseous
wiring
Low profile, provides fracture site compression
Technically demanding, potential wire breakage, requires soft
tissue exposure
Plate and
screws
Rigid fixation
Technically demanding, requires soft tissue exposure, potentially
bulky and/or symptomatic hardware
External
fixation
Rapid and easy application, avoids fracture site,
allows for soft tissue reconstruction
May not achieve anatomic reduction, pin site infection, requires
removal, rarely definitive solution
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K-Wires
K-wires are a commonly used and versatile fixation method for fractures of the hand. They are
inexpensive and relatively easy to apply percutaneously. K-wires alone, however, do not provide rigid
fixation or compression across the fracture site. 9 As such, additional immobilization may be necessary to
prevent fracture fragment displacement in the postoperative period. Multiple K-wire configurations may
be used depending on fracture characteristics. Importantly, a single K-wire does not impart rotational
stability, and at least two K-wires should be employed to prevent fracture rotation (Figure 74.3). The
crossed K-wire technique is commonly used for treatment of hand fractures. With this technique, two
wires cross obliquely in an X configuration. Importantly, the K-wires should never cross at the fracture
site, as this will lead to distraction of the fracture fragments and limited fracture stability. Instead, one
must ensure that the wires cross proximal or distal to the fracture. Although conceptually simple, optimal
application of K-wires can be technically difficult. The wire should be advanced to an appropriate bone
entry site under fluoroscopic guidance. Slow, precise entry into the bone allows for trajectory
modifications and the wire to gain purchase to prevent malposition during advancement.
FIGURE 74.3 Right small finger proximal phalanx transverse fracture (Seymour fracture). A. X-ray findings. B. K-wire fixation.
Tension band wiring is a modification of K-wire fracture fixation that increases construct strength. The
tension band concept converts a distraction force (from the flexor tendons) into a compression force at the
fracture site. In general, two 0.035- or 0.045-inch K-wires are placed across the fracture site. A 24 gauge
(G) or 26G steel wire is then wrapped around the K-wires in a figure-of-eight fashion and secured away
from the tendons to prevent attritional injury. This technique can enable immediate motion but requires
greater soft tissue exposure than K-wires alone.
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Compression Screws
Compression screws may be used for oblique or spiral fractures using the lag principle. This technique is
ideal when the fracture length is at least twice the diameter of the bone. Lag screw fixation requires
drilling a hole in the near cortex that is the same diameter as the outer diameter of the screw. 10 For
example, when applying lag screw fixation for a metacarpal shaft fracture, a 2.0 mm drill bit is used for
the near cortex. The far cortex is drilled with a 1.5 mm drill bit. The near cortex acts as a glide hole,
whereas the far cortex is captured by the screw threads and leads to compression between the fracture
fragments when a 2 mm screw is advanced into the drill hole (Figure 74.4). Prior to screw application, a
countersink should be used to prevent screw head prominence. The procedure requires exacting
technique and precise fracture reduction. Additional care should be taken when applying lag screws in
the softer metaphyseal bone of the metacarpal or phalanges, where aggressive countersinking can lead to
the screw head sinking into the medullary canal during tightening. Multiple screws are required to
achieve anatomic reduction and impart axial stability of the construct.
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FIGURE 74.4 Technique of lag screw fixation. A. Near cortex (gliding hole) is drilled with the larger drill bit. B. The smaller drill
bit is passed into the same tract and drilled in the same trajectory. C. A countersink is used to prevent screw head prominence.
D. Screw length is determined. E. Multiple screws are placed to ensure fracture stability. F. A right index finger metacarpal long
oblique fracture. G. Multiple screws placed using the lag technique.
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Interosseous Wiring
Interosseous wiring is a technically demanding procedure that provides rigid fixation and fracture site
compression. It is mainly used for transverse fractures of the phalanges or metacarpals, in joint
arthrodesis, or in digital replantation. Typically, a 0.045-inch K-wire is used to create a parallel drill hole
in both fracture fragments, dorsal to palmar and radial to ulnar. Alternatively, both wires can be oriented
in the dorsal to palmar plane. Through this drill hole, an 18G needle is placed and used a guide for
insertion of a 24G or 26G steel wire. The wire is then carefully tightened to prevent breakage.
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Plate and Screws
Plate fixation provides a highly stable construct for hand fracture treatment. This technique is most
commonly used for metacarpal shaft fractures and for the treatment of nonunion and malunion, where
restoring length and stability are essential. Plate fixation is rarely used for phalangeal fractures because of
the close relationship of the extensor mechanism to the periosteum of the underlying bone; plate fixation
in the phalanges frequently leads to tendon scarring and stiffness. Conversely, the extensor tendons
overlying the metacarpals do not sit directly on bone and, as such, are at low risk for adhesions after plate
fixation. Dynamic compression style or standard straight plates are available for use in the hand.
Compression plate holes are oblong and allow eccentric application of screws. After fixation of one
fracture fragment to the plate, the first screw in the adjacent fracture fragment is placed eccentrically
away from the fracture; this pulls the fragments into compression as the screw head engages the plate.
Subsequent screws are placed in neutral alignment, as no further compression can be achieved with
additional screws (Figure 74.5). Compared with other techniques for fracture fixation, plate and screw
application requires a relatively large amount of soft tissue dissection and periosteal stripping. Scarring
and plate prominence may lead to extensor tendon adhesions and impaired gliding or pain. As a result,
tenolysis and/or plate removal may be needed after fracture healing.
FIGURE 74.5 Technique of compression plate application. A. Initial screw is placed in neutral position. B. The second screw is
placed eccentrically away from the fracture site. C. The remaining screws are placed in neutral position as no further
compression can occur through the plate. D. Right small finger metacarpal shaft fracture. E. Compression plate fixation.
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External Fixation
External fixation is a relatively simple technique that is useful for fractures with substantial soft tissue
injury, marked comminution, bone loss, and/or contamination. It can be rapidly applied, avoids the
fracture site, and allows early mobilization. Most commonly, two percutaneous pins are placed proximal
and two pins distal to the fracture site. Commercially available external fixator systems connect these pins
using a bridging carbon fiber bar. Rarely is external fixation the definitive solution for hand fracture
management.
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Phalanx Fractures
Distal Phalanx
Distal phalangeal fractures are the most common fractures in the hand. They are classified by location as
tuft, shaft, and base fractures. Tuft fractures most frequently occur in combination with nail bed injuries
and warrant an evaluation of the integrity of the nail plate and nail bed. A concomitant nail bed injury
should be washed out and closed with fine absorbable suture. The nail plate may act as a splint for the
fracture, although these injuries should be protected with an external splint for approximately 3 to
4 weeks. Tuft fractures often heal with a malunion, but these are rarely symptomatic. Nondisplaced shaft
fractures may be managed with immobilization only. Displaced shaft fractures are treated by closed
reduction and application of a single longitudinal K-wire. Articular fractures of the dorsal base of the
distal phalanx often involve the extensor tendon insertion (i.e., mallet fracture). Most of these injuries
may be managed with distal interphalangeal (DIP) joint splinting in full extension for 6 weeks. Dorsal
block K-wire fixation is recommended for fractures involving more than one-third of the articular surface
or in the setting of volar subluxation of the distal fragment (Figure 74.6). In children, fractures may occur
through the physis and entrap a portion of the nail bed (i.e., Seymour fracture) (Figure 74.7). These
fractures should be treated with extraction of the nail bed, irrigation, and K-wire fixation in a timely
fashion to prevent infection and subsequent osteomyelitis.
FIGURE 74.6 Dorsal block pinning of a distal phalanx intra-articular fracture.
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FIGURE 74.7 Seymour fracture. A. Clinical findings. B. X-ray findings. C. Nail bed extracted from fracture site and repaired.
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Proximal/Middle Phalanx
Condylar fractures of the proximal and middle phalanges are by definition intra-articular and are
associated with development of arthritis. Phalangeal condylar fractures are classified as type I
(unicondylar and nondisplaced), type II (unicondylar and displaced), and type III (bicondylar).
Nonoperative management may be considered for nondisplaced fractures, but close radiographic follow-
up is mandatory to rule out subsequent displacement. Displaced fractures are treated with closed
reduction and at least two K-wires or open reduction and screw fixation. 11 Bicondylar fractures may be
challenging to manage and are treated by open reduction through the interval between the central slip
and lateral band with subsequent screw or K-wire fixation. Extreme care must be exercised when
performing open repair of condylar fractures to avoid injury to the vascular supply arising from the
attached collateral ligaments. Early motion, when possible, will limit postoperative stiffness and pain.
Phalangeal neck fractures are inherently unstable. As such, the majority of these injuries are treated with
K-wire fixation. Nondisplaced shaft fractures may be managed with splinting or buddy tape to an
adjacent uninjured digit for 3 to 4 weeks. If malrotated or displaced greater than 10° to 25° in the sagittal
plane or 10° to 15° in the coronal plane, reduction and fixation are required. Transverse or short oblique
fractures are treated with K-wires or, rarely, plate fixation. Long oblique and spiral fractures are treated
with interfragmentary screw fixation (Figure 74.8). The screw diameter should be less than one-third of
the length of the fracture. At least two screws are recommended to impart stability to the construct.
Nondisplaced phalangeal base fractures are treated with splint immobilization for 3 to 4 weeks. If
displaced or associated with malrotation, open reduction and K-wire or screw fixation are warranted.
Proximal interphalangeal (PIP) joint fracture-dislocations require special consideration and are discussed
elsewhere in more detail. Given the articular incongruity that results from these injuries, patients
frequently develop a stiff and painful PIP joint. Treatment options range from dynamic external fixation,
K-wire or screw fixation, and dorsal block pinning to more complex volar plate arthroplasty and hemi-
hamate reconstruction of the volar base of the middle phalanx.
FIGURE 74.8 Left middle finger middle phalanx oblique fracture. A. X-ray findings. B. After lag screw fixation.
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Metacarpal Fractures
Head
Metacarpal head fractures are rare and typically result from an axial load or dorsal fracture-dislocation of
the metacarpophalangeal (MCP) joint. Computed tomography scan may better visualize the fracture
pattern and assist in surgical planning. Nonoperative management is recommended for fractures with
less than 25% articular involvement. For fractures with greater articular involvement, >1 mm articular
incongruity, or collateral ligament instability, surgery is warranted. Fracture fragments may be small and
comminuted, and extreme care must be taken to avoid stripping the vascular supply arising from the
collateral ligaments. Avascular necrosis of the metacarpal head is rare but has been reported. 12 Although
headless screw fixation is an optimal choice of fixation for metacarpal head fractures, most injuries are
comminuted or associated with joint disruption; these injuries may be best treated by dynamic external
fixation or acute arthroplasty. 13
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Neck
Metacarpal neck (i.e., boxer’s) fractures are common and typically involve the fifth metacarpal. This
injury often results from a punching mechanism in the amateur fighter or someone who strikes a hard
object. A relatively large amount of angular deformity is acceptable in the ring and small fingers because
of a mobile carpometacarpal (CMC) joint that can accommodate for palmar angulation. As a result, the
majority of these injuries are managed nonoperatively. Unreduced metacarpal neck fractures with
significant apex dorsal deformity may result in a prominence (metacarpal head) in the palm that is
particularly bothersome to athletes and manual laborers. Nonoperatively managed patients 
 should also
be counseled about the loss of the dorsal knuckle prominence.
Closed reduction of a metacarpal neck fracture is accomplished using the Jahss maneuver 14 (Figure 74.9).
This is most frequently carried out in the emergency department using a nerve block at the wrist. The
MCP and PIP joints are fully flexed, whereas a volar force is directed against the metacarpal shaft, and a
dorsal force is applied to the proximal phalanx. This combination of forces is used to lever the metacarpal
head into anatomic alignment. The hand is then immobilized in an ulnar gutter splint or cast with the
MCP joint in 70° of flexion for 3 weeks, followed by an active range of motion therapy program.
FIGURE 74.9 Jahss maneuver for reducing a metacarpal neck fracture.
Surgery is recommended in the setting of pseudoclawing (hyperextension of the MCP joint and
concomitant PIP joint flexion with attempted digital extension), excessive shortening, and malrotation
after attempted closed reduction. Surgical indications for apex dorsal deformity depend upon the
involved digit (Table 74.2). The amount of tolerated angular deformity is controversial, however, and
multiple studies have shown excellent outcomes with substantial angulation (up to 70° in the fifth
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metacarpal neck). Most commonly, metacarpal neck fractures are managed with percutaneous K-wire
fixation and many configurations can be utilized—transverse, retrograde, and antegrade. Buried
antegrade intramedullary pin application may be superior because it avoids the extensor mechanism and
obviates the risk for pin tract infection (Figure 74.10). Open repair of acute metacarpal neck fractures is
reserved for failed percutaneous treatment or an unacceptable closed reduction.
TABLE 74.2
Acceptable Angulation for Metacarpal Fractures
Digit
Angulation (degrees)
Neck
Index
10
Middle
20
Ring
30–40
Small
50–60
Shaft
Index
10
Middle
20
Ring
30
Small
40
FIGURE 74.10 Left small finger metacarpal neck fracture. A. X-ray findings. B. After intramedullary pinning with antegrade
wires.
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Shaft
Metacarpal shaft fractures may occur from an axial load, torsion, or crush. Indications for surgical
management are similar to metacarpal neck fractures; however, less angular deformity is tolerated in the
metacarpal shaft (see Table 74.2). Nondisplaced fractures may be treated with splinting or casting for
4 weeks with the interphalangeal joints free. Unstable or displaced fractures can be treated with
percutaneous pins or open reduction and plate or lag screw fixation. The operative approach is through a
dorsal longitudinal incision between the metacarpals. The juncturae may be divided to improve exposure
of the fracture. External fixation is reserved for fractures with segmental loss, unstable soft tissue
coverage, or contamination. Nondisplaced oblique and spiral fractures are usually unstable and are often
best treated with surgery. If nonoperative management is selected, weekly radiographs should be
obtained to rule out late displacement. If the fracture is obliquely oriented and the fracture length is at
least twice the bone diameter, lag screws may be the best choice, although placement requires exacting
technique. Percutaneous pinning may also be used for metacarpal shaft fractures, although this requires
longer periods of immobilization and delayed initiation of therapy.
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Base
Extra-articular metacarpal base fractures are managed similarly to shaft fractures. Most are nondisplaced
and managed with immobilization for 3 to 4 weeks. If displaced or obliquely oriented, closed or open
reduction and fixation is recommended. Given the substantial mobility of the thumb CMC joint, a
relatively large amount of displacement is well tolerated. Reduction is indicated if the distal fragment is
flexed greater than 30°, as this amount of deformity leads to compensatory thumb MCP joint
hyperextension.
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Thumb (Bennett/Rolando)
A Bennett fracture represents an oblique intra-articular fracture-dislocation of the thumb metacarpal base.
The anterior oblique (beak) ligament is the main stabilizer of the thumb CMC joint and is responsible for
maintaining the small volar ulnar fragment in anatomic alignment. The metacarpal subluxates
proximally, radially, and dorsally secondary to the pull of the abductor pollicis longus, extensor pollicis
brevis, and adductor pollicis, respectively (Figure 74.11). Closed reduction is achieved with a combination
of thumb axial traction, abduction, and pronation (Figure 74.12). Because the fracture is inherently
unstable, percutaneous pinning with K-wires is advocated. A common configuration is to place a K-wire
across the articular surface perpendicular to the long access of the metacarpal into the second metacarpal
base. An additional wire is placed retrograde across the trapeziometacarpal joint. If an acceptable
reduction cannot be achieved with closed reduction, open reduction is performed through an incision
overlying the dorsal CMC joint with plate, interfragmentary screw, or pin fixation. A Rolando fracture is
similar to a Bennett fracture, except that the fracture is comminuted and characterized by a Y- or T-
shaped fracture pattern.
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FIGURE 74.11 Deforming forces acting a Bennett fracture.
FIGURE 74.12 Reduction maneuver for a Bennett fracture.
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Segmental Loss
Segmental bone loss is common with gunshot wounds to the hand. Self-inflicted injuries typically involve
the nondominant hand. Segmental loss is often associated with open and contaminated wounds and is
managed with external fixation until the wound is clean and definitive soft tissue coverage can be
ensured. On occasion, the distal bone fragment collapses into the void left behind by the bone loss, given
the perception of minimal soft tissue loss. However, when the distal fragment is distracted to anatomic
length, the soft tissue loss becomes apparent. Bone grafting and rigid fixation is recommended during or
after soft tissue reconstruction. Tendon reconstruction is typically delayed because the requisite
immobilization needed to ensure bone union will lead to poor tendon glide and an unsatisfactory
outcome.
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Outcomes
The wide variety of hand fracture types and options for management present challenges for outcomes
reporting. There is no reference standard objective or subjective outcomes measure for hand fracture
management. Although radiographic assessments and functional measurements are the classic means by
which management options are compared, patient-reported outcome measures have been increasingly
used as they provide a greater potential understanding of the patient perception of disability and quality
of life. In general, a combination of these measurements provides the clearest picture of function, pain,
and disability after treatment. Radiographic outcomes typically include fracture union, residual
deformity, hardware complications, or development of arthrosis, whereas functional outcomes include
total active motion (Table 74.3) and grip/pinch strength. The Jebsen-Taylor Hand Function test is one of
the most common functional tests performed to assess outcomes after hand fracture management. The
most commonly used patient-reported outcome measures include the Disabilities of the Arm, Shoulder,
and Hand, Short Form-36, and Michigan Hand Questionnaire. 15-18
TABLE 74.3
Total Active Range of Motion
Result
Motion (degrees)
Excellent
>220
Good
180–219
Fair
130–179
Poor
<130
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Complications
Complications can and will happen in a busy hand trauma practice, regardless of surgeon skill. Because
of the wide range of hand fracture patterns, mechanisms of injury, and available management options,
the possible complications after treatment vary widely. In general, complications are more frequent after
phalangeal and open fractures than with metacarpal fractures. 19,20 The surgeon should be equipped to
identify and treat complications early in an effort to optimize outcomes.
Stiffness is the most common complication after operative or nonoperative hand fracture management. 3
Crush injuries are also a common cause of hand stiffness. Immobilization for greater than 4 weeks
increases the likelihood for stiffness and is minimized by initiation of early motion. 7 Stiffness with active
and passive motion results from joint contracture, whereas diminished active motion only is often the
result of tendon adhesions. Early management is with an intensive rehabilitation program. If there is no
improvement after at least 3 months of therapy, capsulotomy and/or tenolysis may be indicated.
Malunion, or the abnormal alignment of a healed fracture, is not always an indication for surgical
intervention. The deformity may manifest as shortening, rotation, or angular malalignment. In the
immature skeleton, significant intrinsic remodeling ability may result in normal hand function. In older
patients, surgery may be required. Depending upon the type of deformity, a variety of osteotomies may
be performed to restore anatomic alignment (e.g., step cut, transverse, opening or closing wedge).
Fracture nonunion may be hypertrophic or atrophic. Hypertrophic nonunions require open reduction and
stable fixation, typically with a plate and screw construct. These are relatively common in young patients
with neglected hand fractures. Atrophic nonunions are more commonly associated with bone loss or
infection 21 and are treated with bone grafting and plate fixation.
Infection associated with a hand fracture relates to the extent of trauma and wound contamination. If
severe or untreated, a pyogenic infection of the bone (i.e., osteomyelitis) may result. Prompt diagnosis
and treatment of osteomyelitis is mandatory to avoid the frequent need for amputation (up to 40% in
some studies). 22 In the absence of an abscess, acute osteomyelitis is treated with intravenous antibiotics. If
osteomyelitis is chronic or associated with an abscess, intravenous antibiotics and surgical debridement
of nonviable soft tissue and bone is recommended. Any unstable hardware should be removed and the
fracture site stabilized with external fixation and/or an antibiotic spacer. Once infection clearance has
been confirmed, stable fixation is applied with or without bone grafting. K-wire fixation may also lead to
infection, many of which are attributable to patient noncompliance. 23 Appropriate pin care and cleaning
are required to minimize this risk. Furthermore, if pin duration is anticipated to be greater than 6 weeks,
the pins should be buried to decrease the risk for loosening and infection.
Hand fractures may also lead to chronic pain, cold intolerance, and complex regional pain syndrome
(CRPS). Acute pain after a hand fracture is to be expected. However, chronic pain is unusual with healed
fractures, and other causes of pain (e.g., nerve injury, joint instability, post-traumatic arthritis) should be
considered in these cases. Cold intolerance after hand trauma is an unfortunately common occurrence,
affecting approximately 38% of patients. 24 Although the pathophysiology of cold intolerance is unclear, it
appears to be related to vascular dysfunction and an abnormal rewarming response after hand trauma.
CRPS is a chronic, debilitating syndrome characterized by pain, trophic changes, and autonomic
dysfunction that can occur after upper extremity trauma or surgery. 25 Patients with suspected CRPS
should be promptly referred to a pain specialist for initiation of multimodality treatment, including
therapy, antidepressants, anticonvulsants, calcium channel blockers, and adrenergic agents. In rare cases,
amputation may be warranted.
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Conclusion
Hand fracture management is both an art and a science. The surgeon must evaluate not just the fracture
personality but also the patient socioeconomic situation, social support, risk tolerance, and likelihood for
compliance with therapy. Most hand fractures can be treated nonoperatively, yet in certain cases surgery
may expedite recovery and avoid the risks of malunion or arthrosis. In general, one should select the least
invasive treatment option that will achieve a satisfactory reduction and fracture stability. Early motion is
imperative after rigid fixation to combat the inevitable onset of stiffness. The surgeon should be aware of
the possible complications after any treatment, including those related to nonoperative management.
Appropriate therapy helps to address swelling and stiffness, the most common sequelae of hand fracture
management. If managed properly, most hand fractures lead to near normal hand function.
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Acknowledgments
The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24-
AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of Health.
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Questions
1. A 25-year-old right-hand-dominant man is seen in the emergency department 1 week after an
altercation. He complains of worsening right hand pain and an X-ray confirms a right fifth
metacarpal neck fracture (i.e., boxer’s fracture; Figure 74.13). What fracture deformity would be
predicted based on the location of the fracture?
a. Apex ulnar angulation
b. Apex volar angulation
c. Apex radial angulation
d. Apex dorsal angulation
e. No deformity
2. A 34-year-old right-hand-dominant woman is evaluated in the emergency department after
sustaining left hand trauma in a motor vehicle accident. An X-ray confirms a left ring finger proximal
phalanx comminuted, extra-articular fracture (Figure 74.14). What finding would be an indication for
surgery?
a. 5-degree sagittal plane deformity
b. Pain at the fracture site
c. Digital overlap of the ring and small fingers
d. 5-degree coronal plane deformity
e. PIP joint intra-articular congruity
3. A 35-year-old right-hand-dominant man is seen in the emergency department 2 hours after
sustaining a self-inflicted gunshot wound to his left palm. A 4 × 3 cm open wound is noted on the
dorsum of the hand with exposed bone and extensor tendon. An X-ray confirms a comminuted
fracture of the left third metacarpal neck with segmental bone loss (Figure 74.15). What would be the
most appropriate management of the fracture?
a. Plate and screw fixation of the third metacarpal with interposition bone graft
b. Synthetic bilaminar skin substitute application to wound bed and delayed bone
reconstruction
c. Wound debridement and application of an external fixator
d. Immediate third ray amputation
e. Splint application and delayed fracture fixation
4. A 35-year-old right-hand-dominant man is referred to the office 3 days after injuring the right ring
finger while sliding during a baseball game. He is found to have a flexed resting posture of the ring
finger DIP joint without active DIP joint extension. An X-ray shows an intra-articular fracture of the
dorsal base of the distal phalanx (50% of the articular surface) with minimal palmar subluxation of
the distal phalanx (Figure 74.16). What would be the most appropriate management of this injury?
a. Open reduction and internal fixation of the fracture
b. Extension block pinning of the fracture
c. Immediate active range of motion exercises
d. 8 to 12 weeks of DIP joint extension splinting
e. Application of an external fixator
5. A 50-year-old right-hand-dominant man is seen in the office for right thumb pain the day after
falling off his bicycle. He is found to have a swelling and pain about the right thumb base with
thumb metacarpal adduction. An X-ray shows an intra-articular obliquely oriented fracture of the
thumb metacarpal base (i.e., Bennett fracture) with 3 mm of displacement (Figure 74.16). What
maneuvers are used to reduce the fracture?
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a. Thumb traction, abduction, and pronation
b. Thumb traction, adduction, and pronation
c. Thumb traction, abduction, and supination
d. Thumb traction, adduction, and supination

FIGURE 74.13
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FIGURE 74.14
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FIGURE 74.15
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FIGURE 74.16
1. Answer: d. Hand fracture deformities are relatively predictable because of the muscles and
tendons crossing the fracture. Metacarpal fractures lead to an apex dorsal deformity due to intrinsic
muscle pull on the metacarpal head. Proximal phalanx fractures typically result in an apex volar
deformity because the intrinsic muscles flex the base and the extensor mechanisms extend the distal
shaft. Middle phalanx base fractures assume an apex dorsal deformity because of the pull of the
central slip and the flexion moment imparted by the FDS insertion. Middle phalanx fractures distal to
the FDS insertion assume an apex volar posture because the FDS flexes the shaft and the extensor
mechanism extends the distal fragment.
2. Answer: c. There are multiple indications for reduction of a phalangeal fracture. These include
fractures with greater than 10° to 25° of sagittal plane deformity, 10° to 15° of coronal plane
deformity, shortening of more than 2 to 4 mm, intra-articular incongruity, multiple open fractures,
and fractures with soft tissue injury and/or bone loss. Any rotational deformity leading to digital
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overlap is poorly tolerated and can impair grip strength and dexterity. Acute fracture site pain is to
be expected and is not an indication for surgery.
3. Answer: c. Open fractures of the hand are initially treated with washout and debridement.
Immediate or delayed definitive reconstruction of composite injuries of the hand is a matter of some
controversy. Generally, open fractures with segmental loss combined with substantial soft tissue
injury are treated in a staged manner. Temporary skeletal stabilization with wires and an external
fixator are appropriate choices until definitive soft tissue coverage can be achieved. Immediate plate
and screw fixation with bone grafting is inappropriate in the absence of stable soft tissue coverage.
Integra is contraindicated for coverage of open fractures with segmental bone loss. Immediate ray
amputation is contraindicated in the setting of a reconstructible bone and soft tissue defect of the
hand. Splint application only is an appropriate initial management choice in the absence of
significant bone and soft tissue loss. In the setting of segmental bone loss with a soft tissue defect, the
goals are to provide fracture stability and maintain length of the digit to prevent shortening of the
musculotendinous structures acting on the digit.
4. Answer: b. The patient has sustained a mallet fracture. The vast majority of these injuries are
managed nonoperatively in the form of extension splinting for 8 to 12 weeks. Indications for surgery
include a large, displaced bone fragment (one-third or more of the articular surface), palmar
subluxation of the distal phalanx, and loss of DIP joint congruity. Open reduction and internal
fixation of this injury is not indicated given that the fracture can be managed with less invasive and
technically simpler techniques. Immediate range of motion will prevent fracture healing. An external
fixator is unnecessary for a closed distal phalanx fracture without intra-articular comminution. This
patient is best managed with extension block pinning.
5. Answer: a. A Bennett fracture is an oblique, intra-
 articular fracture at the base of the thumb
metacarpal. The anterior oblique ligament is the main stabilizer of the thumb CMC joint and is
responsible for maintaining the small medial fragment in anatomic alignment. The metacarpal,
however, subluxates proximally, radially, and dorsally secondary to the pull of the abductor pollicis
longus, extensor pollicis brevis, and adductor pollicis. Closed reduction is achieved with a
combination of thumb axial traction, abduction, and pronation. Because the fracture is inherently
unstable, percutaneous pinning with K-wires is advocated. A common configuration is to place a
wire across the articular surface perpendicular to the long access of the metacarpal into the second
metacarpal base. An additional wire is placed retrograde across the trapeziometacarpal joint.
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References
Bernstein, ML, Chung, KC. Hand fractures and their management: an international view. Injury. 2006;37:1043.
Chung, KC, Spilson, SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg. 2001;26:908-915.
Meals, C, Meals, R. Hand fractures: a review of current treatment strategies. J Hand Surg Am. 2013;38(5):1021-1031.
Carpenter, S, Rohde, RS. Treatment of phalangeal fractures. Hand Clin. 2013;29(4):519-534.
Diaz-Garcia, R, Waljee, JF. Current management of metacarpal fractures. Hand Clin. 2013;29(4):507-518.
Tulipan, JE, Ilyas, AM. Open fractures of the hand: review of pathogenesis and introduction of a new classification system. Orthop Clin North
Am. 2016;47(1):245-251.
Cheah, AE, Yao, J. Hand fractures: indications, the tried and true and new innovations. J Hand Surg Am. 2016;41(6):712-722.
Black, D, Mann, RJ, Constine, R, et al. Comparison of internal fixation techniques in metacarpal fractures. J Hand Surg Am. 1985;10(4):466-
472.This biomechanical study compared rigidity and strength in torsion and bending in metacarpal fractures treated by five different types of fixation.
The types included dorsal plating, dorsal plating with an interfragmentary lag screw, crossed K-wires, a single intraosseous wire plus a single oblique
K-wire, and a single intraosseous wire alone. Plating techniques were superior to wire techniques with regard to dorsal bending and axial torsion. There
were no significant differences among the three K-wire methods except in torsion. Plate fixation had higher moments and absorbed more energy than
wire fixation.
Jones, WW. Biomechanics of small bone fixation. Clin Orthop Rel Res. 1987;214:11-18.
Freeland, AE, Roberts, TS. Percutaneous screw treatment of spiral oblique finger proximal phalangeal fractures. Orthopedics. 1991;14:384-
388.This article describes the genesis of lag screw fixation for phalangeal fractures. The authors sought to balance the risks and benefits of widely used
K-wire fixation with the existing plate and screw hardware available at the time. The technique of lag screw fixation was proposed as most suitable for
spiral oblique phalangeal fractures in the sagittal plane. They used a 1- to 2-cm mid-axial incision to minimize scar formation and suggested
countersinking the screw head to better distribute the forces over a larger area and to avoid screw head prominence.
Green, DP, Anderson, JR. Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am. 1973;55(8):1651-
1654.This study evaluated 26 displaced proximal phalanx fractures treated by closed reduction, percutaneous pin fixation, and early motion (by means
of buddy taping). The proposed advantages were not needed for splinting/casting and earlier return to work. In this series, 18 of 21 patients (26
fractures) regained a full range of motion within 8 weeks following injury.
McElfresh, EC, Dobyns, JH. Intra-articular metacarpal head fractures. J Hand Surg Am. 1983;8(4):383-393.
Nagle, DJ, Ekenstam, FW, Lister, GD. Immediate silastic arthroplasty for nonsalvageable intraarticular phalangeal fractures. Scand J Plast
Reconstr Surg Hand Surg. 1989;23(1):47-50.
Jahss, SA. Fractures of the metacarpals: a new method of reduction and immobilization. J Bone Joint Surg Am. 1938;20A:178-186.This classic
article describes what is now known as the Jahss maneuver; reduction of a metacarpal neck fracture by upward or dorsal pressure on the flexed distal
fragment, with the metacarpophalangeal and proximal interphalangeal joints of the involved finger held at 90° of flexion. As described in the paper, this
position at the metacarpophalangeal joint relaxes the interosseous muscles and at the same time tenses the collateral ligaments, permitting extension
(correction of the angulation) of the distal fragment through upward or dorsal pressure on the flexed proximal interphalangeal joint.
Baldwin, PC, Wolf, JM. Outcomes of hand fracture treatments. Hand Clin. 2013;29(4):621-630.
Davis Sears, E, Chung, KC. Validity and responsiveness of the Jebsen-Taylor hand function test. J Hand Surg Am. 2010;35(1):30-37.
Horng, YS, Lin, MC, Feng, CT, et al. Responsiveness of the Michigan hand outcomes questionnaire and the disabilities of the arm, shoulder,
and hand questionnaire in patients with hand injury. J Hand Surg Am. 2010;35(3):430-436.
Chung, KC, Pillsbury, MS, Walters, MR, et al. Reliability and validity testing of the Michigan hand outcomes questionnaire. J Hand Surg Am.
1998;23(4):575-587.
Page, SM, Stern, PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am.
1998;23:827-832.
Duncan, RW, Freeland, AE, Jabaley, ME, et al. Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand
Surg Am. 1993;18(3):387-394.
Gajendran, VK, Gajendran, VK, Malone, KJ. Management of complications with hand fractures. Hand Clin. 2015;31(2):165-177.
Reilly, KE, Linz, JC, Stern, PJ, et al. Osteomyelitis of the tubular bones of the hand. J Hand Surg Am. 1997;22(4):644-649.
Botte, MJ, Davis, JL, Rose, BA, et al. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. Clin Orthop
Relat Res. 1992;276:194-201.This study reviewed the complication rates of pin fixation of fractures and dislocations of the hand or wrist over a 4-year
period in 137 patients (422 pins). All pins were unthreaded, measured 0.035 to 0.069 inches (0.9–1.8 mm) in diameter, were placed with a power drill,
and were left outside the skin. Mean duration of time that pins were left in place was 6.5 weeks. Minimum follow-up time was 43 days after pin
removal. A total of 34 complications occurred in 24 patients, and the overall complication rate was 18%. A total of 45 of the 422 pins were involved
(11%). The most common complication was infection (7%), followed by pin loosening (4%), loss of reduction (4%), symptomatic nonunion (4%),
impaled flexor tendon (2%), asymptomatic pseudarthrosis (1%), pin migration (1%), median nerve injury (1%), and radial artery injury (1%).
Osteomyelitis developed in two of the patients with infections.
Nijhuis, TH, Smits, ES, Jaquet, JB, et al. Prevalence and severity of cold intolerance in patients after hand fracture. J Hand Surg Eur Vol.
2010;35(4):306-311.
Zimmerman, RM, Astifidis, RP, Katz, RD. Modalities for complex regional pain syndrome. J Hand Surg Am. 2015;40(7)1469-1472.
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C H A P T E R 7 5
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Management of Wrist Fractures
Mitchell A. Pet and Warren C. Hammert
Key Points
Four radiographic measurements describing orientation of the joint surface have been found to
correlate with patient outcomes after distal radius fracture. These are radial height, radial inclination,
volar tilt, and ulnar variance.
Development of a treatment plan for a distal radius fracture requires consideration of patient factors,
fracture pattern, fracture stability, and associate injuries.
Initial treatment for most distal radius fractures is closed reduction. This maneuver improves patient
comfort, relieves pressure on potentially threatened soft tissues and nerves, and may be the
definitive treatment for stable fracture patterns.
Operative fixation of a distal radius fracture may be achieved using percutaneous pins, volar locking
plate, dorsal spanning plate, external fixator, or a combination. Volar locking plates are currently
very popular because they offer rigid fixation, which facilitates early rehabilitation and can be safely
applied to many fracture patterns.
Acute scaphoid fractures may be radiographically occult. Clinical suspicion with negative
radiographs has historically been followed by immobilization and follow-up radiographic
evaluation. However, early advanced imaging in patients with negative plain films has become
increasingly popular.
Operative fixation of a fractured scaphoid is most commonly accomplished using a cannulated
headless compression screw. Fracture pattern guides the choice of a dorsal or volar approach.
The scaphoid has a retrograde blood supply supplied by branches of the radial artery. Because of this
unique vascular anatomy, the proximal pole of a fractured scaphoid is particularly prone to
avascular necrosis and nonunion.
The diagnosis and treatment of wrist fractures is a constantly evolving field. Development of a safe and
effective treatment algorithm requires an understanding of wrist anatomy (Figure 75.1) and
biomechanics, adherence to the principles of fracture fixation, and attentive facilitation of prompt
rehabilitation.
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FIGURE 75.1 A. The bones of the wrist as seen from the volar surface. B. The distal articular surface of the distal radius and
ulna and the distal radioulnar joint.
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Evaluation of the Patient With Wrist Trauma
Elements unique to upper extremity injuries history include the timing, mechanism and energy of the
injury, occupation/avocation, and prior hand or wrist injuries/surgeries. The injured extremity should be
examined beginning at the elbow and moving distally. A displaced distal radius fracture often results in
gross deformity of the wrist, but carpal fractures and minimally displaced fractures of the distal radius
may not be obvious. Finger, wrist, and forearm motion are assessed, and palpation for focal tenderness
with specific attention to the radius, distal radioulnar joint (DRUJ), and carpus helps to determine
appropriate imaging studies.
Evaluation of the median, ulnar, and radial sensory nerve function is critical, as injury of each can be
associated with an acute wrist fracture. One should be suspicious for acute median nerve dysfunction
(carpal tunnel syndrome), and if numbness persists following closed reduction then emergent operative
intervention may be indicated.
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Distal Radius Fractures
Epidemiology and Cost
Over a half million distal radius fractures occurred in the United States in 2009, with an overall incidence
of 16.2 fractures per 10,000 person years. This age distribution of these fractures is bimodal, with the
highest rates in persons under 18 and over 65 (30.18 and 25.42 per 10,000 personyears, respectively). 1 In
young patients, characteristic injuries occur in men by means of high-energy trauma. In the elderly
population, Caucasian women are most at risk. These fractures are often related to osteoporosis and
frequently occur after low-energy trauma.
The economic burden of distal radius fractures is difficult to measure because care occurs in varied
settings and costs are subject to wide geographic variation. One recent analysis, which stressed
exhaustive examination of direct and indirect costs, estimated that operative and nonoperative treatment
of a distal radius fracture costs $15,403 and $3,775, respectively. The largest driver of this cost was missed
work. 2
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Anatomy
The distal radius is quadrilateral in cross-section with articular surfaces at the radiocarpal joint and DRUJ.
The radiocarpal joint surface has distinct scaphoid and lunate facets separated by the interface ridge. On
its ulnar side, the cartilage-bearing sigmoid notch articulates with the ulnar head at the DRUJ, which
allows pronation and supination of the forearm as the radius rotates and translates around the ulna. The
sigmoid notch is a shallow concavity, with a radius of curvature that is about twice that of the ulnar head.
Consequently, bony constraints offer little joint stability and the soft tissues supporting this joint are
critical. Primary among these is the triangular fibrocartilage complex (TFCC). The TFCC includes the
dorsal and volar radioulnar ligaments and has both superficial styloid and deep foveal insertion points. 3
Volarly the distal radius is concave, with the recessed volar cortex curving anteriorly as it meets the volar
lip of the articular surface. The metaphysis is covered by the pronator quadratus. The dorsal distal radius
is convex in shape and is intimately related to the extensor tendons. The most palpable dorsal structure is
Lister tubercle, which serves as a pulley for the extensor pollicis longus tendon. The dorsal cortex is
considerably thinner than the volar cortex, leading to the common occurrence of dorsally comminuted
fractures.
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Biomechanics of Injury
The three-column theory of the distal radius aids in understanding the biomechanical rationale for
treating distal radius fractures. The radial column, composed of the radial styloid and the scaphoid fossa,
anchors radiocarpal stability through the styloid’s osseous buttress effect and the origin of the volar
radiocarpal ligaments. The intermediate column is composed of the lunate fossa and sigmoid notch. The
lunate fossa has a volar buttress effect and is the primary load-bearing surface of the radiocarpal joint.
The sigmoid notch provides congruity to the DRUJ and tensions its soft tissue attachments. The ulnar
column, composed of the distal ulna and TFCC, shares in transmission of the carpal load and serves as a
stable pivot point for the rotating radius.
Load distribution across the radiocarpal and ulnar carpal joints is dependent on radial length (ulnar
variance). When neutral, 80% of the load is through the radiocarpal joint and 20% through the ulnar
carpal joint. As the ulnar variance increases, the load across the radiocarpal joint decreases and ulnar
carpal joint increases. Conversely, as the variance decreases, the load across the ulnar carpal joint
decreases and radiocarpal joint increases. This relationship is important because a deranged relationship
of the radius and ulna leads to altered load distribution and potentially accelerated arthrosis.
Although distal radius fractures can result from all types of applied forces, the most typical mechanism is
hyperextension, often caused by fall on an outstretched hand. The site of fracture is usually at the
metaphysis due to its primary composition of weak cancellous bone with a thin dorsal cortex. Given the
dorsally and axially directed force of impact, dorsal angulation and comminution are common (Colles
fractures with classic dinner-fork deformity). However, Pechlaner 4 demonstrated in cadaveric experiments
that depending on the energy of the injury, position of the hand during the impact, and on the quality of
the bone, widely variable patterns of fracture and soft tissue derangement can occur with hyperextension.
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Classification
Several distinct fracture patterns have associated eponyms that are used commonly in the clinical setting
(Figure 75.2). In the last 70 years, 15 distinct systems for classifying distal radius fractures have been
proposed in the literature. Perhaps the most commonly utilized are the Frykman, Melone, Fernandez,
Mayo Clinic, and AO classifications. Unfortunately, no single classification has been able to
simultaneously describe fracture characteristics in a simple language, order them into a hierarchy,
provide a guide to treatment, and predict outcomes with reliability and reproducibility. 5
FIGURE 75.2 Eponyms used to describe common patterns of distal radius fracture.
Despite the limited utility of classification systems, we do find that a common nomenclature for the
fragments most commonly comprising a complex intraarticular fracture facilitates good clinical
communication and treatment planning. These fragments are as follows (Figure 75.3):
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Radial column: This is often the largest fragment and bears the insertion of a portion of the
brachioradialis tendon.
Dorsal ulnar corner: The fragment may bear a portion of the sigmoid notch and lunate facet.
Volar rim/lunate facet: This fragment supports much of the load transmitted by the carpus and usually
maintains a strong radiocarpal ligamentous attachment. For this reason, failure to recognize and
stabilize a volar rim fragment can lead to volar subluxation of the carpus.
FIGURE 75.3 Many intra-articular distal radius fractures can be described as consisting of radial column, dorsal ulnar corner,
and volar rim/lunate facet fragments. Not all fragments are present or typical in every fracture, and additional fragments may be
present in complex patterns.
In more complex fracture patterns, additional dorsal wall and intraarticular fragments may be present.
Although every fragment will not necessarily be separate or typical in a given fracture, this framework is
useful in considering how derangements of osseous anatomy are reflected radiographically.
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Radiographic Evaluation
Initial imaging of wrist trauma consists of plain radiography in the posteroanterior (PA), lateral, and
oblique planes. The PA radiograph is taken with the shoulder in 90° of abduction, the elbow in 90° of
flexion, and the wrist and forearm in a neutral position. A standard PA view of the wrist should reveal
the extensor carpi ulnaris tendon groove at the level of or radial to the base of the ulnar styloid (Figure
75.4A). For the lateral, the shoulder is adducted and the elbow held in 90° of flexion with the hand
positioned in the same plane as the humerus. On a true lateral view, the palmar cortex of the pisiform
bone should overlie the central third of the interval between the palmar cortices of the distal scaphoid
pole and the capitate head (Figure 75.4B). Careful positioning is important, as small errors at this stage
can affect interpretation of critical radiographic parameters.
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FIGURE 75.4 A. Clinical picture (top) and a correctly positioned posteroanterior view showing the extensor carpi ulnaris
(ECU) groove radial to the ulnar styloid (bottom). B. Clinical picture (top) and a correctly positioned lateral view showing the
pisiform (white line) overlying the distal scaphoid (green line) and the capitate (red line) (bottom).
Four radiographic measurements describing orientation of the joint surface have been found to correlate
with patient outcomes. 6 These are radial height, radial inclination, volar tilt, and ulnar variance. Radial
height is measured on the PA radiograph as the distance between a line perpendicular to the long axis of
the radius passing through the distal tip of the sigmoid notch at the distal ulnar articular surface of the
radius and a second parallel line at the distal tip of the radial styloid. This measurement averages 10 to
13 mm. Radial inclination is also measured on the PA radiograph and represents the angle between one
line connecting the radial styloid tip and the ulnar aspect of the distal radial articular surface and a
second line perpendicular to the longitudinal axis of the radius. Radial inclination ranges between 21°
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and 25°. The volar tilt of the distal radius is measured on a lateral radiograph. The volar tilt represents the
angle between a line along the distal radial articular surface and one perpendicular to the longitudinal
axis of the radius at the joint margin. The normal volar tilt averages 11° and has a range of 2° to 20°. 7
Ulnar variance refers to the distance between the articular surface of the ulnar head and the ulnar border
of the lunate fossa. It is described as neutral when both are at the same level, ulnar positive when the ulna
is longer than the radius, and ulnar negative when the converse is true. Normal ulnar variance can range
from 0 ± 2 mm. In cases of distal radius fracture, abnormal ulnar positive variance may indicate loss of
radial length due to metaphyseal collapse. 6
For intraarticular fractures, additional measurements are useful to describe relationships between the
articular fragments and the resultant joint (in)congruity. Step describes any longitudinal discontinuity in
the joint surface. Gap refers to transverse separation of articular segments. The teardrop of the distal
radius articular surface refers to the U-shaped outline of the volar rim of the lunate facet. The teardrop
angle refers to the angle between the central axis of the teardrop and the central axis of the radial shaft,
which is normally 70°. A depressed teardrop angle may be the only evidence that the volar rim fragment
is incompletely reduced. 6,8 The anteroposterior (AP) distance is measured on the lateral projection from
the apices of the dorsal rim and volar lunate facet. Normal AP distance is 17 to 21 mm, and an increased
value reflects an unreduced discontinuity between the volar and dorsal lunate facet fragments and
potentially a coronal split in the sigmoid notch. 8
All of the radiographic measurements discussed above are outlined upon a normal radiographic series in
Figure 75.5.
FIGURE 75.5 Measurement of radiographic parameters of the distal end of the radius: radial height (dotted red lines), radial
inclination (dotted white lines), volar tilt (dotted green lines), teardrop angle (solid blue line), and anteroposterior (AP) distance
(dotted yellow line).
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Indications for Operative Treatment
A treatment plan for a given distal radius fracture requires consideration of four main factors.
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Patient Factors
Patient age and activity level are important patient factors. A 2-mm articular step-off after closed
reduction might reasonably prompt surgical intervention for a young healthy laborer. However, this
same step-off might be acceptable in an 85-year-old high-risk surgical candidate who is already unable to
live independently.
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Fracture Pattern
Imaging before and after fracture reduction is evaluated to assess adequacy of the reduction. While the
definition of acceptable reduction is situational and based upon incomplete evidence, biomechanical and
outcomes studies have established some general guidelines. 9
Radial inclination greater than or equal to 15°
Loss of radial length less than 5 mm at the DRUJ (compared to contralateral)
Volar tilt between 15° dorsal and 20° volar
Articular step-off of 2 mm or less
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Fracture Stability
Fractures for which satisfactory reduction cannot be achieved are unstable, and most require operative
treatment. If an acceptable reduction can be obtained, the surgeon must then decide whether it is likely
that the reduction can be maintained with cast/splint immobilization. If a fracture is judged to be stable
after reduction, then nonoperative management should be considered. If it is unstable, then surgical
intervention is usually indicated. Many studies have investigated models for predicting fracture stability.
In a classic study, Lafontaine et al concluded that five factors predicted distal radius fracture instability
and that the presence of three of them correlated with loss of reduction despite cast immobilization 10 :
Initial dorsal angulation greater than 20°
Dorsal comminution
Radiocarpal intraarticular involvement
Associated fracture of the ulna
Age greater than 60 years
In more recent work examining 4000 fractures, Mackenney et al 11 found that the most important
predictors of instability and malunion were advanced age, dorsal comminution, and the position of the
fracture at presentation.
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Associated Injuries
Certain associated injuries may indicate operative treatment of fractures that might otherwise be treated
nonoperatively. Contaminated open fractures should be meticulously debrided and fixation may be done
in an immediate or interval manner. Compartment syndrome and acute carpal tunnel syndrome require
emergent treatment with fasciotomy or carpal tunnel release, respectively, and both are often
accompanied by fracture fixation. Finally, patients with multiple injured limbs may benefit from
operative fixation of otherwise nonoperative wrist fractures to facilitate earlier weight bearing and
rehabilitation.
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Treatment Modalities
Closed Reduction and Plaster Immobilization
Initial treatment for nearly all fractures is closed reduction. This maneuver improves patient comfort,
relieves pressure on potentially threatened soft tissues and nerves, and may be the definitive treatment
for stable fracture patterns. Closed reduction is facilitated by ligamentotaxis, whereby intact soft tissue
attachments guide the bone fragments into alignment when longitudinal traction is applied. 12
Our preferred technique for closed reduction of a distal radius fracture is outlined in Table 75.1 and
demonstrated in Figure 75.6. Other variants are acceptable, 13 though we recommend caution when
recreating the hyperextension that caused injury, as this can stress the median nerve.
TABLE 75.1
Technique for Traction-Assisted Reduction of Distal Radius Fracture
Step
Details
Hematoma block
Raise a wheal of 1% lidocaine in the dermis of the dorsal forearm, directly over fracture using a
25 g needle
Wait 5 min
Enter fracture through dorsal wheal with 18 g needle
Feel needle enter fracture, and then withdraw blood from fracture hematoma to confirm position
Inject 10 cc of 1% lidocaine
Wait 10 min
To allow onset of anesthetic
Apply finger traps
Apply all the way down to the base of index and middle finger. If finger traps slip, apply
benzoin
Hang arm from IV pole
Hang finger traps from an IV pole such that elbow is at 90°
Apply weight
Tie a length of stockinette into a loop such that it fits loosely around the brachium
The stockinette should be spread out to cover much of the brachium to avoid discomfort by
distributing pressure
Suspend 10–15 pounds of weight from this stockinette
Wait 10 min
Allow time for deforming muscles to fatigue and fracture to be reduced by ligamentotaxis
Fluoroscopy and manual
manipulation
Use C-arm to visualize reduction
If necessary, manually manipulate fragments to improve reduction
Splint application
While traction is still applied, apply a well-padded plaster splint that is molded to maintain the
reduction
Removal of traction
Remove the weight and finger traps
Postreduction radiography
C-arm images or formal radiographs are obtained to ensure that reduction has been maintained
by the splint
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