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Closed treatment of hand fractures
The Journal of HAND SURGERY
Barton
7.
McElfreshEC, Dobyns JH. Intra-articularmetacarpalhead fractures. J HANDSURG[Am] 1983;8A:383-93.
8. Lee MLH. Intra-articular and peri-articular fractures of the phalanges. J Bone Joint Surg [Br] 1963;45:103-9. 9. Crawford GP. The molded polythene splint for mallet finger deformities. J HANDSURG[Am] 1984;9A:231-7. 10. Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg [Am] 1964;46:658-69. 11. Barton NJ. Irma-articular fractures and fracture-dislocations. In: Bowers WH, ed. The interphalangeal joints. London: Churchill Livingstone, 1987. 12. Barton NJ. Operative treatment of fractures of the hand. In: Birch R, Brooks D, eds. Operative surgery-the hand. 4th ed. London: Buttenvorths. 1984.
13. McElfresh EC, Dobyns JH, O’Brien ET. Management of fracture-dislocation of the proximal interphalangeal joints by extension block splinting. J Bone Joint Surg [Am] 1972;54:170511. 14. Strong ML. A new method of extension-block splinting for the proximal intetphalangeal joint-preliminary report. J HAND SURG [Am] 1980;5A:606-7. 15. London PS. Sprains and fractures including the interphalangeal joints. Hand 1971;3:155-8. 16. McCue FC, Honner R, Johnson MC, Greek JH. Athletic injuries of the proximal intetphalangeal joint requiring surgical treatment. J Bone Joint Surg [Am] 1970;52:937-56. 17. Steel WM. In: Barton NJ, ed. Fractures of the hand and wrist. Churchill Livingstone (in press).
Closed treatment of hand fractures William E. Burkhalter, MD
The closed treatment of fractures in the hand has gained a poor reputation because of problems of malunion, stiffness, and sometimes loss of skin or other soft tissues. Furthermore, modem techniques and material for internal fixation have become incredibly sophisticated and are far superior to previously used Kirschner wire fixation inserted with a hand drill. Small drills powered by air or electricity and precisely machined screws and plates are now available. It is no wonder that with such equipment and our desire to fix things, more and more fractures in the hand are being treated by internal fixation. Many fractures in the hand require internal fixation, especially the intra-articular types, those with bone loss, and the irreducible or unstable fractures during active motion. However, other fractures can be treated with closed methods with the stabilizing effect of the soft tissues and positioning with external devices. Sarmiento and Latta’ have used soft tissue-stabilizing techniques to treat a wide variety of fractures outside of the hand. In lower extremity fractures, Dehne et al. ,* Brown* and and Urban,’ and B&halter and Protzman’ have also used closed techniques with early functional rehabilitation. It seems that skeletal stability and not necessarily skeletal rigidity is necessary for functional use. Metacarpal shaft fractures In the absence of rotational malalignment and metacarpophalangeal (MP) joint stiffness, considerable osseous deformity may be accepted with no or minimal functional loss. Reprint requests: William E. Burkhalter, MD, Professor and Chief of Hand Surgery, University of Miami School of Medicine, Department of Orthopaedics and Rehabilitation, P.O. Box 016960 (D-27). Miami, FL 33101.
390
THE JOURNAL OF HAND SURGERY
When the patient is first seen, it should be ascertained whether he can open and close the hand completely; by doing this slowly with encouragement from the physician, the patient will realize what motion he is capable, and both patient and surgeon will be rewarded. The functional test includes assessment of range of motion and rotational deformity, if present. Treatment options remain open, but with near complete digital flexion and extension, a nonoperative treatment should be tried. I use a palmar cast applied in two sections. The proximal portion is a short-arm cast applied with the wrist in 30 to 40 degrees of dorsiflexion; the palmar portion must end 1.5 cm proximal to the distal palmar crease to allow full MP joint flexion. The distal part of the cast immobilizes the MP joint in full flexion and is applied after the proximal part has set up. A piece of split felt is applied over the entire dorsal surface of all proximal phalanges of the fingers. Gentle pressure and active digital flexion by the patient bring the MP joints in full flexion. A plaster slab is then applied, carefully contouring the hand to achieve greater MP joint flexion on the ulnar rather than on the radial side of the hand. The dorsal plaster extension is reinforced as necessary, carefully avoiding excess bulk in the palm. Full proximal and distal interphalangeal joint motion is instituted (Fig. 1). If there is extensor lag, the patient is instructed to passively extend the proximal interphalangeal (PIP) joints until full motion is regained actively. When all digits are flexed simultaneously in the presence of fully flexed MP joints, rotational deformities can be diagnosed and treated at the same time. It must be stressed that all fingers should close at the same time to avoid overlapping. Another problem associated with closed treatment of fractures in the hand is to confirm the reduction on x-ray films. The density of the plaster cast and the superimposition of the
Vol. 14A, No. 2. Part 2 March 1989
Closed treatment of had fractures
391
Fig. 1. A-C, Overriding metacarpal fracture in a 23-year-old male construction worker; nearly full function 3 days after injury. D-F, After 3 weeks of closed functional treatment, there is bony union with a good functional result. The patient has resumed full work activities.
Fig. 2. A, Lateral tomograms demonstrate the angulation of proximal phalangeal fracture. B, Readjustment the cast with added dorsal pressure on the distal fragment resulted in correction of angulatory deformity.
metacarpals on lateral views can make the x-ray film useless. If needed, we have used linear tomograms to gain detail. However, a complete series is unnecessary. The distance from the involved metacarpal to the x-ray film cassette can be measured, and with a little experience, a satisfactory cut can be obtained. In cases of multiple fractures, some difficulty
of
may be encountered in identifying each metacarpal on the tomograms. Inclusion of the carpus on the x-ray film views will help identify each metacarpal by its relationship to either the capitate, hook of the hamate, or scaphoid. The precision of the reduction on x-ray films or its failure may change the treatment options; however, when there is
392
The Journal of HAND SURGERY
Burkhalter
Fig. 3, A-B. Rotational deformities are usually obviated by full flexion of the MP joints and simultaneous
flexion of all fingers, avoiding overlapping. A derotation strap may be added as needed.
Fig. 4. Closed treatment of a fracture of the proximal phalanx. A, Initial radiogram. B-C, Splinting of the
adjacent digits with the MP joints immobilized in flexion allows early active motion. The extensor tendon over the proximal phalanx acts as a tension band to further help stabilize the fracture. D, Good position and early healing of the fragments.
full digital flexion and no rotational deformity, it is important to make sure that one is not “txcating” an x-ray diagnosis by open reduction and internal fixation. Most extra-articular fractures of the first metacarpal may be treated by closed methods in a thumb spica cast. When the basilar joint is intact, considerable deformity can be acceptable. However, it is most important to avoid hyperexten-
sion of the MP joint of the thumb. We are aware of the loss of the motion that follows immobilization of the MP joints of the fingers in extension but seem to forget that the same principle applies to the thumb. The range of motion at the MP joint of the thumb varies from person to person and can range from 20 to 90 degrees. The flexion loss caused by an extension contracture will consequently be noticed more by
Vol. 14A, No. 2. Part 2 March 1989
some than others. However, hyperextension deformity of the thumb MP joint caused by overzealous attempts to reduce the flexion deformity of the metacarpal fracture during application of the thumb spica always results in a noticeable functional loss. If the proximal phalanx of the thumb is immobilized in extension, the MP joint will preferentially go into hyperextension rather than the fracture. If the deformity is to be corrected, only the metacarpal should be manipulated and not the more distal portions of the thumb. The fracture position and the absence of hyperextension of the MP joint of the thumb can be verified on x-ray films taken through the cast. Proximal phalanx fracture Sterling Bunnell coined the term “no-man’s_land” to flexor tendon injuries occurring between the distal palmar crease and the PIP joint. Even though many surgeons now repair flexor tendon injuries in this area, the surgery is difficult, and unless perfectly done and rehabilitated, poor results will follow. The “noman’s-land” area corresponds to the proximal phalanx of the finger, and in this area fractures of the proximal phalanx are similarly difficult to manage. The surgical exposure, except distally, is done through tendinous structures that are prone to adherences, followed by loss of motion at the PIP joint. Because of these difficulties, we have attempted to use the same casting method as that described for fractures of the metacarpal. After the proximal portion of the cast has set, the distal or dorsal extension of the cast is fashioned while gentle pressure is applied just proximal to the PIP joint to overcome the tendency of the distal fragment to extend (Fig. 2). This reduces the distal fragment to the proximal, an old orthopedic axiom. The adjacent digits help maintain the alignment. Rotational malalignment is avoided by simultaneous flexion of the fingers in the presence of fully flexed MP joints (Fig. 3). Over the proximal phalanx. the extensor mechanism almost covers the bone completely. Bleeding associated with the fracture compromises the space between the tendon and dorsal cortex. As the PIP joint is actively flexed, the tightened extensor mechanism becomes a tension band on the dorsum of the phalanx. The rehabilitation program for proximal phalangeal fractures is similar to that described for metacarpal fractures. Full active flexion is stressed, with all fingers closing simultaneously to negate the rotational malalignment problem (Fig. 4). With proximal phalangeal fractures, there is a greater tendency for extensor lag at the PIP joint. A flexion contracture can be avoided, and flexion can be improved with passive extension exercises carried out by the patient or with a light extensor assist sling. A lag should not be allowed to become a contracture. The cast must not extend distal to the PIP to avoid blocking its full extension. It is most important to verify the adequacy of the reduction on lateral x-ray film views. Because of the thickness of the plaster and the superimposition of the fingers, a linear tomogram that uses the same technique as that for the metacarpals is necessary to confirm the correction of the dorsal angulation of the proximal phalanx (apex palmar). If dorsal angulation persists, it can be corrected by
Closed treatment of hand fractures
393
adding a layer of felt between the cast and distal portion of the proximal phalanx. If necessary, the dorsal extension of the cast is cut and repositioned to place the MP joints in a greater angle of flexion. The goal is to obtain near-anatomic alignment of the proximal phalanx on both the anteroposterior plane and the lateral tomographic views. Good results can be expected if, in the early stages of treatment, there is radiographic alignment of the proximal phalanx without rotational deformity and good Aexion of the PIP joint with only a mild degree of extensor lag. A supervised rehabilitation program is important to stress full flexion of the PIP joint to prevent the development of an extensor lag contracture. Union of the fracture usually occurs in all cases, and early formation of a callous can be seen radiographically at 3 to 4 weeks. At this time, the finger is clinically stable, and external immobilization can usually be removed. If the phalanx or metacarpal remain tender on direct palpation, immobilization may be continued for another 2 to 3 weeks. Conclusions Closed functional treatment of extra-articular fractures of the proximal phalanges and metacarpals is based on the principle of external positioning combined with active motion.5. ’ Proper external positioning controls the deforming muscle forces that originally created the fracture deformity. The fracture malalignment is the result of muscle forces intrinsic to the patient and not the result of the external forces that created the fracture. Internal fixation is required in certain fractures when the articular surface is involved, the soft tissues are severely disrupted, or there is a loss of bony substance. Modem sophisticated hardware and surgical instruments are now available for internal fixation of these fractures. However, it is important to obtain sufficient skeletal stability to allow some load bearing until osseous union has occurred. In this method early supervised rehabilitation is necessary to avoid the development of unnecessary deformities. We need to remember the indications for surgery and also the requirements placed on the surgeon. One should not compare the best results of open treatment with the worst of closed treatment; compare the best of both.
REFERENCES 1.
Sarmiento A, Latta L. Closed treatment of fractures. New York: Springer-Verlag,
198 1.
2. Dehne E, Metz C, Deffer P, et al. Non operative treatment of the
3. 4. 5.
6.
fractured tibia by immediate weight bearing. J Trauma 1961; 1514. Brown P, Urban J. Early weight bearing treatment of open fractures of the tibia. J Bone Joint Surg [Am] 1969;51:59. Burkhalter W, Protzman R. The tibial shaft fracture. J Trauma 1975;15:785. Burkhalter W. Functional treatment of fractures. in: Boswick J, ed. Current concepts in hand surgery. Philadephia: Lea & Febiger, 1983:146. Burkhalter W, Reyes F. Closed treatment of fractures of the hand. Bull Hosp Jt Dis 1984;44:145.
Barton
7.
McElfreshEC, Dobyns JH. Intra-articularmetacarpalhead fractures. J HANDSURG[Am] 1983;8A:383-93.
8. Lee MLH. Intra-articular and peri-articular fractures of the phalanges. J Bone Joint Surg [Br] 1963;45:103-9. 9. Crawford GP. The molded polythene splint for mallet finger deformities. J HANDSURG[Am] 1984;9A:231-7. 10. Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg [Am] 1964;46:658-69. 11. Barton NJ. Irma-articular fractures and fracture-dislocations. In: Bowers WH, ed. The interphalangeal joints. London: Churchill Livingstone, 1987. 12. Barton NJ. Operative treatment of fractures of the hand. In: Birch R, Brooks D, eds. Operative surgery-the hand. 4th ed. London: Buttenvorths. 1984.
13. McElfresh EC, Dobyns JH, O’Brien ET. Management of fracture-dislocation of the proximal interphalangeal joints by extension block splinting. J Bone Joint Surg [Am] 1972;54:170511. 14. Strong ML. A new method of extension-block splinting for the proximal intetphalangeal joint-preliminary report. J HAND SURG [Am] 1980;5A:606-7. 15. London PS. Sprains and fractures including the interphalangeal joints. Hand 1971;3:155-8. 16. McCue FC, Honner R, Johnson MC, Greek JH. Athletic injuries of the proximal intetphalangeal joint requiring surgical treatment. J Bone Joint Surg [Am] 1970;52:937-56. 17. Steel WM. In: Barton NJ, ed. Fractures of the hand and wrist. Churchill Livingstone (in press).
Closed treatment of hand fractures William E. Burkhalter, MD
The closed treatment of fractures in the hand has gained a poor reputation because of problems of malunion, stiffness, and sometimes loss of skin or other soft tissues. Furthermore, modem techniques and material for internal fixation have become incredibly sophisticated and are far superior to previously used Kirschner wire fixation inserted with a hand drill. Small drills powered by air or electricity and precisely machined screws and plates are now available. It is no wonder that with such equipment and our desire to fix things, more and more fractures in the hand are being treated by internal fixation. Many fractures in the hand require internal fixation, especially the intra-articular types, those with bone loss, and the irreducible or unstable fractures during active motion. However, other fractures can be treated with closed methods with the stabilizing effect of the soft tissues and positioning with external devices. Sarmiento and Latta’ have used soft tissue-stabilizing techniques to treat a wide variety of fractures outside of the hand. In lower extremity fractures, Dehne et al. ,* Brown* and and Urban,’ and B&halter and Protzman’ have also used closed techniques with early functional rehabilitation. It seems that skeletal stability and not necessarily skeletal rigidity is necessary for functional use. Metacarpal shaft fractures In the absence of rotational malalignment and metacarpophalangeal (MP) joint stiffness, considerable osseous deformity may be accepted with no or minimal functional loss. Reprint requests: William E. Burkhalter, MD, Professor and Chief of Hand Surgery, University of Miami School of Medicine, Department of Orthopaedics and Rehabilitation, P.O. Box 016960 (D-27). Miami, FL 33101.
390
THE JOURNAL OF HAND SURGERY
When the patient is first seen, it should be ascertained whether he can open and close the hand completely; by doing this slowly with encouragement from the physician, the patient will realize what motion he is capable, and both patient and surgeon will be rewarded. The functional test includes assessment of range of motion and rotational deformity, if present. Treatment options remain open, but with near complete digital flexion and extension, a nonoperative treatment should be tried. I use a palmar cast applied in two sections. The proximal portion is a short-arm cast applied with the wrist in 30 to 40 degrees of dorsiflexion; the palmar portion must end 1.5 cm proximal to the distal palmar crease to allow full MP joint flexion. The distal part of the cast immobilizes the MP joint in full flexion and is applied after the proximal part has set up. A piece of split felt is applied over the entire dorsal surface of all proximal phalanges of the fingers. Gentle pressure and active digital flexion by the patient bring the MP joints in full flexion. A plaster slab is then applied, carefully contouring the hand to achieve greater MP joint flexion on the ulnar rather than on the radial side of the hand. The dorsal plaster extension is reinforced as necessary, carefully avoiding excess bulk in the palm. Full proximal and distal interphalangeal joint motion is instituted (Fig. 1). If there is extensor lag, the patient is instructed to passively extend the proximal interphalangeal (PIP) joints until full motion is regained actively. When all digits are flexed simultaneously in the presence of fully flexed MP joints, rotational deformities can be diagnosed and treated at the same time. It must be stressed that all fingers should close at the same time to avoid overlapping. Another problem associated with closed treatment of fractures in the hand is to confirm the reduction on x-ray films. The density of the plaster cast and the superimposition of the
Vol. 14A, No. 2. Part 2 March 1989
Closed treatment of had fractures
391
Fig. 1. A-C, Overriding metacarpal fracture in a 23-year-old male construction worker; nearly full function 3 days after injury. D-F, After 3 weeks of closed functional treatment, there is bony union with a good functional result. The patient has resumed full work activities.
Fig. 2. A, Lateral tomograms demonstrate the angulation of proximal phalangeal fracture. B, Readjustment the cast with added dorsal pressure on the distal fragment resulted in correction of angulatory deformity.
metacarpals on lateral views can make the x-ray film useless. If needed, we have used linear tomograms to gain detail. However, a complete series is unnecessary. The distance from the involved metacarpal to the x-ray film cassette can be measured, and with a little experience, a satisfactory cut can be obtained. In cases of multiple fractures, some difficulty
of
may be encountered in identifying each metacarpal on the tomograms. Inclusion of the carpus on the x-ray film views will help identify each metacarpal by its relationship to either the capitate, hook of the hamate, or scaphoid. The precision of the reduction on x-ray films or its failure may change the treatment options; however, when there is
392
The Journal of HAND SURGERY
Burkhalter
Fig. 3, A-B. Rotational deformities are usually obviated by full flexion of the MP joints and simultaneous
flexion of all fingers, avoiding overlapping. A derotation strap may be added as needed.
Fig. 4. Closed treatment of a fracture of the proximal phalanx. A, Initial radiogram. B-C, Splinting of the
adjacent digits with the MP joints immobilized in flexion allows early active motion. The extensor tendon over the proximal phalanx acts as a tension band to further help stabilize the fracture. D, Good position and early healing of the fragments.
full digital flexion and no rotational deformity, it is important to make sure that one is not “txcating” an x-ray diagnosis by open reduction and internal fixation. Most extra-articular fractures of the first metacarpal may be treated by closed methods in a thumb spica cast. When the basilar joint is intact, considerable deformity can be acceptable. However, it is most important to avoid hyperexten-
sion of the MP joint of the thumb. We are aware of the loss of the motion that follows immobilization of the MP joints of the fingers in extension but seem to forget that the same principle applies to the thumb. The range of motion at the MP joint of the thumb varies from person to person and can range from 20 to 90 degrees. The flexion loss caused by an extension contracture will consequently be noticed more by
Vol. 14A, No. 2. Part 2 March 1989
some than others. However, hyperextension deformity of the thumb MP joint caused by overzealous attempts to reduce the flexion deformity of the metacarpal fracture during application of the thumb spica always results in a noticeable functional loss. If the proximal phalanx of the thumb is immobilized in extension, the MP joint will preferentially go into hyperextension rather than the fracture. If the deformity is to be corrected, only the metacarpal should be manipulated and not the more distal portions of the thumb. The fracture position and the absence of hyperextension of the MP joint of the thumb can be verified on x-ray films taken through the cast. Proximal phalanx fracture Sterling Bunnell coined the term “no-man’s_land” to flexor tendon injuries occurring between the distal palmar crease and the PIP joint. Even though many surgeons now repair flexor tendon injuries in this area, the surgery is difficult, and unless perfectly done and rehabilitated, poor results will follow. The “noman’s-land” area corresponds to the proximal phalanx of the finger, and in this area fractures of the proximal phalanx are similarly difficult to manage. The surgical exposure, except distally, is done through tendinous structures that are prone to adherences, followed by loss of motion at the PIP joint. Because of these difficulties, we have attempted to use the same casting method as that described for fractures of the metacarpal. After the proximal portion of the cast has set, the distal or dorsal extension of the cast is fashioned while gentle pressure is applied just proximal to the PIP joint to overcome the tendency of the distal fragment to extend (Fig. 2). This reduces the distal fragment to the proximal, an old orthopedic axiom. The adjacent digits help maintain the alignment. Rotational malalignment is avoided by simultaneous flexion of the fingers in the presence of fully flexed MP joints (Fig. 3). Over the proximal phalanx. the extensor mechanism almost covers the bone completely. Bleeding associated with the fracture compromises the space between the tendon and dorsal cortex. As the PIP joint is actively flexed, the tightened extensor mechanism becomes a tension band on the dorsum of the phalanx. The rehabilitation program for proximal phalangeal fractures is similar to that described for metacarpal fractures. Full active flexion is stressed, with all fingers closing simultaneously to negate the rotational malalignment problem (Fig. 4). With proximal phalangeal fractures, there is a greater tendency for extensor lag at the PIP joint. A flexion contracture can be avoided, and flexion can be improved with passive extension exercises carried out by the patient or with a light extensor assist sling. A lag should not be allowed to become a contracture. The cast must not extend distal to the PIP to avoid blocking its full extension. It is most important to verify the adequacy of the reduction on lateral x-ray film views. Because of the thickness of the plaster and the superimposition of the fingers, a linear tomogram that uses the same technique as that for the metacarpals is necessary to confirm the correction of the dorsal angulation of the proximal phalanx (apex palmar). If dorsal angulation persists, it can be corrected by
Closed treatment of hand fractures
393
adding a layer of felt between the cast and distal portion of the proximal phalanx. If necessary, the dorsal extension of the cast is cut and repositioned to place the MP joints in a greater angle of flexion. The goal is to obtain near-anatomic alignment of the proximal phalanx on both the anteroposterior plane and the lateral tomographic views. Good results can be expected if, in the early stages of treatment, there is radiographic alignment of the proximal phalanx without rotational deformity and good Aexion of the PIP joint with only a mild degree of extensor lag. A supervised rehabilitation program is important to stress full flexion of the PIP joint to prevent the development of an extensor lag contracture. Union of the fracture usually occurs in all cases, and early formation of a callous can be seen radiographically at 3 to 4 weeks. At this time, the finger is clinically stable, and external immobilization can usually be removed. If the phalanx or metacarpal remain tender on direct palpation, immobilization may be continued for another 2 to 3 weeks. Conclusions Closed functional treatment of extra-articular fractures of the proximal phalanges and metacarpals is based on the principle of external positioning combined with active motion.5. ’ Proper external positioning controls the deforming muscle forces that originally created the fracture deformity. The fracture malalignment is the result of muscle forces intrinsic to the patient and not the result of the external forces that created the fracture. Internal fixation is required in certain fractures when the articular surface is involved, the soft tissues are severely disrupted, or there is a loss of bony substance. Modem sophisticated hardware and surgical instruments are now available for internal fixation of these fractures. However, it is important to obtain sufficient skeletal stability to allow some load bearing until osseous union has occurred. In this method early supervised rehabilitation is necessary to avoid the development of unnecessary deformities. We need to remember the indications for surgery and also the requirements placed on the surgeon. One should not compare the best results of open treatment with the worst of closed treatment; compare the best of both.
REFERENCES 1.
Sarmiento A, Latta L. Closed treatment of fractures. New York: Springer-Verlag,
198 1.
2. Dehne E, Metz C, Deffer P, et al. Non operative treatment of the
3. 4. 5.
6.
fractured tibia by immediate weight bearing. J Trauma 1961; 1514. Brown P, Urban J. Early weight bearing treatment of open fractures of the tibia. J Bone Joint Surg [Am] 1969;51:59. Burkhalter W, Protzman R. The tibial shaft fracture. J Trauma 1975;15:785. Burkhalter W. Functional treatment of fractures. in: Boswick J, ed. Current concepts in hand surgery. Philadephia: Lea & Febiger, 1983:146. Burkhalter W, Reyes F. Closed treatment of fractures of the hand. Bull Hosp Jt Dis 1984;44:145.