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Fracture of metacarpal bones and proximal manual phalanges
FRACTURE
OF METACARPAL BONES AND PROXIMAL MANUAL PHALANGES
TREATMENT
WITH EMPHASIS ON THE PREVENTION OF ROTATIONAL DEFORMITIES CHARLES New
J.
SUTRO,
M.D.
l’ork, New J’ork
I
NSUFFICIENT emphasis has been given to the prevention of fixed torsion deformities or overIapping of fractured digits in the course of treatment of fractures of metacarpals or of proximal manual phalanges. A study of normal fingers as we11 as of heaIed fractured
IA
culty in certain instances in detecting the presence of torsion of the involved fingers.’ In order to prevent such torsipn or overlapping of the flexed fractured digits, it is suggested that the mode of treatment should provide for (I) temporary IateraI approximation of all the
IB
FIG. I. A, note the normal range of passive radial rotation of the flexed little finger. B, note the range of passive uInar rotation of the flexed index finger.
ones has reveaIed that minima1 overIapping of the fingers is easiIy detected when they are heId in a flexed attitude. When these fingers are examined in the extended position, onIy those with marked torsion deformities are readiIy recognized as abnorma1. Passive rotary motion is present in the metacarpophaIangea1 joint of each finger in amounts of I 5 to 35 degrees. The little finger presents the greatest range of such radial movement and the index finger the greatest range of such uInar movement. (Fig. I.) If a fracture of a finger is treated using tota encasement with adhesive pIaster, pIaster of paris bandage or traction, one may have diffrMarch,
1931
327
fingers in a flexed attitude and (2) easy access for inspection of the relative position of the fingernaiIs in the immobilization apparatus. A study of one group of cases with simple fractures of the metacarpals and another group with simple fractures of the proxima1 manual phaIanges is presented in which torsion deformities of the fractured fingers were prevented. Simple Fracture of a Single %fetacarpal Bone (Exclusive of Thumb), Twenty-nine Cases. EIeven of the twenty-nine patients presented fractures in the region of the proxima1 third of a singIe metacarpa1 bone and the eighteen others showed fractures of the &staI two-thirds of a singIe metacarpa1 bone.
328
Sutro-Fracture
of MetacarpaIs
2A
and PhaIanges
2B
FIG. 2. A, note the fixation of the distat fragment of the fractured metacarpal bone by rigid Kirschner wire. B, note healing at fracture site eight weeks later. Free movement is present in the joints of the Iittle tinger.
The’ fractures of the metacarpal bones were treated using fixation with rigid Kirschner wires.2 After the fragments were reahgned into normaI relationships under brachia1 p1exu.s bIock anesthesia or intravenous pentothaI@ solution, the fingers were placed in a IIexed attitude. One to three wires were inserted in a horizonta1 pIane anchoring the dista1 portion of the fractured metacarpa1 bone to one or two contiguous normaI metacarpa1 bones. This was done whiIe the Iingers were heId in a flexed attitude. (Fig. 2.) SmaII incisions were made in the skin for the easy introduction of the wires. The position of the wires in the metacarpa1 bones was checked by radiographic examinations made in the operating room. When this procedure was compIeted, the Kirschner wires were cut approximatehy s/4-inch beyond the skin surface. These free ends of the wire were buried in a Iight, short plaster of paris bandage. The Iatter encased the hand to the IeveI of the necks of the metacarpa1 bones. There was no mechanica interference with active or passive movements at the metacarpophaIangea1 or interphaIangea1 articuIations. The Iingers couId be pIaced in IateraI apposition and were examined frequentIy in the flexed attitude in order to check for the presence or absence of a rotation deformity. In two instances in which reduction of the fractured segments in the head or neck region of
the metacarpa1 bone couId not be accompIished by “cIosed manipmation,” open reduction was performed. Through an incision made on the dorsal aspect of the metacarpa1 region near the web space the fractured bone was exposed and realigned. In these two cases fixation of the fragments was done by the introduction of a singIe heavy Kirschner wire. This was inserted in a vertica1 pIane through the periphera1 portion of the articuIar surface of the head and extended into the shaft of the ipsiIatera1 or contiguous metacarpa1 bone. The shaft of the fractured bone was held in pIace temporariIy with a second Kirschner wire. This wire was inserted in a horizonta1 fashion and was removed prior to the appIication of a short pIaster of paris bandage about the hand. This bandage anchored the Kirschner wire which was inserted verticaIIy into the articuIar surface and shaft of the bone. (Fig. 3.) The bandage did not interfere with the movements at the metacarpophalangea1 joints of the non-fractured fingers3 GeneraIIy the wires and tIie pIaster of paris bandage were Ieft in situ from four to six weeks, during which time caIIus usuaIIy made its appearance at the fracture region. Active movements of the fingers were encouraged by a program of occupationa therapy and exercises which was started from twenty-four to fortyeight hours after reduction and fixation of the American
Journal
of Surgery
Sutro-Fracture
of MetacarpaIs
and Phalanges
FIG. 3. A, note fracture through neck of metacarpal bone of IittIe finger; cIosed manipuIation was not successful. B, treatment by open reduction and fixation with Kirschner wires; the (horizontal) wire in the shaft of the metacarpal bone was removed soon after the introduction of the vertica1 wire. c and D, note heaIing at the fracture site and reaIignment of the articuIar surface to the shaft. (Radiographs made eight weeks after the open correction.)
segments of the fractured bone. FoIIow-up examination made from three to five months after the initiaI treatment reveaIed heaIing at the fracture site and good aIignment of the fragments. ExceIIent range of motion was noted at the metacarpophaIangea1 joints. There was absence of torsion or overIapping of the digits. (Fig. 4.1 Simple Fracture of the Proximal Phalanges of the Fingers (Thirteen Cases). Thirteen patients each with fractures of the proximal phaIanges of one or more fingers were treated using the method of partia1 encasement of a11 the fingers in a pIaster of paris mitten. By this means a11 the fingers were flexed and were in IateraI apposition. In each of nine of these thirteen patients there was a fracture of the proxima1 Plarch,
1951
phaIanx of a singIe finger.4 In the tenth case fractures of the proxima1 phaIanges of two contiguous fingers were present whiIe in each of two others the proxima1 phaIanges of four fingers of one hand were simiIarIy invoIved. The thirteenth patient presented fractures of the proxima1 phaIanges of the four fingers of one hand and those of three fingers of the opposite hand. * After correcting the position of the fragments of the fractured phaIanges by manipuIation and traction, a we11 padded gauze bandage was pIaced in the paIm in the area bounded dorsaIIy by the heads of the metacarpa1 bones, * Most of the injuries in this group were caused by the impact of hatch doors of armored tanks against the hands.
Sutro-Fracture
330
of MetacarpaIs
4A
and PhaIanges
4B
4c
FIG. 4. A and B, note comminuted
fracture of metacarpa1 bones of middle and ring fingers (two views); the wire fixation permitted earIy free movement of fingers (wires were removed during the sixth week). c, radiographs made five months after insertion of wires show compIete heaIing at the fracture sites.
5A 56 FIG. 2. A, note pIaster of paris mitten about right hand for treatment of fracture of proxima1 phaIanx of middIe finger. R, note that the index, ring and IittIe fingers can be mobilized without interfering with the position of the fractured middIe finger.
superiorIy by the proxima1 phaIanges and anteriorly by the dista1 phaIanges. The gauze bandage was sufficient in size to hoId the middIe phaIanges at an angIe of I IO to 120 degrees to the proxima1 phaIanges. The hand and the four fIexed fingers which heId the gauze bandage were encased with a pIaster of paris bandage to form a mitten. By this means the fingers were heId in traction, in IateraI apposition and in ffexion. The pIaster covering the dorsa1 aspects of the proxima1 and middIe phaIangea1 regions and the proximal portion of the naiI areas was removed as soon as the bandage became dry. The tips of the digits were heId in pIace by the pIaster of paris
mitten. If radiographic examination reveaIed that the segments of the fractured phaIanx were not accurateIy aligned, pieces of felt were inserted in the area under the proxima1 phaIanx in question and over the gauze bandage. The added feIt pad increased the dorsa1 bow or distracted the fragments of the bone. The fingernaiIs were inspected to determine their reIative positions and were checked for signs of vascuIar disturbances. * For fractures of the proximal phalanx of one finger a11 four fingers were encompassed in the pIaster of paris mitten. (Fig. 5.) On the seventh to the tenth day of immobiIization the three norma digits were passiveIy reIeased from the pIaster of paris mitten severa fifteen- to twenty-minute periods each day to permit them to undergo active and passive exercises. The fingers were pIaced into the mitten when they were not exercised. The fractured digit was not disturbed from the pIaster of paris mitten. After the twenty-first day of immobilization, however, the fractured finger was freed from the mitten for severa fifteen-minute periods of exercise. The mitten was discarded during the sixth week of treatment. Fractures of proxima1 phaIanges of two or more fingers of one hand were treated using encasement of four fingers in a pIaster of paris mitten as described previousIy. The norma * Traction may be added temporariIy to any one of the fingers in the flexed position in order to overcome any persistent recurrent overriding of the fragments. American
Journal
of Surgery
Sutro-Fracture
6A
of MetacarpaIs
6B
and Phalanges
33’
6~
6c
FIG. 6. A and B, this soIdier suffered from fractures of the proxima1 phalanges of the four fingers of the right hand CB) and of the proximal phalanges of three fingers of the Ieft hand (A). c and D, this patient was treated with manipulation and immobilization, and plaster of park mittens on the right and left hands; radiographs (C and D) show the Ieft hand encompassed by the mitten.
FIG. 6~. Radiographs ture show compIete proximal phaIanges.
6~
made four months after the fracheaIing of the seven fractured
6~
FIG. 6~ and G. Photographs made four months after fracture show the range of flexion and extension of the fractured seven fingers. There is absence of torsion or overIapping of the digits.
March,
1951
Sutro-Fracture
332
of Metacarpals
fingers were released daily from the mitten after the seventh to tenth postreduction day for several fifteen-minute periods of exercises and occupational therapy. The fractured digits were released daily for a similar period of time for exercises and occupational therapy approximately three weeks after the application of the plaster of paris bandage. The latter was discarded during the sixth or seventh week of treatment and more vigorous exercises were initiated. (Fig. 6.) Follow-up examination of these thirteen patients made from three to six months after the occurrence of the fractures revealed a free range of active and passive flexion and extension at the metacarpophalangeal and interphalangeal joints of the fingers. There was no evidence of torsion or overlapping of the digits. SUMMARY
AND
CONCLUSION
During the course of treatment of simple fractures of manual phalanges or of metacarpals consideration must be given to the passive rotary movements at the metacarpophalangeal joints as well as at the site of fracture. Since abnormal rotation or overlapping of the digits can best be recognized when the fingers are in a flexed attitude, the mode of treatment should permit all the fingers to be inspected in the suggested position. Fractures of one or more metacarpal bones were treated using fixation with rigid Kirschner wires and plaster of paris bandages. One, two or three Kirschner wires were inserted through the distal fragments into the contiguous normal metacarpal bones. The fingers were held in a flexed attitude during this procedure. In some cases of fractures of the neck or head region of the metacarpal bones a single wire was inserted in a vertical fashion through the articular surface and shaft of the bone. This method of therapy resulted in excellent apposition of the bone fragments without any rotatory deformity of the fractured digits.
and
Phalanges
Fractures of the proximal phalanges of one or more fingers were treated with immobilization of the four flexed fingers in a plaster of paris mitten. The normal fingers were released from the mitten on the seventh to the tenth postreduction day for exercises. The fractured fingers were similarly exercised on and after the twenty-first postreduction day. The plaster of paris mitten resulted in excellent apposition of the fractured segments, with preservation of motion at the joints without any evidence of torsion or overlapping of the fractured digits. REFERENCES I.
ROBERTS, N. Fractures of the phalanges of the hand and metacarpals. Proc. Roy. Sot. Med., 31: 793,
1938.
JAHSS, S. A. Fracture of the metacarpals. J. Bone pr Joint Surg., 20: 178, 1938. WATSOIGJONES, Ii. Fractures and Joint Injuries. Edinburgh, 1943. E. & S. Livingstone. SAYPOL, G. M. and SLA-~~ERY,L. K. Observation on displaced fractures of the hand. Surg., GJ;nec. @ Obk, 79: 522, 1944. 2. WAUGH. R. I.. and FERRAZZAXO. G. P. Fractures of the metacarpals excfusive of the thumb. A new method of treatment. Am. J. Surg., 59: 186, 1943. BERKMAN, E. F. and MILES, C. H. Internal fixation of metacarpal fractures exclusive of the thumb. J. Bone @Joint Surg., 25: 816, 1943. NORMAN, H. R. C. Fractures of the metacarpals treated by a new method. Canadian M. A. J., 49: ‘73. 1943. QVIGLEY, T. B. and URIST, M. R. Interphalangeal joints. Method of digitat skeletal traction which permits active motion. Am. J. Surg., 73: I 75, I 947. 3. MARRIK, M. M. Multiple metatarsal fractures. A method of fixation. &fil. Surgeon, 93: 81, 1943. MOHTON, Il. S. Fractures of the wrist and hand. Canad. M. A. J., 5 I : 430, 1944. ~IUKRAY. G. Use of lonaitudinal wires in bones in treatment of fractures and dislocations. Am. J. Suv., 47: 156, 1945. 4. JAIISS, S. A. Fractures of the proximal phalanges. J. Bone er Joinf Surg., 18: 726, 1936. KAPLAN, E. B. Treatment of fracture of metacarpals and proximal phalanx by skeletal traction. Bull. Hosp. Joint Dis., 5: gg. 1944. GOLDBERG. D. MetacarpaI fractures. New instrument for maintenance-of position after reduction. Am. J. Surg., 72: 758, 1946.
American
Journal
of Surgery
OF METACARPAL BONES AND PROXIMAL MANUAL PHALANGES
TREATMENT
WITH EMPHASIS ON THE PREVENTION OF ROTATIONAL DEFORMITIES CHARLES New
J.
SUTRO,
M.D.
l’ork, New J’ork
I
NSUFFICIENT emphasis has been given to the prevention of fixed torsion deformities or overIapping of fractured digits in the course of treatment of fractures of metacarpals or of proximal manual phalanges. A study of normal fingers as we11 as of heaIed fractured
IA
culty in certain instances in detecting the presence of torsion of the involved fingers.’ In order to prevent such torsipn or overlapping of the flexed fractured digits, it is suggested that the mode of treatment should provide for (I) temporary IateraI approximation of all the
IB
FIG. I. A, note the normal range of passive radial rotation of the flexed little finger. B, note the range of passive uInar rotation of the flexed index finger.
ones has reveaIed that minima1 overIapping of the fingers is easiIy detected when they are heId in a flexed attitude. When these fingers are examined in the extended position, onIy those with marked torsion deformities are readiIy recognized as abnorma1. Passive rotary motion is present in the metacarpophaIangea1 joint of each finger in amounts of I 5 to 35 degrees. The little finger presents the greatest range of such radial movement and the index finger the greatest range of such uInar movement. (Fig. I.) If a fracture of a finger is treated using tota encasement with adhesive pIaster, pIaster of paris bandage or traction, one may have diffrMarch,
1931
327
fingers in a flexed attitude and (2) easy access for inspection of the relative position of the fingernaiIs in the immobilization apparatus. A study of one group of cases with simple fractures of the metacarpals and another group with simple fractures of the proxima1 manual phaIanges is presented in which torsion deformities of the fractured fingers were prevented. Simple Fracture of a Single %fetacarpal Bone (Exclusive of Thumb), Twenty-nine Cases. EIeven of the twenty-nine patients presented fractures in the region of the proxima1 third of a singIe metacarpa1 bone and the eighteen others showed fractures of the &staI two-thirds of a singIe metacarpa1 bone.
328
Sutro-Fracture
of MetacarpaIs
2A
and PhaIanges
2B
FIG. 2. A, note the fixation of the distat fragment of the fractured metacarpal bone by rigid Kirschner wire. B, note healing at fracture site eight weeks later. Free movement is present in the joints of the Iittle tinger.
The’ fractures of the metacarpal bones were treated using fixation with rigid Kirschner wires.2 After the fragments were reahgned into normaI relationships under brachia1 p1exu.s bIock anesthesia or intravenous pentothaI@ solution, the fingers were placed in a IIexed attitude. One to three wires were inserted in a horizonta1 pIane anchoring the dista1 portion of the fractured metacarpa1 bone to one or two contiguous normaI metacarpa1 bones. This was done whiIe the Iingers were heId in a flexed attitude. (Fig. 2.) SmaII incisions were made in the skin for the easy introduction of the wires. The position of the wires in the metacarpa1 bones was checked by radiographic examinations made in the operating room. When this procedure was compIeted, the Kirschner wires were cut approximatehy s/4-inch beyond the skin surface. These free ends of the wire were buried in a Iight, short plaster of paris bandage. The Iatter encased the hand to the IeveI of the necks of the metacarpa1 bones. There was no mechanica interference with active or passive movements at the metacarpophaIangea1 or interphaIangea1 articuIations. The Iingers couId be pIaced in IateraI apposition and were examined frequentIy in the flexed attitude in order to check for the presence or absence of a rotation deformity. In two instances in which reduction of the fractured segments in the head or neck region of
the metacarpa1 bone couId not be accompIished by “cIosed manipmation,” open reduction was performed. Through an incision made on the dorsal aspect of the metacarpa1 region near the web space the fractured bone was exposed and realigned. In these two cases fixation of the fragments was done by the introduction of a singIe heavy Kirschner wire. This was inserted in a vertica1 pIane through the periphera1 portion of the articuIar surface of the head and extended into the shaft of the ipsiIatera1 or contiguous metacarpa1 bone. The shaft of the fractured bone was held in pIace temporariIy with a second Kirschner wire. This wire was inserted in a horizonta1 fashion and was removed prior to the appIication of a short pIaster of paris bandage about the hand. This bandage anchored the Kirschner wire which was inserted verticaIIy into the articuIar surface and shaft of the bone. (Fig. 3.) The bandage did not interfere with the movements at the metacarpophalangea1 joints of the non-fractured fingers3 GeneraIIy the wires and tIie pIaster of paris bandage were Ieft in situ from four to six weeks, during which time caIIus usuaIIy made its appearance at the fracture region. Active movements of the fingers were encouraged by a program of occupationa therapy and exercises which was started from twenty-four to fortyeight hours after reduction and fixation of the American
Journal
of Surgery
Sutro-Fracture
of MetacarpaIs
and Phalanges
FIG. 3. A, note fracture through neck of metacarpal bone of IittIe finger; cIosed manipuIation was not successful. B, treatment by open reduction and fixation with Kirschner wires; the (horizontal) wire in the shaft of the metacarpal bone was removed soon after the introduction of the vertica1 wire. c and D, note heaIing at the fracture site and reaIignment of the articuIar surface to the shaft. (Radiographs made eight weeks after the open correction.)
segments of the fractured bone. FoIIow-up examination made from three to five months after the initiaI treatment reveaIed heaIing at the fracture site and good aIignment of the fragments. ExceIIent range of motion was noted at the metacarpophaIangea1 joints. There was absence of torsion or overIapping of the digits. (Fig. 4.1 Simple Fracture of the Proximal Phalanges of the Fingers (Thirteen Cases). Thirteen patients each with fractures of the proximal phaIanges of one or more fingers were treated using the method of partia1 encasement of a11 the fingers in a pIaster of paris mitten. By this means a11 the fingers were flexed and were in IateraI apposition. In each of nine of these thirteen patients there was a fracture of the proxima1 Plarch,
1951
phaIanx of a singIe finger.4 In the tenth case fractures of the proxima1 phaIanges of two contiguous fingers were present whiIe in each of two others the proxima1 phaIanges of four fingers of one hand were simiIarIy invoIved. The thirteenth patient presented fractures of the proxima1 phaIanges of the four fingers of one hand and those of three fingers of the opposite hand. * After correcting the position of the fragments of the fractured phaIanges by manipuIation and traction, a we11 padded gauze bandage was pIaced in the paIm in the area bounded dorsaIIy by the heads of the metacarpa1 bones, * Most of the injuries in this group were caused by the impact of hatch doors of armored tanks against the hands.
Sutro-Fracture
330
of MetacarpaIs
4A
and PhaIanges
4B
4c
FIG. 4. A and B, note comminuted
fracture of metacarpa1 bones of middle and ring fingers (two views); the wire fixation permitted earIy free movement of fingers (wires were removed during the sixth week). c, radiographs made five months after insertion of wires show compIete heaIing at the fracture sites.
5A 56 FIG. 2. A, note pIaster of paris mitten about right hand for treatment of fracture of proxima1 phaIanx of middIe finger. R, note that the index, ring and IittIe fingers can be mobilized without interfering with the position of the fractured middIe finger.
superiorIy by the proxima1 phaIanges and anteriorly by the dista1 phaIanges. The gauze bandage was sufficient in size to hoId the middIe phaIanges at an angIe of I IO to 120 degrees to the proxima1 phaIanges. The hand and the four fIexed fingers which heId the gauze bandage were encased with a pIaster of paris bandage to form a mitten. By this means the fingers were heId in traction, in IateraI apposition and in ffexion. The pIaster covering the dorsa1 aspects of the proxima1 and middIe phaIangea1 regions and the proximal portion of the naiI areas was removed as soon as the bandage became dry. The tips of the digits were heId in pIace by the pIaster of paris
mitten. If radiographic examination reveaIed that the segments of the fractured phaIanx were not accurateIy aligned, pieces of felt were inserted in the area under the proxima1 phaIanx in question and over the gauze bandage. The added feIt pad increased the dorsa1 bow or distracted the fragments of the bone. The fingernaiIs were inspected to determine their reIative positions and were checked for signs of vascuIar disturbances. * For fractures of the proximal phalanx of one finger a11 four fingers were encompassed in the pIaster of paris mitten. (Fig. 5.) On the seventh to the tenth day of immobiIization the three norma digits were passiveIy reIeased from the pIaster of paris mitten severa fifteen- to twenty-minute periods each day to permit them to undergo active and passive exercises. The fingers were pIaced into the mitten when they were not exercised. The fractured digit was not disturbed from the pIaster of paris mitten. After the twenty-first day of immobilization, however, the fractured finger was freed from the mitten for severa fifteen-minute periods of exercise. The mitten was discarded during the sixth week of treatment. Fractures of proxima1 phaIanges of two or more fingers of one hand were treated using encasement of four fingers in a pIaster of paris mitten as described previousIy. The norma * Traction may be added temporariIy to any one of the fingers in the flexed position in order to overcome any persistent recurrent overriding of the fragments. American
Journal
of Surgery
Sutro-Fracture
6A
of MetacarpaIs
6B
and Phalanges
33’
6~
6c
FIG. 6. A and B, this soIdier suffered from fractures of the proxima1 phalanges of the four fingers of the right hand CB) and of the proximal phalanges of three fingers of the Ieft hand (A). c and D, this patient was treated with manipulation and immobilization, and plaster of park mittens on the right and left hands; radiographs (C and D) show the Ieft hand encompassed by the mitten.
FIG. 6~. Radiographs ture show compIete proximal phaIanges.
6~
made four months after the fracheaIing of the seven fractured
6~
FIG. 6~ and G. Photographs made four months after fracture show the range of flexion and extension of the fractured seven fingers. There is absence of torsion or overIapping of the digits.
March,
1951
Sutro-Fracture
332
of Metacarpals
fingers were released daily from the mitten after the seventh to tenth postreduction day for several fifteen-minute periods of exercises and occupational therapy. The fractured digits were released daily for a similar period of time for exercises and occupational therapy approximately three weeks after the application of the plaster of paris bandage. The latter was discarded during the sixth or seventh week of treatment and more vigorous exercises were initiated. (Fig. 6.) Follow-up examination of these thirteen patients made from three to six months after the occurrence of the fractures revealed a free range of active and passive flexion and extension at the metacarpophalangeal and interphalangeal joints of the fingers. There was no evidence of torsion or overlapping of the digits. SUMMARY
AND
CONCLUSION
During the course of treatment of simple fractures of manual phalanges or of metacarpals consideration must be given to the passive rotary movements at the metacarpophalangeal joints as well as at the site of fracture. Since abnormal rotation or overlapping of the digits can best be recognized when the fingers are in a flexed attitude, the mode of treatment should permit all the fingers to be inspected in the suggested position. Fractures of one or more metacarpal bones were treated using fixation with rigid Kirschner wires and plaster of paris bandages. One, two or three Kirschner wires were inserted through the distal fragments into the contiguous normal metacarpal bones. The fingers were held in a flexed attitude during this procedure. In some cases of fractures of the neck or head region of the metacarpal bones a single wire was inserted in a vertical fashion through the articular surface and shaft of the bone. This method of therapy resulted in excellent apposition of the bone fragments without any rotatory deformity of the fractured digits.
and
Phalanges
Fractures of the proximal phalanges of one or more fingers were treated with immobilization of the four flexed fingers in a plaster of paris mitten. The normal fingers were released from the mitten on the seventh to the tenth postreduction day for exercises. The fractured fingers were similarly exercised on and after the twenty-first postreduction day. The plaster of paris mitten resulted in excellent apposition of the fractured segments, with preservation of motion at the joints without any evidence of torsion or overlapping of the fractured digits. REFERENCES I.
ROBERTS, N. Fractures of the phalanges of the hand and metacarpals. Proc. Roy. Sot. Med., 31: 793,
1938.
JAHSS, S. A. Fracture of the metacarpals. J. Bone pr Joint Surg., 20: 178, 1938. WATSOIGJONES, Ii. Fractures and Joint Injuries. Edinburgh, 1943. E. & S. Livingstone. SAYPOL, G. M. and SLA-~~ERY,L. K. Observation on displaced fractures of the hand. Surg., GJ;nec. @ Obk, 79: 522, 1944. 2. WAUGH. R. I.. and FERRAZZAXO. G. P. Fractures of the metacarpals excfusive of the thumb. A new method of treatment. Am. J. Surg., 59: 186, 1943. BERKMAN, E. F. and MILES, C. H. Internal fixation of metacarpal fractures exclusive of the thumb. J. Bone @Joint Surg., 25: 816, 1943. NORMAN, H. R. C. Fractures of the metacarpals treated by a new method. Canadian M. A. J., 49: ‘73. 1943. QVIGLEY, T. B. and URIST, M. R. Interphalangeal joints. Method of digitat skeletal traction which permits active motion. Am. J. Surg., 73: I 75, I 947. 3. MARRIK, M. M. Multiple metatarsal fractures. A method of fixation. &fil. Surgeon, 93: 81, 1943. MOHTON, Il. S. Fractures of the wrist and hand. Canad. M. A. J., 5 I : 430, 1944. ~IUKRAY. G. Use of lonaitudinal wires in bones in treatment of fractures and dislocations. Am. J. Suv., 47: 156, 1945. 4. JAIISS, S. A. Fractures of the proximal phalanges. J. Bone er Joinf Surg., 18: 726, 1936. KAPLAN, E. B. Treatment of fracture of metacarpals and proximal phalanx by skeletal traction. Bull. Hosp. Joint Dis., 5: gg. 1944. GOLDBERG. D. MetacarpaI fractures. New instrument for maintenance-of position after reduction. Am. J. Surg., 72: 758, 1946.
American
Journal
of Surgery