Hand and Wrist Surgery - part 7 pot

F R A C T U R E S A N D D I S L O C A T I O N S O F T H E H A N D 342 In the event of failure of obtaining a successful closed reduction, an open reduc- tion should be performed. The joints can be approached via a transverse incision along Langer’s lines at the level of the carpometacarpal joint. Reduction of the third carpometacarpal joint is the key to the reduction of the remaining joints as this joint functions as the keystone of the transverse and longitudinal arches of the hand. K-wire fixation of the reduced joints produces a joint that will remain stable during the course of immobilization. Internal fixation with pins, screws, or plates can be performed to maintain stability. High-energy injuries often require internal fixation as they are often associated with fractures. In the event of multiple dislocations, K-wire fixation of all dislocated joints need not be performed. The second and third carpometacarpal joints should be stabilized, as they are the keystones of the hand, and the fifth carpometacarpal joint should be stabilized to avoid subluxation and ulnar deviation. The fourth carpometacarpal joint need not be pinned if its adjacent joints have been pinned, as the strong inter- metacarpal ligaments are not disrupted and will contribute to stability. After reduction and pinning of the carpometacarpal dislocation, the hand should be splinted for pain management and soft tissue rest. After a week, gentle active and passive range-of-motion exercises of the fingers and wrist can be performed. The K wires can be removed after 6 to 12 weeks. Patients with concomitant frac- tures require the longer length of time before K-wire removal. After removal of the K wires, progressive active and passive range-of-motion and strengthening exercise should be performed. Complications Percutaneous pinning has seen rare complications. Post-operative stiffness may be present but early and appropriate hand therapy can often eliminate this complica- tion. Fluroscopic guidance may aid in the accurate placement of the K wire. Suggeste d Readings Ahmad S, Plancher KP. Carpometacarpal dislocation of the fingers. Op Tech Sports Med 1996;4:256–267. Fisher MR, Rogers LF, Hendrix RW. Systematic approach to identifying fourth and fifth carpometacarpal joint dislocation. AJR 1986;140:319–324. Gurland M. Carpometacarpal joint injuries of the fingers. Hand Clin 1992;8: 733–744. Jebson PJ, Engber WD, Lange RH. Dislocation and fracture dislocation of the car- pomteacarpal joints. Orthop Rev 1994;23:19–28. Lawlis JF, Gunther SF. Carpometacarpal dislocation: Long-term followup. J Bone Joint Surg [Am] 1991;73A:52–59. Van Der Lei B, Kalsen HJ. Dorsal carpometacarpal dislocation of the index fin- ger: a report of three cases and a review of the English language literature. J Trauma 1992;32:789–793. Section IX Fractures and Dislocations of the Wrist A. Wrist Fractures and Dislocations Scaphoid Fractures: “Classic” Volar Approach Kevin D. Plancher Percutaneous Treatment of Proximal Pole Scaphoid Fractures Joseph F. Slade III and John D. Mahoney Scaphoid Nonunion James W. Vahey and Kevin D. Plancher B. Fractures of the Distal R ad iu s Radial Styloid Fractures James H. Calandruccio Extraarticular Distal Radius Fractures Kydee K. Sheetz and Matthew D. Putman Intraarticular Distal Radius Fractures: Volar Approach, Dorsal Approach, and Arthroscopic Reduction Kevin D. Plancher S C A P H O I D F R A C T U R E S 345 Figure 56–1. A patient demonstrating the location of the “snuffbox.” 56 Scaphoid Fractures: “Classic” Volar Approach Kevin D. Plancher His to ry and Clinical Presentation A 17-year-old boy presented to the emergency room with a dull, deep pain in the wrist after a fall, while he was rock climbing, on an outstretched hand. The patient remembers that his wrist was radially deviated when he fell. The patient reports dis- comfort in the wrist on the thumb side with mild swelling and ecchymosis. Phy si ca l Exami na ti on The major structures of the wrist are palpated. Pain with axial compression of the thumb is suggestive of a scaphoid fracture. The patient also has pain in the anatomic snuffbox between the first and third dorsal compartments (Fig. 56–1). Dia gn os ti c Studies Initial imaging of the patient should include a zero posteroanterior (PA) x-ray of the wrist (Fig. 56–2). If the fracture is not seen, the patient should have PA x-rays of the wrist in radial and ulnar deviation (scaphoid and longitudinal profile with the elbow flexed at 90 degrees). These views are used to better define the anatomy of the scaphoid and allow visualization of its margins. A clenched fist with radial and ulnar deviation views may also diagnose a scapholunate ligament tear as the cause of the patient’s pain. If all x-rays are negative, further imaging to diagnose an occult scaphoid fracture that is not seen on plain films may be done with a bone scan. A Figure 56–2. Radiograph, zero posteroanterior (PA), of the wrist demonstrating a scaphoid fracture. F R A C T U R E S A N D D I S L O C A T I O N S O F T H E W R I S T 346 Figure 56–3. The vasculature of the scaphoid (volar and dorsal). negative bone scan 3 to 5 days following an injury rules out a scaphoid fracture. We routinely use computed tomography (CT) evaluation of the scaphoid when there is evidence of a fracture. This test gives the best definition of cortical integrity, frac- ture pattern and the ability to evaluate a humpback deformity or dorsal intercalated segment instability (DISI) pattern. Magnetic resonance imaging (MRI) is quickly replacing CT evaluation and it demonstrates more anatomy, which allows for visu- alization of the fracture and ligament disruptions. Dif fe rent ia l Diagnosis Scaphoid fracture Distal radius fracture Radioulnar joint injury Perilunate ligament disruption Injury of the extensor carpi radialis (brevis and longus) or flexor carpi radialis tendons Wrist sprain Dia gn os is Scaphoid Fracture The scaphoid is the most frequently injured carpal bone. Scaphoid injuries are most commonly seen in young men, are often misdiagnosed as sprained wrists, and are rarely seen in children because the distal radial physis usually fails first. Fractures are localized within the proximal, middle (waist), or distal third of the bone. The incidence of avascular necrosis increases as fractures are located more prox- imally in poorly vascularized areas (Fig. 56–3). Most scaphoid fractures occur at the waist, followed by the proximal pole and then the distal pole. Orientation of the frac- ture is a clue to its stability (Fig. 56–4). The most stable fracture orientation is the horizontal oblique, wherein the axis of the load is perpendicular to the fracture line. Transverse fractures may be unstable. The most unstable fracture has a vertical oblique orientation; fragments are vulnerable to longitudinal shearing forces from the radius. PEARLS • Plain radiograph initially should be a zero PA • Correlate clinical exam with diagnostic studies and utilize CT or MRI when necessary. • If closed treatment is decided, need to follow guidelines of 6 weeks in a long-arm cast • Avoid damaging underlying articular cartilage during inter- nal stabilization. • Avoid damaging the vascula- ture by keeping the volar inci- sion into the joint capsule not too deep or too proximal. PITFALLS • Misdiagnosis and failure to diagnose • Failure to follow-up clinically with a painful snuffbox on phys- ical examination and negative plain x-rays • Treating a proximal pole frac- ture of the scaphoid as if it were a distal pole fracture • Poor screw placement and not verifying placement intraoperatively S C A P H O I D F R A C T U R E S 347 Figure 56–4. The Russe classification. Nonsurgical Mana ge me nt Wrist and thumb immobilization is the first step in acute treatment for non- displaced distal scaphoid fractures and is an option for treating some of the more complex scaphoid fractures. Scaphoid fractures that present more than 3 weeks after the injury may need more aggressive treatment, and orthopedic consultation is suggested. Waist fractures should be considered for open reduction; however, nondisplaced, horizontal oblique fractures of the waist have the best chance of successful nonsurgical treatment. Though closed treatment has less surgical risk, prolonged immobilization and nonunion are other risks to consider. Closed treat- ment consists of 6 weeks in a long-arm cast, followed by a short-arm cast worn until healing is seen on radiographs. Waist fractures require a total of 8 to 12 weeks of immobilization. Vertical oblique fractures of the waist should be referred to an orthopedist. Closed treatment of stable, nondisplaced fractures on the proximal pole can be at- tempted; however, orthopedic referral is suggested because open treatment is prefer- able. Proximal pole fractures require 12 to 24 weeks of immobilization for closed treatment. Surgical Management An incision is made over the center of the tubercle of the scaphoid. This can be easily palpated with the wrist in full radial deviation. The incision is curved toward the thumb at the distal end. The proximal end of the incision extends along the radial border of the flexor carpi radialis tendon. An incision is made in the sheath of the flexor carpi radialis tendon and the tendon is retracted to expose the anterior capsule over the scaphoid bone. The capsule is incised from the tubercle to the tip of the radius. Care should be taken to avoid the underlying articular cartilage of the scaphoid. The radiolunate ligament is divided to provide adequate exposure of the proximal pole of the scaphoid (Fig. 56–5). F R A C T U R E S A N D D I S L O C A T I O N S O F T H E W R I S T 348 Figure 56–5. The surgical exposure of the scaphoid fracture. Figure 56–6. The jig, and the drilling, tapping, and placement of the screw. After the joint between the scaphoid and trapezium is identified, an incision is made in the joint capsule around the tubercle of the scaphoid. To avoid damage to the blood vessels entering the scaphoid, the incision should not be too deep or too proximal. The hemarthrosis is suctioned, and soft tissue that is attached to the fracture site is removed. Loose bone fragments are removed. The wrist is manipulated to assess S C A P H O I D F R A C T U R E S 349 the instability of the fracture, and the scapholunate ligament is examined for possi- ble tears. The fracture is then reduced, assuring the correction of any angular, rotary, or translocation deformity. To maintain the reduction, a Kirschner wire (K wire) may be inserted into the tip of the tubercle directed toward the apex of the proximal pole. The fracture is then fixed using a guiding jig. If there is doubt regarding the alignment of the jig, a radiograph should be taken with a K wire inserted in the guide. Once the guide is in the correct position, the screw is placed in position (Fig. 56–6). Radiographs can verify placement of the screw and reduction of the fracture. The wrist capsule is closed and the radiolunate ligament is repaired. The capsule over the scaphoid is closed and the soft tissues are sutured. The skin is closed and a bandage is applied. The bandage should allow for sufficient movement to prevent stiffness in the joint. Complications With proper technique, most complications can be avoided. However, adhesions can cause stiffness in the joint, and volar scar tenderness has been seen. Nerve dam- age during surgery is a risk as well as the development of a neuroma at the surgical site. Poor screw placement or other technique problems can cause a nonunion of the fracture. Suggeste d Readings Barton NJ. Twenty questions about scaphoid fractures. J Hand Surg [Br] 1992;17B: 289–310. Downing ND, Oni JA, Davis TR, Vu TQ, Dawson JS, Martel AL. The relationship between proximal pole blood flow and the subjective assessment of increased den- sity of the proximal pole in acute scaphoid fractures. J Hand Surg [Am] 2002;27A: 402–408. Gellman H, Caputo RJ, Carter V, et al. Comparison of short and long thumb-spica casts for nondisplaced fractures of the carpal scaphoid. J Bone Joint Surg [Am] 1989; 71A:354–357. Hebert TJ. Open volar repair of acute scaphoid fractures. Hand Clin 2001;17: 589–599. Herndon JH. Scaphoid Fractures and Complications. Rosemont, IL: American Acad- emy of Orthopaedic Surgeons; 1994. Krimmer H. Management of acute fractures and nonunions of the proximal pole of the scaphoid. J Hand Surg [Br] 2002;27B:245–248. Plancher KD. Methods of imaging the scaphoid. Hand Clin 2001;17:703–721. Polsky MB, Kozin SH, Porter ST, Thoder JJ. Scaphoid fractures: dorsal versus volar approach. Orthropedics 2002;25:817–819. Powell JM, Lloyd GJ, Rintoul RF. New clinical test for fracture of the scaphoid. Can J Surg 1988;31:237–238. F R A C T U R E S A N D D I S L O C A T I O N S O F T H E W R I S T 350 Raskin KB, Parisi D, Baker J, Rettig ME. Dorsal open repair of proximal pole scaphoid fractures. Hand Clin 2001;17:601–610. Taleisnik J. Fracture of the carpal bones. In: Green DP, ed. Operative Hand Surgery, 2nd ed. New York: Churchill Livingstone; 1988. [...]... technique, and earlier range of motion can optimize postoperative wrist motion Suggested Readings Barton NJ Experience with scaphoid grafting J Hand Surg [Br] 19 97; 22B:2:153–160 Cooney WP Bone-grafting techniques for scaphoid nonunion Tech Hand Upper Extrem Surg 19 97; 1:148–1 67 Green DP The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion J Hand Surg [Am] 1985;10A:5 97 605 Hastings... fracture: simple or complex? J Hand Surg [Br] 1992;17B:156–159 Mayfield JK, Johnson RP, Kilcoyne RK Carpal dislocations: pathomechanics and progressive perilunar instability J Hand Surg [Am] 1980;5:226–241 Richards RS, Bennett JD, Roth JH, Milne K Arthroscopic diagnosis of intraarticular soft tissue injuries associated with distal radial factures J Hand Surg [Am] 19 97; 22 :77 2 76 6 374 ... RADIAL STYLOID FRACTURES 59 Radial Styloid Fractures James H Calandruccio History and Clinical Presentation A 40-year-old man lost control of his four-wheeler and landed on his dominant wrist He was initially examined at a local emergency room where a closed deformity about the wrist level was observed A thumb-spica splint was applied, and he was referred to an orthopedic surgeon whom, he saw 5 days... a lateral projection of the wrist, and an oblique view with the forearm in 35 degrees of supination These films were negative Follow-up serial films at 4 weeks demonstrated a fracture of the proximal pole of the scaphoid (Fig 57 1) Figure 57 1 Posteroranterior view of the hand showing acute proximal pole scaphoid fracture 351 Figure 57 2 Evaluation of acute radial-sided wrist pain The diagnosis of... U R E S 57 Percutaneous Treatment of Proximal Pole Scaphoid Fractures Joseph F Slade III and John D Mahoney History and Clinical Presentation A 20-year-old male college football player sustained a hyperextension injury to his wrist after a fall during practice He initially had radiographs taken, and his injury was diagnosed as a sprain and was splinted for 2 weeks He was referred to the hand clinic... range-of-motion exercises are being performed, there is an increased likelihood of K-wire breakage from motion imparted by overlying tendons and other soft tissue Some degree of wrist stiffness 3 67 F R AC T U R E S A N D D I S L O C AT I O N S O F T H E W R I S T Figure 58–8 Range-of-motion check in a patient at 1-year follow-up showing slight decrease in the operation side The patient reported no pain... mobility and makes anatomic reduction easier Following A B Figure 59–3 Lateral (A) and posteroanterior (B) roentgenograms of wrist injury in Figures 59–1 and 59–2 at 12-month follow-up 371 F R AC T U R E S A N D D I S L O C AT I O N S O F T H E W R I S T secure fixation of the scaphoid, the distal radial intraarticular fracture is reduced and rigidly fixed Derotation of the extended lunate and flexed... wound 5 days after surgery, and a long-arm thumb splint was reapplied until the sutures were removed 12 days after surgery A nonremovable thumb spica splint was worn for 3 weeks The patient’s digital sensation had not improved The patient returned in 1 week with increasing pain and swelling of the hand and fingers, further restricting finger movement He was given two steroid dose packs and additional narcotic... a wrist sprain His pain gradually subsided and became asymptomatic after an unknown amount of time However, over the last 2 years he has noticed wrist stiffness, mild and occasional pain, and mild decreased wrist motion Physical Examination The right wrist has no swelling There is mild tenderness on palpation and mild tenderness with Watson shift testing; however, there is no subluxation The right wrist. .. placement of the screw in a free -hand fashion Verification of jig placement with the image intensifier before screw insertion prevents malplacement Prolonged postoperative immobilization is not necessary Use a firm, padded bandage to provide wrist support and protection for the first 2 weeks At this time, remove the sutures and begin a program of active motion rehabilitation 3 57 F R AC T U R E S A N D D . of acute fractures and nonunions of the proximal pole of the scaphoid. J Hand Surg [Br] 2002;27B:245–248. Plancher KD. Methods of imaging the scaphoid. Hand Clin 2001; 17: 703 72 1. Polsky MB, Kozin. [Am] 1989; 71 A:354–3 57. Hebert TJ. Open volar repair of acute scaphoid fractures. Hand Clin 2001; 17: 589–599. Herndon JH. Scaphoid Fractures and Complications. Rosemont, IL: American Acad- emy of. Plancher His to ry and Clinical Presentation A 1 7- year-old boy presented to the emergency room with a dull, deep pain in the wrist after a fall, while he was rock climbing, on an outstretched hand. The