Hand Fracture Management

1
Hand Fracture Management

• Angie Dickerson-Schnatz MPT,OCS,CHT
• UD ORTHO LECTURE 2007

2
Hand Fractures

• Nagi Disability Model
• Pathology hand / finger fracture
• Impairments
• Pain
• ROM loss
• Strength loss
• Functional limitations
• Inability to open doors/ twist and pull knob
• Inability to get hand in pocket
• Disability
• Unable to operate paint gun

3
Metacarpal Fractures

• Injury-direct to metacarpal, indirect through
  finger twisting force
• Soft tissue involvement
• Must be stabilized to allow early motion
• cast/splint cast,
  preop 5th mc fx
• ORIF

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Metacarpal Fractures

• Fluorscopy, in OR
• 22 yo soccer player

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Metacarpal Fractures

• Xray

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Metacarpal Fractures
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Metacarpal Fractures
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Metacarpal Fractures

• PT management
• Protect fracture/prevent contracture
• splint in MCP flexion/ surgeon guided
• PIP extension
• Edema control
• Fluid flush
• Coban wrap
• Soft tissue mobilization
• scar management
• vibration/desensitization

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Metacarpal Fractures
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Metacarpal Fractures
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Metacarpal Ligaments
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Metacarpal Fractures

• Tendon Glides
• Finger ROM
• PIP mobs
• NO PASSIVE MOTION
• WITHOUT BONY UNION

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Metacarpal Fractures

• Tendon Glides

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Metacarpal Fractures

• Tendon Glides

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Metacarpal Fractures

• Confirmed union
• Progress intrinsic
• stretch

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Metacarpal Fractures

• Confirmed union
• Progress intrinsic stretch
• PROM/ Stretch
• Gradual strength progression

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Metacarpal Fractures

• Complications
• malrotation
• implant pain
• prolonged MCP extension
• contracture
• loss of motion due to
• intra-articular fracture (bony block)
• extensor lag due to
• metacarpal shortening

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Metacarpal Ligaments
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Phalangeal Fractures

• Distal phalanx
• Tuft fracture
• nail bed involvement
• Management
• desensitization
• functional exercise
• active ROM
• 40yo CPA, tuft fracture with
• FDP avulsion

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Phalangeal Fractures

• Middle and Proximal Phalangeal fractures
• Stable Fracture
• early immobilization
• protected motion
• buddy taping
• blocked motion with splint
• Splint MCP flexion, IP ext as stable
• Tendon gliding
• Progress to strengthening after union

21
Phalangeal Fractures

• Middle and Proximal Phalangeal fractures
• Unstable/displaced fractures
• ORIF
• 20 yo F MVA

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Phalangeal Fractures

• Middle and Proximal Phalangeal fractures
• Unstable/displaced fractures
• ORIF

23
Phalangeal Fractures

• Middle and Proximal Phalangeal fractures
• Unstable/displaced fractures
• ORIF
• Closed reduction and percutaneous pinning
• Fixation to allow early motion
• protected motion
• tendon gliding / blocked IP flexion
• AROM / AAROM
• scar mobilization

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Phalangeal Fractures

• Middle and Proximal Phalangeal fractures
• lateral band anatomy

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Phalangeal Fractures

• Middle and Proximal Phalangeal fractures
• Unstable/displaced fractures
• ORIF
• 2 weeks later

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Phalangeal Fractures

• Middle and Proximal Phalangeal fractures
• Unstable/displaced fractures
• PROM after union
• IP joint mobs
• blocked flexion
• splinting
• serial cast
• cylinder cast
• PIPer DIPer

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Phalangeal Fractures

• Serial casting
• Cylinder casting

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Phalangeal Fractures

• Complications
• fracture in articular surface
• malunion
• adhesions
• PIP joint contracture
• tendon injury
• nerve injury
• CRPS / RSD

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Phalangeal Fractures

• Phase 1
• Protect fracture
• Protect soft tissue
• Edema control

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Phalangeal Fractures

• Phase 1
• Protect fracture
• Protect soft tissue
• Edema control

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Hand Fractures

• Phase 1
• Edema control

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Hand Fractures

• Phase 2
• Restore motion
• thermal modalities
• AROM
• joint mobilization (HLBS)
• scar mobilization
• dynamic / progressive
• static splinting
• tendon gliding

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Hand Fractures

• Phase 3
• Restore strength
• wrist
• grip
• NMES
• weights
• exercise tubing

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Hand Fractures

• Phase 4
• Restore Function
• dexterity tasks
• functional tasks
• simulated tasks via BTE
• or Biodex

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PIP Sprain/Dislocation

• Unstable
• Block extension 30 degrees
• Splint 2-3 week
• Stable
• Splint 3-5 days
• buddy strapping

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Hand Fractures

• Volar plate fracture
• composite flexion

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PIP Sprain/Dislocation

• Results in
• Stiffness
• Edema
• Goals
• Prevent flexion contracture
• Prevent loss of terminal finger extension
• Return Flexion
• Edema control
• Improve Tendon gliding

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PIP Sprain/Dislocation

• Prevent flexion contracture
• Serial casting
• Dynamic splinting with less than 20 degree
  (capiner)
• Strengthening in 4-6 weeks

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PIP Sprain/Dislocation

• Regain flexion
• Active finger flexion
• IP joint mobs
• Place and hold
• Strengthening in 4-6 weeks

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PIP Sprain/Dislocation

• Treatment to improve tendon gliding
• Blocked DIP flexion to maximize tendon gliding of
  FDP

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PIP Sprain/Dislocation

• Treatment to improve tendon gliding
• TGEs

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UCL Sprain Thumb MCP

• Gamekeepers thumb
• Grade I and II
• Splint/Thumb Spica up to 5 weeks
• Treatment pain modified
• Regain MP Flexion
• Strengthen
• Avoid tip pinch 8 weeks

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UCL Sprain Thumb MCP

• Gamekeepers thumb
• Grade I and II
• Splint/Thumb Spica up to 5 weeks

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UCL Sprain Thumb MCP

• Grade III
• Surgery
• Splint 4 weeks
• Scar mobilization
• Outcomes
• 20-30 ROM MCP (Mitsionis et al 2000, Downey et
  al 1995)
• Grip and pinch 90-100 uninvolved (Downey et al
  1995, Melone et al 2000)

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Hand Lab

• Tendon Glides
• Finger ROM
• MCP Mobs
• PIP Mobs
• Blocked Flexion
• Intrinsic stretch