Bone and Joint Injuries: Hand, Wrist, and Distal Radius

CHAPTER
63


Bone and Joint Injuries: Hand, Wrist, and Distal Radius



Francisco del Piñal


Bone and joint injuries in the hand, wrist, or radius are very common and require exacting care to achieve a good result. Complications may occur even when things are correctly performed. When things are performed faultily, even an average result is rare. Hand surgeons see an enormous number of complications after fractures and realize that the ability, as surgeons, to cause further harm is immense.


Some of the complications stem from overt malpractice, whereas others originate from traps that can be deceptive even for relatively expert surgeons. This chapter only addresses the most common errors and the less common but more detrimental ones. The chapter also offers some solutions for those untoward results. Some of the alternatives I propose here are unproved and require an open mind. However, experience has shown some complications cannot be solved by following the current “standard of care.” Areas of general knowledge are not covered here.


I have adopted several principles in managing fractures through the years:


Principles in Fracture Management


1. Incorrect or marginal treatment will result in either poor or very poor outcomes.


Surgeons must study all published data regarding fracture management to be able to make well-informed decisions.


2. Overly aggressive surgery will trigger major complications.


Surgery in itself causes additional damage and interferes negatively in the outcome. Hence, only what truly needs to be operated should be operated, and with the least possible invasiveness. In other words, the damage the surgeon is going to inflict has to be worthwhile. Unnecessarily aggressive surgery will mostly yield poor results.


I have a low threshold to operate in search of the anatomical exactness on radiographs. However, some patients can tolerate some deformity and still have a good functional result. Nevertheless, there are two reasons for searching for perfect radiographs in my practice. The first, and most logical, is that restoring the anatomy is a surgeon’s goal and avoids preventable problems. The second, less obvious, reason is that even if an abnormal radiographic result will yield a functional result for most patients, this may not be true for a worker’s compensation case. Another surgeon may argue that the cause of the patient’s complaint is a “faulty” reduction that is evident on the radiograph. This may be the first step of a claim, and my practice is very much biased toward work-related injuries.


3. The policy of “sensible radicalism” yields the best results.


This essentially means that the surgeon should not complicate a case that may benefit from a simple treatment. However, the surgeon also should not accept a poor result to keep the surgery simple to avoid complications. Complex, unsolved problems require newer approaches and sometimes aggressive surgeries to achieve a good result.


The application of this principle requires surgeons to be good technicians. This means not just being a good plastic surgeon (understanding soft tissue management and being efficient in microsurgery) but also being a good orthopaedic surgeon (competent at arthroscopy, knowledgeable in fixation, understanding bone healing).


4. Complex surgery is for skilled surgeons.


A skillful technician will achieve reproducible results in complicated surgery. On the other hand, complicated surgery performed by a poor technician yields catastrophic results. As a corollary, easy surgery is more popular but not necessarily the best for the patient’s problem.


Fractures of the Phalanges and Metacarpals


A hand surgeon commonly sees digital fractures. Most cases respond well to the following:


• Reduction under local anesthesia


• Immobilization or protected range of motion for 3 to 4 weeks


• Self-directed exercises


When the reduction does not meet the criteria of acceptability1 (Table 63.1), surgery is recommended. Because articular fractures need an exacting reduction, most require surgery too. Finally, open fractures require emergent débridement and fixation. Patients with special needs (professional sportsmen, surgeons, etc.) may need surgery despite meeting the criteria referred to in Table 63.1 to shorten the recovery period. The presence of multiple fractures is in itself not an indication for surgery. However, it is quite common that one of them fails to meet the criteria of acceptability, making surgery necessary for all of them1 (Fig. 63.1).


Open reduction and internal fixation, although attractive to surgeons, has a deleterious effect on the functional outcome of any digital fracture.13 Hence if surgery is needed, the surgeon should determine the least invasive method that provides stable fixation to allow immediate range of motion. The surgical options are wide-ranging. Table 63.2 provides a summary of methods that meet most of my needs. Needless to say, the surgeon should be prepared to change plans according to the personality of the fracture and the intraoperative findings. I have achieved very satisfying results by using intramedullary headless cannulated screws for fractures of metacarpals and phalanges.4 A 1-mm K-wire is introduced through a nick in the skin, retrogradely (distal to proximal), and through the head of the metacarpal–proximal phalanx. This K-wire is used to reduce and align the fracture. Next, the K-wire is used as a guide for a double-threaded headless cannulated screw (as a rule, 2.-mm diameter for phalanges and 3 mm for metacarpals)4 (Fig. 63.2). The procedure is particularly indicated in transverse and short oblique fractures. Fixation can be performed in a matter of minutes, allowing immediate range of motion, with minimal trauma. The operation is not indicated when there is bone loss but can be used successfully in very complex scenarios (Fig. 63.3).


Phalangeal fractures, more so than metacarpal fractures, are prone to complications and bad results: lack of full range motion; loss of normal alignment; lack of union; and the catastrophic infection are among the most prevalent.


Ideally, a finger should recover an excellent result after any fracture, defined as more than 240 degrees of total active motion (TAM; active flexion of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints minus the extension deficits in these joints). However, loss of the normal arc motion is common. Incomplete range of motion can be related to poorly executed surgery; a noncooperative patient; combined injuries; and, very often, late initiation of active range of motion.


Table 63.1 Criteria of acceptability for phalangeal fractures depending on the location of the fracture




















Diaphysis


Metaphysis


10° of sagittal angulation


20° of sagittal angulation


10° of coronal angulation


10° of coronal angulation


0° of rotational deformity


0° of rotational deformity


Source: From Chow SP, Pun WK, So YC, et al. A prospective study of 245 open digital fractures of the hand. J Hand Surg Br 1991;16(2):137–140.


Table 63.2 Surgical options for fracture


























Fracture type


Options


Stable fractures


Early protected range of motion


Unstable fractures


• Transverse or short oblique


Intramedullary screws


• Long oblique


Lag screws


• Comminuted


Blocked plates (with or without bone graft)


• Bone loss


• Blocked plates with bone graft


• Axial K-wires with bone graft (for P2 or thumb P1)


• Vascularized bone graft


An uncooperative patient will spoil any complex reconstruction. However, most cases of insufficient range of motion I see are related to faulty fixation, overinvasive fixation, or a dorsally placed plate. The latter is especially relevant, because it is axiomatic that any plate placed on the dorsal surface of the proximal phalanx will yield a poor functional result (Fig. 63.4).






Incomplete range of motion is much more common in phalangeal than metacarpal fractures, because the former is surrounded by tendons and has a minimal gliding layer. Restrictive adhesions are common and require tenolysis. Tenolysis is sometimes offered as a simple solution for dealing with the adhesions, but my experience has often not shown this to be the case. Extensor tenolysis rarely yields a normal result (260 degrees of total active motion), particularly if multiple fingers are involved.5 By the same token, when flexor tendons are involved, an excellent result is rarely possible, and there is an unknown (but real) risk of flexor tendon rupture during or after the operation, a catastrophic situation. Again, the surgeon must resist the temptation to place a plate dorsally in a proximal phalanx. Although easier, technically speaking, the plates destroy the gliding layer and create massive adhesions that are nearly impossible to resolve. Tenolysis in an uncooperative patient is highly discouraged, because the possibility of complications is high and the likelihood of improvement nil. These factors have led me to become increasingly concerned regarding patients with adhesions after digital fractures, and I recommend all readers not to approach tenolysis lightly. Lack of full range of motion after a tenolysis is poorly accepted and is a major cause of patient dissatisfaction. All this underscores the importance of doing things right from the beginning.


Delay in starting active range of motion in a phalangeal fracture for more than 3 or 4 weeks will unavoidably yield a poor result because of adhesions. Early range of motion should be encouraged in stable fractures using functional braces.1 Others require immobilization, because they are not as stable, but they will still heal in 3 weeks. However, if the fracture characteristics arouse concerns of not healing by 3 to 4 weeks (basically because of poor contact or comminution), surgery is recommended. Delayed healing will cause hypertrophic callus and more inflammation, entrapping the flexor and extensor tendons over large surfaces. By the same token, if the surgeon decides to operate on a fracture, surgery must be followed by immediate range of motion. As a rule, open reduction and internal fixation followed by immobilization is nonsensical.


Malunions


Malunions should not occur if the basic tenets of fracture management are applied. As stated earlier, low or no toler ance for deformity in phalangeal fractures (see Table 63.1) will reward the surgeon with mostly good results. By the same token, corrections that appear to fall within the acceptable limits on radiographs after reduction may develop into a major deformity and the need for corrective osteotomy if left unaddressed. It is important to highlight that malunions are often associated with delayed healing, and this in turn creates an adhesion issue, thus compounding the problem exponentially. The need for secondary surgery and a poor functional result will be nearly guaranteed if the surgeon is not prepared to perform a complex surgical reconstruction (discussed later). It is therefore of utmost importance to achieve healing of the digit in the customary 3 or 4 weeks. The surgeon must do everything possible to procure stability to permit full range of motion as soon as possible.


Metacarpal fractures, as opposed to phalangeal fractures, are much more tolerant of deformity, particularly in less-demanding individuals. However, they can be a source of problems as well. A 50-degree flexion deformity in the neck of the fifth metacarpal may be considered as highly successful to the surgeon but can be unbearable for a patient if the injury occurred at work. For this reason, I am very reluctant to leave radiological deformities unaddressed. Furthermore, the fact that a generous soft tissue layer protects them makes the metacarpals less prone to extensor and flexor adhesions after localized trauma. However, after major trauma, the bed becomes heavily scarred and devascularized—the fat disappears. In this setting, adhesions are impossible to solve unless a gliding layer is restored again6 (Fig. 63.5).




Nonunions


When a large amount of bone is devascularized, such as in severe cortical comminuted fractures, or when the fracture is combined with a soft tissue injury, the surgeon should consider nonunion as a possibility—a functional catastrophe at best. Even the most benign of these scenarios will have a poor result requiring secondary surgery.


The surgeon should do everything possible to achieve healing in the customary 3 to 4 weeks. In my practice this includes providing rigid fixation with the minimal possible devascularization, liberal use of cancellous bone graft, and provision of good soft tissue cover and vascularized bone graft for the worst cases. I use this armamentarium with the sensible radicalism mentioned previously—that is, if I have any doubt that the patient may experience a delayed healing, I opt for a more aggressive treatment. For example, a fracture may heal with a plate, but if there is cortical comminution, the healing is going to be slow and interfere with the result. Thus I would add cancellous bone graft (Fig. 63.6).


It is important to understand that surgery may convert a somewhat misaligned yet potentially healing fracture into a nonunion because of the negative effect that exposure has on the blood supply. Salvage of any nonunion may require “exceptional” surgery if a good result is to be obtained. I typically combine new fixation and vascularized bone graft to speed healing (Fig. 63.7).


Infection and Osteomyelitis


After any fixation, the appearance of infection is a major disaster. Fortunately, the infection rate in phalangeal fractures is very low. In fact, it has been calculated to be 2% in open fractures and less if closed.6 Although some of them can be treated by removal of the hardware and antibiotic therapy, amputation is also quite prevalent.2,6,7 Established infection in the tubular bones of the hand resulted in an amputation rate approaching 50% in a study by Reilly et al.7


The management of infection depends on whether there is bony stability and whether there is associated combined soft tissue loss (Table 63.3). In the “ideal” case of infection with bone continuity, hardware removal and oral antibiotics will cure the problem. The issue becomes increasingly complicated if the soft tissue cover is insufficient or the fixation is tenuous.


In my experience, most severe infections occur as a combination of open fracture and poor coverage, as after a crush. It is axiomatic that if the soft tissues are left unattended (i.e., they are not radically débrided and good cover is not provided at the time of initial treatment), infection is unavoidable. Infection in the setting of poor coverage does not clear until the bone is radically débrided and a good soft tissue provided (which is what the surgeon should have done in the first place). Even if, after a heroic surgical operation, amputation is avoided, infection will rarely clear without a high price: a major loss of motion and/or arthrodesis of a neighboring joint (Fig. 63.8).



I have had positive experience using vascularized bone graft taken from the toe metatarsal for long defects and the phalanx for medium and small defects.8 As in most cases of infection in the fingers there is a need of soft tissue cover; there is no role for the medial femoral condyle corticoperiosteal flap.


Table 63.3 Management of infected digital fractures

































Soft tissue cover


Bone stability


Treatment


Ok


+


1 + 2


+/−


+


1 + 2 + 3 + 4 (local flap)


++


+


1 + 2 + 3 + 4 (distant flap)


+


+/−


1 + 2 + 3 + 4 + 5


Any



1 + 2 + 3 + 6


Notes: 1, Hardware removal; 2, antibiotics; 3, débridement; 4, local flap (minor soft tissue defect) or free flap (major defect); 5, cancellous bone graft; 6, vascularized bone flap.



Articular Fractures


Articular fractures need exacting reduction if pain and early degeneration are to be avoided. Although any joint can be injured and be a source of problems, because of its prevalence, the young age of the group involved, and the high impact it has on hand global function, this discussion focuses solely on the so-called PIP joint “sprain,” which may have an extremely poor outcome.


PIP joint dislocations are extremely common. Most are reduced on the side of a sports field by a well-intentioned coach, and many do well. Some, however, are actually impacted fracture dislocations and difficult to diagnose even if proper radiographs are taken. These subtle differences, which are not appreciated initially, can evolve and become evident later.


At the PIP joint level the following difficult problems occur: condylar malunions, impacted fracture–dislocation, and irreversible damage or partial joint loss.


Condylar malunions are managed by a dorsal approach and after creating a distally based extensor flap that contains most of the central band and part of the lateral bands. The joint is flexed and the malunion comes easily into view. After stable fixation, active flexion exercises are encouraged, whereas the extensor repair is strong enough to allow active assisted exercises (Fig. 63.9). What is key at the time of mobilization and fixation of the displaced fragment is to understand that aggressive maneuvers may lead to fragment devascularization and, in turn, necrosis. Radiographs of a previously perfect result may reveal a collapsed joint—a disaster that only can be solved in young individuals by a joint transfer or an arthrodesis.


Malunion after impacted fracture dislocation of the base of the middle phalanx is more common. Unless properly performed radiographs are taken, the diagnosis will be missed. Unfortunately, this is common, but most cases are amenable to reconstruction. I favor a shotgun approach to fully see the deformity. Then, by using ultrathin bone instruments (dental picks and 1.0-mm rongeurs) the fracture is re-created and fixation with 1.3-mm screws or cerclage wire is carried out.9 I have had very good results in previously nonoperated patients with this approach (Fig. 63.10). Conversely, I have had mostly disappointing results when patients have been “aggressively” operated previously (i.e., screws, plates, or combined approaches). In this situation there is an enormous amount of scarring, and the risk of devascularization of the fragments is very high. I believe most of these cases will end up requiring a salvage operation, which I would recommend from the outset in some individuals.




Some patients are seen for unsalvageable joint trauma or previously failed surgery that are already beyond reconstruction. For those patients the only alternative is an arthrodesis, a prosthesis, or a vascularized joint transfer.10 I do not believe a prosthesis has a role in the PIP joint for active patients. I have a fair experience (nearly 50 cases) in transferring PIP joints from the second toe to the PIP joint of fingers and in MCP joint reconstruction (both metatarsophalangeal and PIP joints). My results can be summarized as follows: When the injury is isolated to the joint and there is minimal scarring, a very good result can be expected. However, when there is multitissue damage (flexor tendon, previous flaps, or late reconstructions) a moderate (30–50 degrees of active range of motion) result can be anticipated. In most published series the cases are mixed, and it is difficult for the reader to determine the real benefit of the joint transfer in young individuals (Fig. 63.11).


Carpus Fractures


The scaphoid is the most commonly fractured bone in the carpus and the most difficult to handle. Furthermore, being a bone mostly covered by cartilage, the blood supply has limited entryways, and mismanaged fractures have a high rate of nonunions and delayed union. The introduction by Herbert and Fisher11 of the double-threaded screw marked a benchmark in the treatment of scaphoid fractures. A high success rate was reported for fractures and nonunions alike.11 Some factors that are known to carry a poor prognosis for healing have been found to be a clear indication for surgery:


• Proximal pole fractures


• Displaced fractures (more than a 1 mm)


• Delayed presentation (more than 4 weeks)


As for other fractures, to shorten the recovery period, patients in certain types of professions benefit from surgery despite it not being, technically speaking, medically indicated.


Unfortunately, what was not underlined when the procedure was presented was that the technique is exacting and without room for error. The risk of causing devastating damage to the joint is even higher if inexperience is combined with the now in vogue percutaneous approach. Understanding the complex scaphoid anatomy is key to avoiding complications.12 The industry has a major role in pushing the product, which may have overwhelmingly negative effects for the joint (Fig. 63.12).




When the scaphoid has failed to unite by a certain time after the fracture (6–12 weeks), the possibility of healing without intervention is nil. The nonunited scaphoid requires treatment in symptomatic patients, and it is probable that asymptomatic “patients” should also undergo reconstruction to avoid development of the scaphoid nonunion advanced collapse (SNAC) wrist. However, surgery is controversial in truly asymptomatic patients, because a clear progression to degeneration is not certain, whereas patients may become symptomatic if the surgery is unsuccessful. Scaphoid nonunion on its own is the topic of several books, so summarizing it is a difficult endeavor. There are myriad techniques, but the basic modifiers are the blood supply of the proximal pole, the location of the fracture, the loss of length of the scaphoid, and the degree of degeneration of the joint. Table 63.4 summarizes my current management protocol of scaphoid nonunion.


The presence of blood supply in the proximal fragment is a sine qua non condition to proceed to reconstruction. I have found that if the proximal fragment is avascular, there is no way to achieve healing of the cartilage cover (though the bone may heal). An exceptional reconstructive operation may be indicated apart from a salvage operation.13 The problem is that the definition of vascularity is subjective. Part of the confusion relates to the fact that authors (surely unconsciously) stretch the term to their benefit to glorify the virtues of a proposed technique. However, I have tried nearly every technique, and I have reached the conclusion that when the scaphoid is necrotic (i.e., fragmented, “toothpaste” aspect with yellowish deposits), healing is impossible. However, a hypovascular scaphoid (the bone may not have bleeding points but has normal bony structure at surgery) deserves an attempt at reconstruction, independently of the imaging result. Any hypovascular fracture benefits from vascularized bone transplant, and the scaphoid is no exception. Finally, if the scaphoid has good blood supply, then nonvascularized bone graft is enough.


The location of the fracture is important for the approach and the method of fixation. Ideally all reconstructions should be fixed with screws, but a small fragment may not have enough volume to harbor the screw without further fragmentation. K-wires may be the only feasible method in this scenario. Another major breakthrough in the management of the scaphoid has been the introduction by Ho of the arthroscopy in scaphoid nonunion.14 This method is particularly useful in hypovascular proximal poles, because the surgeon does not disturb the remaining blood supply and bone can be added into the nonunion (Fig. 63.13).


If the scaphoid is deformed and flexed, the so-called humpback deformity, the surgeon must restore the length. Otherwise, the wrist joint mechanics will be distorted and degeneration will ensue. Again there are several methods: a nonvascularized wedge graft, a pedicled volar graft,15 and a distant medial femoral condyle flap are among the most popular.16 I do not hesitate, if the defect is long and any of the unfavorable modifiers are present, to proceed directly to a vascularized transfer. This may be considered overkill, but if one minimizes dissection at the time of flap harvesting, the donor site sequelae are negligible, and the benefit of the blood supply undeniable (Fig. 63.14).


Oct 23, 2018 | Posted by in General Surgery | Comments Off on Bone and Joint Injuries: Hand, Wrist, and Distal Radius
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