Stable Fixation of the Hand and Wrist PDF
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Stable Fixation of the Hand and Wrist "A good hand surgeon should slip into the hand and out again without the hand ever knowing he was there." Attributed to Sterling Bunnell by Raymond M. Curtis Alan E. Freeland Michael E. Jabaley James L. Hughes Stable Fixation of the Hand and Wrist With 900 Halftone and 60 Line Illustrations Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Alan R Freeland, M.D. Professor and Chief, Section of Hand Surgery,University of Mississippi Medical Center; Attending Staff, Jackson Veteran's Administration Hospital, Mississippi Methodist Rehabilitation Center, Blake Clinic for Crippled Children and Mississippi Children's Rehabilitation Center, Jackson, Mississippi, U.S.A. Michael E. Jabaley, M.D. Clinical Professor, Division of Plastic Surgery, University of Mississippi Medical Center; Attending Staff, St. Dominic's-Jackson Health Services Center, Mississippi Baptist Medical Center, River Oaks Hospital, Mississippi Methodist Rehabilitation Center, Jackson, Mississippi, U.S.A. James L. Hughes, M.D. Professor and Chief, Division of Orthopaedic Surgery, University of Mississippi Medical Center; Attending Staff, Jackson Veteran's Administration Hospital, Mississippi Methodist Rehabilitation Center, Blake Clinic for Crippled Children and Mississippi Children's Rehabilitation Center, Jackson, Mississippi, U.S.A. Library of Congress Cataloging in Publication Data Freeland, Alan E. Stable fixation of the hand and wrist. Includes bibliographies and index. 1. Hand-Fractures-Treatment. 2. Wrist-Fractures Treatment. 3. Internal fixation in fractures. I. Jabaley, Michael E. II. Hughes, James L. (James Langston), 1937- . III. Title. [DNLM: 1. Fracture Fixation, Internal-methods. 2. Hand-surgery. 3. Wrist-surgery. WE 830 F854s] RD559.F74 1986 617'.575044 86-3763 @ 1986 by Springer-Verlag New York Inc. Softcover reprint of the hardcover 1s t edition 1986 All rights reserved. No part of this book may be translated or reproduced in any form without written permission from Springer-Verlag, 175 Fifth Avenue, New York, New York 10010, U.S.A. The use of general descriptive names, trade names, trademarks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information of this book is believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Typeset by Arcata GraphicslKingsport, Kingsport, Tennessee. 9 8 7 6 5 4 3 2 1 ISBN-13: 978-1-4613-8642-1 e-ISBN-13: 978-1-4613-8640-7 DOl: 10.1007/978-1-4613-8640-7 Foreword In the past, conservative (or nonoperative) treatment of fractures of the hand has been the rule and severe and multiple fractures usually did not receive surgical atten tion. There are probably several reasons why this is so. Rarely did these fractures threaten life; they usually healed rapidly; and after immobilization, hand pain usually subsided. At the same time, intraarticular fractures frequently were unstable and often displaced and attempts to correct deformity were considered difficult to achieve. As a result, the ultimate joint motion in many cases was limited. It can fairly be said that decisions and techniques regarding internal fixation of small joints and bones were not known to most surgeons. Although the history of internal fixation is not extensive, there have been some exciting events. In the 16th century gold plates were used to repair cleft palates. Later, the Chinese employed wire loop sutures to correct difficult fractures. In the 18th century silver cerclage wires were used to achieve fixation and promote early bone healing. Although these fracture treatments occasionally proved successful, more frequently they did not and they never enjoyed wide acceptance. Doctors Alan Free land, Michael Jabaley, and James Hughes have described this history of bone fixation in a manner that is both colorful and educational and they have managed to extract the essential features that lend continuity to the story of the development of internal fixation. While the modem· treatment of fractures has progressed rapidly, changes in the treatment offractures of the hand and wrist have been a good deal slower in developing. Metallic fixation of fractures of the hip and the long bones of the lower extremities and of the arm all developed throughout the first half of this century. In the 1950's, '60's, and '70's, newer methods of rigid internal fixation and external fixation came to be used more frequently and more effectively. While these developments were occurring, there was also a growing experience with the use of wire fixation and tension banding as a technique was perfected and accepted. Still, rigid bone fixation was used relatively infrequently about the hand and these principles were not widely applied in small bone fractures. It is certainly true that many types of hand injury did not require rigid bone fixation but, at the same time, many others did. One wonders: why the delay? One problem had to do with both reducing and holding difficult fractures about the hand in a way that allowed early and extensive joint motion of involved joints. A more basic challenge involved soft tissue management: how to expose bone without entrap ping gliding structures in the inevitable scar which follows? These problems, of course, are integrally associated with the main goals of the treatment of hand fractures and must be addressed. Perhaps nowhere is it as important as in the hand and wrist to achieve maximum motion and strength in concert with accurate alignment and stable union. Stable Fixation of the Hand and Wrist describes a new system that has been devel oped, tested, tried, and used for rigid internal fixation of problem fractures and chal lenging reconstructions of the hand and wrist. This is not the application of techniques of hip surgery or knee surgery adjusted to the size of hand surgery; instead, it is a description of new techniques of hand surgery developed after a special anatomic and functional analysis to restore maximum use and, at the same time, maintain We dedicate this book to our wives and femmes fatales, who are one and the same. Janis Foerschl Freeland Mary Galbreath Jabaley Virginia Haynes Hughes We used their time to write our book while they managed our households and personal affairs. We love and appreciate them. Preface The status of internal fixation of the bones of the hand and wrist today closely parallels that of open fractures and of the tibia twenty years ago. At that time, traditionalists considered the use of internal fixation in such fractures heresy. Today, however, these methods are on firm footing and internal fixation of the skeleton of the hand and wrist is rapidly moving in that direction. Many hand and wrist fractures can and should be managed by simple protection or by closed reduction and functional rehabilitation. Indeed, when stabilization is necessary, Kirschner wire fixation remains the benchmark against which all other techniques are measured. Nevertheless, during the past several years, other implants such as screws, plates, tension band wires and external fixators have been designed in sizes proportionate to the bones in the hand and wrist. These devices can be a valuable addition to the surgeon's armamentarium. Fractures must be well selected. Aseptic operating technique is mandatory. Gentle handling of soft tissues and bone is essential. The surgeon must be well educated and trained in implant application techniques. Soft tissue coverage must be provided for the implants. When we started to use these methods in the hand and wrist, we were skeptical at first and later apologetic. In time, we have found that there are certain fractures that will clearly respond better in our hands from more stable fixation. Therefore, we have become and remain advocates of the stable fixation techniques that are described in this book. We are not, however, doctrinaires. We do not hesitate to use closed techniques or Kirschner wires when we feel they are indicated. The most important rule is to perform the treatment most appropriate for the individual patient and the individual fracture according to the responsible surgeon's judgment and ability. This book is a rather early contribution in the use of the internal and external fixation methods described within. This book is not a manual of operating techniques for Heim, Pfeiffer, and Meuli have already described these techniques in the Small Fragment Manual. This book does not show a hundred consecutive cases for each use of the internal fixation methods described with the only variable being the implants used and then comparing these to other methods of treatment. Rather, this book shows a vast panorama of examples where we feel that we have used implant methods successfully and to the advantage of the patient. We recognize that the methods of internal fixation in the hand and wrist described in this book are neither for all fractures nor for all surgeons. We do hope that the methods contained within will be a contribution leading to improved fixation in the skeleton of the hand. We look forward to more improvement and refinement of fixation techniques. Stable fixation within the hand and wrist may allow the early use of continuous passive motion machines for even earlier rehabilitation of hand fractures in the near future. Bank bone may now become widely used for grafting in the hand and wrist, sparing the patient a second operation at a donor site. There will be new ideas, new designs for implants and instruments which will continue to bring us increasingly predictable and better results for our patients. We owe special thanks to our families at home and our families at work. We thank our parents, wives, and children for their support and encouragement. Sue Spencer typed the manuscript and did many other things that made this book possible. Janice Muzzi and Gloria Lightwine were invaluable in performing library X PREFACE research. Sally Pearson, R.N. and Jerry Skinner, a first class private investigator from Booneville, Mississippi helped to locate several patients for final evaluation who could not be reached by ordinary means. Jim Goodman, our illustrator, and Bill DeVeer and Michael Moody, our photographers, contributed substantially to this volume. Springer-Verlag assigned us incomparable Senior Editors, Dr. Jerry L. Stone and Anna Deus. We are indebted to all of these individuals for their loyalty, hard work and dedication to excellence. Credits would not be complete without thanking Godi Segmuller, a pioneer and leader in the use of internal fixation in the skeleton of the hand. His celestial energy has illuminated our lives and our efforts. He plays two roles-dearest personal and professional friend and our best constructive critic simultaneously and interchangeably. This little poem might best describe the effect that he has had on us. Good, better, best Never let it rest Until the good is better And the better becomes best. We wish to recognize the Resident Staff at the University of Mississippi Medical Center. These young men and women have been an inspiration to us and have made all of our endeavors both constructive and enjoyable through their contributions to patient care, education and clinical research. They made concrete contributions to the care of the majority of the patients presented in this book and often enlightened us regarding academic points contained herein. Many of our colleagues and associates made important contributions. In particular, we would like to thank Bill Burkhalter, Chris Ethridge, Luther C. Fisher, III, Hill Hastings, II, E. Thomas James, Jesse Jupiter, Ron Kendig, Tom McCraney, Charlie Rhea, McWillie Robinson, Bill Stewart, Tom Turner, Bob Vander Griend, E. Frazier Ward, and Ray White. These individuals provided advice, support, encouragement, and direct contributions to the material in this book. Several of these individuals assumed extra patient-care duties so that our time could be freed for the completion of this work. Finally, and perhaps most importantly, we thank our dedicated and very excellent occupational therapists: Mary Adams, Melinda Lamon, Susan Jiminez, and Karen Pennell. Contents SECTION I History and Basic Science Chapter 1 History 3 Chapter 2 Bone Healing 9 Chapter 3 The AO/A SIF Principles: Fracture (Cast) Disease 11 Chapter 4 Precision Implants and Instrumentation 14 Chapter 5 The Lag Screw 17 Chapter 6 Plates 20 Chapter 7 Tension Band Wires 23 Chapter 8 External Fixation 25 Chapter 9 Indications for Stable Fixation 28 Bibliography 31 SECTION II Fracture Repair Metacarpals and Carpals Chapter 10 Bennett's Fracture 39 Chapter 11 Vertical Trapezial Fractures 42 Chapter 12 Rolando's Fracture 44 Chapter 13 Reverse Bennett's Fracture 45 Chapter 14 Dorsal Oblique Hamate Fracture 47 Chapter 15 Other Metacarpal Base Fractures 49 Chapter 16 Transverse and Short Oblique Metacarpal Shaft Fractures 52 Chapter 17 Oblique and Spiral Metacarpal Shaft Fractures 55 Chapter 18 Subcapital Metacarpal Fractures 58 Chapter 19 Intraarticular Metacarpal Head Fractures 63 Chapter 20 Multiple Metacarpal Fractures 66 Chapter 21 Scaphoid Fractures 71 Phalangeal Fractures Chapter 22 Marginal Fractures at the Base of the Proximal Phalanx 79 Chapter 23 Intraarticular Split Fractures of the Base of the Proximal Phalanx 81 Chapter 24 Transverse and Short Oblique Phalangeal Fractures 84 Chapter 25 Oblique and Spiral Phalangeal Shaft Fractures 90 Chapter 26 Spiral Oblique Phalangeal Fractures with Butterfly Fragments 93 Chapter 27 Unicondylar Phalangeal Fractures 97 Chapter 28 Bicondylar Fractures of the Proximal Phalanx 99 xii CONTENTS Chapter 29 Fractures of the Volar Margin of the Middle Phalanx Associated with Unstable Dorsal Proximal Interphalangeal Joint Dislocation 102 Chapter 30 Volar Fracture-Dislocation of the Proximal Interphalangeal Joint 104 Chapter 31 Intraarticular Fractures of the Dorsal Lip of the Distal Phalanx 105 Chapter 32 Large Displaced Fracture of the Volar Lip of the Distal Phalanx Associated with Flexor Digitorum Profundus Rupture 107 Distal Radial Fractures Chapter 33 Colles' Fractures 111 Chapter 34 Smith's Fractures 116 Chapter 35 Volar Radiocarpal Fracture-Dislocation (Volar Barton's Fracture) 117 Chapter 36 Radial Styloid Fractures 123 Special Fracture Categories Chapter 37 Polyfractures in the Hand 129 Chapter 38 Polytraumatized Patient 131 Chapter 39 Open Fractures 134 Chapter 40 Children's Fractures 152 Bibliography 159 SECTION III Reconstruction Chapter 41 Delayed Union, Nonunion, and Pseudoarthrosis 167 Arthrodesis Chapter 42 Wrist Arthrodesis 181 Chapter 43 Distal Radioulnar Arthrodesis 192 Chapter 44 Limited Intercarpal Arthrodesis 196 Chapter 45 Thumb Trapeziometacarpal Joint Arthrodesis 198 Chapter 46 Other Carpometacarpal Arthrodeses 201 Chapter 47 Intermetacarpal Bone Block for Arthrodesis Between the Thumb and Index Finger Metacarpals to Maintain Palmar Abduction of the Thumb 206 Chapter 48 Thumb Metacarpophalangeal Joint Arthrodesis 208 Chapter 49 Index Metacarpophalangeal Joint Arthrodesis 213 Chapter 50 Proximal Interphalangeal Joint Arthrodesis 217 Chapter 51 Thumb Interphalangeal Joint Arthrodesis 221 Chapter 52 Finger Distal Interphalangeal Joint Arthrodesis 222 Corrective Osteotomies Chapter 53 Corrective Osteotomy-Distal Radius 227 Chapter 54 Corrective Osteotomy-Metacarpal 232 Chapter 55 Corrective Osteotomy-Phalangeal 238
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