Published on March 13, 2014
BENNETT’S FRACTURE Dr. Lokesh Sharoff
• Irish surgeon Edward Bennett in 1882 • Base of 1st MC # intra- articular #s
Mechanism of injury Axial blow directed against partially flexed MC Usually in fist fighters
ANATOMY • Base of MC pulled radially & dorsally by APL while the distal attachment of the adductor levers pulls the base further dorsally • Avulsion # :Smaller volar lip fragment remains attached to the AOL that anchors the fragment to tubercle of trapezium
VARIABLES • Two primry variables • Size of the volar lip fragment • Amt of displacement of shaft
Clinical features • H/o injury / blow • Swelling and pain in the carpometacarpal region • Painful and restricted movement at the first carpometacarpal joint. Pain on gripping, dorsiflexion, etc. • Thumb appears shortened.
Normal ROM of 1st CMC -Flexion –Extension Arc of 50* -Abduction-Adduction arc of 40* -Pronation-Supination arc of 15*
DIAGNOSIS • Intra articular status • AP & Oblique • Billing & Gedda’s lateral view
Billings and Gedda view • True lateral view (by Billing and Gedda's technique) hand pronated by 15-20° on the cassette and the tube is directed obliquely 15° distal to proximal, centering at the carpometacarpal joint. • Characteristic fracture is seen.
ASSOCIATIONS - # Trapezium - Ulnar collateral ligament injury
Treatment options - C.R. - CRIF - ORIF
CR - Indications - Undisplaced - Minimally displaced - Old age with medical co-morbidities
CR- Method - By giving a cast and leaving the IP joint free for 6 weeks. - In 1st CMC joint- loss of stability is more of a complication than stiffness.
CRIF - Indications - Pure #s in which reduction can be achieved with no dislocation
CRIF - method - Manual traction is giving by acting against the muscle forces and direct pressure over the base of 1st MC - K-wire is passed – transfixed to carpus
Open reduction - Indications - # dislocations - Open #s - Failed CR - Tissue interposition - Late unreduced dislocation
ORIF - method - Without ligament reconstruction - With ligament reconstruction- WAGNER technique –split FCR tendon
TREATMENT cont’d • Check X rayIf >3mm incongruity in joint go for ORIF • ORIF :with cortical screws probably the best • Technically more demanding, more secure & active range of motion
POST OP Tt • Thumb spica cast x 4wks • 10 th day S/R & window for pintract care
COMPLICATIONS • Malunionrec/persistent subluxation of trapezio MC jt • CLINKSCALES closing wedge osteotomy
• ROLANDO 1910 • TYPE 2 THUMB MC # • BENNETT’S # + LARGE DORSAL FRAGMNT • #BASE OF 1ST MC WITH Y/T SHAPED INTRA ARTICULAR FRAGMENT • PROBABLY A COMMINUTED BENNETT’S FRACTURE
• A difficult # to treat but least common among adult thumb MC # • ORIF attempted only if single large dorsal & volar fragments • ORIF of comminuted #s ----experienced surg in AO techniques • Traction& Ex fix are reasonable alternatives • If joint surface incongrous on check x ray immobilise the thumb for a minimal period & early active motion to remold badly distorted articular surface
GAME KEEPER’S THUMB
• C/c laxity of UCL without h/o trauma as occupational deformity in British game keepers • MC among Skiers due to fall on an outstretched handA/c UCL injurySkier’s thumb • MOI: valgus or abdn force probably combined with hyper extension • UCL,dorsal capsule,ulnar aspect of volar plate& occasionally rent in adductor aponeurosis with avulsion #s of its insertion on the volar base of prox phalanx
• Stener lesion : in total tear of UCL addr aponeurosis interposed; prevents adequate healing • CLINICAL FEATURES: Painful swollen MP joint, max tenderness ulnar aspect. • Differentiate partial & total tear difficult but important.
DIAGNOSIS • Stener lesion : tender at ucl just prox to MP jnt • Valgus stress at MCP in flexion & ext and compare amt of radial deviation with opposite side under LA/Wrist block. • VST with radiological support >5-15deg +ve[in 30* flexion] • Difficult to suspect & diagnose when asso with prox phalax# • Routine x ray before VST to r/o a]shear # .rad side of head of MC b]prox phalanx, ulnar aspect of base
DIAGNOSIS cont’d • MRI: 100% sensitive to stener lesion • USG : Skilled person can detect stener lesion
DIFFERENTIAL DIAGNOSIS - Boxers knuckle – it is a dorsal tear in the capsule of the MCP joint. - Sesamoid # - to take oblique views
Indications - Non-operative -RCL Injuries - Volar or dorsal Subuluxation - Boxers knuckle -Sesamoid # -Partial ucl injuries
Indications -Operative -Steners lesion -Unreduced dislocation -Failed conservative rx -Complete lig mid-substance tear -Complete tear with bony avulsion
TREATMENT -Partial tearsWell molded thumb spica cast in slight flexion of MP jt x3-4 wks - then , 2 weeks arom - then 2 weeks passive rom
SURGICAL Tt - Collateral lig injuries 1- Mid substance tear 2-Tear at the distal ends
SURGICAL Tt - Ligament tear asso. With bony fragments 1- If fragment too small 2- if large bony fragment
SURGICAL Tt - Ligament tear with osteochondral fragment 1-if Fragment very small 2-if fragment is large 3-if fixation is not possible in a fragment
POST OP Tt • Removable thumb spica brace or splint x 3- 4 wks ,ROM EXERCISES • Rmove pull out sutures& K wire 4-6 wks • REPAIR OF OLD UCL INJURIES: • Using EPB tendon,addr pollicis[Neviaser et al]palmaris longus TG
• Avulsion #s to be treated if >25% of articular surface involved.
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