ࡱ> ji#( b/ 0DTimes New RomanȷȷԳ0 0DArialNew RomanȷȷԳ0 0"@  @@``  @n?" dd@  @@`` |\       S ~1?`[QDf3f@8I g42d2d 0 ppp@ <4BdBd肂ȷ r2___PPT9/ 00___PPT10 pp? ;The Nonsurgical Management of Proximal Phalangeal Fractures<;,   #Phil Wright SHO in A&E LGI 6/6/2002Preamble  dAnatomy Patterns of Injury Examination Nonsurgical treatment options Follow up Prognosis Literature ec' 3Anatomy See chartPatterns of InjuryaDisplacement and angulation affected by: mechanism of injury muscles acting as deforming forces>)#)9 GClassificationA-O/ASIF (see chart)  Examination  $Look Feel Move Skin Soft tissue Bone  Examination  Malrotation common complication careful clinical examination with fingers flexed should converge toward base of scaphoid tubercle Hint: look at fingers end on when semiflexed if too painful to flexN 1 1E@6 e,  .Which fractures can be managed conservatively?/.$oProbably undisplaced impacted Possibly displaced but stable on reduction Probably not intra-articular unstable t  "   "  , H   How?qNo reduction and early active motion Closed reduction and immobilisation Closed reduction and early active motionrr:* 5No Reduction & Early Active Motion (Buddy Strapping!)65(jTape uninjured finger to injured Early mobilisation reduces stiffness Only for stable # with no angulationF%nk,' -  #Closed reduction and Immobilisation$#(Circular cast short arm cast incorporation fingers good stability problems with swelling Cast with outrigger cast/bslab with finger splint poor stability LK.K.r$ #Closed reduction and Immobilisation$$(Gutter splint ulnar or radial easy to apply plaster bunches in palm, therefor difficult to immobilise MCPJ in flexion Volar and dorsal backslabs simple and stable can be removed and replaced/adjustedLh7h7b2  8 5Closed reduction and Early Active Motion (Burkhalter)66* When MCPJ flexed extensor hoods are taught Act as dynamic tension band - # site compressed # reduced under digital block short arm cast applied wrist 30 extension MCPJ 90 flexion&%% 5Closed reduction and Early Active Motion (Burkhalter)66* Cast extends to level of PIPJ dorsally & blocks full extension Trimmed into palm to allow flexion allows early mobilisation but effective in controlling recurvatum angulation frequent follow up may fail and have to be abandoned>o   6 Follow Up  Regular examination both clinical and radiological need to ensure fracture remains undisplaced/ does not redisplace for early active motion pts need to be instructed in exercises,S  @Length of Immobilisation Need to achieve bone healing and recovery of motion simultaneously Immobilisation should not be continued until radiographic consolidation Smith & Ryder (1935) average 5 mo. (range 1 to 17 mo.) clinical healing usually 3 - 4 weeks after 3 weeks immobilisation protect (buddy strap)@#P,CPosition of Immobilisation Intrinsic plus or JIP James position MPJ fully flexed, IPJ fully extended when MPJ flexed collateral ligaments at maximum length (can not contract) PIP joints more likely to stiffen in flexion (?why) Prognosis  Violence of injury Soft tissue damage Tendon injury (esp. extensor) Joint involvement more than one # in same finger age of patient (>50) length of immobilisationThe Evidence (ha ha ha)Ebinger et al. 2000 Looked at a system of closed reduction and early active motion 45 patients (48 fractured proximal phalanges) 27 treated non-operatively 18 patients (21 fractures) operatively&Ebinger et al. 2000 Applied 2 thermoplastic splints Fingers in intrinsic plus position Dorsal component extends to PIPJ Volar component extends to palmar flexion crease Finger also buddy strapped,d+Ebinger et al. 2000 EAM from day 1 weekly follow up splint removed at 4 weeks Final follow up at 24 mo. 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