Hand clinics
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The surgeon treating traumatic injuries to the TMC joint should be aware of the fundamental misconceptions and pervasive axiomatic myths perpetuated in the medical literature: namely that the volar beak ligament is the prime stabilizer, that the dorsal ligament complex plays no significant role in TMC joint function, and that the APL is a deforming force in Bennett fractures. On the contrary, stability of the TMC joint in power pinch and power grasp depends on the TMC joint's two prime stabilizers, the volar beak of the thumb metacarpal and the dorsal radial ligament complex; and the APL is not a deforming force in a Bennett fracture. ⋯ Rolando multipart fractures of the thumb metacarpal into the TMC joint are best treated closed, with traction in opposition with pin fixation; pure dislocations of the TMC joint that tear the dorsal ligament complex and Bennett fractures with an associated dorsal ligament complex tear (as diagnosed by the screw-home-torque technique) require open reduction and dorsal ligament complex repair. The current literature is so replete with myths and folklore regarding the anatomy that a conscientious surgeon treating a traumatic dislocation or in-stability of the TMC joint should return to the cadaver room and carefully review and understand TMC joint anatomy.
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Management of children's fractures requires a thorough knowledge of the developing skeleton, with recognition of the injury present and its potential course based on mechanism and anatomy, a dedication to complete and repeated clinical and radiologic examinations, and a willingness to intercede if unacceptable angulation or any rotation occurs in the course of treatment. The ability to remodel follows a well-defined course and may be anticipated within certain margins, but expectations of this ability should not be overemphasized or even contemplated outside the direction of joint motion. Growth arrest following injury, although a real concern, remains rare. Persistent stiffness, particularly at the PIP joint, occurs much more frequently than is perceived, particularly for phalangeal shaft, condylar, and neck fractures.
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Although complete collateral ligament tear and instability involving the metacarpophalangeal joints of the fingers, especially those on the radial aspect of the index finger, are rare, they may be underdiagnosed, underestimated, and potentially disabling. Awareness and suspicion of the injury, coupled with careful physical and imaging examinations, confirm the diagnosis and its extent. ⋯ Late ligament repair or reconstruction is typically slightly less reliable than acute repair, yet often improves outcomes. Arthritic joints may require reconstruction.
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Comparative Study
The treatment of unstable metacarpal and phalangeal shaft fractures with flexible nonlocking and locking intramedullary nails.
Metacarpal and phalangeal shaft fracture fixation can be achieved by closed IM nailing. This technique provides sufficient stability to commence early unsupported joint motion and minimize soft-tissue irritation and scar formation. Stability is enhanced by proximal nail locking; a measure that extends the indications to spiral and comminuted fractures. The surgical technique is simple but requires attention to detail.
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Phalangeal fractures in children are common, and conservative treatment leads frequently to a good functional outcome. Articular or displaced fractures require early re-cognition and special attention, including surgery. In children, remodeling occurs primarily in the sagittal plane, and rotational deformities are often unacceptable.