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Key Techniques in Orthopaedic Surgery

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plate; (D) K-wires and 
tension band.
iii. Transverse K-wires: place one pin proximal
and one or two pins distal to the fracture,
securing the ends in the adjacent metacarpal
(Fig. 19–1D). If the fracture pattern is oblique
or spiral, consider limiting fixation to the
injured metacarpal, placing two or more pins
perpendicular to the fracture line.
3. Base fractures
a. Reduce by applying longitudinal distraction and
digital pressure against the metacarpal base.
b. Stabilize with one of the following techniques:
i. Diverging K-wires: place two pins through
the base of the fifth metacarpal, one passing
into the base of the fourth metacarpal and
the other into the hamate. Acceptable fixa-
tion is usually achieved without spearing the
fragment(s) (Fig. 19–1E).
ii. Intramedullary K-wire: place one pin retro-
grade through the metacarpal head with the
metacarpophalangeal joint flexed. Drive 
the pin down the metacarpal shaft and
across the carpometacarpal joint into the
carpus. Advancing the pin proximally into
the metacarpal canal will leave the metacarpo-
phalangeal joint free for early motion.
Open reduction and internal fixation
1. Head and neck fractures
a. Make a dorsal longitudinal incision over the
fifth metacarpophalangeal joint. Offset to one
side in an effort to decrease adhesion forma-
tion between the skin and extensor tendons
(Fig. 19–2A).
b. Release the radial or ulnar sagittal band, leaving
a cuff of tissue for later repair (Fig. 19–2B). If the
radial sagittal band is incised, the junctura tend-
inum interconnecting the ring and small finger
extensor tendons may also require division.
c. Retract the extensor tendons and identify and
preserve the metacarpophalangeal joint collat-
eral ligaments.
d. Clean debris from the fracture site and reduce
the fragments. Stabilize intra-articular head frac-
tures with screws if possible to permit early joint
e. Address neck fractures by pinning, tension band
wiring, or plating. The mini condylar plate is
useful for neck fractures with intra-articular
extension and is ideally positioned on the lateral
surface of the bone (Fig. 19–3A).
f. A mini suture anchor is recommended for fixa-
tion of displaced collateral ligament avulsion
injuries. Alternatively, an intraosseous wiring
technique may be employed.
2. Shaft and base fractures
a. Make a longitudinal incision over the fracture
site, offset to one side, and retract the extensor
b. Split the periosteum longitudinally and expose
the fracture subperiosteally. Preserve the attach-
ment of the extensor carpi ulnaris tendon
c. Clean debris from the fracture site and reduce
the fragments.
d. Stabilize spiral and long oblique shaft frac-
tures with at least two interfragmentary screws 
(Fig. 19–3B).
e. Treat comminuted shaft fractures and shaft frac-
tures necessitating bone graft with straight
plates. Secure the plates dorsally with at least
two screws (four cortices) at both ends of the
fracture (Fig. 19–3C). T-shaped, L-shaped, and
mini condylar plates are indicated for metacarpal
fractures at the proximal diaphyseal metaphy-
seal junction or base. Short oblique shaft frac-
tures are ideally treated with a single lag screw
and neutralization plate.
f. Consider cerclage or tension-band wiring for
fractures found difficult to stabilize by other
methods. One or two K-wires supplemented by a
26-gauge wire loop affords a fairly stable con-
struct (Fig. 19–3D).
External fixation
1. Consider for any fifth metacarpal fracture with sig-
nificant bone loss, comminution, soft-tissue injury,
or infection.
2. Place one or two pins proximal and one or two pins
distal to the zone of injury. Position the pins through
small mid-lateral incisions to avoid impaling the
extensor tendons.
1 9 F I F T H M E TA C A R PA L F R A C T U R E 1 1 9
3. Assemble clamps and connecting bars onto the
pins, bring the fracture out to length, reduce the
fragments, and tighten the construct.
4. If significant displacement persists, consider con-
comitant open reduction with supplemental 
K-wire/screw fixation. Subchondral defects should
be bone grafted; larger defects may necessitate
structural grafting.
1. Reapproximate the periosteum over the implants if
possible using 4-0 resorbable sutures.
2. If the junctura tendinum and one or both sagittal
bands have been divided, repair with 4-0 non-
resorbable sutures.
3. After repairing the deep structures, release the
tourniquet and apply pressure to the wound.
4. Copiously irrigate the wound and coagulate small
bleeding vessels with bipolar cautery.
5. Reapproximate the skin edges with either inter-
rupted sutures or a subcuticular closure.
6. Cut pins external to the skin surface and bend or
cap the ends.
7. Apply a light dressing and ulnar gutter splint.
8. Support the arm in a temporary sling in the setting
of regional anesthesia.
Suggested Readings
Faraj AA, Davis TRC. Percutaneous intramedullary
fixation of metacarpal shaft fractures. J Hand Surg
Foster RJ. Stabilization of ulnar carpometacarpal
dislocations or fracture dislocations. Clin Orthop
Freeland AE, Jabaley ME. Stabilization of fractures in
the hand and wrist with traumatic soft tissue and bone
loss. Hand Clin 1988;4:425–436.
Greene TL, Noellert RC, Belsole RJ. Treatment of unstable
metacarpal and phalangeal fractures with tension band
wiring techniques. Clin Orthop 1987;214:78–84.
Gropper PT, Bowen V. Cerclage wiring of metacarpal
fractures. Clin Orthop 1984;188:203–207.
Jupiter JB, Axelrod TS, Belsky MR. Fractures and
dislocations of the hand. In: Browner BD, Jupiter JB,
Levine AM, Trafton PG, eds. Skeletal Trauma. 2nd ed.
Vol. 2. Philadelphia, PA: W.B. Saunders, 1998, pp.
Lane CS. Detecting occult fractures of the metacarpal
head: the Brewerton view. J Hand Surg 1977;2:131–133.
Njus N. Percutaneous pin fixation of the diaphysis of
the metacarpals. In: Blair WF, ed. Techniques in Hand
Surgery. Baltimore, MD: Williams & Wilkins, 1996, 
pp. 229–238.
Parsons SW, Fitzgerald JAW, Shearer JR. External
fixation of unstable metacarpal and phalangeal
fractures. J Hand Surg 1992;17B:151–155.
Stern PJ. Fractures of the metacarpals and phalanges. 
In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s
Operative Hand Surgery. 4th ed. Vol. 1. Philadelphia, 
PA: Churchill Livingstone, 1999, pp. 711–732.
1 2 0 W R I S T A N D H A N D
Section Four
Hip and Femur
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Key Techniques in
Orthopaedic Surgery
The prime indications for total hip arthroplasty are
relief of hip pain and improvement of hip function as a
result of any disabling hip condition. These conditions
1. Osteoarthritis
2. Inflammatory arthritis (rheumatoid arthritis, psori-
atic arthritis, etc.)
3. Posttraumatic arthritis
4. Osteonecrosis
1. Active sepsis (absolute)
2. Active causalgia/reflex dystrophy (absolute)
3. Neuropathic joint (relative)
4. Insufficient musculature about the hip girdle
5. Inability or unwillingness to adhere to postopera-
tive precautions (relative)
Preoperative Preparation
1. Complete history and physical examination.
Record location, quality and activities associated
with hip pain. Also document gait pattern, leg
length, and range of motion.
2. Appropriate medical and anesthetic evaluation.
3. Document preoperative neurovascular status.
4. Radiographs including anteroposterior (AP) of the
pelvis, true or “frog leg” lateral of affected hip, and
AP and lateral of lumbar spine.
5. The preoperative radiographs should be assessed in
conjunction with the appropriate hip prosthetic
templates to determine approximate sizes for both
the acetabular and femoral components. Existing