/

ORIF of the 5th Carpometacarpal Joint with Bridging Plate

    Overview

    Learn the Open Reduction and Internal Fixation of the 5th Carpometacarpal Joint with Bridging Plate using Synthes 15 mm Compact Hand Set surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Open Reduction and Internal Fixation of the 5th Carpometacarpal Joint with Bridging Plate using Synthes 15 mm Compact Hand Set surgical procedure.
    Punching injuries to the hand are widespread and account for significant attendances to the Emergency department. Axial loading along the metacarpus in a closed fist can result in a fracture-subluxation of the hamatometacarpal joint. These injuries are often missed on routine examination and radiographs. Poorly managed injuries can result in disabling sequelae with pain, deformity and functional loss.
    These fracture subluxations can sometimes be managed by manipulation followed by stabilisation in plaster splints. More often, they require surgical intervention with minimally invasive percutaneous wiring. This technique has been described elsewhere on this website. However, occasionally, the fracture fragments are displaced to an extent where simple manipulation is insufficient to regain the normal anatomy. This is a guide for management of this challenging cohort of patients that require open reduction. The technique combines the principles of internal fixation of intra-articular fractures along with the philosophy of distraction ligamentotaxis with a bridge plate.

    Readers will also find of use the following OrthOracle techniques:
    Closed reduction and K wiring of 5th carpometacarpal fracture-dislocation.
    Internal fixation of 5th metacarpal neck fracture (Synthes LCP plate)
    Guyons canal release



    Indications

    Fracture dislocation of the Carpometacarpal joint (CMC Joint) has traditionally been considered an uncommon injury with a paucity of literature on its management. They account for less than 1% of the hand injuries and are more common in the dominant hand. Lilling et al (1979) discussed the mechanism and showed that an axial loading vector along the shaft of the 5th metacarpal results in disruption of the CMC joint. The displacement of the fragments is dictated by the pull of the various deforming forces of the Flexor Carpi Ulnaris, Extensor Carpi Ulnaris and Abductor Digiti Minimi.
    Cain et al (1987) graded these injuries into 3 types depending upon the fracture pattern of the hamate in relation to the CMCJ subluxation:
    Type 1a – Pure subluxation or dislocation with no fracture
    Type 1b – Subluxation/Dislocation with associated dorsal avulsion fracture of hamate
    Type 2 – Subluxation/Dislocation with comminution of dorsal hamate rim
    Type 3 – Subluxation/Dislocation with coronal splitting of hamate
    The classification helps in planning management of these injuries but is not necessarily prognostic of the final functional outcome.
    Recently, Kim et al (2012) have proposed a variation to this classification based on CT findings.
    INDICATIONS
    The treatment goal is to restore normal anatomy and function to the hand. AO principles dictate an anatomical reduction and rigid internal fixation of intra-articular fractures. This facilitates early mobilisation and return to function. However the structural configuration of the complex hamatometacarpal joint makes this a challenging problem. Distraction ligamentotaxis with bridge plating is an established modality for complex comminuted intra-articular injuries. This technique combines the advantages of both these philosophies to achieve an optimal functional outcome.
    My indications for this procedure are-
    Type 3 fractures with a coronal split or a comminution of the hamate
    Failure of manipulation in Type 1 and Type 2 injuries
    Delayed or missed diagnosis
    SYMPTOMS & EXAMINATION
    The majority of these injuries occur secondary to high energy trauma such as direct punches against a hard object, road-traffic accidents and falls. The patient presents with pain and swelling over the dorso-ulnar border of the hand. There is tenderness over the base of the metacarpus and movements of the finger may be restricted with pain. A common finding is the presence of a bony lump over the base of the metacarpus. There may be an apparent extensor lag of the small finger at the metacarpophalangeal joint. Presence of any rotational abnormality should be evaluated and documented. Comparison can be made with the opposite uninjured hand. Open injuries must be examined for any loss of tendon and nerve function.
    IMAGING
    Plain radiographs are the first line of investigations for diagnosis. I always request three radiographic views of the hand – Posteroanterior, lateral and oblique. The lateral radiographic view is essential to identify the dorsal subluxation/dislocation of the base of the metacarpus. It is not uncommon to miss this in the routine PA and oblique radiographs. The metacarpal height is reduced and the metacarpal head will appear to be flexed forward. Kauffmann et al (2017) described a “hand fan sign” on oblique radiographs as a subtle indicator of the injury. Any concomitant fractures around the CMC joint are identified and their intra-articular extensions documented.
    Unfortunately, these injuries are often missed on plain Xrays. Pullen et al (1995) showed that CT scans are the ideal modality to diagnose and delineate the pathoanatomy of these fractures. This is particularly true for Type 2 and 3 fractures to enable planning of adequate management. We routinely perform a CT scan for these injuries at our Unit.
    ALTERNATIVE TREATMENT
    “Masterful inactivity”: Immediate mobilization of the hand and fingers with pain relief has been tried by Petrie & Lamb. Despite obvious radiographic abnormalities at 4-year follow-up, there was no significant functional disability identified in their cohort. Unfortunately, these results have not been reproducible elsewhere.
    Conservative with closed reduction followed by plaster immobilisation: This is best reserved for stable injuries with no significant displacements of the fracture fragments (Cain Type 1). Unfortunately, injuries associated with displaced intra-articular fractures are not amenable for reduction with manipulation.
    Closed reduction and percutaneous pinning: This procedure has established itself as the “Gold Standard” for the management of carpometacarpal fracture subluxations. A step-by-step guide is available elsewhere on this website. However, the success of the technique is dependent on adequate restoration of the anatomy by closed manipulation. This is often unattainable in Type 3 injuries. The additional complications of pin-track infections and splint immobilization are a secondary source of problems.
    Closed reduction and external fixator:This device will span the CMC joint and allows reduction with ligamentotaxis. Again, this technique depends on the anatomical restoration with manipulation and distraction – which is often not possible in this cohort of patients. Moreover, placement of proximal pins in the small carpal bones can be technically challenging. Finally, the device requires meticulous pinsite care in the postoperative period to prevent infections and complications.
    Salvage: Untreated or redisplaced injuries often present with pain and reduced grip strength. This is related to secondary osteoarthritis at the CMC joint with/without persistent subluxation. Such cases will require salvage procedures such as resection arthroplasty, interposition arthroplasty or an arthrodesis.
    CONTRAINDICATIONS: There are no specific contraindications.
    Lilling M, Weinberg H. The mechanism of dorsal fracture dislocation of the fifth carpometacarpal joint. The Journal of hand surgery. 1979 Jul 1;4(4):340-2.
    Cain Jr JE, Shepler TR, Wilson MR. Hamatometacarpal fracture-dislocation: classification and treatment. The Journal of hand surgery. 1987 Sep 1;12(5):762-7.
    Kim JK, Shin SJ. A novel hamatometacarpal fracture–dislocation classification system based on CT scan. Injury. 2012 Jul 1;43(7):1112-7.
    Kauffmann P, Le Borgne P, Slimani H, Quoirin E, Bejinariu L, Bilbault P. Signe de l’éventail dans la luxation carpométacarpienne dorsale. Journal de Traumatologie du Sport. 2017 Mar 1;34(1):62-4.
    Pullen C, Richardson M, McCullough K, Jarvis R. Injuries to the ulnar carpometacarpal region: are they being underdiagnosed?. Australian and New Zealand journal of surgery. 1995 Apr;65(4):257-61

    Setup

    Informed consent is an important part of the procedure and the risks and benefits should be clearly explained to the patient. The dorsal branch of ulnar nerve lies in close proximity and can be injured either by the fracture fragments or during surgical exposure. The ulnar nerve in the Guyon’s canal is at risk of injury during the fixation process with screws. The metalwork straddles the joint and should be removed, necessitating a second surgical procedure. Lastly, the intra-articular fragmentation can be a precursor for future secondary osteoarthritis of the CMC joint.
    I prefer regional anaesthesia with axillary block for this procedure. The patient is placed supine with the limb extended on an arm table and supported on a lead hand. Upper arm tourniquet is applied and inflated after exsanguination. A prescrub is performed followed by a sterile prep with Chlorhexidine. I routinely administer a single dose of antibiotics for this procedure.

    Operation – 1

    Preoperative radiographs show a fracture dislocation of the 5th CMCJ.
    The PA view highlights the ease with which the diagnosis of this injury may be missed. Note the dorsal hamate fracture in the lateral radiographs(Annotated H). Also note the forward flexion of the heads of the 4th and 5th metacarpals (Annotated F). A closer inspection reveals some comminution in the hamate. This should alert the surgeon and further details of the fracture anatomy should be sought with a CT scan.

    The comparison views of the coronal and sagittal images in the CT scan identify the fracture anatomy in greater detail
    The marker lines indicate the location of the coronal and sagittal splits in the hamate and shows the depressed fragment of the articular surface.

    The coronal images of the CT scan reveal a displaced fracture of the body of the hamate
    Note the ulnar fragment in the hamate.

    The sagittal images of the scan reveal the depressed articular fragment in the hamate
    There is a coronal split of the dorsal surface of the hamate along with the depressed fragment of the distal articular surface.

    The axial images of the CT scan confirm the comminution in the hamate
    An analysis of the CT images and comparative radiographs becomes crucial in planning the management of this injury. Closed reduction and percutaneous pinning is likely to fail in this scenario, as the depressed fragment requires elevation to restore articular congruity.

    The dorsum of the hand reveals a bony lump at the 5th CMCJ.
    The bony lump (Annotated B) is a useful surface marker to identify the affected CMC joint.

    A longitudinal incision is marked and made between the 4th and 5th metacarpals and the overlying CMC joint. The 4th and 5th metacarpals are traced as shown in the picture and the CMC joint identified in the region of the bony deformity. The incision is marked between the two metacarpals so as to allow adequate exposure of both the 4th and 5th CMC joints

    A No.15 blade is used for the skin incision
    The skin is incised with care to protect the dorsal cutaneous nerve in the subcutaneous tissues as shown in the following images

    The subcutaneous tissue is dissected carefully with scissorsAfter the skin incision, blunt dissection is used to tease open the subcutaneous tissues

    The dorsal cutaneous branch of the ulnar nerve lies in the subcutaneous tissues between the 4th and 5th metacarpalsThis is a branch of the ulnar nerve that arises 5 cm proximal to the ulnar styloid in the distal forearm. It extends dorsally travelling superficial to the extensor retinaculum in the wrist to reach the hand where it is responsible for cutaneous sensation to the ulnar half of the dorsum of the hand.
    N: Dorsal cutaneous branch of the ulnar nerve

    The nerve is sought for, identified and dissected carefullyThe nerve is mobilized with blunt dissection using scissors. Once released, the nerve is protected by retracting it away with the skin flaps. Note that the nerve braches in the middle third of the incision. Retraction of the nerve can be ulnar or radial depending upon its mobility.

    The extensor tendons are exposedNote the extensor to the ring finger (EDC4) on the top of the exposed wound and the two tendons to the small finger (EDC5 & EDM) on the bottom of the exposed wound.

    The approach continues on the radial edge of the small finger extensorsA sharp incision with a knife is the best way to continue the deeper approach. There are no other important structures at risk once the nerve has been protected and retracted in the previous step.

    The sharp dissection is carried right unto the base of the 5th metacarpal and the dorsum of the hamateThe periosteum on the dorsum of these bones is incised with the knife.

    The periosteum is elevated from the dorsum of the hamate and the 5th metacarpalThe periosteal sleeve is closely adherent to the bone in this region and requires a combination of a periosteal elevator (as shown in the picture) and a knife to elevate it. Note the underlying fracture in the hamate appearing in view as the periosteum is lifted.

    The periosteum is elevated off the entire dorsal surface of the hamateSharp dissection with a knife (as shown in the picture) is required to facilitate this. It is important to expose the entire dorsal surface of the hamate so as to accurately identify and reduce the fracture fragments.

    The CMC joint is exposed with the adjacent bonesThe CMC joint with hamate (Annotated H) on the proximal side and the metacarpal bases (Annotated 4 and 5 for each metacarpal) on the distal side is revealed.
    The inetrmetacarpal ligament lies between the bases of the 4th and 5th metacarpals (Annotated I). Note the biconcave anatomy of the distal end of the hamate to accommodate the bases of the two metacarpals.

    The carpometacarpal ligament is incised to gain exposure to inside the CMC jointIt is essential to visualize the articular surfaces within the CMC joint to achieve and confirm satisfactory reduction. The ligament needs to be incised to facilitate this.

    The fractured fragments of the hamate are mobilizedThe assistant facilitates visualization of the articular surfaces within the CMC joint with longitudinal traction of the 4th and 5th fingers. The dorso-radial fragment of the hamate is elevated like a trapdoor to provide access to the depressed central fragment. The ulnar fragment of the hamate may also need to be retracted to aid in this step.

    The depressed central fragment of the articular surface is elevated back to its normal position, and the other fragments then reduced A blunt instrument such as a McDonalds Elevator (as shown in the picture) is used to carefully elevate the depressed articular fragment. Excess force is avoided as it may result in further fragmentation. Continued traction on the ring and small fingers by the assistant allows distraction within the CMC joint, which aids in this reduction manoeuver.

    The mobilised central fragment may need to be manoeuvred into its anatomical location. A pair of forceps is being used in this case to gently coax the fragment out of its depressed position.
    Note that the dorso-radial fragment (Annotated R) is being mobilized with a hook so as to allow the repositioning of the central fragment (Annotated C).
    Once the articular fragment is elevated to its anatomical location, the remaining dorsal fragments can be reduced back. Remember to continue with traction on the small and ring fingers to enable and assist in this step.

    The dorso-radial fragment is replaced
    The trapdoor created using the dorsoradial fragment is now replaced back to complete the reduction

    The fracture reduction is checked visuallyThe picture shows excellent reduction of the fragments from the dorsal aspect. The articular reduction is also confirmed with direct visualization inside the CMC joint.
    Rotational abnormalities are uncommon with these injuries. However, alignment of the small finger in relation to the remaining fingers is good indicator for satisfactory rotational correction.

    The reduction of the hamate fracture is manually stabilized and then a K-wire is inserted in the hamate for temporary fixationThe thumb of the surgeon’s non-dominant hand can be used to manually stabilize the reduction of the hamate. This leaves the dominant hand free to use instruments for fixation as seen in the next step.
    Note that there is still some dorsal subluxation of the metacarpal base. This can be corrected during fixation in the forthcoming steps.

    A K-wire is inserted in the hamate for temporary fixation
    I am using a 0.9 mm K-wire to affix the main dorsal fragment of the hamate. Alternatively a 1.1mm K wire can be used.
    This wire will be eventually replaced with a screw. Therefore, it is important to choose a wire thickness that is no bigger than the drill bit to be used at the later stage.

    Operation – 2

    The reduction of the fracture is confirmed again after the insertion of the temporary K-wireA visual confirmation of the fracture reduction is evident. I suggest an Image Intensifier radiograph at this stage to confirm adequate fracture reduction.
    If unsatisfactory, the K-wire can be removed and the reduction steps be repeated. It is important to not proceed any further until you are satisfied with the reduction of the fracture fragments in the hamate.

    The temporary K-wire keeps the articular fragment elevatedThe wire supports the reduced articular fragment in its position while simultaneously affixing the dorsal fragment to the remaining body of the hamate.

    Definitive fixation with Synthes 1.5 mm Compact Hand Set
    The ideal implant size depends upon the size of the fracture fragments. I have chosen the 1.5 mm implant for this particular case. A bigger implant here would not have allowed me to achieve appropriate interfragmentary fixation. On the other hand, a smaller sized implant would not have provided adequate fixation across the CMC joint (as detailed in later steps). I have previously used a Synthes 2.0 mm Compact Hand Set for different variations of this injury.
    The plate design has been chosen according to the plan for definitive fixation. A T-plate or a Y-plate is perfect in this situation as it will allow me to stabilize the hamate with at least 2 screws through the horizontal segment of the plate, while leaving me enough scope in the long vertical limb on the metacarpal shaft to support the CMC joint in a reduced position. The vertical limb should be long enough to accommodate 2 screws in the metacarpus.

    The Synthes 1.5 mm Compact Hand plate is threaded over the K-wireThe importance of the location of the temporary K-wire cannot be overemphasized. In a perfect position, it allows the surgeon to replace the wire eventually with a screw through the plate. However, it isn’t essential to do so. The screw replacing the K-wire can lie outside the plate with equally satisfactory results.

    The plate is secured to the hamate, drill the 1st hole through the plate into the hamateThe position of the horizontal limb of the plate is confirmed on the hamate. It is important to ensure that you can insert atleast 2 screws through the plate into the hamate for sufficient fixation.
    A drill sleeve is used to appropriately centre the drill hole as well as to protect the tissues

    A 1.1 mm drillbit is used to create the pilot hole for the 1.5 mm screw.
    The hook of the hamate forms the radial and distal edge of the Guyons canal. The ulnar nerve in the Guyon’s canal is at a risk of iatrogenic injury with a careless drilling technique. It is important to guide the drill bit radially (as shown in the image) into the hook of the hamate.
    It is important to ensure that the horizontal limb of the plate overlies the hook of the hamate so that the drill bit does not inadvertently injure the ulnar nerve in the Guyon’s canal.
    If using a locking plate system, the far cortex need not be drilled.

    A depth gauge is used to measure the screw length
    The hook of the depth gauge should engage the far cortex to ensure correct screw length.

    Choose a 1.5mm screw of the appropriate length
    The screws on the Synthes Compact Hand Set are made of Titanium and have self-tapping threads for ease of insertion. The screw is loaded onto the screwdriver and stabilized in the holding sleeve (Annotated S). An important tip is to remeasure the chosen screw on the graduated scale attached to the instrument set before insertion.

    The 1.5 mm screw is inserted into the predrilled hole in the hamate
    The screw is completely tightened while ensuring good hold in the cortex of the bone.

    The combination of the transfixing K-wire and the screw ensures stability of the hamate fracture

    The longitudinal,distal limb of the plate is positioned on the metacarpal shaftThe dorsal subluxation of the metacarpal base at the CMC joint is reduced with longitudinal traction of the ring and small fingers. This reduction will be maintained by affixing the plate across the joint onto the metacarpal shaft.
    The plate straddling the joint will preserve distraction ensuring sustained reduction.

    The distal segment of the plate is secured to the metacarpal shaft using a 1.5mm screw.The CMC joint is held in distraction and the plate secured to the metacarpal shaft. A 1.1mm drill is used to create a bicortical pilot hole in the shaft

    The screw size is measured using a depth gauge
    As before, it is important to engage the hook across the far cortex for the correct size of the screw

    The appropriate sized screw is inserted into the metacarpal shaft and tightened.
    A visual examination confirms that the fracture of the hamate and the dorsal subluxation of the metacarpal base remain well reduced.
    A check Xray with Mobile Image Intensifier is essential at this stage to check for radiological reduction and appropriateness of the screw sizes.

    The implant acts as a bridge plate across the CMC joint with transfixion in the hamate proximally and the metacarpus distally. This maintains a distraction within the joint.
    This “detensioning” of the CMC joint is crucial to prevent a collapse of the metacarpal base into the reduced articular surface of the hamate. It allows for early mobilization of the fingers and hand without the consequence of deforming forces by the tendons of Flexor Carpi Ulnaris, Extensor Carpi Ulnaris and Abductor Digiti Minimi.
    It is important to choose an implant size that will provide the required stability without a risk of failure. I therefore do not use implants smaller than 1.5mm for this procedure.

    The second screw is inserted into the hamate, following initial fixation across the jointA second screw is now inserted into the hamate in the remaining vacant hole in the horizontal limb of the plate. A similar process of predrilling a pilot hole with a 1.1mm drill, followed by measurement of the screw size with a depth gauge is followed before screw insertion. Note that the K-wire is still in situ

    The temporary transfixing K-wire is now removed and is replaced with a cortical screwThe hamate fracture reduction retains its stability with the two intrafragmentary screws through the horizontal limb of the plate.

    No further drilling is required if you have used the appropriate K-wire for temporary fixation. One can choose to overdrill the near cortex for insertion of a lag screw through the plate. However, in my experience, this can sometimes lead to fragmentation of the thin shell of the dorsal bony fragment.
    The remnant hole (after wire removal) is measured and an appropriate size cortical screw inserted.

    The three screws in the hamate are now well fixed and tightened

    The distal fragment is secured with an additional second screw. The familiar process of drilling a pilot hole with a 1.1mm drill, followed by measurement with a depth gauge and insertion of the correctly sized screw is done.

    At least 2 distal bicortical screws and two to three proximal screws are required for a stable construct.
    In this particular case, the proximal screws perform an additional role of inter-fragmentary fixation of the hamate fracture. Finally, the proximal screws in the hamate act like a raft supporting the articular fragment and preventing its collapse

    Repeat conformation of fracture reduction is undertaken visually and radiologically. Note the CMC joint is not collapsed due to the bridge plating principle (marked by the pointing forceps in the surgeon’s hand)

    Post operative imaging is done to confirm fracture reduction, implant placement and screw sizes. It is important to ensure that the screw threads and screwtips do not penetrate into the CMC joint.

    A comparison of the preop and postop PA views shows that the joint space has been regained and that there is no obvious fracture displacement anymore

    A comparison of the preop and postop lateral images shows that the joint subluxation is well reduced. The dorsally prominent shadow of the 5th metacarpal shaft is due to a previously malunited fracture.

    Operation – 3

    The periosteum over the hamate is sutured backAn absorbable suture (4’0 Vicryl) is used to repair the soft tissues over the hamate and the CMC joint. It is often difficult to approximate the ends of the periosteal sleeve over the plate. I use a mass closure technique grasping soft tissues overlying the bone and joint. It is crucial to avoid impingement of the extensor tendons during this suturing

    I do not routinely suture the tendons but allow them to fall back into their original positions

    The previously preserved and retracted dorsal cutaneous nerve is allowed to fall back into its normal position. It is important to check that the epineurium has remained intact

    Skin closure is done with a nonabsorbable sutureI use 5’0 monofilament nylon for an interrupted closure of the skin wound. However, a subcuticular closure with an absorbable suture can be alternatively done according to the surgeon’s preference

    The sutured wound with accurate approximation of the tattoo edges

    A soft bulky dressing over nonadherent Jelonet is applied. A plaster is usually not required after this fixation

    Post Operative

    Finger mobilization exercises are commenced immediately. The wound is redressed within a week when formal therapy exercises with full active mobilsation of the hand are started. Sutures are removed at 2 weeks. Activities of daily living can be commenced as soon as pain allows. Mobilisation exercises of the hand and wrist are progressively increased. Xrays are repeated at 6 weeks to confirm fracture healing. I advise patients against heavy activities until the fracture is consolidated.
    Stiffness is a common complication following this injury and its surgical fixation. Extensor tendon adhesions are partly to blame and can be minimized with early therapy and scar massage. I have not yet had to reexplore for extensor tenolysis in my practice.
    The movements in the 5th CMC joint play a critical role in the cupping and gripping manoeuvres of the hand. The bridge plate spans the CMC joint and should be removed in a second procedure. I wait for atleast 6-8 weeks before planning the removal of metalwork. The follow-up surgery can be undertaken through the previous scar taking similar precautions to protect the dorsal cutaneous branch of the ulnar nerve during the surgical approach.

    Recommended Reading


    Yoshida R, Shah MA, Patterson RM, Buford Jr WL, Knighten J, Viegas SF. Anatomy and pathomechanics of ring and small finger carpometacarpal joint injuries. The Journal of Hand Surgery. 2003 Nov 1;28(6):1035-43. This was a cadaveric study that recreated the axial loading force using a customised jig to identify the injury patterns. The 20 specimens were examined fluoroscopically as well as with detailed dissection to analyse the correlation between the injury patterns and the ligament anatomy. The authors recognise the complex patterns of injury and detail them. This is a good article to understand the rationale of investigations and treatment of this injury
    Büren C, Gehrmann S, Kaufmann R, Windolf J, Lögters T. Management algorithm for index through small finger carpometacarpal fracture dislocations. European Journal of Trauma and Emergency Surgery. 2016 Feb 1;42(1):37-42. This paper reviews the literature for the etiopathogenesis, investigation modalities and treatment options for these injuries. They summarise that operative fixation is the ideal treatment to restore anatomy and function in the hamatocarpal fracture dislocations.
    Jung HS, Song MK, Lee JS. Use of the bridge plate technique for the treatment of hamatometacarpal fracture-dislocations. The Journal of Hand Surgery (Asian-Pacific Volume). 2020 Mar;25(01):67-75. The authors present their outcome of treatment using a bridge plate across the CMC joint in 16 patients. They reported excellent functional recovery with all patients returning to their original jobs within 5 weeks. They concluded that this was an effective treatment modality for these complex injuries.
    Chaves C, Dubert T. Ulnar-sided carpometacarpal fractures and fractures-dislocations. A systematic review and publication guidelines. Orthopaedics & Traumatology: Surgery & Research. 2020 Oct 21. This paper reviewed 500 articles on this injury published over a 100 years. They recognized that the low incidence of the injury resulted in a plethora of case series. However, they were able to conclude that conservative treatment and percutaneous pinning should be reserved for the stable injuries. They suggested that unstable injuries and those with delayed presentation are best treated with open fixation.

    Tags:

    You might be interested in

    Luân Trần

    Bác sĩ khoa Chi trên - Bệnh viện Quân Y 175.

    Leave a Reply

    Your email address will not be published.

    Dark mode powered by Night Eye