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Surgical Treatment for Thumb Fractures

Posted on: 09/13/2012
The opposable thumb is still the one thing that distinguishes humans from other mammals. The anatomy is different from any of the other fingers. Without the thumb, we could not grip, pinch, grasp, or use the hand as we do now. Fine motor control for everyday actions like zipping a zipper, buttoning a button, or picking up any item would be severely impaired.

That's why the treatment of thumb fractures and restoration of normal function is so important. This article is intended to help surgeons understand surgical options for thumb fractures given the fact that there are many ways to manage thumb fractures and very few evidence-based guidelines.

In fact, the present state of orthopedic treatment for this problem still rests with the surgeons' choice based on experience and preferences. This is because studies to provide best practice, evidence-based guidelines have not been developed yet. The authors approach this topic from two different sides.

The first is by focusing on treatment goals, which are to stabilize the fracture so it can heal, restore normal alignment when there are deformities, care for soft tissue injuries, and return normal use of the thumb and hand. The second is by type of fracture. Various types of fractures are discussed based on which bone is affected; location, type, and severity of the break; open versus closed fractures; and ways to repair each one.

Surgical and fixation techniques (use of hardware such as wires, plates, and screws) are discussed with X-rays, drawings, and photos to help the reader understand each one. Specific fracture types including skier's thumb, metacarpal fractures, and Bennett and Rolando fractures are described with treatment options for each one presented.

The presence of soft tissue injuries (e.g. torn ligaments, damaged joint surface, muscle tears) complicates treatment decisions and may determine when open surgery is needed to complete repairs and/or reconstruction. Likewise, fractures that have displaced separated or twisted (rotated) may require more invasive surgical techniques in order to make the necessary repairs. The presence of multiple bone fragments or thumb dislocation (or other instability) can hinder successful return-of-function.

Advantages and disadvantages of using each type of suture (double row versus single row), fixation method, locking versus nonlocking plates, and hardware removal are provided as well. More surgeons are using bioabsorbable plates and screws as the materials continue to improve. The advantage of not having a second surgery to remove the hardware is weighed against the disadvantages of foreign body reactions and higher refracture rates.

Loss of strength and worse clinical results have also been noted with the newer biodegradable copolymer hardware. Some surgeons are sticking with the metal implants until hardware composition improves enough to eliminate these potential problems.

Review articles like this one are helpful to surgeons when there are no definitive best practice, evidence-based guidelines to guide treatment decisions. As you might expect, simple fractures are usually straightforward and easier to treat. There isn't a lot of controversy among surgeons in the best approach. It's the more complex fractures that require open incisions and fixation that create such challenges. Surgeons rely on their own experiences, expertise, and intuition when repairing or reconstructing these fractures.

References:
Abdo Bachoura, and Eon K. Shin, MD. Latest Techniques in the Management of Thumb Fractures. In Current Orthopaedic Practice. July/August 2012. Vol. 23. No. 4. Pp. 305-312.

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