How to Chunk out Studying for the CHT Exam - Hand Fractures
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[00:00:00] If you understand the anatomy of the hand, uh, and you understand how everything is supposed to work, it would just help make it easier. And then when you understand fractures, then you can take what you know and understand about fractures and then be able to apply it to all areas of the arm in terms of fractures.
You understand surgeries and the types of surgeries, the types of surgeries don't necessarily change. But what changes are, the one that they pick based on the area. But it's all on like hand fractures and dislocations, therapist management of, and, uh, surgeries, like surgical management of. And this is key because it's, it's gonna, you're gonna see it come up time and time again in all different types of cases, right?
Bones are bones. Bones are bones. bones and bones, right? So you're going to have your intra articular
types of fractures and then [00:01:00] you're going to have your extra articular fractures. We're just looking at fractures. There's really two types of fractures. There's the fractures that are inside the bone. And this is something I do too. I take a complex word, I translate it into an easy word, and then because I am able to translate it into an easy word, I can then translate it into a complex word.
So if you're not familiar to seeing some of this word, this is why it's important to do a certain amount of reading. And reading in the sense that You can skim over the chapters as you're reviewing. Um, so you can catch the words and the words and how they use it. Um, and you don't have to like recall it and quiz yourself necessarily, but you want to be able to understand and be able to be, be able to translate.
Like I always, when I think about, um, [00:02:00] anatomical position, I still sometimes put my arms out because this, all of this is volar. Um, So when you see the chapters and you read, you're reading in a one dimensional way. You see these graphs and you're like, oh, apex, dorsal and volar and you're like, Oh God, what is that?
Um, if you just put your hand out and you say, this is volar and this is dorsal. That, that now adds, you've added a visual component and a tactile component, kinesthetic component. Thank God we have our hands, right? For the most part, we have our hands and these, believe it or not, this is our cheat sheet.
Don't tell them. It might make you take it off, right? Put it, put it outside. So, so inside the bone is extra articular. I used to be so confused about this because it just didn't make any sense. Right? Extra intra articular inside the joint. Inside the joint. And this is outside the [00:03:00] joint. You can remember me, I'm extra.
I'm outside of the joint. So intra and extra articular. So the reason why you want to kind of always keep these things in mind is because extra articular types of fractures tend to be quote unquote easier. Intraarticular is less predictable. It's less predictable. Why? Because structurally you've gone now and broken inside the joint and you've broken inside that articular cartilage and so now the congruency of your joint may be lost.
That's why it makes it harder. Uh, it might have been dislocated. So anytime you have a fracture, it's one thing, but when you have a fracture and dislocation, you just like compounded your problem, right? Um, but really what it comes down to a lot is the stability and the congruency of the joint to be able to move.
And that's what makes it less predictable, um, harder to treat. [00:04:00] And if there's, you know, Um, if it's bad enough, you're going to need surgery. And then you have to think about like, why, what type of surgery would you have? So it goes back to, um, uh, the evaluation, right? It goes back to the evaluation. Now, you kind of know a little bit of the, the general information.
You go back to the evaluation, you think about the date of injury, the date of surgery, you know, where exactly, very specifically, is the fracture, um, was it delayed, were soft tissue issues a problem? Are there capsular tightness? Is the tendon gliding? All that stuff, right? And then you think about the prognosis.
What are they allowed to do? When? Based on stability, based on complexities. So that's how when you start to think about fractures, you've got to build up like using the evaluation, using the prognosis and being able to get into treatment, right? So in terms of, um, in terms of surgeries, right? So if you have fractures, what kind of surgery would you have?
So there are several different types of surgeries. I think there's, um, [00:05:00] there's five of one that they really, you know, talk about in terms of fracture fixation. The surgeries are done to increase stability, right? And then to, to get alignment
and alignment isn't just in one direction or another, it might be a rotational deformity. So surgery is going to help to stabilize, align, and fix any kind of rotational deformities. And
one of the most common ones that you'll see is wire fixation.
And it's actually, uh, wire's Kirschner. It's good for fractures that require minimum soft tissue, uh, problems, uh, bony exposures. It's used with loop tension bands. So, um, you might have, um, intro articular type of [00:06:00] fracture where they need to distract from the joint a little bit and especially in the fingers they're gonna do k wires and then they're gonna put rubber bands to distract the joint a little bit those are called loop tension bands have a wire loop which is used for compression of a fracture site but anything wire specific it could be just a simple wire like pins where you'll see most of the time you'll see a minimum of two to stabilize a fracture, right?
And then it might be a three. Um, but K wires or, um, Kirshner wire fixations are the weakest fixation. It is the most common in fingers, but remember when I said that you can use this knowledge to combat compound what you know, and it's because pretty much this is for any kind of fracture where you're going to run into in the arm, right?
But you'll see most of them in the fingers just because the, the size is so small. And then the next type of, uh, fixation you're going to see are screws. So screws, start thinking about, and the [00:07:00] screws, you might see it, um, for like a bigger bow, right? Because, uh, P1, they wouldn't necessarily put, uh, screws in P, P2 or P3, just because of the fact that they're such small.
small bones, but P1 might be able to sustain a screw or two screws. It can often be seen in wrist fractures as well. One common one is a scalpoid fracture. You'll see a screw go through there. And then you have, um, ORIFs. So all ORIFs, um, Open reduction internal fixation. So you see plates and screws. So just think about where would you see plates and screws.
You can see them in, uh, P1 fractures. You can see them essentially in sometimes in P2 fractures, but very rarely just because the structures, uh, make for complications due to our skin and tendons, uh, that adhere down. So doing, you know, um, an ORI app up here [00:08:00] can cause problems. Where else can you see fixations like that?
You can see them in the metacarpals. Uh, where can you see? They're too big, plates and screws, so you would never see them in carpal fractures, right? Um, you would only see them use plates and screws if they were doing a fusion to stop all movement, because it's too big. wrist bones are so small, uh, you would see them in distal radius fractures, you would see them in forearm fractures, you see them in elbow fractures, shoulder fractures, right?
So you just kind of think about where you've seen them and how they would just be able to be applied to so many different areas. Um, intramedullar, uh, fraction, uh, fixation,
fixation, and that's going to be like that And you don't necessarily see a bunch of these. You might, um, see that in the shoulder if it's a humerus fracture, but really it's not often used in the hand. [00:09:00] It might be, but they tend to be just a, like a straight down nail. Um, and if they did that, And you've seen them in the, um, it's actually done as pins, K wires versus the, uh, that type of fixation because they tend to leave those fixations in, they don't remove them, or it's pinned, you put them in for four to six weeks and then you pull them out, right?
And then the fifth one is external fixators.
External fixators, they tend to be used when all else is can not stabilize and fix the problem and provides temporary distractions of the fracture site. Um, unfortunately I've seen it in small fingers for PE, uh, two types of fractures, um, and they're terrible. They, they just, they don't do well. Um, but it's usually because it's so, um, so fragmented and the bone is so small that you have intra and extra because it's, I mean, it's just completely crushed.
You know, [00:10:00] I've seen them where they're trying to provide the stability, but the hardware itself is just so heavy. And even with splinting, it just can't really hold everything together. And um, you know, bone fractures need to be essentially reduced to be as close as possible. I'm about to go into some fractures and how to really.
Think about it. So it comes down to foundational knowledge, right? So let's say this is, um, let me see, this is, um, this is, uh,
this is your metacarpal. This is P1, P2, and then P3, right? If you're looking like this, this is volar, right? And then on the back is dorsal. So on the back, you can't see the extensor mechanism. [00:11:00] But you know it's there, right? And then on the front side, you have your volar plate, your volar plate, and your volar plate, right?
Volar plate of the MP, volar plate of the PIP, and of course the volar plate too.
Then you have, um, and Then you have your tendons, right? Then you have your
superficialis, and then you have your profundus, right? So they kind of just run right around the same area. And then you have your collateral ligaments, right? You have your collateral ligaments. Here's the thing with collateral [00:12:00] ligaments. So in the PIP, they're always taut. They're always tight, both in flexion and extension.
That's how I draw flexion and extension. PIP, they're always tight, right? Now collateral ligaments in the MP are a little bit different. Um, there is, Um, or there are two, um, two parts to it. It's the, the true and the accessory, I
think I was looking at like a really old, uh, note and they were saying that, I think it was, there's another word for proper, I don't know Also known, AKA proper. If you [00:13:00] haven't seen it, it's okay. It's in the 7th edition. They call it the True and then the Accessory. Right, but it's, it's um, it's essentially it's a collateral ligament, but the collateral ligament of the MP has two parts.
And the reason why it's important is because instead of like the PIP and the DIP where they're tight in both flexion and extension, um, the True, is loose in extension and tight inflection. Tight inflection. Loose in extension. Right? And so if, you know, you might understand that the MPs always need to be in a safe position of between, you know, 60 and 80 degrees, right?
to, to kind of, you know, protect the MPs from being stuck in extension. [00:14:00] You might know that, but the why behind that is because of the collateral ligaments, the true portion being tight inflection and being loose in extension. Now, why would you want them to be tight and loose? inflection, um, because in a way it doesn't make sense, right?
Because you're, you're putting them into a safe position so they wouldn't get tight. And you're right. It won't get tight if it's inflection because the true collateral ligament, when it's inflection, it has to go around this big old metacarpal head. And the metacarpal head puts a stress on, like stretches it out to keep it loose, even though it's tight inflection.
Does that make sense? I think that's the best I've ever explained it. Somebody tell me that it makes sense to them, right? So that's why, um, anytime anything happens to the MPs, you think how [00:15:00] I need to put them in here. It's because of the true, um, collateral ligament, right? Now you might have a question where it's just talking about collateral ligaments, right?
But if they break it down into true and accessory, which sometimes are assholes and they do that, right? You know, it's the true that is tight inflection and loosen extension. The accessory part of the collateral ligament is attached to the molar plate. Remember the plate. So the molar plate, when goes into, um, flexion, slides down proximally.
Proximal. So when you go into flexion, it's supposed to slide down proximally, right? Dude, this is what I do. Distal proximal. Distal proximal. Like, it [00:16:00] will help you make sense of stuff and then it slows you down on the exam. You get that visual and kinesthetic, um, understanding. Okay, so the accessory, you go into flexion, the, the, the boulder plate goes and moves, um, moves proximally, right?
Well because the accessory portion of the collateral ligament is attached to the boulder plate, it will also move proximally, so it will stay nice and loose. And that's why MPs need to be placed in a safe position, uh, of between 60 and 80 degrees. Right? Um, does that make sense? There's also these structures, um, a, a, um, a bowler, and this is not just being really finicky and picky, but you, you [00:17:00] have on the, on, you have your extensor mechanism on the back of the fingers.
You have a dorsal capsule. Right? And then on the volar part, you have what's called a fibrous digital sheath. Fibrous digital sheath. It's just the same thing, just in a different location. So they call it a fibrous digital sheath. What do you think a dorsal capsule is? Dorsal is in the back of the hand.
Capsule is just fibrous sheath. Right? But when you think about all the structures that are there, it's how it can play a role in why a finger doesn't move after a fracture, after a dislocation, why there's no glide in the tendon, why the joints get so stiff, right? And then you're going to have your, your [00:18:00] ulnar side and you have your radial side.
So when you start seeing radial you know, an ulnar collateral ligament. So radio and ulnar is just for location just like the dorsal and volar. It's just for location. So you understand
