Bennett's fracture: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==


<br>A Bennett fracture, also known as a Bennett fracture-dislocation is an intra-articular fracture of the base of the first&nbsp;[[Metacarpal Fractures|metacarpal]] which leads to dislocation of the first carpometacarpal joint. The [[fracture]]&nbsp;involves the joint between the first metacarpal and the proximal carpal bone, the&nbsp;trapezium. The fracture is unstable and has an inadequate reduction/fixation which&nbsp;leads to long term consequences such as [[osteoarthritis]], weakness, or loss of function&nbsp;of the first carpometacarpal joint.<ref name=":0">C. Brownlie. Bennett Fracture Dislocation: Review and Management; Australian&nbsp;Family Physician vol 40, No. 6, June 2011</ref> This joint is called the carpometacarpal (CMC)&nbsp;joint, and is normally stabilized by a ligament called the deep ulnar ligament. Due to&nbsp;the position of the fracture fragment there is some detachment of this ligament from&nbsp;the bone, causing a dislocation of the joint.<ref>Physioroom.com Bennett’s Fracture. http://www.physioroom.com/injuries/hand_and_wrist/bennetts_fracture_full.php<nowiki/>(Accessed 5/05/2013)</ref>  
<br>A Bennett fracture, also known as a Bennett fracture-dislocation, is an intra-articular fracture of the base of the first&nbsp;[[Metacarpal Fractures|metacarpal]] which leads to dislocation of the first carpometacarpal joint (CMCJ). The [[fracture]]&nbsp;involves the joint between the first metacarpal and the proximal carpal bone, the&nbsp;trapezium. The fracture is unstable and has an inadequate reduction/fixation which&nbsp;leads to long term consequences such as [[osteoarthritis]], weakness and / or loss of function.<ref name=":0">C. Brownlie. Bennett Fracture Dislocation: Review and Management; Australian&nbsp;Family Physician vol 40, No. 6, June 2011</ref><ref>Physioroom.com Bennett’s Fracture. http://www.physioroom.com/injuries/hand_and_wrist/bennetts_fracture_full.php<nowiki/>(Accessed 5/05/2013)</ref>  


<br>  
<br>  
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== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


<br>The first carpometacarpal joint is unique, it has only an articulation between the&nbsp;trapezium and the base of the first metacarpal. The articulation is saddle-shaped&nbsp;which allows greater motion. <ref name=":0" /> The ligaments in&nbsp;this joint are the anterior (volar) and posterior oblique ligaments, the anterior and&nbsp;posterior intermetacarpal ligaments, and the dorsal radial ligament. The anterior&nbsp;oblique ligament is the most important for stability in the carpo-metacarpal joint.<ref>Mark E Baratz, MD; Chief editor: Harris Gellman, Bennett Fracture, Medscap&nbsp;reference http://emedicine.medscape.com/article/1238036-overview#a05<nowiki/>(Accessed&nbsp;5/05/2013)</ref><br>  
<br>The first CMCJ is unique, it has only an articulation between the&nbsp;trapezium and the base of the first metacarpal. The articulation is saddle-shaped&nbsp;which allows greater motion. <ref name=":0" /> The ligaments in&nbsp;this joint are the anterior (volar) and posterior oblique ligaments, the anterior and&nbsp;posterior intermetacarpal ligaments, and the dorsal radial ligament. The anterior&nbsp;oblique ligament is the most important for stability in the carpo-metacarpal joint.<ref>Mark E Baratz, MD; Chief editor: Harris Gellman, Bennett Fracture, Medscap&nbsp;reference http://emedicine.medscape.com/article/1238036-overview#a05<nowiki/>(Accessed&nbsp;5/05/2013)</ref><br>  


== Differential Diagnosis  ==
== Differential Diagnosis  ==


<br>Very common injuries on the first metacarpal are [http://orthopedics.about.com/cs/handcondiitions/a/gamekeepers.htm gamekeepers thumbs], [http://www.wheelessonline.com/ortho/rolandos_fracture Rolando&nbsp;fracture] and a Bennett fracture.
<br>Other common injuries involving the first metacarpal include Rolando fractures, extra-articular fractures and [http://orthopedics.about.com/cs/handcondiitions/a/gamekeepers.htm gamekeepers thumb]  


The first differentiation clue can be found during the inspection/palpation of&nbsp;the location of the injury. Bennett fractures are associated with pain and weakness of the&nbsp;pinch grasp and swelling and ecchymosis over the carpal metacarpal joint of the thumb. The patient will be <u>unable to perform</u> functional tasks such as tying a&nbsp;shoe or using a key.&nbsp;Possible complications can be infection, malunion or nonunion, arthritis and&nbsp;stiffness with contracture.<ref>KJAER-PETERSEN K. et al.; “Bennett’s fracture”, Journal of Hand Surgery, 1990 Feb;&nbsp;15(1):58-61</ref><sup></sup><br>  
The first differentiation clue can be found during the inspection/palpation of&nbsp;the location of the injury. Bennett fractures are associated with pain and weakness of the&nbsp;pinch grasp and swelling and ecchymosis over the carpal metacarpal joint of the thumb. The patient will be <u>unable to perform</u> functional tasks such as tying a&nbsp;shoe or using a key.&nbsp;Possible complications can be infection, malunion or nonunion, arthritis and&nbsp;stiffness with contracture.<ref>KJAER-PETERSEN K. et al.; “Bennett’s fracture”, Journal of Hand Surgery, 1990 Feb;&nbsp;15(1):58-61</ref><sup></sup><br>  
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== Examination  ==
== Examination  ==


If a Bennett fracture is suspected, the subjective history of the patient should include trauma to the hand or thumb followed by immediate pain and swelling or ischemia.<ref>HOWARD FM.; “Fractures of the basal joint of the thumb”, Clinical Orthopaedics and&nbsp;Related Research, 1987 Jul;(220):46-51</ref>
If a Bennett fracture is suspected, the subjective history of the patient should include trauma to the hand or thumb followed by immediate pain and swelling or ischemia.<ref>HOWARD FM.; “Fractures of the basal joint of the thumb”, Clinical Orthopaedics and&nbsp;Related Research, 1987 Jul;(220):46-51</ref> The most common mechanism of injury is axial force (compression) applied to the thumb whilst in flexion.


On physical examination a Bennett's fracture of the first carpo metacarpal joint may present with:
On physical examination a Bennett's fracture of the first carpo metacarpal joint may present with:
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Although [[X-Rays|X-ray]] films can be used to diagnose this condition, a [[CT Scans|CT scan]] should be ordered to&nbsp;evaluate the extent of the damage. On&nbsp;these CT scans a Bennett fracture will present can as an intra-articular fracture and dislocation of base of the&nbsp;first metacarpal. Even though there is a dislocation there should still be a small&nbsp;fragment of the first metacarpal that continues to articulate with trapezium.  
Although [[X-Rays|X-ray]] films can be used to diagnose this condition, a [[CT Scans|CT scan]] should be ordered to&nbsp;evaluate the extent of the damage. On&nbsp;these CT scans a Bennett fracture will present can as an intra-articular fracture and dislocation of base of the&nbsp;first metacarpal. Even though there is a dislocation there should still be a small&nbsp;fragment of the first metacarpal that continues to articulate with trapezium.  
== Medical Management    ==
<br>Bennett fractures have several options of management. Each treatment has it’s&nbsp;advantages and disadvantages.<ref name=":0" />


<sup></sup><br>''Type I - Closed Reduction''


== Medical Management    ==
<br>The first type of management is closed reduction and plaster casting. This is a non-invasive procedure and remains the first option if possible.The major issue in closed&nbsp;reduction is to obtain and maintain adequate fracture reduction to allow healing in an&nbsp;anatomical position. Consequences of an inaccurate reposition are pain and grip&nbsp;weakness in short term and osteoarthritis of the first metacarpal joint in long term.&nbsp;Hence it is recommended to let these fractures be treated by specialist hand&nbsp;surgeons.<br>All the variant methods of closed reduction involve traction on the thumb to pull&nbsp;metacarpal distally with concurrent pressure pushing the metacarpal base medially to&nbsp;return it to anatomical position.&nbsp;Closed reduction is performed under adequate analgesia/sedation follow by plaster&nbsp;cast immobilization for ±6 weeks. A cast with the thumb in a moderate adduction and&nbsp;opposition is most effective by reducing the fracture fragments.<ref>CULLEN J.P. Et al; Simulated Bennett Fracture Treated With Closed Reduction and&nbsp;Percutaneous Pinning; The journal of Bone and Joint Surgery, 1997</ref>


<br>Bennett fractures have several options of management. Each treatment has it’s&nbsp;advantages and disadvantages.<ref name=":0" />  
<sup></sup><br>''Type II - K-wires''


<sup></sup><br>''Type I''<br>The first type of management is closed reduction and plaster casting. This is a non-invasive procedure and remains the first option if possible.The major issue in closed&nbsp;reduction is to obtain and maintain adequate fracture reduction to allow healing in an&nbsp;anatomical position. Consequences of an inaccurate reposition are pain and grip&nbsp;weakness in short term and osteoarthritis of the first metacarpal joint in long term.&nbsp;Hence it is recommended to let these fractures be treated by specialist hand&nbsp;surgeons.<br>All the variant methods of closed reduction involve traction on the thumb to pull&nbsp;metacarpal distally with concurrent pressure pushing the metacarpal base medially to&nbsp;return it to anatomical position.&nbsp;Closed reduction is performed under adequate analgesia/sedation follow by plaster&nbsp;cast immobilization for ±6 weeks. A cast with the thumb in a moderate adduction and&nbsp;opposition is most effective by reducing the fracture fragments.<ref>CULLEN J.P. Et al; Simulated Bennett Fracture Treated With Closed Reduction and&nbsp;Percutaneous Pinning; The journal of Bone and Joint Surgery, 1997</ref>  
<br>A second method of reduction involves reduction of the fracture followed by&nbsp;percutaneous insertion of a Kirschner wire through the base of the metacarpal across&nbsp;the joint and into the trapezium to hold the reduction in place. The wire remains in&nbsp;place for about 4 weeks after which a rehabilitation program is started.<ref name=":0" />  


<sup></sup><br>''Type II''<br>A second method of reduction involves reduction of the fracture followed by&nbsp;percutaneous insertion of a Kirschner wire through the base of the metacarpal across&nbsp;the joint and into the trapezium to hold the reduction in place. The wire remains in&nbsp;place for about 4 weeks after which a rehabilitation program is started.<ref name=":0" />
<sup></sup><br>''Type III - Open Reduction''  


<sup></sup><br>''Type III''<br>This last treatment is necessary when there is a significant displacement (&gt;3mm).<ref>Dr MAULIK S. Et al.; “Bennett fracture dislocation”, Radiopaedia, 2012.&nbsp;http://radiopaedia.org/articles/bennett-fracture-dislocation<nowiki/>(Accessed 5/05/2013)</ref>Type III involves an open reduction, which involves opening up the fracture and&nbsp;reduction under direct vision followed by insertion of either Kirschner wires (Fig1) or&nbsp;lag screws in order to hold the reduction in place. Like the second type of&nbsp;management, after the reduction there is an immobilization period of 4 weeks.<br>This type is preferable where there is a large proximal fragment and that ORIF should&nbsp;be used where the fracture is irreducible or a Kirschner wire is unable to be passed&nbsp;across the fracture.<ref>Zhang X. Et al.; Treatment of a Bennett Fracture Using Tension Band Wiring, Journal&nbsp;of Hand Surgery, 2012, Volume 37, issue 3, p427-433</ref><br> <br>  
<br>This last treatment is necessary when there is a significant displacement (&gt;3mm).<ref>Dr MAULIK S. Et al.; “Bennett fracture dislocation”, Radiopaedia, 2012.&nbsp;http://radiopaedia.org/articles/bennett-fracture-dislocation<nowiki/>(Accessed 5/05/2013)</ref>Type III involves an open reduction, which involves opening up the fracture and&nbsp;reduction under direct vision followed by insertion of either Kirschner wires (Fig1) or&nbsp;lag screws in order to hold the reduction in place. Like the second type of&nbsp;management, after the reduction there is an immobilization period of 4 weeks.<br>This type is preferable where there is a large proximal fragment and that ORIF should&nbsp;be used where the fracture is irreducible or a Kirschner wire is unable to be passed&nbsp;across the fracture.<ref>Zhang X. Et al.; Treatment of a Bennett Fracture Using Tension Band Wiring, Journal&nbsp;of Hand Surgery, 2012, Volume 37, issue 3, p427-433</ref><br> <br>  


== Physical Therapy Management    ==
== Physical Therapy Management    ==


<br>Generally, hand fractures are treated by immobilization with a cast or splint. The use&nbsp;of static and dynamic splinting in the treatment of hand injuries is essential in many&nbsp;cases to maximize functional outcome. Protocols for rehabilitation must be based&nbsp;upon stability of the fracture and fracture management (operative or nonoperative).&nbsp;<br>Treatment consists of active, passive, and resistive exercises. For exercises do we need some revalidation materials. The muscles need to be stronger because the fracture has weaked them. In the rehab the PowerWeb is a very handy material. It gives resistance to all the movements in the hand- or wristjoint. In the web the patient can do a flexion, extension, opposition, abduction or adduction against resistance. The patient must pay attention that he doesn’t overload the joints. Another helpful tool is the exercise putty. It has the same intention as the PowerWeb. With these exercises the muscles of the thumb will be much stronger than before and this is necessary for the revalidation of the Bennett’s Fracture.<ref>Dell, P. C., and R. B. Dell. "Management of Carpal Fractures and Dislocations." Hunter - Mackin - Callahan Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc.,2002. 1171-1184.</ref>
<br>Generally, hand fractures are treated by immobilization with a cast or splint regardless of whether surgical or conservative treatment was required. Physical therapists and / or occupational therapists are usually heavily involved in creating and adapting these in consultation with the treating team or surgeon. Protocols for rehabilitation must be based&nbsp;upon stability of the fracture and fracture management (operative or nonoperative).
 
<sup></sup><br>The goal of rehabilitation is to decrease pain and restore function. Modalities such as&nbsp;cold packs may be beneficial for controlling pain. Special attention should be paid to&nbsp;preserve full function of the uninvolved fingers, especially if the dominant hand is&nbsp;involved. This will be done by strengthening exercises e.g. finger flexion exercises.&nbsp;Exercise intensity and difficulty should be progressed until full function is achieved.<ref>MDGuidelines.com, Return to work is the best measure of healthcare outcomes.&nbsp;www.mdguidelines.com/fracture-fingers-and-thumb (Accessed 5/05/2013)</ref><br>Soft tissue mobilization and joint mobilization is also a possibility to apply.<ref>Joe Godges, “Physical Therapy Protocols for Conditions of Wrist and Hand Region”,&nbsp;KP So Cal Ortho PT Residency , 2004</ref> The&nbsp;earlier the patient starts with rehabilitation, the earlier there are results in recovery of&nbsp;mobility and strength. This can result to an earlier return to work.<ref>Feehan, L. M., and K. Bassett. "Is There Evidence for Early Mobilization Following an&nbsp;Extraarticular Hand Fracture." Journal of Hand Therapy 24 Nov. 2008</ref>


Following the immobilisation period, physiotherapists and specialist hand therapists are involved in the facilitation of restoring maximal function to the hand.<br>.<ref>Dell, P. C., and R. B. Dell. "Management of Carpal Fractures and Dislocations." Hunter - Mackin - Callahan Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc.,2002. 1171-1184.</ref> <sup></sup>Modalities employed include&nbsp;[[cryotherapy]], joint mobilisation, strengthening & flexibility exercises, dexterity re-education and specific education.&nbsp;Exercise intensity and complexity should be progressed appropriately following designated protocol usually provided by the surgeon.<ref>MDGuidelines.com, Return to work is the best measure of healthcare outcomes.&nbsp;www.mdguidelines.com/fracture-fingers-and-thumb (Accessed 5/05/2013)</ref><ref>Joe Godges, “Physical Therapy Protocols for Conditions of Wrist and Hand Region”,&nbsp;KP So Cal Ortho PT Residency , 2004</ref> Evidence supports the positive impact of early physiotherapy intervention to facilitate optimal return to function and return to work/sport in hand fractures.<ref>Feehan, L. M., and K. Bassett. "Is There Evidence for Early Mobilization Following an&nbsp;Extraarticular Hand Fracture." Journal of Hand Therapy 24 Nov. 2008</ref>
== References ==
== References ==
<references />  
<references />  


[[Category:Primary Contact|Conditions]]
[[Category:Primary Contact|Conditions]]

Revision as of 21:20, 9 December 2018

Definition/Description[edit | edit source]


A Bennett fracture, also known as a Bennett fracture-dislocation, is an intra-articular fracture of the base of the first metacarpal which leads to dislocation of the first carpometacarpal joint (CMCJ). The fracture involves the joint between the first metacarpal and the proximal carpal bone, the trapezium. The fracture is unstable and has an inadequate reduction/fixation which leads to long term consequences such as osteoarthritis, weakness and / or loss of function.[1][2]


Clinically Relevant Anatomy[edit | edit source]


The first CMCJ is unique, it has only an articulation between the trapezium and the base of the first metacarpal. The articulation is saddle-shaped which allows greater motion. [1] The ligaments in this joint are the anterior (volar) and posterior oblique ligaments, the anterior and posterior intermetacarpal ligaments, and the dorsal radial ligament. The anterior oblique ligament is the most important for stability in the carpo-metacarpal joint.[3]

Differential Diagnosis[edit | edit source]


Other common injuries involving the first metacarpal include Rolando fractures, extra-articular fractures and gamekeepers thumb

The first differentiation clue can be found during the inspection/palpation of the location of the injury. Bennett fractures are associated with pain and weakness of the pinch grasp and swelling and ecchymosis over the carpal metacarpal joint of the thumb. The patient will be unable to perform functional tasks such as tying a shoe or using a key. Possible complications can be infection, malunion or nonunion, arthritis and stiffness with contracture.[4]

Examination[edit | edit source]

If a Bennett fracture is suspected, the subjective history of the patient should include trauma to the hand or thumb followed by immediate pain and swelling or ischemia.[5] The most common mechanism of injury is axial force (compression) applied to the thumb whilst in flexion.

On physical examination a Bennett's fracture of the first carpo metacarpal joint may present with:

  • visible deformity if the fracture is displaced
  • pain and swelling +/- ecchymosis over carpo metacarpal joint of the thumb
  • tenderness to touch
  • warmth over area in acute phase
  • decreased pinch grasp and decreased grip strength13 


Although X-ray films can be used to diagnose this condition, a CT scan should be ordered to evaluate the extent of the damage. On these CT scans a Bennett fracture will present can as an intra-articular fracture and dislocation of base of the first metacarpal. Even though there is a dislocation there should still be a small fragment of the first metacarpal that continues to articulate with trapezium.

Medical Management[edit | edit source]


Bennett fractures have several options of management. Each treatment has it’s advantages and disadvantages.[1]


Type I - Closed Reduction


The first type of management is closed reduction and plaster casting. This is a non-invasive procedure and remains the first option if possible.The major issue in closed reduction is to obtain and maintain adequate fracture reduction to allow healing in an anatomical position. Consequences of an inaccurate reposition are pain and grip weakness in short term and osteoarthritis of the first metacarpal joint in long term. Hence it is recommended to let these fractures be treated by specialist hand surgeons.
All the variant methods of closed reduction involve traction on the thumb to pull metacarpal distally with concurrent pressure pushing the metacarpal base medially to return it to anatomical position. Closed reduction is performed under adequate analgesia/sedation follow by plaster cast immobilization for ±6 weeks. A cast with the thumb in a moderate adduction and opposition is most effective by reducing the fracture fragments.[6]


Type II - K-wires


A second method of reduction involves reduction of the fracture followed by percutaneous insertion of a Kirschner wire through the base of the metacarpal across the joint and into the trapezium to hold the reduction in place. The wire remains in place for about 4 weeks after which a rehabilitation program is started.[1]


Type III - Open Reduction


This last treatment is necessary when there is a significant displacement (>3mm).[7]Type III involves an open reduction, which involves opening up the fracture and reduction under direct vision followed by insertion of either Kirschner wires (Fig1) or lag screws in order to hold the reduction in place. Like the second type of management, after the reduction there is an immobilization period of 4 weeks.
This type is preferable where there is a large proximal fragment and that ORIF should be used where the fracture is irreducible or a Kirschner wire is unable to be passed across the fracture.[8]

Physical Therapy Management[edit | edit source]


Generally, hand fractures are treated by immobilization with a cast or splint regardless of whether surgical or conservative treatment was required. Physical therapists and / or occupational therapists are usually heavily involved in creating and adapting these in consultation with the treating team or surgeon. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative or nonoperative).

Following the immobilisation period, physiotherapists and specialist hand therapists are involved in the facilitation of restoring maximal function to the hand.
.[9] Modalities employed include cryotherapy, joint mobilisation, strengthening & flexibility exercises, dexterity re-education and specific education. Exercise intensity and complexity should be progressed appropriately following designated protocol usually provided by the surgeon.[10][11] Evidence supports the positive impact of early physiotherapy intervention to facilitate optimal return to function and return to work/sport in hand fractures.[12]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 C. Brownlie. Bennett Fracture Dislocation: Review and Management; Australian Family Physician vol 40, No. 6, June 2011
  2. ↑ Physioroom.com Bennett’s Fracture. http://www.physioroom.com/injuries/hand_and_wrist/bennetts_fracture_full.php(Accessed 5/05/2013)
  3. ↑ Mark E Baratz, MD; Chief editor: Harris Gellman, Bennett Fracture, Medscap reference http://emedicine.medscape.com/article/1238036-overview#a05(Accessed 5/05/2013)
  4. ↑ KJAER-PETERSEN K. et al.; “Bennett’s fracture”, Journal of Hand Surgery, 1990 Feb; 15(1):58-61
  5. ↑ HOWARD FM.; “Fractures of the basal joint of the thumb”, Clinical Orthopaedics and Related Research, 1987 Jul;(220):46-51
  6. ↑ CULLEN J.P. Et al; Simulated Bennett Fracture Treated With Closed Reduction and Percutaneous Pinning; The journal of Bone and Joint Surgery, 1997
  7. ↑ Dr MAULIK S. Et al.; “Bennett fracture dislocation”, Radiopaedia, 2012. http://radiopaedia.org/articles/bennett-fracture-dislocation(Accessed 5/05/2013)
  8. ↑ Zhang X. Et al.; Treatment of a Bennett Fracture Using Tension Band Wiring, Journal of Hand Surgery, 2012, Volume 37, issue 3, p427-433
  9. ↑ Dell, P. C., and R. B. Dell. "Management of Carpal Fractures and Dislocations." Hunter - Mackin - Callahan Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc.,2002. 1171-1184.
  10. ↑ MDGuidelines.com, Return to work is the best measure of healthcare outcomes. www.mdguidelines.com/fracture-fingers-and-thumb (Accessed 5/05/2013)
  11. ↑ Joe Godges, “Physical Therapy Protocols for Conditions of Wrist and Hand Region”, KP So Cal Ortho PT Residency , 2004
  12. ↑ Feehan, L. M., and K. Bassett. "Is There Evidence for Early Mobilization Following an Extraarticular Hand Fracture." Journal of Hand Therapy 24 Nov. 2008
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