今日の臨床サポート

手指の骨折、脱臼、ボクサー骨折

著者: 長岡正宏 駿河台日本大学病院 整形外科

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2017/04/27
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 手指の骨とは中手骨・基節骨・中節骨・末節骨で、それぞれに骨折がある。
  1. 脱臼はCM関節、MP関節、PIP関節、DIP関節があり、それぞれに脱臼・脱臼骨折がある。
  1. 突き指に伴う、骨折・脱臼・脱臼骨折( )、末節骨骨折を伴ったマレットフィンガー( )、ボクサー骨折( )、母指のCM関節脱臼骨折(Bennett脱臼骨折、)、などが有名である。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
長岡正宏 : 特に申告事項無し[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 手指の骨とは中手骨・基節骨・中節骨・末節骨で、それぞれに骨折がある。
 
手指の骨・関節

出典

 
  1. 脱臼はCM関節、MP関節、PIP関節、DIP関節があり、それぞれに脱臼・脱臼骨折がある[1]
 
手指の骨折・脱臼・脱臼骨折

出典

 
  1. スポーツで多く発生する[2]。 解説 
  1. 突き指で骨折・脱臼・脱臼骨折することがある。 解説 
  1. 末節骨骨折を伴ったマレットフィンガーがある[3]。 解説 
  1. ボクサー骨折とはパンチによる中手骨頚部骨折を指すことが多い[2]。 解説 
 
 
  1. 母指のCM関節脱臼骨折をBennett脱臼骨折と呼ぶ[4][5]。 解説 
  1. 骨折の回旋変形で指屈曲時の隣接指への重なり(scissoring, overlapping)を生じる[1][6]。 解説 
問診・診察のポイント  
  1. 受傷機転を詳細に聞く。 解説 

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文献 

著者: K O GEDDA
雑誌名: Acta Chir Scand Suppl. 1954;193:1-114.
Abstract/Text
PMID 13188578  Acta Chir Scand Suppl. 1954;193:1-114.
著者: J E Cain, T R Shepler, M R Wilson
雑誌名: J Hand Surg Am. 1987 Sep;12(5 Pt 1):762-7.
Abstract/Text Seventeen male patients with a fourth metacarpal fracture and fifth carpometacarpal joint injury were treated. Distinct patterns of injury were recognized and in each case fell into one of three categories. Type IA lesions were characterized by subluxation or dislocation of the fifth carpometacarpal joint without hamate avulsion fracture. Type IB lesions were identical to type IA lesions except for the appearance of a small dorsal rim hamate avulsion fracture. Type II lesions were distinguished by subluxation or dislocation of the fifth carpometacarpal joint and comminution of the dorsal hamate rim. Finally, type III lesions exhibited coronal splitting of the hamate.

PMID 3655238  J Hand Surg Am. 1987 Sep;12(5 Pt 1):762-7.
著者: A C Rettig, R Ryan, K D Shelbourne, J R McCarroll, F Johnson, S K Ahlfeld
雑誌名: Am J Sports Med. 1989 Jul-Aug;17(4):567-72.
Abstract/Text Fifty-six fractures of the metacarpal occurring in 53 athletes were studied from September 1985 to December 1986, regarding mechanism of injury, type of fracture, type of treatment, and time lost from sport. Age range of the patients was 8 to 28 years with greater than 77% being in the 14 to 18 year age range, the high school athlete. Twenty-nine of the fractures occurred in football, 14 in basketball, and the remainder were divided between various other sports. The most common mechanism of injury involved falls or hitting an object such as a helmet or another player. Fractures were evenly divided regarding which digit was involved in football, whereas most basketball injuries occurred in the fourth and fifth metacarpal. Fractures were analyzed as to type of radiographic appearance and this was correlated with time lost from competition or participation. No significant difference among fracture type regarding time lost was noted. Forty-six of the fractures (82%) were minimally displaced or undisplaced and were treated by means of simple casting and/or splinting whereas 10 were displaced. Two of the 10 underwent closed reduction and casting; 3 underwent closed reduction and percutaneous pin fixation; and 5 (9%) underwent open reduction internal fixation using AO type plates and screws. All fractures healed primarily clinically and radiographically. The average time lost from practice or competition in this group overall was 13.7 days, (range, 0 to 56 days). Average time lost from basketball was 19.8 days and from football 10.63 days overall. Average time lost from sport in stable fractures treated with casting or splinting was 12.3 days.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 2782541  Am J Sports Med. 1989 Jul-Aug;17(4):567-72.
著者: G L Dixon, N F Moon
雑誌名: Clin Orthop Relat Res. 1972 Mar-Apr;83:151-6.
Abstract/Text
PMID 5014806  Clin Orthop Relat Res. 1972 Mar-Apr;83:151-6.
著者: O Langhoff, K Andersen, K Kjaer-Petersen
雑誌名: J Hand Surg Br. 1991 Nov;16(4):454-9.
Abstract/Text The relationship between methods of treatment, quality of reduction and the occurrence of late disability and osteo-arthritic changes was studied in 17 Rolando's fractures. Three were undisplaced, 14 were displaced: of these excellent reduction was achieved in five of 11 treated by open reduction and in none of the three treated by percutaneous K wire fixation. After a median interval of 5.8 years, six of 16 reviewed patients had minor symptoms, while nine had no symptoms. Radiographic examination of 11 patients showed signs of osteoarthritis in six. We did not establish a relationship between the quality of reduction and the occurrence of late symptoms and osteoarthritis.

PMID 1779167  J Hand Surg Br. 1991 Nov;16(4):454-9.
著者: E C McElfresh, J H Dobyns
雑誌名: J Hand Surg Am. 1983 Jul;8(4):383-93.
Abstract/Text One hundred and three intra-articular metacarpal head fractures in 100 patients are presented and classified by anatomical involvement on roentgenographic examination. The fractures were epiphyseal (Salter-Harris type III, n = 4), ligament avulsions from metacarpal head (n = 17), osteochondral (n = 8), oblique (sagittal, n = 22), vertical (coronal, n = 4), horizontal (transverse, n = 4), comminuted (n = 31), boxer's fractures with extension into the joint (n = 3), loss of substance (n = 6), and occult compression with avascular necrosis (n = 4). Experience with fractures involving large intra-articular defects suggests that they should be reconstructed to give a congruous metacarpal head; the digit should then be mobilized as early as technically feasible.

PMID 6886332  J Hand Surg Am. 1983 Jul;8(4):383-93.
著者: A Ali, J Hamman, D P Mass
雑誌名: J Hand Surg Am. 1999 Jul;24(4):835-44.
Abstract/Text Many clinical studies have demonstrated that in the conservative care of boxer's fractures (casting, with or without reduction), between 20 degrees and 70 degrees of dorsal angulation is acceptable. This biomechanical study characterized how boxer's fracture angulation affects the ability of the intrinsic muscles to initiate grip. The flexor digiti minimi and third volar interosseous were modeled in this study. Muscular excursion of the intrinsics were modeled with a cable and sheath device. Metacarpophalangeal joint flexion per unit excursion curves were collected when the metacarpal neck was at a fracture angle of 0 degree, 15 degrees, 30 degrees, 45 degrees, 60 degrees, and 75 degrees . As fracture angles increased, the distance between the origin and insertion of the flexor digiti minimi decreased, creating shortening, or slack, of the modeled muscle. Slack was defined as excursion generating no joint flexion. Muscle shortening data were integrated with Jacobsen's muscle fiber length data and Elftmann's fiber length/tension relationship to estimate how the fracture angle affects the initiation of metacarpophalangeal joint flexion and the strength of grip. According to this model's data, fracture angles of up to 30 degrees are compatible with nearly normal mechanics. A 30 degrees angulation is associated with a flexor digiti minimi grip strength of 92% maximum and preserves 78% of the intact finger's range of motion. We therefore conclude that 30 degrees is the upper limit for acceptable final angulation.

PMID 10447177  J Hand Surg Am. 1999 Jul;24(4):835-44.
著者: F A Reyes, L L Latta
雑誌名: Clin Orthop Relat Res. 1987 Jan;(214):23-30.
Abstract/Text Stable fractures of the metacarpal and proximal phalanges can be treated satisfactorily by closed methods. The problem in those unstable fractures is whether to treat with open or closed reduction. Stiffness of the proximal interphalangeal joint (PIP), malunion, rotation deformities, shortening, and nonunion are known complications of fractures of the proximal phalanx. Fractures at the base of the proximal phalanx. Fractures at the base of the proximal phalanx have low incidence of complications if they are treated closed. Fractures at the shaft carry a much larger risk of complications with either type of treatment. This study of 158 fractures of the proximal phalanx demonstrates that there is a place for conservative treatment in the management of unstable shaft fractures of the proximal phalanx.

PMID 3791748  Clin Orthop Relat Res. 1987 Jan;(214):23-30.
著者: R T Manktelow, J L Mahoney
雑誌名: Plast Reconstr Surg. 1981 Oct;68(4):571-6.
Abstract/Text A scissoring deformity of the fingers frequently results from malunion of a phalangeal or metacarpal fracture. If union occurs with rotation, the injured digit will scissor with an adjacent digit on flexion of the hand. Malrotation can be corrected by a technique of step osteotomy of the metacarpal with removal of a longitudinal strip of bone. The placement of the transverse cuts of the osteotomy determines the direction of rotational correction and the width of dorsal strut determines the amount of rotational correction. Firm fixation with two interosseous wires ensures good bony union and allows early mobilization.

PMID 7280104  Plast Reconstr Surg. 1981 Oct;68(4):571-6.
著者: Y Suzuki, T Matsunaga, S Sato, T Yokoi
雑誌名: J Hand Surg Br. 1994 Feb;19(1):98-107.
Abstract/Text The authors have developed a new skeletal traction system for comminuted intraarticular fractures and fracture-dislocations in the hand. The system consists of two or three Kirschner wires and rubber bands, and is easy to assemble. It is more compact and comfortable than the banjo splint, and equally effective, and it allows early motion of the affected digits. A description of the technique is followed by the clinical results of seven cases of severe articular injuries in the hand. At the time of follow-up, the average range of the affected PIP joint motion was about 80 degrees. The final active motion of the injured DIP joint ranged from 0 to 40 degrees in flexion and that of the affected thumb (trapezial fracture) was not limited. The average follow-up period was 13.1 months.

PMID 8169490  J Hand Surg Br. 1994 Feb;19(1):98-107.
著者: N Sawant, Y Kulikov, G E B Giddins
雑誌名: J Hand Surg Eur Vol. 2007 Feb;32(1):102-4. doi: 10.1016/j.jhsb.2006.06.010. Epub 2006 Oct 23.
Abstract/Text Avulsion fractures of the metacarpophalangeal joints are uncommon and there are few reports on their outcome after conservative treatment. We treated seven such patients with fracture fragment sizes between 10% and 25% of the width of the articular surface on the radiograph by early active mobilisation in neighbour strapping. The outcome of treatment was assessed at a mean follow-up of 57 (range 8-94) months. The mean visual analogue pain score was 0.6 (range 0-2) and the mean visual analogue function score was 9 out of 10 (range 6-10). The mean DASH score was 3.1 (range 0-12.5). All but one patient had normal grip strength and a full range of finger movement. We believe that the majority of avulsion fractures of the metacarpophalangeal joint can be managed successfully without surgery.

PMID 17056167  J Hand Surg Eur Vol. 2007 Feb;32(1):102-4. doi: 10.1016・・・
著者: V Potenza, R Caterini, F De Maio, S Bisicchia, P Farsetti
雑誌名: Injury. 2012 Feb;43(2):242-5. doi: 10.1016/j.injury.2011.10.036. Epub 2011 Dec 10.
Abstract/Text The purpose of this study was to report the medium-term results in 28 patients affected by closed displaced fractures of the neck of the fifth metacarpal bone (boxer's fracture) with an associated severe swelling of the hand, who were treated with percutaneous transverse K-wire pinning, to verify the effectiveness of this surgical treatment. We opted for this treatment in all cases in which malrotation of the fifth finger and volar angulation of the metacarpal head greater than 30° were associated with a severe swelling of the hand. All the patients were reviewed clinically and radiologically at an average of 25 months after surgery. At the final follow-up, no patient reported residual pain. All patients had full extension of the fifth finger, except two in whom we observed a limitation of the extension of the fifth metacarpophalangeal (MP) joint of about 10°, without significant impairment of hand function. All patients had at least 90° flexion of the fifth MP joint and full range of motion of the interphalangeal (IP) joints. No patient had rotational deformity of the fifth finger with a deficit of grip strength. At the final follow-up, a residual palmar angulation of the head of the fifth metacarpal was found in three patients, with a mean of 7°. The disabilities of the arm, shoulder and hand (DASH) scale had a mean value of 5, and all patients considered their result as good or excellent. We recommend percutaneous transverse pinning in all boxer's fractures in which operative treatment is indicated, especially in patients with severe soft-tissue swelling. The surgical procedure is easy to perform, and surgical results are generally good.

Copyright © 2011 Elsevier Ltd. All rights reserved.
PMID 22154304  Injury. 2012 Feb;43(2):242-5. doi: 10.1016/j.injury.201・・・

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