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CURRENTCONCEPTS

Hand Fractures: A Review of Current

Treatment StrategiesClifton Meals, MD, Roy Meals, MD

CME INFORMATION AND DISCLOSURES

The Review Section of JHS will contain at least 3 clinically relevant articles selected by the

editor to be offered for CME in each issue. For CME credit, the participant must read the

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of clinical data and apply it to their practice and the provision of patient care.

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should claimonlythe creditcommensuratewith theextent of theirparticipationin theactivity.

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Disclosures for thisArticle

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Learning Objectives

• Appraise the history and epidemiology and mechanics of hand fractures.

• Clarify the diagnosis of hand fractures through clinical and radiographic findings.

• List general operative and nonoperative treatment principles of hand fractures.

• Elucidate the treatment principles of individual hand fractures, including the thumb.

• Discuss the complications of hand fractures and their treatment.

Deadline: Each exam purchased in 2013 must be completed by January 31, 2014, to be

eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to

complete each month’s JHS CME activity i s 2 hours.

Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.

Fractures of the tubular bones of the hand are common and potentially debilitating. The

majority of these injuries may be treated without an operation. Surgery, however, offers

distinct advantages in properly selected cases. We present a review of hand fracture

management, with special attention paid to advances since 2008. The history and mecha-nisms of these fractures are discussed, as are treatment options and common complications.

Early mobilization of the fractured hand is emphasized because soft tissue recovery may be

more problematic than that of bone. (J Hand Surg 2013;38A:1021–1031. Copyright © 2013

by the American Society for Surgery of the Hand. All rights reserved.)

Key words Hand, fracture, metacarpal, phalanges.

C u r r e n t C o n c e p t s

© ASSH Published by Elsevier, Inc. All rights reserved. 1021

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THE HAND IS VALUABLE AND vulnerable. Its ability

to both sense and manipulate its environment is

unique in nature. As such, the hand is fre-

quently injured. Despite its mechanical refinement, the

hand is particularly resilient to fractures, and when they

occur, broken digits can often be treated without an

operation. Surgery, nonetheless, has a place in the man-

agement of carefully chosen cases. Although hand frac-tures are generally forgiving, soft tissue injury is not. It

is easy for the treating physician to do more harm than

good, even without cutting the skin. Hand surgeons

have special claim to only the most complicated inju-

ries; many fractures of the hand can be treated by a

variety of physicians. The majority of hand fractures are

appropriately treated by emergency physicians, primary

care doctors, and general orthopedic and plastic sur-

geons. The following is intended for an accordingly

broad audience. We present management strategies for

the most representative tubular bone fractures of thehand. We highlight recent research to avoid rehashing

previous reviews.1–4

HISTORY

Rudimentary care of hand fractures (eg, rest and eleva-

tion) is presumably as old as humans themselves. Up-

right posture may have contributed to an increase in

these injuries, and today, falls from standing height

remain a major source of hand injuries. The ancient

Egyptian Imhotep described reduction and immobiliza-

tion of fractures in 3000 BC. Hippocrates in 200 BC and

Galen in AD 160 recommended prolonged immobiliza-

tion of broken bones and frequent dressing changes.

More durable, plaster-based splinting materials were

developed in the Middle East as early as the 10th

century. As this technology reached 19th-century Eu-

rope, it permitted less frequent splint exchange in an era

of population expansion and increased demand for

medical attention. Sophisticated splinting of the hand

and the so-called “intrinsic-plus” position were advo-

cated by James in the 20th century. The Belgian sur-

geon Lambotte described operative care of a phalangeal

fracture as early as 1904.5 He stabilized this proximal

phalanx with a fixateur externe, a phrase he coined.6

Kirschner developed the use of fine wires for skeletal

traction; this technique and fixation with K-wires are

relevant to the treatment of hand fractures a century

later. Twentieth-century advances in anesthesia, radiol-

ogy, and metallurgy have helped to refine the operative

care of hand fractures. The fact remains, however, as it

was known to ancient physicians, that the ma jority of these injuries can be treated without surgery.7

EPIDEMIOLOGY

Hand fractures are among the most common skeletal

injuries. As is the case with many orthopedic injuries,

young men and elderly women are most susceptible.

Modes of injury in different age groups are predictable:

children and young adults are frequently injured in

sports-related activities, middle-age manual laborers are

prone to work-related injuries, and older patients may

experience hand trauma as the result of a fall or motorvehicle collision. The distal phalanx is the most com-

monly fractured bone in the hand.1 A large subset of

young adult males fracture their fifth metacarpal, clas-

sically the result of violent contact with the fist.3,8

DIAGNOSIS

Diagnosis of hand fractures begins with a thorough

patient interview. The patient should describe the mech-

anism of injury because this may suggest certain reduc-

tion maneuvers, assist in identifying secondary injuries,

and reveal pathological fractures. A very low-impactinjury leading to fracture, for instance, should raise the

suspicion of osteoporosis or enchondroma. In addition

to a history of the injury, it is important to note the

patient’s handedness, their functional status, occupa-

tion, hobbies, and expectations for recovery. A 25-year-

old concert pianist and a retiree with the same fracture

represent different challenges to the treating physician.

Physical examination of the hand begins with noting

skin integrity including abrasions and lacerations and

the location and extent of any bruising, swelling, or

underlying deformity. A neurovascular examination is

undertaken with attention paid to the digits distal to any

injury. Angular and particularly rotational deformity

can be subtle when the patient is unable to make a full

fist and demonstrate parallel digital alignment. In this

instance, examining end-on the digital pulps and the

planar alignment of the nails with respect to the adja-

cent digits and the opposite hand is revealing. Caution

must be exercised, however, when identifying a patho-

logical supination deformity in the small finger because

the uninjured small finger tends to scissor with the ring

finger at midflexion and then come into parallel align-

FromtheDepartmentofOrthopedics,GeorgeWashingtonUniversityMedicalCenter,Washington,DC,

andthe Department ofOrthopedics,UCLAMedicalCenter,Los Angeles,California.

Received forpublicationAugust7, 2012;acceptedFebruary7, 2013.

Nobenefits inany form have been receivedor will bereceived related directlyor indirectlyto the

subject of thisarticle.

Corresponding author: Clifton Meals,MD, GeorgeWashington UniversityMedical Center, De-

partment of Orthopedics, 22nd & I Street, NW, 7th Floor, Washington, DC 20037; e-mail:

[email protected].

0363-5023/13/38A05-0032$36.00/0http://dx.doi.org/10.1016/j.jhsa.2013.02.017

1022 HAND FRACTURES: CURRENT TREATMENT STRATEGIES

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ment with full flexion. The hand should be lightly

palpated, seeking points of maximal tenderness. Passive

and active range of motion should be documented at all

affected and adjacent joints. Range of motion maneu-

vers may be facilitated by neuroblockade at the meta-

carpophalangeal (MCP) joints or the wrist but not be-

fore recording a neurological examination. In

evaluating a hand fracture, injury to nerves, vessels,ligaments, and tendons must be identified and treated

with the same attention due any broken bone.

Good-quality radiographs are the cornerstone of

fracture diagnosis. Most metacarpal fractures are accu-

rately characterized with posteroanterior, semiprona-

tion, and lateral views of the hand. A true lateral view

of the hand, evident by the superimposition of the

pisiform and distal pole of the scaphoid and the stag-

gering of each finger, may be difficult to obtain.9 None-

theless, this orthogonal view is necessary to fully char-

acterize fractures and may identify injuries not obviousin other views (eg, fracture dislocations of the ulnar

carpometacarpal joints).10 To accurately identify and

characterize phalangeal fractures, the same views, per-

haps with the inclusion of a semisupination view and a

fan lateral view, must be obtained with the x-ray beam

centered over the area of concern, not through the

center of the palm as with screening films. Advanced

imaging of the tubular bones of the hand is rarely

necessary, although magnetic resonance imaging (MRI)

may help to evaluate concomitant soft tissue injuries

and pathological fractures.

Fractures are evaluated with respect to their location,

orientation, displacement, angulation, degree of com-

minution, and any associated joint involvement or dis-

location. Especially in the setting of infection or open

injury, the presence of radiopaque foreign bodies must

be noted. X-rays reveal more than fracture lines, and

this information should be noted. Degenerative, onco-

logical, rheumatological, and metabolic processes are

evident on radiographs, and each is potentially more

serious than the patient’s primary complaint.

TREATMENTGeneral principles

Most hand fractures are well managed without surgery.

This was known to ancient physicians; however, today

we better appreciate the dangers of prolonged immobi-

lization.7 Stiffness, pressure sores, and, rarely, compart-

ment syndrome may result from mismanaged casting or

splinting, and in this sense, “conservative” treatment

may be particularly risky. Surgery is indicated when

early mobilization of soft tissues is critical, when the

fracture is otherwise unreducible, in instances of poly-

trauma or open fracture, and in the face of concomitant

injury to nerves, vessels, and soft tissue.1

Open fractures of the hand are common and may

necessitate irrigation and debridement in the operating

room. Initial management is case-based but often con-

sists of irrigation, sterile coverage of the wound, anti-

biotics, and tetanus prophylaxis.

Reduction is appropriate in the initial care of dis-

placed fractures, and special techniques for certain frac-

tures are discussed later. All reduction maneuvers rely

on gentle traction. They are in general aided by nerve

blocks and gentle flexion of the MCP joints and wrist.

Splints should selectively limit motion of injured

parts. Plaster molds well and is preferable for holding a

reduction. Fiberglass and other materials may be appro-

priate for soft tissue injuries and stable fractures. Im-

mobilization of the wrist in extension is desirable to

minimize stiffness, although patients are often reluctant

to assume this posture on their own.3

A dorsal splintextending from the midforearm to the fingertips is use-

ful in this regard. Such a splint holds the wrist in some

extension, flexes the MCP joints to 90°, and permits full

extension of the interphalangeal joints. Patients may be

reluctant to flex their MCP joints, and an overly bulky

splint may obscure residual extension. To aid in flexion

of the MCP joints, the distal end of the splint may be

held down with strips of tape that span the palm and are

attached at the wrist. When properly applied, the dorsal

hand splint has utility in treating a wide variety of hand

fractures.

Splints may be used until the fracture is healed or

exchanged for a cast once soft tissue swelling has

resolved. For the vast majority of metacarpal and pha-

langeal fractures, clinical stability occurs well before

radiographic evidence of healing. Initiation of protected

mobilization should be based on time since injury and

fracture site tenderness rather than x-rays. Over-reliance

on radiographs for confirmation of healing may result in

a permanently stiff hand. Immobilizing hand fractures

for longer than 4 weeks is rarely necessary. Movement

of noninjured portions of the hand, as well as the

forearm, elbow, and shoulder, should be encouragedfrom the outset. In this regard, slings are counterpro-

ductive.

Distal phalanx

Tuft fractures of the distal phalanx result from crush

injuries, and soft tissue trauma is often of greater con-

cern than the broken bone. Large subungual hematomas

should be decompressed by manually drilling a hole in

the nail plate with a hypodermic needle or electrocau-

tery device. Significant injury to the nail matrix is best

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treated by removal of the nail plate and suture of the

nail bed. This may help to prevent entrapment of nail

matrix in the fracture site and formation of an osseous

inclusion cyst. Open injuries, including those created to

decompress a hematoma or repair the nail bed, require

oral antibiotics and protective splinting of the distal

interphalangeal (DIP) joint alone for 10 to 14 days.

Healing of the bone, often by fibrous union, is predict-

able and alleviates symptoms, although tenderness may

persist for many months.1

Transverse fractures through the shaft of the distal

phalanx may take on apex-volar angulation but are

typically stable owing to the nail plate dorsally and the

pulp’s fibrous septae volarly. Conservative treatment is

appropriate. Comminuted or longitudinal fractures may

be more likely to displace and may be fixed with

Kirschner wires.1 Recent case series highlight a subset

of patients who developed symptomatic nonunions of

distal phalanx fractures. These were effectively treated

open with cortical miniscrews11 or percutaneously with

variable pitch headless screws.12

Dorsal epiphyseal avulsions of the distal phalanx

result in an apex-dorsal, “mallet finger” deformity.

Conservative treatment involves extension splint-

ing and care of soft tissue injury. If avulsed, the

nail plate should be reduced beneath the nail fold

to reapproximate the nail matrix and stabilize the

fracture.1 Greater involvement of the joint surface

or marked subluxation may be indications for sur-

gery, although this is a matter of debate.13 Both

acute and chronic mallet finger may be addressed

operatively. The use of mini-screws, extension

block pinning, sutures over a button, and Kirschner

wires as joysticks technique have all been de-scribed (Figs. 1 and 2).14,15 A recent multicenter

comparison of various surgical techniques for mal-

let finger found no significant difference in out-

comes.13

“Jersey finger” is the apex-volar equivalent of mallet

finger and involves avulsion of the flexor digitorum

profundus tendon. Surgery is generally indicated, and

direct repair with a suture-over-button technique may

be accomplished in the first 2 weeks after injury. Lon-

ger delays may involve retraction and degeneration of

the flexor tendon and are treated on a case-by-casebasis.16

Middle and proximal phalanx

Minimally displaced, stable, extra-articular fractures of

the middle and proximal phalanges, in a compliant

patient, may be “buddy-taped” to an adjacent, uninjured

finger. Figl et al17 have recently described a “conser-

vative functional” modification of the buddy-taping

technique in which the wrist and MCP joints are

casted in the safe position for 4 weeks. Motion at the

FIGURE 1: Kirschner wire fixation technique for a mallet finger injury. The distal interphalangeal DIP joint is flexed, and

Kirschner wires are used to block the avulsed fragment from displacing proximally. The fracture is reduced with extension of the

finger. The DIP joint is cross-pinned.

FIGURE 2: Sutures-over-button technique for mallet finger injuries. The DIP joint is opened dorsally with an H-shaped incision.

Bone holes are made with a Kirschner wire and suture is passed with the aid of hollow-bore needles. The suture exits the finger

pulp and is tied over a button. The DIP joint is cross-pinned.



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interphalangeal joints is encouraged, particularly ex-

tension at the proximal interphalangeal (PIP) joint.

Unstable fractures, especially in older patients and in

the setting of digital arthritis, are likely to result in

stiffness if treated conservatively. Other potentially op-

erative fractures include displaced or intra-articular

fractures in general, volar base injuries to the middlephalanx, and longitudinal unicondylar fractures of the

head of the proximal phalanx.1 With regard to the latter,

Tan et al18 demonstrated satisfactory short-term out-

come with intra-articularly placed screws. For these

fractures, and for all fractures of the middle and prox-

imal phalanx, a wide variety of procedures have been

described, many involving the use of Kirschner wires.1

Selection of an operative strategy is case-based and

depends heavily on surgeon preference. Regardless of

which hardware is chosen, attention to soft tissue is

paramount, namely with careful operative technique,brief immobilization in the intrinsic-plus position, and

early motion. Although anatomical fixation of middle

and proximal phalangeal fractures with screws, with or

without plates, is appealing, it is fraught with problems.

Namely, the intra- and postoperative disturbance of the

closely aligned extensor tendon mechanism portends

stiffness. This is particularly vexing when rigid fixation

is not secured and is followed by a period of prolonged

postoperative immobilization. It is better to accept a less

than perfect radiographic reduction and achieve early

motion.

PIP joint fractures are problematic, especially given

the importance of the PIP joint to hand function in

general. As more of the volar base of the middle pha-

lanx is detached, the collateral ligaments no longer

prevent the middle phalanx from moving dorsally.19,20

Extensive comminution may complicate treatment and

require osteochondral bone grafting. A number of es-

tablished surgical options exist for these injuries, al-

though none is clearly superior.21 Much new literature

exists, as well, regarding novel or modified treat-

ment of PIP joint fracture dislocations. Any surgi-

cal strategy should adhere to the treatment guide-

lines proposed by Kiefhaber and Stern22: (1) that

gliding reduction of the PIP joint be restored and

subluxation at the fracture site be eliminated, (2)

that early motion be established, and (3) as a

secondary goal, that the joint surface be restored.

Cheah et al23

report satisfactory results with a volarmini-plate and screw technique at short-term follow-up.

Percutaneous Kirschner wire fixation with dorsal block

pinning has been described, as has a percutaneous in-

tramedullary technique for disimpaction and reduction

of volar fragments, also with dorsal block pinning (Fig.

3).20,24 Dynamic external fixation of the injured PIP

joint is one treatment option (Fig. 4). Advantages in-

clude relative ease of application and the potential for

early motion25–28; however, these wire and elastic con-

structs are not foolproof. Finsen29 reports only modest

restoration of motion with Suzuki pins and rubber trac-tion, potentially related to their use of stiff vessel loops

rather than more pliable rubber bands.

For chronic PIP joint fracture dislocations, Hamada

et al30 describe a 2-stage procedure in which the injured

joint is held in a distracted position for 1 week before

either percutaneous or open reduction and fixation and

the placement of a second, articulating external fixator.

Initial outcomes were positive, although long-term

studies are lacking.30

Displaced fractures at the base of the proximal pha-

lanx typically assume an apex-volar angulation and

should be reduced. Malunion may lead to a pseudo-clawing of the digit with hyperextension at the fracture

site, extensor lag of the interphalangeal joints, and ad-

herence of flexor tendons.28

Metacarpal fractures

Fractures of the metacarpal neck are among the most

common fractures of the hand. These so-called “box-

er’s” fractures are typically incurred by young men, not

necessarily boxers, who strike a solid object with a

clenched fist.1 The fifth metacarpal neck is the most

FIGURE 3: Percutaneous, intramedullary disimpaction technique for treatment of fractures at the base of the middle phalanx. A

Kirschner wire is inserted retrograde into the middle phalanx and used to reduce fragments at the phalangeal base under

fluoroscopic guidance. The reduced joint is block-pinned in flexion.



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vulnerable and most frequently injured. The fifth meta-

carpal is also the most mobile bone of the palm and,

therefore, especially tolerant of the typical apex-dorsal

deformity. Whereas up to 70° of angulation may be

compensated for in the fifth metacarpal, only 10° is

tolerated in the second and third rays.1,31 The Jahss

reduction maneuver involves flexion of the MCP joint,PIP joint, and DIP joint and use of the curled finger to

push the metacarpal head dorsally.32 Immobilization of

boxer’s fractures may be beneficial; however, success-

ful treatment without immobilization has been de-

scribed.31 Nonsurgical intervention may be particularly

appropriate in patients unlikely to return for follow-

up.33

Surgery is reserved for cases in which an ade-

quate reduction of both angular and rotational de-

formity cannot be maintained or where an adjacent

ray is damaged. High functional demand also is not

necessarily an indication for surgery because even

with neglect, residual disability is typically negli-

gible to none. Fixation with Kirschner wires either

down the medullary canal or transversely to an

uninjured ray are both effective treatment methods

in properly selected patients.34,35

According to the incidence of this fracture, much

continues to be written regarding its management. Strub

et al36 performed a prospective study in which patients

with boxer’s fractures were treated conservatively and

without reduction or with reduction and intramedullary

splinting. Although the surgical group reported greater

satisfaction with the appearance of the hand, hands

were functionally similar in both groups.36 Hofmeister

et al37 have also recently challenged the dogma that the

fifth MCP joint must be immobilized in flexion. In a

prospective, randomized trial involving young, active

patients, the authors showed equivalent results withvolar-outrigger-type and extension short-arm casts.37

Anterograde pinning of the fractured fifth metacarpal

has been recently recommended as an alternative to

traditional retrograde fixation (Fig. 5).38

Metacarpal shaft fractures may be transverse, in

which case, like their boxer’s fracture counterpart, de-

formity is typically apex-dorsal. As in boxer’s fractures,

surgery is indicated when an acceptable reduction can-

not be maintained. Again, greater deformity is allowed

in the more mobile fourth and fifth rays. Spiral and

oblique fractures are more unstable, and reduction must

restore rotational alignment as a first priority. Mild

shortening encountered in spiral or oblique fractures

may be tolerated to a degree because hands with this

deformity often overcome initial extensor lag and de-

formity-related weakness.39 In general, metacarpal

shaft fractures are biologically splinted by the interpal-

mar plate ligament (intermetacarpal ligaments) and in-

terosseous muscles (less so the second and fifth ray).

The presence of fractures in adjacent ray(s) is a relative

indication for surgery.

A variety of surgical strategies exist, including plate-

FIGURE 4: Dynamic external fixation technique for treatment of fractures at the base of the middle phalanx. Kirschner wires areinserted in the distal proximal phalanx, proximal middle phalanx, and distal middle phalanx. Leverage on a longitudinal Kirschner

wire may be used to reduce the fracture. Rubber bands are configured to provide longitudinal traction. The interphalangeal joints

are free and may be moved.



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screw constructs and intramedullary fixation.1 Rhee et

al40 recently described a retrograde, intramedullary

splinting technique in which 1 or more wire ends are

left out dorsally at the phalangeal base. The authors

report the ability to stabilize different fracture configu-

rations with few complications.40

Despite the ease with which intramedullary devices

are implanted, they are not foolproof. In a study com-

paring plate and screw fixation with a percutaneous

nailing technique, Ozer et al41 identified a number of

complications in the intramedullary group: loss of re-

duction, joint penetration, tendon irritation, and symp-

tomatic hardware. Fewer such complications were en-

countered with plate and screw constructs.41 Plate

fixation has been shown to be effective in cases of multiple metacarpal head fractures.42

Fracture dislocations of the metacarpal bases are

unusual, particularly at the more stable second and

third carpometacarpal joints. When they do occur,

they may be missed.10 They are typically unstable

and require Kirschner wire stabilization. When

treatment is delayed, open reduction is often nec-

essary. Late arthritis of the fifth MCP joint is

exceedingly rare; however, arthrodesis of this joint

is a theoretical solution.1

Thumb fractures

Many thumb fractures are treated like finger fractures.

The thumb is distinct from the other digits, however,

and special consideration is due. The thumb’s unique

orientation gives the hand great capability and predis-

poses the thumb to certain injuries, particularly of the

metacarpal base. Whereas adjacent fingers can compen-

sate for one another, there is no surrogate for the thumb.

Likewise, there are few functions of the hand in which

the thumb does not participate. Given these demands,

intra-articular fractures of the thumb demand the utmost

care. Geometric deformity, conversely, is well toler-

ated. The slightly deformed thumb has no parallel digit

with which to interfere, and the thumb’s range of mo-

tion makes it additionally resistant to malunion.1 Typ-

ical apex-dorsal angular deformity of the metacarpal

seen radiographically is often masked clinically by con-

tours of the surrounding intrinsic muscles. Because of

the thumb’s oblique orientation with respect to the

palm, radiographs need to be taken orthogonally to the

thumb, the lateral with the thumbnail perpendicular to

the x-ray film, and either the posteroanterior or the

anteroposterior (Robert) view with the thumbnail par-

allel to the cassette.

PhalangesSimple fractures of the thumb phalanges may be treated

like other phalanx fractures: gentle reduction is fol-

lowed by immobilization, in this case with a thumb

spica splint. Safe splinting of the thumb holds all joints

in extension and the thumb in abduction. When conser-

vative measures fail, percutaneous fixation is usually

appropriate. Rarely do simple fractures of the thumb

require open reduction and internal fixation. Bony mal-

let injuries to the thumb pose no unique problems.

Intra-articular fractures of the thumb deserve special

attention. Fractures at the thumb MCP joint are likely to

involve the collateral ligaments, and testing their integ-

rity is critical. An intact radial collateral ligament is

necessary for joint stability. Injury to the ulnar collateral

ligament or its attachment to the base of the proximal

phalanx (gamekeeper’s thumb), prevents effective

pinch and should be corrected. If reapproximation of

bony fragments is impossible or fails, debridement of

bone with reinsertion of the ligament end is possible.

Arthrodesis of the thumb MCP joint, owing to the great

range of motion at the thumb base, is an acceptable

salvage procedure.1

FIGURE 5: Retrograde Kirschner wire technique for fixation of distal metacarpal fractures. With the metacarpophalangeal (MCP)

joints in flexion, parallel (not shown) Kirschner wires are inserted retrograde into the metacarpal shaft and exit the skin dorsally at

the metacarpal base. Under fluoroscopy, the distal ends of the Kirschner wires are positioned in the metacarpal head. The wrist

and protruding Kirschner wires are flexed into extension.



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First metacarpal

Extra-articular fractures near the base of the thumb are

common, and deforming forces are more complex here

than in other metacarpals. The abductor pollicis brevis,

adductor pollicis, and flexor pollicis brevis muscles flex

the distal fragment, and the abductor pollicis longus

distracts and extends the proximal fragment. Mild de-

formation of this sort is accommodated by the trapezio-

metacarpal joint, although excessive deformity forces

this joint into hyperextension. Closed reduction by vo-

larly directed pressure on the fracture apex followed bypercutaneous Kirschner wire fixation is useful when

angulation exceeds 30°.1

Fracture dislocations at the base of the first metacar-

pal are known by 2 eponyms. Bennett fractures are

avulsions of the ulnar metacarpal base. Rolando frac-

tures are impaction injuries in which both the ulnar and

the radial elements of the thumb base are fractured from

the shaft. At the base of the thumb, the abductor pollicis

longus tendon inserts radially and the deep anterior

oblique ligament inserts ulnarly. In Rolando fractures,

both of these soft tissue attachments are separated from

the shaft.

In Bennett fractures, the shaft is pulled proximally by

the intact abductor pollicis longus tendon. Given this

deforming force, nonoperative treatment of Bennett

fractures is frequently unsuccessful.43 Fractures with

less displacement may be reduced with longitudinal

traction and fixed with a Kirschner wire through the

trapezium, adjacent metacarpal, or both. More displace-

ment necessitates open reduction and internal fixation.

Zhang et al44 recently described a Kirschner wire and

tension band technique for displaced Bennett fractures

(Fig. 6). They offered that the tension band allows for

compression at the fracture site and earlier motion than

with Kirschner wires alone. An obligatory second sur-

gery to remove hardware is a notable drawback.44 Used

with many fixation techniques, an arthroscope may help

ensure anatomical reduction of the basal joint.45

Rolando fractures leave the shaft of the first meta-

carpal in an essentially anatomical position, but without

bony connection to the basal joint. Surgical reduction

and fixation is required in most cases, but it may be

difficult in these fractures that, by definition, are com-minuted. In these cases, external fixation is advanta-

geous, and various configurations have been advocated.

Marshland et al46 have described a monolateral external

fixation technique with good results.

Severe and combined injuries

The hand may be severely traumatized in motor vehicle

or industrial accidents. Whether the skin is open or

closed, compartment syndrome may develop, necessi-

tating fasciotomies and release of the carpal tunnel,

either for existing symptoms or preemptively.47 Open

fractures should be irrigated, covered, reduced where

possible, and immobilized.48 Antibiotic and tetanus

prophylaxis may be administered on a case-by-case

basis. In addition to skin, tendons, vessels, nerves, and

other soft tissue are often injured. Repair and recovery

of these tissues is facilitated by a rigid underlying

skeleton, and the doctrine of closed, conservative, frac-

ture care may be inapplicable. True rigidity is achieved

with plate and screw constructs or an external fixator.

Locking plate and screw constructs may be used to fix

comminuted, metaphyseal, or osteoporotic bone. These

FIGURE 6: Tension-band technique for fixation of Bennett’s fractures. The fracture is reduced with distraction and pronation of

the thumb. Counterpressure from a clamp is applied while a Kirschner wire is passed across the fracture. A tension band is fixed

in a figure of eight.



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invasive techniques are readily carried out in the setting

of open fractures that must be thoroughly washed out.

Bannasch et al49 showed that postoperative infection

rates after open reduction and internal fixation of open

and closed hand fractures are equally low. Despite the

necessity of more aggressive treatment in combined

injuries, early movement, wherever feasible, remains

the rule.3

Care of the healing fracture

Early movement is once again emphasized. Uninvolved

rays should be unencumbered in order to encourage

early use, and minimally stable parts (eg, reduced joint

surfaces) should be moved when healing is sufficient to

resist displacement, typically at 2 to 3 weeks for me-

taphyseal bone. Pain should be aggressively managed,

meaning the best modality at a given time should be

sought, if even reassurance and long courses of opioids

are avoided. A more comfortable patient has a psycho-logical and physical reason to follow her or his doctor’s

instructions. These instructions should be explained

clearly, and patients’ questions should be addressed.

Effective communication invests patients in their own

care, and this motivation is perhaps the most powerful

rehabilitative tool.

COMPLICATIONS

Stiffness is a far more common and difficult to treat

complication of metacarpal and phalangeal fractures

than are malunion, nonunion, and arthrosis combined.Each of these complications may occur with or without

an operation, and each is more easily prevented than

treated. Strictly surgical complications—hardware

prominence, hardware infection, and wound break-

down—are often primarily related to technique. Man-

agement of complications lies on a broad spectrum

from the simple to the complex. A comprehensive ac-

counting of these procedures is outside the scope of this

manuscript, and the reader is referred to more detailed

sources.1–4 Several specific hand fracture complica-

tions have been addressed in recent literature and they

are presented later.

In a small case series, Ozcelik et al50 described the

successful treatment of distal phalanx nonunions with

olecranon bone graft. Meijs et al51 have treated thumb

distal phalanx nonunions with a percutaneous compres-

sion screw.

Hsu et al,52 in a review of 408 smooth Kirschner

wires implanted for fractures of the hand and wrist,

identified few complications. Only 3% of pins were

associated with a “major complication”: infection re-

quiring surgical drainage, nonunion or malunion requir-

ing surgical correction, and fracture through a pin track.

Six percent of pins were complicated by superficial

infection. Infections were more likely in the metacar-

pals and phalanges than they were in the wrist. Poor

compliance with pin care was the only other reliable

risk factor for infection. Notably, medical comorbidities

did not increase rates of infection.52 Skin tension on a

Kirschner wire with repeated motion will lead to skin

necrosis and infection. Strategic choice of the Kirschner

wire’s entry point through the skin, and sharp relief of

residual tension minimizes these problems.

Cold intolerance is a known complication of hand

trauma in general, may linger long after the inciting

injury, and affects up to 38% of hand fracture pa-

tients.53 This complication may prompt questions of the

treating physician, and there are few good answers at

present. Smits et al,54 using thermal imaging, identified

no difference in rewarming patterns between previously

fractured hands and their uninjured counterparts.Even bony injuries that may seem trivial clinically

and radiographically may require many months for

maximal recovery of soft tissue gliding, suppleness, and

comfort. Advising the patient of this pre-emptively al-

lays anxiety and builds trust.

In summary, fractures of the phalanges and

metacarpals are common and at least temporarily

debilitating. They call attention to the hand’s great

capability, vulnerability, and resilience. Most hand

fractures may be treated without an operation;

however, conservative treatment must be exercisedwith care and may in fact require greater skill and

sustained attention. Mobilization is vital to support

soft tissue healing, which is often more problem-

atic than healing of underlying bone. In properly

selected cases, surgery may speed recovery and

avoid complications such as malunion and arthro-

sis. A variety of procedures offer either relative or

absolute stability, the latter necessary only after

more severe trauma. Postoperative care is at least

as important as the operation itself. Properly man-

aged, many fractured hands return essentially tonormal—a relief to the patient and satisfaction to

his or her doctor.

REFERENCES

1. Day C, Stern P. Fractures of the metacarpals and phalanges. In:

Wolfe S, ed. Green’s Operative Hand Surgery. 6th ed. Philadelphia:

Elsevier Churchill Livingstone; 2011.

2. Calandruccio J, Jobe M. Fractures, dislocations, and ligamentous

injuries. In: Canale S, Beaty J, eds. Campbell’s Operative Ortho-

paedics. 11th ed. Philadelphia: Mosby; 2008.

3. Henry M. Hand fractures and dislocations. In: Bucholz R, Heckman

J, Court-Brown C, Tornetta P, eds. Rockwood and Green’s Fractures



JHS Vol A , May

7/22/2019 1-s2.0-S0363502313002438-main


in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins;

2010.

4. Jupiter J, Axelrod T, Belsky M. Fractures and dislocations of the

hand. In: Browner B, Jupiter J, eds. Skeletal Trauma: Basic Science,

Management, and Reconstruction. 4th ed. Philadelphia: Saunders;

2009.

5. Van Derelst E. Les debuts de l’osteosynthese en Belgique. Brussels:

Societe Belge de Chirurgie Orthopedique et de Traumatologie, Im-

primerie des Sciences; 1973.

6. Lambotte A. Chirurgie: operatoire des fractures. Paris: Masson &

Cie; 1913.

7. Harness N, Meals R. History of fracture fixation of the hand and

wrist. Clin Orthop Relat Res. 2006;445:19–29.

8. Stanton J, Dias J, Burke F. Fractures of the tubular bones of the hand.

J Hand Surg Eur Vol. 2007;32(6):626–636.

9. Tuncer S, Aksu N, Dilek H, Ozkan T, Hamzaoglu A. Fractures of the

fingers missed or misdiagnosed on poorly positioned or poorly taken

radiographs: a retrospective study. J Trauma. 2011;71(3):649–655.

10. Gaheer R, Ferdinand R. Fracture dislocation of carpometacarpal

joints: a missed injury. Orthopedics. 2011;34(5):399.

11. Chim H, Teoh L, Yong F. Open reduction and interfragmentary

screw fixation for symptomatic nonunion of distal phalangeal frac-

tures. J Hand Surg Eur Vol. 2008;33(1):71–76.

12. Henry M. Variable pitch headless compression screw treatment of distal phalangeal nonunions. Tech Hand Up Extrem Surg. 2010;

14(4):230S–233S.

13. Lucchina S, Badia A, Dornean V, Fusetti C. Unstable mallet frac-

tures: a comparison between three different techniques in a multi-

center study. Chin J Traumatol. 2010;13(4):195–200.

14. Lee S, Kim K, Yang D, Moon K, Choy W. Modified extension-block

K-wire fixation technique for the treatment of bony mallet finger.

Orthopedics. 2010;33(10):728.

15. Lee S, Kim H, Lee K, Kim K, Choy W. Modified pull-out wire

suture technique for the treatment of chronic bony mallet finger. Ann

Plast Surg. 2010;65(5):466–470.

16. Tuttle H, Olvey S, Stern P. Tendon avulsion injuries of the distal

phalanx. Clin Orthop Relat Res. 2006;445:157–168.

17. Figl M, Weninger P, Hofbauer M, Pezzei C, Schauer J, Leixnering

M. Results of dynamic treatment of fractures of the proximal phalanxof the hand. J Trauma. 2011;70(4):852–856.

18. Tan J, Foo A, Chew W, Teoh L. Articularly placed interfragmentary

screw fixation of difficult condylar fractures of the hand. J Hand

Surg Am. 2011;36(4):604–609.

19. Dias J. Intraarticular injuries of the distal and proximal interphalan-

geal joints. In: Berger R, Weiss A, eds. Hand Surgery. 1st ed.

Philadelphia: Lippincott Williams & Wilkins; 2004.

20. Vitale M, White N, Strauch R. A percutaneous technique to treat

unstable dorsal fracture-dislocations of the proximal interphalangeal

joint. J Hand Surg Am. 2011;36(9):1453–1459.

21. McAuliffe J. Dorsal fracture dislocation of the proximal interpha-

langeal joint. J Hand Surg Am. 2008;33(10):1885–1888.

22. Kiefhaber T, Stern P. Fracture dislocations of the proximal inter-

pahlangeal joint. J Hand Surg Am. 1998;23(3):369–380.

23. Cheah A, Tan D, Chong A, Chew W. Volar plating for unstable

proximal interphalangeal joint dorsal fracture-dislocations. J Hand

Surg Am. 2012;37(1):28–33.

24. Waris E, Alanen V. Percutaneous, intramedullary fracture reduction

and extension block pinning for dorsal proximal interphalangeal

fracture-dislocations. J Hand Surg Am. 2010;35(12):2046–2052.

25. Körting O, Facca S, Diaconu M, Liverneaux P. Treatment of com-

plex proximal interphalangeal joint fractures using a new dynamic

external fixator: 15 cases. Chir Main. 2009;28(3):153–157.

26. Ruland R, Hogan C, Cannon D, Slade J. Use of dynamic distraction

external fixation for unstable fracture-dislocations of the proximal

interphalangeal joint. J Hand Surg Am. 2008;33(1):19–25.

27. Kneser U, Goldberg E, Polykandriotis E, et al. Biomechanical and

functional analysis of the pins and rubbers tractions system for

treatment of proximal interphalangeal joint fracture dislocations.

Arch Orthop Trauma Surg. 2009;129(1):29–37.

28. Ellis S, Cheng R, Prokopis P, et al. Treatment of proximal interpha-

langeal dorsal fracture-dislocation injuries with dynamic external

fixation: a pins and rubber band system. J Hand Surg Am. 2007;

32(8):1242–1250.

29. Finsen V. Suzuki’s pins and rubber traction for fractures of the base

of the middle phalanx. J Plast Surg Hand Surg. 2010;44(4–5):209–

213.

30. Hamada Y, Hibino N, Tonogai I, Konishi T, Satoura M, Yamano M.

Staged external fixation for chronic fracture-dislocation of the prox-

imal interphalangeal joint: outcomes of patients with a minimum

2-year follow-up. J Hand Surg Am. 2012;37(3):434–439.

31. Statius Muller M, Poolman R, van Hoogstraten M, Steller E. Imme-

diate mobilization gives good results in boxer’s fractures with volar

angulation up to 70 degrees: a prospective randomized trial compar-

ing immediate mobilization with cast immobilization. Arch Orthop

Trauma Surg. 2003;123(10):534–537.

32. Jahss S. Fractures of the metacarpals: a new method of reduction and

immobilization. J Bone Joint Surg Am. 1938;20(1):178–186.

33. ten Berg P, Ring D. Patients lost to follow-up after metacarpal

fractures. J Hand Surg Am. 2012;37(1):42– 46.

34. Beredjiklian P. Small finger metacarpal neck fractures. J Hand Surg

Am. 2009;34(8):1524–1526.35. Mohammed R, Farook M, Newman K. Percutaneous elastic in-

tramedullary nailing of metacarpal fractures: surgical technique and

clinical results study. J Orthop Surg Res. 2011;6:37.

36. Strub B, Schindele S, Sonderegger J, Sproedt J, von Campe A,

Gruenert J. Intramedullary splinting or conservative treatment for

displaced fractures of the little finger metacarpal neck? A prospec-

tive study. J Hand Surg Eur Vol. 2010;35(9):725–729.

37. Hofmeister E, Kim J, Shin A. Comparison of 2 methods of immo-

bilization of fifth metacarpal neck fractures: a prospective random-

ized study. J Hand Surg Am. 2008;33(8):1362–1368.

38. Schädel-Höpfner M, Wild M, Windolf J, Linhart W. Antegrade

intramedullary splinting or percutaneous retrograde crossed pinning

for displaced neck fractures of the fifth metacarpal? Arch Orthop

Trauma Surg. 2007;127(6):435–440.

39. Al-Qattan M. Outcome of conservative management of spiral/longoblique fractures of the metacarpal shaft of the fingers using a palmar

wrist splint and immediate mobilisation of the fingers. J Hand Surg

Eur Vol. 2008;33(6):723–727.

40. Rhee S, Lee S, Lee S, Kim J, Baek G, Lee Y. Prospective multicenter

trial of modified retrograde percutaneous intramedullary Kirschner

wire fixation for displaced metacarpal neck and shaft fractures. Plast

Reconstr Surg. 2012;129(3):694–703.

41. Ozer K, Gillani S, Williams A, Peterson S, Morgan S. Compar-

ison of intramedullary nailing versus plate-screw fixation of ex-

tra-articular metacarpal fractures. J Hand Surg Am. 2008;33(10):

1724–1731.

42. Souer J, Mudgal C. Plate fixation in closed ipsilateral multiple

metacarpal fractures. J Hand Surg Eur Vol. 2008;33(6):740–744.

43. Livesley P. The conservative management of Bennetts fracture sub-

luxation: a 26-year follow-up. J Hand Surg Br. 1990;15(3):291–294.

44. Zhang X, Shao X, Zhang Z, Wen S, Sun J, Wang B. Treatment of a

Bennett fracture using tension band wiring. J Hand Surg Am. 2012;

37(3):427–433.

45. Culp R, Johnson J. Arthroscopically assisted percutaneous fixation

of Bennett fractures. J Hand Surg Am. 2010;35(1):137–140.

46. Marsland D, Sanghrajka A, Goldie B. Static monolateral external

fixation for the Rolando fracture: a simple solution for a complex

fracture. Ann R Coll Surg Engl. 2012;94(2):112–115.

47. Al-Qattan M. The triad of multiple metacarpal fractures and/or

dislocations of the fingers, severe hand swelling and clinical evi-

dence of acute median nerve dysfunction. J Hand Surg Eur Vol.

2008;33(3):298–304.

48. Capo J, Hall M, Nourbakhsh A, Tan V, Henry P. Initial management



JHS Vol A , May

7/22/2019 1-s2.0-S0363502313002438-main


of open hand fractures in an emergency department. Am J Orthop

(Belle Mead NJ). 2011;40(12):E243–E248.

49. Bannasch H, Heermann A, Iblher N, Momeni A, Schulte-Mönting J,

Stark G. Ten years stable internal fixation of metacarpal and pha-

langeal hand fractures-risk factor and outcome analysis show no

increase of complications in the treatment of open compared with

closed fractures. J Trauma. 2010;68(3):624–628.

50. Ozçelik I, Kabakas F, Mersa B, Purisa H, Sezer I, Ertürer E.

Treatment of nonunions of the distal phalanx with olecranon bone

graft. J Hand Surg Eur Vol. 2009;34(5):638–642.51. Meijs C, Verhofstad M. Symptomatic nonunion of a distal phalanx

fracture: treatment with a percutaneous compression screw. J Hand

Surg Am. 2009;34(6):1127–1129.

52. Hsu L, Schwartz E, Kalainov D, Chen F, Makowiec R. Complica-

tions of K-wire fixation in procedures involving the hand and wrist.

J Hand Surg Am. 2011;36(4):610–616.

53. Nijhuis T, Smits E, Jaquet J, Van Oosterom F, Selles R, Hovius S.

Prevalence and severity of cold intolerance in patients after hand

fracture. J Hand Surg Eur Vol. 2010;35(4):306–311.

54. Smits E, Nijhuis T, Huygen F, Selles R, Hovius S, Niehof S.

Rewarming patterns in hand fracture patients with and without coldintolerance. J Hand Surg Am. 2011;36(4):670–676.

JOURNAL CME QUESTIONS

Hand Fractures: A Review of Current

Treatment Strategies

Which of the following is appropriate in

nonoperative treatment of hand fractures?

a. Fiberglass is better for holding fracture reduction

than molded plaster.

b. Manipulation is aided by flexion of the metacar-

pophalangeal and wrist joints.

c. Immobilization of the wrist should be in flex-

ion.

d. A splint should maintain the metacarpophalangeal

joint in neutral position.

e. Hand fractures are not aided by nerve blocks.

How many degrees are compensated for in index

finger metacarpal neck fractures?

a. 10

b. 20

c. 50

d. 70

e. 100

To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.



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