Hand Fracture Clinical Presentation
- Author: Erik D Schraga, MD; Chief Editor: Trevor John Mills, MD, MPH more...
Hand fractures usually are not difficult to diagnose. Most patients provide a history of preceding trauma. Physicians initially evaluating injuries should elicit details of the trauma, as this may benefit the hand surgeon. If an industrial injury is the cause, details may help prevent injury to others. Document the following important details in ED records:
Hand dominance of patient
Hand that is injured
Occupation and hobbies requiring dexterity
Questions regarding the mechanism of injury include the following:
Did injury occur in a clean or dirty environment?
Were crush injuries sustained?
What was the position of the hand at time of injury?
Was injury the result of high-pressure grease, water, air, or paint injection?
Did a thermal, electric, or chemical injury occur?
Was patient wearing any type of jewelry on fingers?
If so, has it been removed?
Questions regarding the injury as the result of an assault include the following:
Was hand open or fist clenched?
Are lacerations present, particularly overlying the metacarpophalangeal (MCP) joint (may indicate significant tendon injury)?
Did the patient's fist contact mouth or teeth?
Note subjective motor or sensory deficits. Note length of time since initial injury. Document number of years since last tetanus immunization if lacerations or abrasions were sustained.
Obtain significant medical history. Include documentation of disorders that may compromise healing and record previous hand injury or disability.
Record medication and allergy history.
Note other risk factors that may preclude adequate healing, such as tobacco or cocaine use.
Physical examination is of vital importance in evaluating the injured hand. Develop a comprehensive routine for examining all hand injuries regardless of mechanism of injury.
Five metacarpal bones are joined to wrist, articulating with the distal carpal row. Metacarpophalangeal anatomy is depicted in the illustrations below.
Thumb articulates chiefly with trapezium, creating a freely movable joint.
Remaining metacarpals articulate with trapezoid, capitate, and hamate from radial to ulnar direction. Ring and little fingers have about 20-25° of mobility at articulation in the anteroposterior (AP) plane. Index and middle fingers have no flexion or extension capability at articulation.
Thumb consists of proximal and distal phalanges.
Remaining fingers consist of proximal, middle, and distal phalanges.
Proximal interphalangeal (PIP) joints allow flexion and extension and minimal abduction and adduction.
Palm of hand is referred to as volar or palmar surface.
Back of hand is referred to as dorsal surface.
Borders of hand are referred to as radial or ulnar.
The anatomic position of the hand is with the palms facing forward.
Fingers often are counted by roman numerals, with thumb as number I, but most clinicians prefer to use common names (ie, thumb, index finger, middle finger, ring finger, little finger) to avoid potential confusion.
Fingers are divided into segments by distal and proximal interphalangeal creases and digital creases. These segments correspond to underlying phalanges. Volar creases may not overlie corresponding joints precisely.
Description of function
Rotation of hand from neutral position to palm up position is termed supination. Rotation to palm down position is termed pronation.
Radial and ulnar deviation correspond to movement of hand to stated direction from anatomic position.
Extension of hand refers to dorsal movement and flexion refers to volar movement.
Flexion and extension of fingers correspond to dorsal and volar movements, as mentioned above.
Abduction of fingers refers to movement of fingers away from an imaginary line drawn through the middle of the third finger. Adduction refers to movement toward this midline.
Carpometacarpal joint of thumb is capable of palmar adduction or flexion (toward midline), palmar abduction (away from palmar surface), radial abduction, retroposition (extension) adduction, and opposition. Interphalangeal joint of thumb can flex and extend only.
Start hand examination by comparing injured hand to uninjured hand.
Note skin and soft tissue changes such as edema, erythema, cyanosis, ecchymosis, lacerations, and abrasions.
Abnormal positioning, especially of the fingers, may indicate fracture or tendon injury. Identification of rotational malalignment is critical. Assessment of rotational deformity is described in the image below.
Categorize location of the injury as ulnar, radial, volar, or dorsal.
Check vascular status by noting capillary refill at nail ridge. If fracture is more proximal, radial and ulnar artery pulsation should be noted. If bleeding is present, do not clamp or ligate a vessel blindly, as nerves closely follow blood vessels.
Remember to assess nerve integrity prior to instillation of anesthetics.
The 3 major nerves of the hand are the radial, median, and ulnar nerves.
Loss of sweating is apparent if sensory nerves are injured. In an uncooperative patient, hand may be immersed in hot water for 10 minutes. Skin distal to nerve injury will not wrinkle.
Two-point discrimination testing using a bent paper clip is easy and reliable. Ability to discriminate at less than 5 mm on fingertip is normal. If patient has abnormal discrimination, always test in relation to uninjured hand, as sensitivity is variable.
Although anatomic variation is possible, generally, the sensory distribution is as follows:
The ulnar nerve supplies the fifth finger and the medial aspect of the fourth finger.
The median nerve supplies the volar aspect of the first through third fingers as well as the lateral aspect of the volar surface of the fourth finger.
The radial nerve supplies the dorsal surface of the entire hand except for the fifth finger.
The radial nerve extends the wrist and the fingers.
The ulnar nerve allows adduction of the fourth and fifth fingers and adduction of the thumb.
The median nerve adducts the second and third fingers and allows opposition of the thumb to the fifth finger.
Hammert WC. Treatment of nonunion and malunion following hand fractures. Clin Plast Surg. 2011 Oct. 38 (4):683-95. [Medline].
[Guideline] Rubin DA, Daffner RH, Weissman BN, Bennett DL, Blebea JS, Jacobson JA, et al. ACR Appropriateness Criteria acute hand and wrist trauma. [online publication]. Reston (VA): American College of Radiology (ACR). 2008. [Full Text].
Capo JT, Hall M, Nourbakhsh A, Tan V, Henry P. Initial management of open hand fractures in an emergency department. Am J Orthop (Belle Mead NJ). 2011 Dec. 40 (12):E243-8. [Medline].
Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg. 2008 Oct. 16(10):586-95. [Medline].
Ozçelik D, Toplu G, Unveren T, Kaçagan F, Senyuva CG. Long-term objective results of proximal phalanx fracture treatment. Ulus Travma Acil Cerrahi Derg. 2011 May. 17(3):253-60. [Medline].
Ben-Amotz O, Sammer DM. Practical Management of Metacarpal Fractures. Plast Reconstr Surg. 2015 Sep. 136 (3):370e-9e. [Medline].
Kollitz KM, Hammert WC, Vedder NB, Huang JI. Metacarpal fractures: treatment and complications. Hand (N Y). 2014 Mar. 9 (1):16-23. [Medline].
Pavic R, Malovic M. Operative treatment of Bennett's fracture. Coll Antropol. 2013 Mar. 37(1):169-74. [Medline].
Houshian S, Jing SS. Treatment of Rolando fracture by capsuloligamentotaxis using mini external fixator: a report of 16 cases. Hand Surg. 2013. 18(1):73-8. [Medline].
Gajendran VK, Gajendran VK, Malone KJ. Management of complications with hand fractures. Hand Clin. 2015 May. 31 (2):165-77. [Medline].
American Society for Surgery of the Hand, Idler RS, Mantktelow RT. The Hand Examination and Diagnosis. New York: Churchill Livingstone; 1990. 13-73.
Antosia R, Lyn E. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998.
Harwood-Nuss A, Wolfson A. Hand injuries. Clinical Practice of Emergency Medicine. 4th ed. 2005. 1062-1065.
Rosen P, Doris P. Musculoskeletal trauma. Diagnostic Radiology in Emergency Medicine. 1992. 178-182.
Ruiz E, Cicero JJ. Hand injuries and infections. Emergency Management of Skeletal Injuries. St. Louis, MO: Mosby-Year Book; 1990. 339-59.
Simon RR, Koenigsknecht SJ. Fractures of the hand. Emergency Orthopedics. 4th ed. New York: McGraw-Hill; 2001. 97-133.
Stewart C, Winograd S. Hand injuries: a step by step approach for clinical evaluation and definitive management. Emerg Med Rep. 1997. 18:223-234.
Tintinalli JE, Ruiz E, Krome RL. Injuries to the hand and digits. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw Hill; 2004. 2004: 1665-1674.