eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Hand

Author: Jon Alke, MD, Staff Physician, Stanford/Kaiser Emergency Medicine Residency, Stanford University School of Medicine
Coauthor(s): Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Contributor Information and Disclosures

Updated: Dec 10, 2009

Introduction

Background

Hand fractures, a frequent emergency department complaint, are the most common fractures of the body. Proper management at initial evaluation of hand injuries can prevent a significant amount of morbidity and disability. Emergency physicians, often the first to assess these fractures, must have the skills to properly evaluate and manage these injuries.

This article focuses entirely on fractures of the hand. Please see other articles for information on wrist injuries, soft-tissue hand injuries, and dislocations. Also see Medscape's Fracture Resource Center.

Pathophysiology

Basic concepts about bony structures of the hand help to understand injury patterns and manage hand fractures. The hand is a group of gliding bones surrounded by soft tissue. A relatively immobile center consisting of the second and third metacarpal bones provides fixed support on which intrinsic movements of the hand depend. More mobile bones of the hand, such as the first, fourth, and fifth metacarpals, may tolerate a greater degree of angulation without disability, while the less mobile second and third metacarpal bones must have more precise reduction to ensure proper function.

Frequency

United States

More than 16 million people each year receive emergency care for hand injuries. Common emergencies include fractures, ligamentous injuries, and infections.

Mortality/Morbidity

• Disability from hand injuries may result in loss of sensation, strength, and flexibility, the chief functions of the hands. Preserving function relies on maintaining the structural relationships of the intrinsic hand structures as well as musculotendinous connections from the forearm.
• Prevention of disability from hand injuries is the primary goal of treatment. Maintenance of function, rather than cosmesis, is of paramount concern in the management of hand injuries.

Age

Hand fractures occur in all age groups, although fractures in young children should prompt suspicion of child abuse.

Clinical

History

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
• Mechanism of injury
  • 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?
• Injury as the result of an assault
  • 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

• 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.
• Hand structure
  • Five metacarpal bones are joined to wrist, articulating with the distal carpal row. Metacarpophalangeal anatomy is depicted in the illustrations below.
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    Metacarpophalangeal musculoskeletal structure.

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    Metacarpophalangeal musculoskeletal structure.

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    Metacarpophalangeal ligaments.

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    Metacarpophalangeal ligaments.

  • 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.
• Terminology
  • 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.
• Hand examination
  • 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.
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    Assessment of the hand for rotational deformities of the fingers or metacarpals is essential, as such deformities, if untreated, may result in significant functional compromise. With fingers flexed at the metacarpophalangeal and proximal interphalangeal joints and extended at the distal interphalangeal joints, fingers should all point toward the scaphoid bone (see image).

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    Assessment of the hand for rotational deformities of the fingers or metacarpals is essential, as such deformities, if untreated, may result in significant functional compromise. With fingers flexed at the metacarpophalangeal and proximal interphalangeal joints and extended at the distal interphalangeal joints, fingers should all point toward the scaphoid bone (see image).

  • 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 to clamp or ligate a vessel blindly, as nerves closely follow blood vessels.
• Neurologic examination
  • Remember to assess nerve integrity prior to instillation of anesthetics.
  • The 3 major nerves of the hand are the radial, median, and ulnar nerves.
• Sensory examination
  • 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.
  • Motor examination
    • 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.

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