eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Hand: Treatment & Medication

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: Jul 29, 2008

Treatment

Prehospital Care

• Prehospital care of most orthopedic injuries consists of administering pain medication, splinting the hand in the position in which it was found, applying ice, and elevating the extremity, if possible.
• Obtain as much information about mechanism of injury and conditions at the scene as possible.

Emergency Department Care

• ED care of hand fractures involves recognition of fracture, pain management, reduction and or splinting as appropriate, and referral. Primary concern is preservation of function.
• Fractures of the phalanges are the most common hand fractures. Fortunately, most are simple fractures and may be treated with padded aluminum splints or buddy taping.
• Except for distal phalanx fractures, all patients should be referred to a hand surgeon.
• Distal phalanx fractures
  • The most common distal phalanx injury is comminuted tuft fracture. No angulation or displacement is usually present, because the septa hold fragments in place on the volar surface and the nail acts as a splint along the dorsal surface.
  • Subungual hematoma, a common complication, may be treated by trephination (if the patient is experiencing significant discomfort) or nail removal and repair of nail bed. Treatment is controversial. Some authors advocate nail removal if hematoma comprises more than 50% of the nail surface, while others recommend removal only if the nail is disrupted, as long-term outcome does not improve with removal and repair of the nail bed. Regardless of treatment, warn the patient of potential nail deformity secondary to nail bed injury.
  • Antibiotics commonly are prescribed if nail is removed; trephination of subungual hematoma does not require antibiotic prophylaxis.
  • Treatment: Open injuries require thorough irrigation. These fractures usually are splinted with a padded aluminum splint extending from the volar proximal phalanx and curving around the fingertip to the proximal dorsal phalanx. This provides optimal protection.
• Dorsal avulsion fracture (mallet finger)
  • This fracture occurs due to forced flexion of an extended DIP joint, resulting in avulsion of the attachment of the extensor tendon. The deep flexor tendon pulls on the phalanx, causing distraction of the phalanx from the fragment, leading to subluxation of the phalanx in the volar direction.
  • On examination, the patient will have loss of extension at the DIP joint and tenderness over the dorsal aspect of the joint. 
  • Treatment is controversial. Many hand surgeons advocate exploration and open fixation, while others advocate splinting alone.
  • In the ED, the best course of action is splinting the distal phalanx in extension and the PIP joint in flexion for 6-8 weeks. Orthopedic referral is required. 
• Transverse fracture of distal phalanx
  • Transverse fractures usually are stable.
  • Transverse fractures may be splinted as described above.
  • If angulation persists after closed reduction, fracture may require surgical fixation with Kirschner wire.
• Middle and proximal phalangeal fractures
  • Usual descriptive terms such as transverse or oblique apply.
  • Examine fingers for rotational deformity. Flexing fingers slightly and observing nail plates best assesses this alignment.
  • Axes of nail plates should point toward the scaphoid bone and be essentially parallel. Compare to opposite hand. As little as 10° of deviation may be disabling.
  • A true lateral radiograph may be required to demonstrate anterior angulation of the fragment, as an oblique view often fails to show the degree of angulation.
  • Tendons will be injured if angulation is significant.
• Fracture of middle phalanx
  • Middle phalanx fractures have unpredictable stability after reduction.
  • These fractures require splinting.
  • Some advocate buddy taping if the phalanx is stable. Buddy taping allows mobility, may prevent stiffness, and aids quicker return to baseline activity.
  • Buddy taping alone is not appropriate for any displaced or rotated fracture. Do not use in transverse fractures, as stability is unpredictable.
  • Perform follow-up radiography in 7 days to assess stability.
  • If a fracture can not be stabilized with buddy taping, apply a gutter splint for 10-14 days, then obtain follow-up radiography. 
• Transverse fracture of the proximal phalanx
  • Transverse fractures of the proximal phalanx are usually unstable fractures, as interosseous muscles pull proximal fragments in a volar direction and central slip pulls the distal fragments dorsally.
  • Proximal phalanx fractures require splinting and, frequently, open reduction.
• Oblique and spiral fractures
  • Oblique and spiral fractures frequently cause malrotation of the involved finger.
  • Oblique and spiral fractures usually are unstable after reduction.
  • As with middle phalanx fractures, these fractures require splinting with either ulnar or radial gutter splints extending out to involve the digit to the distal phalanx.
• Condylar fractures
  • Condylar fractures may be noted only on oblique radiograph.
  • These fractures usually require open fixation.
• Comminuted fractures of the head of the middle and proximal phalanges may be treated with closed reduction and immobilization.
• Intra-articular fractures require orthopedic referral and often open reduction and fixation (ORIF).
  • Splint in the safe position.
  • Wrist should be extended 15-20° and MCP flexed about 70°.
  • Interphalangeal (IP) joints should be flexed 10-20° or the least amount needed to maintain reduction.
  • Complications
    • These fractures may results in malrotation, degenerative arthritis, adhesion of tendon to bone (more common in open or widely angulated fractures), and joint stiffness from immobilization.
    • Boutonniere deformity (from rupture of extensor hood apparatus at PIP joint) may result from improperly treated middle phalanx fracture.
    • Flexor tendon rupture is rare.
• Metacarpal fractures
  • Divided below by location (head, shaft, neck, base) for discussion purposes.
  • Applying extension, abduction, and adduction forces to joints tests their integrity.
  • MCP collateral ligaments are taut in flexion and lax in extension, thus stability must be tested in multiple degrees of angulation.
• Metacarpal head fractures
  • Metacarpal head fractures often are severely comminuted and complicated by poor healing, even with appropriate ED care.
  • ED management includes splinting.
  • Immediate orthopedic referral is mandatory.
  • Complications include malrotation of finger, extensor tendon injury, posttraumatic arthritis, and avascular necrosis.
• Metacarpal neck fractures
  • Metacarpal neck fractures usually occur as a result of a direct blow to the knuckles and are the most common type of metacarpal fracture.
  • Fracture at the neck of the fifth metacarpal is termed boxer's fracture.
  • Mechanism of injury results in angulation of distal segment toward palm.
  • ED physician must inspect for rotational deformity.
  • Attachments of metacarpals to carpals are different for each finger and require different approaches.
    • Metacarpals of middle and index fingers are fixed at the distal carpal row and do not allow flexion or extension. Eliminate angulation at the fracture sites of these fingers. Patients cannot tolerate more than 10-15° angulation of these fractures. ED management includes closed reduction, gutter splint, and prompt orthopedic referral. Metacarpal neck fractures often require wire placement to ensure alignment.
    • The metacarpals of the ring and little fingers allow flexion and extension at carpal attachments. These patients can tolerate greater angulation at fracture without loss of function. Up to 30-40° of angulation is acceptable. In a satisfactory outcome, the fifth finger can extend to 180° without deformity.
  • Complications
    • Failure to correct rotational component can result in loss of function.
    • Failure to correct excessive angulation results in flexion of PIP joint and hyperextension of MCP joint when extending finger.
    • Extensor tendon injury
    • Collateral ligament injury
• Metacarpal shaft fractures
  • Metacarpal shaft fractures produce dorsal angulation and malrotation. 
  • Rotational deformities can be detected in 3 ways: Convergence test (scissoring), comparing the plane of the nail plates to the uninjured hand, and examining the diameter of fracture fragments on radiography.
  • Correct index and middle finger angulation, more than 10 º is not acceptable. 
  • Ring and little fingers may tolerate up to 20 º of angulation.
  • Little or no shortening of bones usually takes place, as transverse metacarpal ligaments hold fragments in place. Patients can tolerate 3 mm of shortening if no rotation or angulation is present.
  • Treat by splinting for 4-6 weeks.
  • Multiple fractures and those with shortening, angulation, or rotation require reduction and, usually, fixation.
  • Complications
    • Malrotation weakens grip and causes pain on grasping.
    • Tendon injury frequently occurs with these fractures, and MCP joint may become stiff if splinted improperly (ie, in extension).
• Metacarpal base fractures
  • Intraarticular fractures at base of index and middle fingers are rare and, if present, usually of little clinical significance.
  • They may be associated with other fractures.
  • Fracture at base of fifth metacarpal is common and often associated with subluxation of metacarpal-hamate joint. Splint this fracture in a gutter splint and immediately refer patient to a hand surgeon.
• Metacarpal fractures of the thumb: Fractures of the first metacarpal are fairly rare, as bone is quite mobile.
  • Bennett fracture
    • Bennett fracture is an oblique, intraarticular fracture at the volar base of the ulnar aspect of the first metacarpal.
    • Displacement of the larger fragment occurs from pull of the abductor pollicis longus muscle.
    • Emergency department treatment consists of immobilization in a thumb spica splint and orthopedic referral, as this injury requires surgery. If satisfactory reduction cannot be achieved, percutaneous wiring by orthopedic specialist is recommended.
    • Complications include traumatic arthritis and malunion (may result in subluxation of metacarpal-trapezial joint).
  • Rolando fracture
    • This rare fracture is similar to the Bennett fracture, except that in addition to a small palmar fragment a large dorsal fragment creates a T- or Y-shaped fracture at the base of the metacarpal.
    • More commonly, the base of the metacarpal is severely comminuted.
    • ED treatment is thumb spica splint.
    • This fracture requires immediate orthopedic follow-up care for ORIF.

Consultations

Hand surgeon

Medication

Control pain with commonly prescribed medications. Acetaminophen with codeine or hydrocodone usually suffices.

Prescribe antibiotics for open fractures, usually a cephalosporin (ie, cefazolin sodium) with broad-spectrum coverage added for grossly contaminated wounds.

Analgesics

Pain control is essential to quality patient care. It ensures patient comfort and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Antibiotics

Therapy must cover all likely pathogens in this clinical setting. Antibiotic combinations may be required for broad coverage in grossly contaminated wounds.

Cefazolin (Ancef, Kefzol, Zolicef)

First-generation, semisynthetic cephalosporin that, by binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication. Primarily active against skin flora, including Staphylococcus aureus. Typically used alone for skin and skin-structure coverage.
Total daily dosages are same for IV/IM routes.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in treatment of septicemia and skin-structure infections.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients with open fractures.
May need to adjust dose in patients diagnosed with renal impairment.

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