Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Hand Fracture Treatment & Management

  • Author: Erik D Schraga, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Oct 17, 2015
 

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.

Next

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.[3]

In a study of 145 cases of open hand fractures and/or dislocations, 102 cases received definitive and final management in the emergency department; in the other 43 cases, additional management took place in the operating room. Antibiotics were administered within 4 hours after injury, and irrigation and debridement were performed within 6 hours.[4]

Distal phalanx fractures

The most common distal phalanx injury is a 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. 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 and 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.[5, 6]

Oblique and spiral fractures

Oblique and spiral fractures frequently cause malrotation of the involved finger. Oblique and spiral fractures usually are unstable after reduction.[5]  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. These fractures may result 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

Metacarpal fractures are extremely common, constituting one in five fractures that present to the emergency department[7] and between 18% and 44% of all hand fractures.[8] Metacarpal fractures are organized 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.[5]

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 incude the following:

  • 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 include the following:

  • 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.}[9]  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.[10]  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.

Previous
Next

Consultations

Hand surgeon

Previous
 
 
Contributor Information and Disclosures
Author

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, Council of Emergency Medicine Residency Directors, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, Association of Academic Chairs of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Jon Alke, MD Staff Physician, Stanford/Kaiser Emergency Medicine Residency, Stanford University School of Medicine

Jon Alke, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

William R Fraser, DO Associate Clinical Professor, Department of Emergency Medicine, Ohio University College of Osteopathic Medicine; Program Director, Department of Emergency Medicine, Doctors Hospital

William R Fraser is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

References
  1. Hammert WC. Treatment of nonunion and malunion following hand fractures. Clin Plast Surg. 2011 Oct. 38 (4):683-95. [Medline].

  2. [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].

  3. Oetgen ME, Dodds SD. Non-operative treatment of common finger injuries. Curr Rev Musculoskelet Med. 2008 Jun. 1(2):97-102. [Medline]. [Full Text].

  4. 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].

  5. 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].

  6. 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].

  7. Ben-Amotz O, Sammer DM. Practical Management of Metacarpal Fractures. Plast Reconstr Surg. 2015 Sep. 136 (3):370e-9e. [Medline].

  8. Kollitz KM, Hammert WC, Vedder NB, Huang JI. Metacarpal fractures: treatment and complications. Hand (N Y). 2014 Mar. 9 (1):16-23. [Medline].

  9. Pavic R, Malovic M. Operative treatment of Bennett's fracture. Coll Antropol. 2013 Mar. 37(1):169-74. [Medline].

  10. 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].

  11. Gajendran VK, Gajendran VK, Malone KJ. Management of complications with hand fractures. Hand Clin. 2015 May. 31 (2):165-77. [Medline].

  12. American Society for Surgery of the Hand, Idler RS, Mantktelow RT. The Hand Examination and Diagnosis. New York: Churchill Livingstone; 1990. 13-73.

  13. Antosia R, Lyn E. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998.

  14. Harwood-Nuss A, Wolfson A. Hand injuries. Clinical Practice of Emergency Medicine. 4th ed. 2005. 1062-1065.

  15. Rosen P, Doris P. Musculoskeletal trauma. Diagnostic Radiology in Emergency Medicine. 1992. 178-182.

  16. Ruiz E, Cicero JJ. Hand injuries and infections. Emergency Management of Skeletal Injuries. St. Louis, MO: Mosby-Year Book; 1990. 339-59.

  17. Simon RR, Koenigsknecht SJ. Fractures of the hand. Emergency Orthopedics. 4th ed. New York: McGraw-Hill; 2001. 97-133.

  18. Stewart C, Winograd S. Hand injuries: a step by step approach for clinical evaluation and definitive management. Emerg Med Rep. 1997. 18:223-234.

  19. 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.

 
Previous
Next
 
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).
Phalangeal fractures. Complex unstable fracture of the proximal phalanx. Image courtesy of Mark Baratz, MD.
Displaced fourth and fifth metacarpal fractures, anteroposterior view.
Fourth and fifth metacarpal fractures, oblique view.
Metacarpophalangeal ligaments.
Metacarpophalangeal musculoskeletal structure.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.