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Fractures of the metacarpals and phalanges
HAND
Fractures of the metacarpals and phalanges
A clear history as to the precise mechanism of injury should be obtained to help reveal both the type of injury sustained and any potentially associated injuries. Axial loading frequently results in shearing articular or metaphyseal compression fractures, while one should maintain a high index of suspicion for injuries proximal to the hand. A bending element is often required for joint dislocations or diaphyseal fractures, while torsional forces may result in spiral fractures (with a high likelihood of mal-rotation) or more complex dislocation patterns. Higher energy injuries with crushing forces typically result in much greater soft tissue trauma, which increases the likelihood of an associated open injury and neurovascular compromise (including compartment syndrome) and can significantly influence the available treatment options. The common symptoms associated with hand fractures and dislocations include pain, swelling, weakness, stiffness and deformity. Patients should be questioned about the initial deformity and reduction manoeuvres that may have been attempted. Numbness and subjectively altered sensation indicate nerve involvement, which may be as a direct result of the injury or a secondary effect of swelling. With an open injury it is important to ascertain the nature of the environment in which the injury was sustained, the degree of wound contamination and the likelihood of foreign bodies must be considered. The time from injury to presentation is also a vital piece of information.
Benjamin JF Dean Christopher Little
Abstract Hand fractures and dislocations are amongst the most frequently encountered orthopaedic injuries. A thorough assessment including history, clinical examination and radiological investigations is essential before deciding upon an appropriate management plan. The vast majority of injuries can be managed non-operatively, but knowing when surgery is likely to improve the functional outcome is the key in selecting when to proceed with a specific surgical intervention. This review article aims to summarize the key concepts in the management of these injuries so that the reader can better understand the rationale behind the surgical decision making process.
Keywords dislocations; fractures; hand; metacarpal; phalangeal
Introduction/epidemiology
Clinical examination and signs
Hand fractures and dislocations are amongst the most common orthopaedic injuries presenting to Accident and Emergency (A&E) departments, comprising approximately a quarter of all patients attending with a fracture or dislocation.1 Males are typically affected more commonly than females; sport related injuries are particularly common in the 3rd decade and workplace related injuries in the 5th decade. A large prospective study from Norway found that fractures were distributed around the hand as follows: 46% phalangeal, 36% metacarpal, with nearly 10% of the overall total affecting the little finger metacarpal neck.2 The borders of the hand is most commonly affected, with injuries to the thumb and the little finger ray predominating. Hand fractures and dislocations represent a considerable burden upon society in terms of medical costs and reduced workplace productivity, so minimizing the functional loss that may occur following injury is important not only in terms of the patient’s quality of life but also to minimize the overall cost to society.
Tenderness, swelling, bruising, crepitus, deformity, restricted motion and instability are common signs of injury. The skeletal examination can often be carried out more thoroughly following the use of local anaesthetic, which can be used either locally or as a block to specific nerves; obviously the documentation of the neurological status of the digit/s is vital prior to the administration of any local anaesthetic agents. Such blockade also allows tendon and ligament integrity to be assessed without pain, whilst facilitating the irrigation of wounds. Remembering to examine adequately for the presence of rotational deformity is essential. Mal-rotation of one bone segment that may occur as a result of a fracture is best appreciated from the alignment of the next most distal segment (best observed when the intervening joint is flexed to 90 degrees) and from the assessment of the relative alignment of the nail plates of the injured digit in relation to those of the adjacent uninjured digits. Apparent digit mal-rotation may also be a manifestation of unequal swelling in the palm; if doubt exists (having considered the injury mechanism and fracture pattern, twisting injuries are more likely to be associated with mal-rotation than axial compression injuries), re-assessing the hand after treatments to reduce swelling (elevation and ice) may be appropriate as long as not too long a time elapses.
History and mechanism of injury A well-taken history is important in order to tailor the management to the specific needs of the patient. Age, occupation, hand dominance, recreational activities and medical co-morbidity are all key parts of the general information that must be factored into the decision making process.
Imaging Plain radiographs should be undertaken in at least two planes centred at the level of the suspected injury, typically consisting of orthogonal postero-anterior (PA) and lateral views, with additional oblique views and cross-sectional imaging being obtained where diagnostic doubt exists, or to aid treatment planning. Ultrasound scanning performed by an experienced person may be useful to assess ligament and tendon integrity
Benjamin JF Dean MRCS(Ed) Orthopaedic Registrar Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK. Christopher Little FRCS (Orth) Consultant Hand Surgeon Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK.
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and to detect radiolucent foreign bodies. MR imaging (MRI) is helpful to detect occult fractures, particularly in the carpus3 (Figure 1). Computed tomography (CT) scans may be used to plan the approach to and fixation of complex intra-articular injuries, or to assess the skeleton where plain films are hard to interpret due to overlapping bony shadows (such as assessing the carpo-metacarpal joints).
Associated injuries Open injuries require prompt surgical debridement and antibiotic prophylaxis should be standard for these injuries. Significantly displaced distal phalangeal fractures are associated with the disruption of the nail matrix. Soft tissue coverage can be achieved by a variety of means ranging from skin grafts to local or free flaps. Tendon disruption may occur with specific injuries, a common example being the terminal extensor tendon with distal interphalangeal joint (DIPJ) injuries, the bony mallet injury (Figure 2). Neurovascular injuries are rare following simple closed fractures and dislocations of the hand, but common with open hand trauma, particularly in the case of injuries as a result of sharp objects. The term ‘combined injuries’ refers to a hand fracture associated with one or more of the aforementioned soft tissue injuries (skin, tendon or neurovascular injury). Mutilating hand trauma is a complex and highly challenging area that is covered elsewhere.4
Figure 2 A lateral radiograph demonstrating the bony mallet injury, note the extensor lag of the distal interphalangeal joint.
and those where non-union will not impair function (many small palmar plate avulsion injuries; note that those associated with joint instability are different injuries requiring a different approach). A stable fracture can be considered as one that will maintain an acceptable position at rest and when early mobilization protocols are initiated, with fractures that will not retain an acceptable position under these circumstances being defined as unstable. When instability is present the best treatment option is the least invasive that can adequately restore skeletal stability. In this way early motion is permitted and the potential adverse effects of surgery and of prolonged immobilization upon the tissues are minimized. Fractures that are likely to displace with early mobilization are considered ‘potentially unstable’ and can be managed with a period of immobilization (undesirable in the fingers as stiffness may ensue), surgical intervention to stabilize the fracture, or early mobilization with a protective resting splint with frequent clinical and radiographic monitoring to allow prompt surgical intervention in the event that unacceptable displacement occurs. The most critical elements in deciding between operative and non-operative treatment are the assessments of rotational malalignment and stability. Non-operative treatment avoids the complications of surgical treatment and is cheaper, but may not restore and maintain skeletal position and stability. Where reduction and early motion are deemed necessary, a closed reduction with percutaneous K-wire stabilization (CRPP) may be considered. Open surgery increases soft tissue trauma, but can potentially achieve the most stable and anatomic reduction and so allow aggressive early mobilization. Generally a good rule is that the more aggressive the surgeon’s intervention has been, the more aggressive the post-operative rehabilitation must be.
Principles of management Most digit fractures will unite without intervention, so the overriding aim of treatment of the skeletal elements of hand injuries is to restore function to the hand by maintaining joint mobility and stability. Early mobilization of the digits is the best way to maintain/regain mobility. Union of a fracture in its anatomical position is often not necessary for this goal to be achieved, and it is important that both the surgeon and the patient have a clear idea of the treatment objectives from the outset. Surgeons treating patients with hand fractures should have a good understanding of the injuries that require anatomic reduction (mal-rotated finger fractures and many intra-articular injuries), those that can be allowed to malunite without long-term function being compromised (many border digit metacarpal fractures),
Distal phalangeal fractures Anatomy and classification The human distal phalanx is characterized by a broad, spade-like tuberosity (the tuft) with a proximal projecting spine and a wide diaphysis containing a palmar concavity to create the ungual fossa.5 The soft tissue of the palmar surface can be divided into
Figure 1 Axial MRI of the wrist demonstrating a trapezial ridge fracture that was not visible on plain radiographs.
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Dorsal base fractures/the mallet fracture A mallet fracture is an injury to the extensor mechanism at the dorsum of the DIPJ associated with an intra-articular fracture at that level. As long as the joint remains reduced, mallet splintage (with check films in the splint over the first 2 weeks) is all that is needed (Figure 3). There is controversy as regards the management of mallet injuries that involve large displaced articular fragments. One large series has shown that the non-operative treatment of all mallet fractures, even those with DIPJ subluxation and involving significant portions of the joint, resulted in excellent function and pain free motion in a majority of patients.8 Bony mallet injuries with larger avulsed fragments are prone to joint instability (the palmar element subluxing); this may require closed reduction and trans-articular wiring of the joint, with the extensor fragment sometimes requiring separate control using a dorsal blocking wire (a technique described by Ishiguro).9 The wires pass through the joint, so care and attention to the pin sites with a low threshold for early wire removal is important to minimize the risk of a septic arthritis. Internal fixation has an unacceptably high complication rate.
the proximal and distal pulp. Nail bed injuries may accompany distal phalangeal fractures; the presence of a subungual haematoma should alert one to this possibility. The dorsal portion of the distal phalanx and the nail plate create the outer layers of a sandwich, which contains the nail matrix as the filling. When a fracture breaches the seal between the nail plate and the hyponychium, it constitutes an ‘open’ injury and should be treated as such. The relationship between the bone and soft tissue structures is of prime importance when considering the management of these injuries. Distal phalanx fractures may be of the tuft, the shaft or of the base. A key consideration is the attachment of the terminal extensor and flexor tendons to the dorsum of the epiphysis and palmar metaphysis of the distal phalanx respectively; fractures distal to the tendon insertions will be separated from any internal deforming forces as a result, whereas those that pass between the insertions (such as the Seymour fracture6 seen in skeletally immature people) will displace with the basal fragment extending and the distal fragment flexing. Seymour injuries are often open, with the nail plate pulling out from the eponychial fold; they require wash-out, reduction, nail bed repair and, often, CRPP. Dorsal base articular rim fractures are inherently unstable as a result of these deforming forces; these injuries represent extensor insertion avulsions and are referred to as bony mallet fractures (Figure 2).
Volar base fractures These may be either a small basal rim fracture representing a palmar plate avulsion or a closed avulsion injury of the flexor digitorum profundus (FDP) tendon with a bony fragment attached. FDP avulsion injuries can be type 1, 2 or 3 according to the Leddy and Packer classification system,10 which reflects the degree of retraction of the tendon stump (in practice, one into the palm, two to the level of the PIP joint and three at the level of the DIP joint). If the bony fragment is large enough it may be fixed with a compression screw, otherwise the injury is treated in accordance with the modern principles of flexor tendon reinsertion (Figure 4).
Tuft fractures Rim fractures of the tuft are often caused by crush injuries and are usually fairly stable, being splinted by the nail matrix dorsally and the pulp on the volar surface; while the rim elements not uncommonly fail to unite, the functional outcome is generally good and initial expectant management is appropriate. A splint may be use for comfort (as a thimble) but early motion of the digit and desensitization is important. Any significant displacement in the distal portion of the distal phalanx that supports the nail matrix will often be associated with an open injury; treatment should focus on formal exploration, wash-out and repair of the nail bed with the fracture being reduced and pinned to provide support to the surgical repair of the nail matrix unless the reinserted nail plate gives sufficient stability. Surgical exploration of the nail matrix is not obligatory if the fracture is closed, regardless of the presence or size of a subungual haematoma. The haematoma may need to be drained for pain relief (trephining the nail plate at its base). Generally active range of motion exercise can be begun at around a week following matrix repair provided the DIPJ has not been pinned; if the DIPJ has been pinned then pin removal is typically at the 3e4-week mark.7 The patient must be aware of the potential for nail deformity and the time required for stable nail regrowth, which is typically 5 months.
Proximal and middle phalanx fractures Anatomy and classification Fractures of the middle and proximal phalanges can be grouped by the anatomic regions of head, neck, shaft and base. Axial
Shaft fractures The majority of shaft fractures can be managed with splintage and this involves immobilization of the DIPJ. Active range of motion exercises involving the DIPJ can begin once the fracture has had time to consolidate at approximately the 3-week mark. Significantly displaced shaft fractures are prone to non-union, CRPP is usually sufficient for these fractures unless there is interposed tissue blocking the reduction which would then necessitate open reduction.
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Figure 3 Lateral radiograph of the bony mallet injury of Figure 2 treated with a mallet splint, this radiograph confirms a satisfactory reduction with a fully extended joint.
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a and b. This variation of an FDP avulsion had a multi-fragmentary articular element and a fracture across the metaphyseo-diaphyseal junction. The tendon was reattached with a suture anchor, which could be inserted into the medulla by hyper-extending at the fracture site; the joint element was secured with a screw. Figure 4
loading mechanisms of injury may produce unicondylar or bicondylar fractures of the head or intra-articular fractures of the base. Base fractures may be subdivided into dorsal base, volar base or the more comminuted complete articular fractures that are often known as ‘pilon’ fractures. The periosteal surfaces of the proximal and middle phalanges are intimately related to the flexor and extensor tendons. The tendons of flexor digitorum superficialis (FDS) and FDP join the fibres of the fibro-osseous tunnel to cover the entire palmar surface of each bone. Consequently displaced shaft fractures result in tendons being exposed to sharp bone edges, which can result in the formation of troublesome adhesions. As a result it is important to achieve tendon gliding across the fracture site during healing. Proximal phalangeal fractures will normally angulate with an apex volar deformity. The interossei flex the proximal fragment while the distal fragment is hyperextended by the central slip’s pull on the base of the middle phalanx. The deformity associated with middle phalangeal fractures is less predictable. The more proximal middle phalangeal fractures tend to angulate with an apex dorsal deformity, FDS flexes the distal fragment and the central slip extends the proximal fragment. The more distal fractures tend to angulate with an apex volar deformity with FDS flexing the proximal fragment. The extensor mechanism is reliant upon the dorsal length of the proximal phalanx; bony malunion and consequent phalangeal shortening can result in a loss of interphalangeal extension (fixed flexion deformity). Middle phalangeal shortening tends to
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produce PIP joint hyperextension due to the loss of distal joint extension and the characteristic swan neck deformity results. Management The majority of fractures can be managed non-operatively. Transverse shaft fractures will tend to be much more stable than oblique, spiral or comminuted fractures. The degree of displacement is related to the inherent stability of the fracture. Stable fractures can be managed with splintage and early protected motion. Excellent results can be achieved by immobilization of the affected digit in the ‘safe’ or ‘intrinsic plus position’ (metacarpophalangeal (MCP) joint flexion to 90 degrees with full extension of the interphalangeal joints) for 2e3 weeks, followed by buddy strapping until clinical union has been achieved. Extremely stable undisplaced fractures can be managed by buddy strapping from day 1 without a period of immobilization. It is important to check for the maintenance of the reduction, consequently all patients should be reviewed at 1 week for repeat radiographs. A commonly used treatment for fractures that are displaced and unstable after reduction is CRPP.11 Great care must be taken when using this method in the phalanges as a result of the broad extensor mechanism; in the proximal two thirds of the proximal phalanx it is almost impossible to avoid tethering the extensor mechanism. Kirschner wires (K-wires) can be inserted in a crossed or longitudinal manner via an antegrade or retrograde approach. Typically an extra-articular approach through the base is preferred for the middle phalanx, while proximal
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phalangeal fractures can be managed antegrade through a flexed MCP joint or retrograde through a flexed PIPJ. Post-operative management is tailored to the individual patient but the K-wires are generally protected with some form of external splintage, until the point at which the wires are removed and gentle mobilization can begin. Routinely K-wires are removed 4 weeks following their insertion. If the fracture cannot be adequately reduced by closed means then open reduction and internal fixation (ORIF) is the treatment of choice. Mal-rotation, significant shortening, angulation of more than 10 degrees and less than 50% bone apposition are unacceptable features. Severe open injuries and injuries with
bone loss invariably require ORIF. As a result of ORIF being associated with the most severe injuries and consequently poor prognostic factors, results are often felt to be sub-optimal.12 Options for ORIF include intra-osseus wiring, screw and plate fixation (Figure 5). While the surgical approach chosen should reflect the injury pattern and any open wounds, proximal third fractures of the proximal phalanx are often best approached with a mid line dorsal tendon splitting incision, mid and distal third fractures through one or two mid lateral incisions.13 ORIF must result in rigid fixation to allow early mobilization, a failure to achieve sufficiently secure fixation achieves the worst of both worlds and often a poor outcome.
a, b and c. Unstable proximal phalangeal fracture treated with ORIF via two mid lateral incisions. Figure 5
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Intra-articular fractures Splinting is only appropriate for minimally displaced fractures that are inherently stable. CRPP is an acceptable form of treatment as long as anatomic reduction of the articular surface can be achieved. More rigid fixation can be achieved with screws sometimes in combination with minicondylar plates, but inadequate bone stock may contraindicate ORIF.
collateral ligament (UCL) is a common injury, which is rarely accompanied by a full MP joint dislocation. Rupture of the UCL typically presents with pain and tenderness around the ulnar border of the MP joint. Stress testing in full extension and 30 degrees of flexion should be undertaken to reveal any instability. A Stener lesion is where the distally ruptured UCL is prevented from healing by the interposed adductor aponeurosis. Non-operative management is the mainstay of treatment for thumb MP joint injuries; typically this involves a minimum period of 4 weeks of thumb MP joint immobilization with either a cast or a splint. Only the complete UCL rupture with a Stener lesion requires operative intervention. In a recent prospective study of 24 patients a palpable tender mass on the ulnar side of the MP joint was used as the sole diagnostic criterion for the Stener lesion.17 In this study all patients with a Stener lesion were treated operatively with ligament repair, while all those without were managed non-operatively; outcomes in both groups were equivalent at 1 year. The presence of greater than 30 degrees valgus instability with stress testing in full extension is highly predictive of a Stener lesion.18
Volar base fractures of the middle phalanx Fractures at the base of the middle phalanx can be particularly unstable in direct relation to the percentage of the articular surface involved. When the volar fragment makes up greater than 40% of the articular surface it carries the majority of the collateral ligament and volar plate insertions, and as a result the dorsal fragment and remainder of the phalanx will sublux proximally and dorsally due to the pull of the central slip. Dynamic extension block splinting is an effective management strategy for these injuries provided the volar fragment involves less than 40% of the joint surface (Figure 6). Extension block pinning can be used for fractures involving greater than 40% of the articular surface provided the reduction occurs spontaneously with PIP joint flexion. Other techniques include a single compression screw (provided the fragment is large enough) and volar plate arthroplasty (felt by many to give unsatisfactory results); presently use of a hemihamate bone-graft is gaining popularity.14
Metacarpal fractures Anatomy and classification The metacarpals make up three arches of the hand: these are the two transverse arches that exist at the level of the CMC and MCP joints and the longditudinal arch, which is made up from their long convex dorsal surfaces. The metacarpals are bound together firmly by interosseus ligaments at their bases and by the deep transverse intermetacarpal ligaments distally. These strong ligamentous attachments help to maintain the transverse arches, but flattening may occur with multiple fractures or crush injuries. The distal carpal row forms the fixed transverse arch of the hand, which is the stable foundation upon which the remaining hand structure is constructed. The second and third CMC joints allow for the rigid attachment of the index and middle finger metacarpals, thus forming the fixed unit of the hand; the CMC joints of the ring and little fingers allow for more flexion and extension, important for grip power. Metacarpal fractures may be broken down into those of the head, neck, shaft and base. Shaft and neck fractures typically demonstrate apex dorsal angulation as a result of the deforming pull of the interossei. The normal neck to shaft angle of 15 degrees should be remembered when assessing these injuries radiographically. The term ‘pseudoclawing’ refers to the compensatory MCP hyperextension and PIPJ flexion that may occur in response to the apex dorsal angulation. The relative inflexibility of the index and middle finger CMC joints (where motion is negligible) compared to the ring and little finger CMC joints (motion is 15 and 25 degrees respectively) has important implications for deciding when to intervene surgically. The thumb CMC joint is the most mobile with around 50 degrees of flexion and extension, and 40 degrees of abduction and adduction.
Pilon fractures of the PIPJ The combination of complete articular surface involvement and metaphyseal compaction with bone loss is the most functionally devastating of the pilon fractures involving the PIPJ. Immobilization in flexion, ORIF, extension block splinting, dynamic force couple, skeletal traction and a silicone spacer have all been described in the management of these injuries. Although anatomic restoration of the joint surface should be one’s aim, this is seldom possible due to the amount of articular and metaphyseal comminution. The clinical outcomes following splint immobilization are generally unsatisfactory, while the outcomes following treatment with skeletal traction and ORIF are similar.15 The significant surgical complications associated with ORIF mean that skeletal traction is often the preferred treatment. While a distracting dynamic fixator can be fashioned using bent K-wires with or without rubber bands, several commercially-available modern devices are marketed to apply skeletal traction across the PIPJ while active ranges of motion exercises are begun. Avulsion fractures from the base of the proximal phalanges Marginal fractures of the base of the proximal phalanx involving the MP joint usually represent avulsion fractures of a collateral ligament. There is frequently a substantial palmar bony avulsion fragment. As the risk of non-union with non-operative treatment is high some authors advise early internal fixation with a lag screw using a dorsal approach.16 The advantages of this approach include early mobilization and a reduced risk of non-union.
Management The vast majority of metacarpal neck and shaft fractures may be treated non-operatively; intra-articular fractures of the head and base may also be managed non-operatively as long as the fracture is stable and minimally displaced. Metacarpal fractures with significant rotational deformity or shortening cannot be satisfactorily
Thumb MP joint ligament injuries The prime stabilizers of motion at the thumb MPJ are the radial and ulnar collateral ligaments. Complete rupture of the ulnar
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a and b. This PIP joint fracture-subluxation was unstable after reduction when extending beyond 40 degrees. An extension-blocking splint was fashioned preventing extension beyond 40 degrees, but allowing free flexion. The joint was monitored and, as it remained stable, the amount of extension prevented by the splint was reduced by 10 degrees each week from 3 1/2 weeks after injury, with close monitoring maintained. Figure 6
managed non-operatively. Splinting is directed towards neutralizing deforming forces and pain control while remembering the position of safe immobilization; the MCP joints are held in full flexion in combination with wrist dorsiflexion.19 The splint can be
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removed as soon as the patient is comfortably able to move the hand and this should not be later than 3 weeks following the injury. In fact the immediate mobilization of fifth metacarpal neck fractures yields excellent results in spite of high degrees of angulation.20
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Metacarpal head fractures Articular fractures of the metacarpal head are often as a result of direct trauma. Non-operative management is indicated for those which are minimally displaced and stable to active stress testing. Non-operative treatment consists of splint immobilization for 2e3 weeks followed by early protected motion. ORIF is indicated when there is significant loss of articular congruency or instability with active stress.21 Collateral ligament avulsion injuries are difficult to reduce and hold with closed methods, meaning that ORIF is often required. Fixation may be with K-wires, screws or interosseus wires. The metacarpal head is approached dorsally with a tendon splitting approach. Early rigid fixation is important in order to allow early mobilization and prevent extensor mechanism tethering. Screw fixation is possible if the fragment diameter is greater than three times the diameter of the screw hole; movement within a few days is important with this technique. Ideally the fixation devices should be clear of the joint surface (Figure 7). If the fracture configuration means that fixation implants would cross the articular cartilage, either well counter-sunk headed screws or
small headless compression bone screws should be used to ensure no metal is exposed within the joint. Fixation by K-wires results in a stable but non-rigid form of fixation, thus movement must wait until around the 2- week mark. Metacarpal neck fractures Rotational deformity must be corrected and the degree of acceptable angulation depends on the digit involved. Less than 15 degrees of angulation may be tolerated in the index and middle finger metacarpals due to the rigid CMCJs. The more mobile ring and little finger metacarpals can tolerate more angulation with 35 and 45 degrees accepted respectively.22 Treatment is symptomatic and mobilization is begun as early as possible; if needed, splint immobilization involves holding the MCP joints in 90 degrees of flexion with around 30 degrees of wrist extension, while the PIPJs are left free to allow immediate motion. Indications for surgical intervention include the inability to achieve or maintain a satisfactory reduction where one is required. Rotational malalignment is unacceptable,
a, b and c. Pre and post-operative radiographs of a distal metacarpal fracture treated with ORIF. Figure 7
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a and b. The use of an IM K wire to stabilize an angulated fifth metacarpal shaft fracture. Figure 8
while excessive angulation and marked palmar comminution are relative indications for surgery. Intra-medullary (IM) K-wire stabilization is the surgical treatment of choice for most single metacarpal fractures; the use of multiple diverging contoured wires will give rotational control23 e the so-called bouquet technique, although the authors prefer to use direct reductionabsolute stability techniques (ORIF) where the injury is rotationally unstable. Other techniques include the use of crossed K-wires and transfixion to adjacent intact metacarpals. Anatomic reduction is not essential for injuries where there is no mal-rotation and a relative stability fixation technique has been
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used. The indications for ORIF include multiple fractures, open injuries, irreducible fractures and injuries that are rotationally unstable. The techniques available for ORIF include K-wires in combination with tension bands and specifically designed hand plates with screws. Metacarpal shaft fractures Less angular deformity can be tolerated in metacarpal shaft fractures in comparison to metacarpal neck fractures due to the longer lever arm that will deliver the metacarpal head into the palm. Transverse, short oblique, oblique and spiral fractures fracture
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a, b and c. An open metacarpal fracture with significant bone loss treated with bridge plating without bone-grafting, radiographs at the 7 month follow up demonstrate bony union. Figure 9
patterns may be seen. Of note oblique and spiral types are particularly prone to acquiring rotational deformity as they shorten. Acceptable angulation is less than 10 degrees for the index and middle finger metacarpals, and less than 20e30 degrees in the ring and little finger metacarpals respectively; no rotational deformity is acceptable, while up to 5 mm of shortening can be tolerated. A moulded splint not including the MCP joints can be employed for shaft fractures proximal to the neck; the splint is discontinued after
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around 4 weeks. Indications for surgical intervention include the inability to achieve or maintain a satisfactory reduction, open fractures, multiple fractures and fractures with bone loss. Again a multitude of techniques have been described in the literature, with IM K-wires being increasingly popular (Figure 8). The biomechanical strength of K-wire fixation has been shown to be significantly inferior to plates and screws. The interfragmentary lag screw is extremely effective in resisting loading forces, but two or more
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should be used unless a neutralization plate is applied as well. Plates function most effectively as tension bands (applied on the dorsal surface); with the availability of locking plates, fractures with marked bone loss or segmental fragmentation can be successfully treated with bridge plating techniques without the need for bonegraft in many cases (Figure 9).
CRPP can involve direct pinning at the fracture site or the splintage of the fracture site by securing the metacarpal to the adjacent metacarpal both proximally and distally. It may be difficult to control rotation without ORIF. Interfragmentary lag screw fixation is the treatment of choice for spiral fractures, screw fixation alone is acceptable as long as the
a and b. A Bennett’s fracture treated with ORIF. Figure 10
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fracture length is at least three times the diameter of the metacarpal and at least two screws are used.24 Short oblique fractures can be treated with a lag screw in combination with a dorsal neutralization plate. The complications of ORIF are not infrequent but its great benefit is to allow early mobilization. Thumb metacarpal shaft fractures Thumb metacarpal fractures are common and account for around 25% of all metacarpal fractures. Most fractures are proximal in which the distal fragment is adducted and supinated; the injury may be partial articular, complete articular or epi-basal in nature. Reduction is therefore performed using longitudinal traction with pronation and abduction to correct the angulation, a well-moulded cast is then applied for 3e4 weeks. The thumb CMCJ’s mobility means that angulation is well tolerated and surgical fixation is often not required for nonarticular injuries. Intra-articular fractures of the thumb base The most common of this type is Bennett’s fracture-dislocation. Bennett’s fracture-dislocation is a partial articular injury, involving a volar ulnar portion of the articular surface that is held in place by the volar oblique ligament and the remaining metacarpal fragment, which is displaced dorsally and into supination by the pull of abductor pollicis longus (APL) (Figure 10a). A true lateral and hyperpronated AP view, also known as ‘Robert’s’ view, may be used to best visualize this injury. Due to the articular involvement and unstable nature of the injury, closed reduction and CRPP are indicated on most occasions. Reduction is achieved using longditudinal traction with a combination of extension, abduction and pronation with direct pressure onto the base of the metacarpal, following by percutaneous pinning of the shaft fragment to the trapezium or index finger metacarpal. CRPP is followed by immobilization with a short arm thumb spica cast for around 6 weeks. If attempted closed reduction results in greater than 2 mm of joint surface displacement then open reduction is indicated. Lag screws or pinning may be used depending on the surgeon’s preference (Figure 10b). Rolando’s fracture-dislocation is a complete articular injury and in addition to the palmar fragment found in Bennett’s fracture, it is characterized by a larger dorsal fragment with varying degrees of comminution. Treatment options include closed reduction and casting, soft dressing with early motion, skeletal traction and early motion, and ORIF. Some authors advocate the use of skeletal traction with early motion as the treatment of choice.25 Traction is applied from an obliquely applied metacarpal wire to an outrigger device, while active motion is begun immediately and maintained for 6 weeks. Other authors prefer pinning the thumb metacarpal to the index metacarpal in order to distract the comminuted metaphyseal zone as it is allowed to heal,6 or using an external fixator. ORIF has the advantage of allowing early motion, but runs the risk of devascularizing fracture fragments with an already precarious blood supply and may be technically difficult in the presence of significant comminution. As a result ORIF is best reserved for the irreducible fracture or those with minimal comminution16 (Figure 11).
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a and b. A Rolando’s fracture treated with ORIF. Figure 11
Carpo-metacarpal fracture-dislocations The little finger CMC joint is the most commonly affected. The concern is that with no treatment the persistent subluxation and incongruity leads to pain and reduced grip strength. Undisplaced injuries can be managed with cast immobilization and regular checks for the maintenance of reduction. Displacement necessitates operative treatment. To determine if the joint is dislocated, either a CT or use of the intra-medullary axis convergence technique (described by Shewring26) can be used (Figure 12a). CRPP is the treatment of choice providing closed reduction can be achieved. Manual reduction is followed by the placement of K-wires through the metacarpal shaft and into the carpal bones and the adjacent stable metacarpals (Figure 12b). Open reduction is indicated if closed reduction is not possible, and also in cases of excessive swelling, cases of delayed presentation and open
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injuries27; this may also be preferred if there is a single, large fragment off the dorsal lip of the carpus, reduction and stabilization of which would restore stability and allow early motion. Index finger CMC joint dislocations more commonly require open
reduction because of extensor carpi radialis brevis interposition. Open reduction is generally accompanied by K-wire fixation. Whether open or closed reduction is employed, cast immobilization follows and the wires are removed at 4e6 weeks.
a and b. a The intra-medullary axis covergance technique, note that the ring and little metacarpal lines do not meet the index and middle lines at a point in the distal radius suggesting joint dislocations. b demonstrates this injury treated with CRPP. Figure 12
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Conclusions
11 Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000; 8: 111e21. 12 Pun WK, Chow SP, So YC, et al. Unstable phalangeal fractures. Treatment by AO screw and plate fixation. J Hand Surg 1991; 16A: 113e7. 13 Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint: treatment with the force couple splint. Clin Orthop Relat Res 1987; 214: 101e12. 14 Williams RM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 2003 Sep; 28: 856e65. 15 Stern PJ, Roman RJ, Kiefhaber TR, et al. Pilon fractures of the proximal interphalangeal joint. J Hand Surg 1991; 16A: 844e50. 16 Scewring DJ, Thomas RH. Avulsion fractures from the base of the proximal phalanges of the fingers. J Hand Surg Eur Vol February 2003; 28: 10e4. 17 Abrahamsson S, et al. Diagnosis of displaced ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg Am May 1990; 15: 457e60. 18 Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop Relat Res; 1993 Jul: 165e71. 19 Burkhalter WE. Closed treatment of hand fractures. J Hand Surg 1989; 14A: 390e3. 20 Bansal R, Craigen MA. Fifth metacarpal neck fractures: is follow-up required? J Hand Surg Eur Vol 2007 Feb; 32: 69e73. Epub 2006 Nov 27. 21 McElfresh EC, Dobyns JH. Intraarticular metacarpal head fractures. J Hand Surg 1983; 8: 383e93. 22 Ashkenaze DM, Ruby LK. Metacarpal fractures and dislocations. Orthop Clin North Am 1992; 23: 19e33. 23 Foucher G, Chemorin C, Sibilly A. A new technic of osteosynthesis in fractures of the distal 3d of the 5th metacarpus. Nouv Presse Med 1976 Apr 24; 5: 1139e40. 24 Lee SG, Jupiter JB. Phalangeal and metacarpal fractures of the hand. Hand Clin 2000; 16: 323e32. 25 Breen TF, Gelberman RH, Jupiter JB. Intraarticular fractures of the basilar joint of the thumb. Hand Clin 1988; 4: 491e501. 26 Hodgson PD, Shewring DJ. The ‘Metacarpal Cascade Lines’; use in the diagnosis of dislocation of the Carpometacarpal joints. J Hand Surg Eur Vol June 2007; 32: 277e81. 27 Rawles Jr JG. Dislocations and fracture dislocations at the carpometacarpal joints of the fingers. Hand Clin 1988; 4: 103e12.
Fractures and dislocations of the hand are a complicated and diverse group of injuries. Despite this complexity and diversity they share a common theme in management. The hand is a delicate and sensitive organ that requires both flexibility and stability in order for optimal function. Therefore the individual surgeon must tailor treatment in order to achieve an optimal functional outcome for the patient. This may be with splinting for a stable injury, or with CRPP or ORIF for an unstable injury. A good general rule to remember is that the more aggressive the surgical intervention has been, the more aggressive the rehabilitation regime must be. A successful outcome also involves trying to avoid the potential complications such as nerve hypersensitivity and infection. Finally the management of the patient’s expectations are also important: it is crucial that the patient is aware that fractures and dislocations of the hand produce swelling, stiffness and pain that frequently take more than a year to overcome. A
REFERENCES 1 Packer GJ, Shaheen MA. Patterns of hand fractures and dislocations in a district general hospital. J Hand Surg 1993; 18: 511e4. 2 Hove LM. Fractures of the hand. Distribution and relative incidence. Scand J Plast Reconstr Surg 1993 Dec; 27: 317e9. 3 Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol 2003; 76: 296e300. 4 Henry Mark. Fractures and dislocations of the hand. In: Bucholz RW, Heckman JD, eds. Rockwood and Green’s fractures in adults. 5th edn. Philadelphia, PA: Lippincott Williams and Wilkins, 2002. 5 Shrewsbury MM, Johnson RK. Form, function and evolution of the distal phalanx. J Hand Surg 1983; 8: 475e9. 6 Seymour N. Juxta-epiphyseal fracture of the terminal phalanx of the finger. J Bone Joint Surg 1966; 48: B347e9. 7 Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther ApreJun 2003; 16: 2. 8 Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg Am 1984; 66: 658e69. 9 Ishiguro T, et al. Extension block with Kirschner wire for fracture dislocation of the distal interphalangeal joint. Orthoped Traumatol 1999; 7: 105e11. 10 Leddy JP, Packer JW. Avulsion of the profundus tendon insertion in athletes. J Hand Surg Am 1977 Jan; 2: 66e9.
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Fractures of the metacarpals and phalanges
A clear history as to the precise mechanism of injury should be obtained to help reveal both the type of injury sustained and any potentially associated injuries. Axial loading frequently results in shearing articular or metaphyseal compression fractures, while one should maintain a high index of suspicion for injuries proximal to the hand. A bending element is often required for joint dislocations or diaphyseal fractures, while torsional forces may result in spiral fractures (with a high likelihood of mal-rotation) or more complex dislocation patterns. Higher energy injuries with crushing forces typically result in much greater soft tissue trauma, which increases the likelihood of an associated open injury and neurovascular compromise (including compartment syndrome) and can significantly influence the available treatment options. The common symptoms associated with hand fractures and dislocations include pain, swelling, weakness, stiffness and deformity. Patients should be questioned about the initial deformity and reduction manoeuvres that may have been attempted. Numbness and subjectively altered sensation indicate nerve involvement, which may be as a direct result of the injury or a secondary effect of swelling. With an open injury it is important to ascertain the nature of the environment in which the injury was sustained, the degree of wound contamination and the likelihood of foreign bodies must be considered. The time from injury to presentation is also a vital piece of information.
Benjamin JF Dean Christopher Little
Abstract Hand fractures and dislocations are amongst the most frequently encountered orthopaedic injuries. A thorough assessment including history, clinical examination and radiological investigations is essential before deciding upon an appropriate management plan. The vast majority of injuries can be managed non-operatively, but knowing when surgery is likely to improve the functional outcome is the key in selecting when to proceed with a specific surgical intervention. This review article aims to summarize the key concepts in the management of these injuries so that the reader can better understand the rationale behind the surgical decision making process.
Keywords dislocations; fractures; hand; metacarpal; phalangeal
Introduction/epidemiology
Clinical examination and signs
Hand fractures and dislocations are amongst the most common orthopaedic injuries presenting to Accident and Emergency (A&E) departments, comprising approximately a quarter of all patients attending with a fracture or dislocation.1 Males are typically affected more commonly than females; sport related injuries are particularly common in the 3rd decade and workplace related injuries in the 5th decade. A large prospective study from Norway found that fractures were distributed around the hand as follows: 46% phalangeal, 36% metacarpal, with nearly 10% of the overall total affecting the little finger metacarpal neck.2 The borders of the hand is most commonly affected, with injuries to the thumb and the little finger ray predominating. Hand fractures and dislocations represent a considerable burden upon society in terms of medical costs and reduced workplace productivity, so minimizing the functional loss that may occur following injury is important not only in terms of the patient’s quality of life but also to minimize the overall cost to society.
Tenderness, swelling, bruising, crepitus, deformity, restricted motion and instability are common signs of injury. The skeletal examination can often be carried out more thoroughly following the use of local anaesthetic, which can be used either locally or as a block to specific nerves; obviously the documentation of the neurological status of the digit/s is vital prior to the administration of any local anaesthetic agents. Such blockade also allows tendon and ligament integrity to be assessed without pain, whilst facilitating the irrigation of wounds. Remembering to examine adequately for the presence of rotational deformity is essential. Mal-rotation of one bone segment that may occur as a result of a fracture is best appreciated from the alignment of the next most distal segment (best observed when the intervening joint is flexed to 90 degrees) and from the assessment of the relative alignment of the nail plates of the injured digit in relation to those of the adjacent uninjured digits. Apparent digit mal-rotation may also be a manifestation of unequal swelling in the palm; if doubt exists (having considered the injury mechanism and fracture pattern, twisting injuries are more likely to be associated with mal-rotation than axial compression injuries), re-assessing the hand after treatments to reduce swelling (elevation and ice) may be appropriate as long as not too long a time elapses.
History and mechanism of injury A well-taken history is important in order to tailor the management to the specific needs of the patient. Age, occupation, hand dominance, recreational activities and medical co-morbidity are all key parts of the general information that must be factored into the decision making process.
Imaging Plain radiographs should be undertaken in at least two planes centred at the level of the suspected injury, typically consisting of orthogonal postero-anterior (PA) and lateral views, with additional oblique views and cross-sectional imaging being obtained where diagnostic doubt exists, or to aid treatment planning. Ultrasound scanning performed by an experienced person may be useful to assess ligament and tendon integrity
Benjamin JF Dean MRCS(Ed) Orthopaedic Registrar Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK. Christopher Little FRCS (Orth) Consultant Hand Surgeon Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK.
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and to detect radiolucent foreign bodies. MR imaging (MRI) is helpful to detect occult fractures, particularly in the carpus3 (Figure 1). Computed tomography (CT) scans may be used to plan the approach to and fixation of complex intra-articular injuries, or to assess the skeleton where plain films are hard to interpret due to overlapping bony shadows (such as assessing the carpo-metacarpal joints).
Associated injuries Open injuries require prompt surgical debridement and antibiotic prophylaxis should be standard for these injuries. Significantly displaced distal phalangeal fractures are associated with the disruption of the nail matrix. Soft tissue coverage can be achieved by a variety of means ranging from skin grafts to local or free flaps. Tendon disruption may occur with specific injuries, a common example being the terminal extensor tendon with distal interphalangeal joint (DIPJ) injuries, the bony mallet injury (Figure 2). Neurovascular injuries are rare following simple closed fractures and dislocations of the hand, but common with open hand trauma, particularly in the case of injuries as a result of sharp objects. The term ‘combined injuries’ refers to a hand fracture associated with one or more of the aforementioned soft tissue injuries (skin, tendon or neurovascular injury). Mutilating hand trauma is a complex and highly challenging area that is covered elsewhere.4
Figure 2 A lateral radiograph demonstrating the bony mallet injury, note the extensor lag of the distal interphalangeal joint.
and those where non-union will not impair function (many small palmar plate avulsion injuries; note that those associated with joint instability are different injuries requiring a different approach). A stable fracture can be considered as one that will maintain an acceptable position at rest and when early mobilization protocols are initiated, with fractures that will not retain an acceptable position under these circumstances being defined as unstable. When instability is present the best treatment option is the least invasive that can adequately restore skeletal stability. In this way early motion is permitted and the potential adverse effects of surgery and of prolonged immobilization upon the tissues are minimized. Fractures that are likely to displace with early mobilization are considered ‘potentially unstable’ and can be managed with a period of immobilization (undesirable in the fingers as stiffness may ensue), surgical intervention to stabilize the fracture, or early mobilization with a protective resting splint with frequent clinical and radiographic monitoring to allow prompt surgical intervention in the event that unacceptable displacement occurs. The most critical elements in deciding between operative and non-operative treatment are the assessments of rotational malalignment and stability. Non-operative treatment avoids the complications of surgical treatment and is cheaper, but may not restore and maintain skeletal position and stability. Where reduction and early motion are deemed necessary, a closed reduction with percutaneous K-wire stabilization (CRPP) may be considered. Open surgery increases soft tissue trauma, but can potentially achieve the most stable and anatomic reduction and so allow aggressive early mobilization. Generally a good rule is that the more aggressive the surgeon’s intervention has been, the more aggressive the post-operative rehabilitation must be.
Principles of management Most digit fractures will unite without intervention, so the overriding aim of treatment of the skeletal elements of hand injuries is to restore function to the hand by maintaining joint mobility and stability. Early mobilization of the digits is the best way to maintain/regain mobility. Union of a fracture in its anatomical position is often not necessary for this goal to be achieved, and it is important that both the surgeon and the patient have a clear idea of the treatment objectives from the outset. Surgeons treating patients with hand fractures should have a good understanding of the injuries that require anatomic reduction (mal-rotated finger fractures and many intra-articular injuries), those that can be allowed to malunite without long-term function being compromised (many border digit metacarpal fractures),
Distal phalangeal fractures Anatomy and classification The human distal phalanx is characterized by a broad, spade-like tuberosity (the tuft) with a proximal projecting spine and a wide diaphysis containing a palmar concavity to create the ungual fossa.5 The soft tissue of the palmar surface can be divided into
Figure 1 Axial MRI of the wrist demonstrating a trapezial ridge fracture that was not visible on plain radiographs.
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Dorsal base fractures/the mallet fracture A mallet fracture is an injury to the extensor mechanism at the dorsum of the DIPJ associated with an intra-articular fracture at that level. As long as the joint remains reduced, mallet splintage (with check films in the splint over the first 2 weeks) is all that is needed (Figure 3). There is controversy as regards the management of mallet injuries that involve large displaced articular fragments. One large series has shown that the non-operative treatment of all mallet fractures, even those with DIPJ subluxation and involving significant portions of the joint, resulted in excellent function and pain free motion in a majority of patients.8 Bony mallet injuries with larger avulsed fragments are prone to joint instability (the palmar element subluxing); this may require closed reduction and trans-articular wiring of the joint, with the extensor fragment sometimes requiring separate control using a dorsal blocking wire (a technique described by Ishiguro).9 The wires pass through the joint, so care and attention to the pin sites with a low threshold for early wire removal is important to minimize the risk of a septic arthritis. Internal fixation has an unacceptably high complication rate.
the proximal and distal pulp. Nail bed injuries may accompany distal phalangeal fractures; the presence of a subungual haematoma should alert one to this possibility. The dorsal portion of the distal phalanx and the nail plate create the outer layers of a sandwich, which contains the nail matrix as the filling. When a fracture breaches the seal between the nail plate and the hyponychium, it constitutes an ‘open’ injury and should be treated as such. The relationship between the bone and soft tissue structures is of prime importance when considering the management of these injuries. Distal phalanx fractures may be of the tuft, the shaft or of the base. A key consideration is the attachment of the terminal extensor and flexor tendons to the dorsum of the epiphysis and palmar metaphysis of the distal phalanx respectively; fractures distal to the tendon insertions will be separated from any internal deforming forces as a result, whereas those that pass between the insertions (such as the Seymour fracture6 seen in skeletally immature people) will displace with the basal fragment extending and the distal fragment flexing. Seymour injuries are often open, with the nail plate pulling out from the eponychial fold; they require wash-out, reduction, nail bed repair and, often, CRPP. Dorsal base articular rim fractures are inherently unstable as a result of these deforming forces; these injuries represent extensor insertion avulsions and are referred to as bony mallet fractures (Figure 2).
Volar base fractures These may be either a small basal rim fracture representing a palmar plate avulsion or a closed avulsion injury of the flexor digitorum profundus (FDP) tendon with a bony fragment attached. FDP avulsion injuries can be type 1, 2 or 3 according to the Leddy and Packer classification system,10 which reflects the degree of retraction of the tendon stump (in practice, one into the palm, two to the level of the PIP joint and three at the level of the DIP joint). If the bony fragment is large enough it may be fixed with a compression screw, otherwise the injury is treated in accordance with the modern principles of flexor tendon reinsertion (Figure 4).
Tuft fractures Rim fractures of the tuft are often caused by crush injuries and are usually fairly stable, being splinted by the nail matrix dorsally and the pulp on the volar surface; while the rim elements not uncommonly fail to unite, the functional outcome is generally good and initial expectant management is appropriate. A splint may be use for comfort (as a thimble) but early motion of the digit and desensitization is important. Any significant displacement in the distal portion of the distal phalanx that supports the nail matrix will often be associated with an open injury; treatment should focus on formal exploration, wash-out and repair of the nail bed with the fracture being reduced and pinned to provide support to the surgical repair of the nail matrix unless the reinserted nail plate gives sufficient stability. Surgical exploration of the nail matrix is not obligatory if the fracture is closed, regardless of the presence or size of a subungual haematoma. The haematoma may need to be drained for pain relief (trephining the nail plate at its base). Generally active range of motion exercise can be begun at around a week following matrix repair provided the DIPJ has not been pinned; if the DIPJ has been pinned then pin removal is typically at the 3e4-week mark.7 The patient must be aware of the potential for nail deformity and the time required for stable nail regrowth, which is typically 5 months.
Proximal and middle phalanx fractures Anatomy and classification Fractures of the middle and proximal phalanges can be grouped by the anatomic regions of head, neck, shaft and base. Axial
Shaft fractures The majority of shaft fractures can be managed with splintage and this involves immobilization of the DIPJ. Active range of motion exercises involving the DIPJ can begin once the fracture has had time to consolidate at approximately the 3-week mark. Significantly displaced shaft fractures are prone to non-union, CRPP is usually sufficient for these fractures unless there is interposed tissue blocking the reduction which would then necessitate open reduction.
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Figure 3 Lateral radiograph of the bony mallet injury of Figure 2 treated with a mallet splint, this radiograph confirms a satisfactory reduction with a fully extended joint.
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a and b. This variation of an FDP avulsion had a multi-fragmentary articular element and a fracture across the metaphyseo-diaphyseal junction. The tendon was reattached with a suture anchor, which could be inserted into the medulla by hyper-extending at the fracture site; the joint element was secured with a screw. Figure 4
loading mechanisms of injury may produce unicondylar or bicondylar fractures of the head or intra-articular fractures of the base. Base fractures may be subdivided into dorsal base, volar base or the more comminuted complete articular fractures that are often known as ‘pilon’ fractures. The periosteal surfaces of the proximal and middle phalanges are intimately related to the flexor and extensor tendons. The tendons of flexor digitorum superficialis (FDS) and FDP join the fibres of the fibro-osseous tunnel to cover the entire palmar surface of each bone. Consequently displaced shaft fractures result in tendons being exposed to sharp bone edges, which can result in the formation of troublesome adhesions. As a result it is important to achieve tendon gliding across the fracture site during healing. Proximal phalangeal fractures will normally angulate with an apex volar deformity. The interossei flex the proximal fragment while the distal fragment is hyperextended by the central slip’s pull on the base of the middle phalanx. The deformity associated with middle phalangeal fractures is less predictable. The more proximal middle phalangeal fractures tend to angulate with an apex dorsal deformity, FDS flexes the distal fragment and the central slip extends the proximal fragment. The more distal fractures tend to angulate with an apex volar deformity with FDS flexing the proximal fragment. The extensor mechanism is reliant upon the dorsal length of the proximal phalanx; bony malunion and consequent phalangeal shortening can result in a loss of interphalangeal extension (fixed flexion deformity). Middle phalangeal shortening tends to
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produce PIP joint hyperextension due to the loss of distal joint extension and the characteristic swan neck deformity results. Management The majority of fractures can be managed non-operatively. Transverse shaft fractures will tend to be much more stable than oblique, spiral or comminuted fractures. The degree of displacement is related to the inherent stability of the fracture. Stable fractures can be managed with splintage and early protected motion. Excellent results can be achieved by immobilization of the affected digit in the ‘safe’ or ‘intrinsic plus position’ (metacarpophalangeal (MCP) joint flexion to 90 degrees with full extension of the interphalangeal joints) for 2e3 weeks, followed by buddy strapping until clinical union has been achieved. Extremely stable undisplaced fractures can be managed by buddy strapping from day 1 without a period of immobilization. It is important to check for the maintenance of the reduction, consequently all patients should be reviewed at 1 week for repeat radiographs. A commonly used treatment for fractures that are displaced and unstable after reduction is CRPP.11 Great care must be taken when using this method in the phalanges as a result of the broad extensor mechanism; in the proximal two thirds of the proximal phalanx it is almost impossible to avoid tethering the extensor mechanism. Kirschner wires (K-wires) can be inserted in a crossed or longitudinal manner via an antegrade or retrograde approach. Typically an extra-articular approach through the base is preferred for the middle phalanx, while proximal
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phalangeal fractures can be managed antegrade through a flexed MCP joint or retrograde through a flexed PIPJ. Post-operative management is tailored to the individual patient but the K-wires are generally protected with some form of external splintage, until the point at which the wires are removed and gentle mobilization can begin. Routinely K-wires are removed 4 weeks following their insertion. If the fracture cannot be adequately reduced by closed means then open reduction and internal fixation (ORIF) is the treatment of choice. Mal-rotation, significant shortening, angulation of more than 10 degrees and less than 50% bone apposition are unacceptable features. Severe open injuries and injuries with
bone loss invariably require ORIF. As a result of ORIF being associated with the most severe injuries and consequently poor prognostic factors, results are often felt to be sub-optimal.12 Options for ORIF include intra-osseus wiring, screw and plate fixation (Figure 5). While the surgical approach chosen should reflect the injury pattern and any open wounds, proximal third fractures of the proximal phalanx are often best approached with a mid line dorsal tendon splitting incision, mid and distal third fractures through one or two mid lateral incisions.13 ORIF must result in rigid fixation to allow early mobilization, a failure to achieve sufficiently secure fixation achieves the worst of both worlds and often a poor outcome.
a, b and c. Unstable proximal phalangeal fracture treated with ORIF via two mid lateral incisions. Figure 5
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Intra-articular fractures Splinting is only appropriate for minimally displaced fractures that are inherently stable. CRPP is an acceptable form of treatment as long as anatomic reduction of the articular surface can be achieved. More rigid fixation can be achieved with screws sometimes in combination with minicondylar plates, but inadequate bone stock may contraindicate ORIF.
collateral ligament (UCL) is a common injury, which is rarely accompanied by a full MP joint dislocation. Rupture of the UCL typically presents with pain and tenderness around the ulnar border of the MP joint. Stress testing in full extension and 30 degrees of flexion should be undertaken to reveal any instability. A Stener lesion is where the distally ruptured UCL is prevented from healing by the interposed adductor aponeurosis. Non-operative management is the mainstay of treatment for thumb MP joint injuries; typically this involves a minimum period of 4 weeks of thumb MP joint immobilization with either a cast or a splint. Only the complete UCL rupture with a Stener lesion requires operative intervention. In a recent prospective study of 24 patients a palpable tender mass on the ulnar side of the MP joint was used as the sole diagnostic criterion for the Stener lesion.17 In this study all patients with a Stener lesion were treated operatively with ligament repair, while all those without were managed non-operatively; outcomes in both groups were equivalent at 1 year. The presence of greater than 30 degrees valgus instability with stress testing in full extension is highly predictive of a Stener lesion.18
Volar base fractures of the middle phalanx Fractures at the base of the middle phalanx can be particularly unstable in direct relation to the percentage of the articular surface involved. When the volar fragment makes up greater than 40% of the articular surface it carries the majority of the collateral ligament and volar plate insertions, and as a result the dorsal fragment and remainder of the phalanx will sublux proximally and dorsally due to the pull of the central slip. Dynamic extension block splinting is an effective management strategy for these injuries provided the volar fragment involves less than 40% of the joint surface (Figure 6). Extension block pinning can be used for fractures involving greater than 40% of the articular surface provided the reduction occurs spontaneously with PIP joint flexion. Other techniques include a single compression screw (provided the fragment is large enough) and volar plate arthroplasty (felt by many to give unsatisfactory results); presently use of a hemihamate bone-graft is gaining popularity.14
Metacarpal fractures Anatomy and classification The metacarpals make up three arches of the hand: these are the two transverse arches that exist at the level of the CMC and MCP joints and the longditudinal arch, which is made up from their long convex dorsal surfaces. The metacarpals are bound together firmly by interosseus ligaments at their bases and by the deep transverse intermetacarpal ligaments distally. These strong ligamentous attachments help to maintain the transverse arches, but flattening may occur with multiple fractures or crush injuries. The distal carpal row forms the fixed transverse arch of the hand, which is the stable foundation upon which the remaining hand structure is constructed. The second and third CMC joints allow for the rigid attachment of the index and middle finger metacarpals, thus forming the fixed unit of the hand; the CMC joints of the ring and little fingers allow for more flexion and extension, important for grip power. Metacarpal fractures may be broken down into those of the head, neck, shaft and base. Shaft and neck fractures typically demonstrate apex dorsal angulation as a result of the deforming pull of the interossei. The normal neck to shaft angle of 15 degrees should be remembered when assessing these injuries radiographically. The term ‘pseudoclawing’ refers to the compensatory MCP hyperextension and PIPJ flexion that may occur in response to the apex dorsal angulation. The relative inflexibility of the index and middle finger CMC joints (where motion is negligible) compared to the ring and little finger CMC joints (motion is 15 and 25 degrees respectively) has important implications for deciding when to intervene surgically. The thumb CMC joint is the most mobile with around 50 degrees of flexion and extension, and 40 degrees of abduction and adduction.
Pilon fractures of the PIPJ The combination of complete articular surface involvement and metaphyseal compaction with bone loss is the most functionally devastating of the pilon fractures involving the PIPJ. Immobilization in flexion, ORIF, extension block splinting, dynamic force couple, skeletal traction and a silicone spacer have all been described in the management of these injuries. Although anatomic restoration of the joint surface should be one’s aim, this is seldom possible due to the amount of articular and metaphyseal comminution. The clinical outcomes following splint immobilization are generally unsatisfactory, while the outcomes following treatment with skeletal traction and ORIF are similar.15 The significant surgical complications associated with ORIF mean that skeletal traction is often the preferred treatment. While a distracting dynamic fixator can be fashioned using bent K-wires with or without rubber bands, several commercially-available modern devices are marketed to apply skeletal traction across the PIPJ while active ranges of motion exercises are begun. Avulsion fractures from the base of the proximal phalanges Marginal fractures of the base of the proximal phalanx involving the MP joint usually represent avulsion fractures of a collateral ligament. There is frequently a substantial palmar bony avulsion fragment. As the risk of non-union with non-operative treatment is high some authors advise early internal fixation with a lag screw using a dorsal approach.16 The advantages of this approach include early mobilization and a reduced risk of non-union.
Management The vast majority of metacarpal neck and shaft fractures may be treated non-operatively; intra-articular fractures of the head and base may also be managed non-operatively as long as the fracture is stable and minimally displaced. Metacarpal fractures with significant rotational deformity or shortening cannot be satisfactorily
Thumb MP joint ligament injuries The prime stabilizers of motion at the thumb MPJ are the radial and ulnar collateral ligaments. Complete rupture of the ulnar
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a and b. This PIP joint fracture-subluxation was unstable after reduction when extending beyond 40 degrees. An extension-blocking splint was fashioned preventing extension beyond 40 degrees, but allowing free flexion. The joint was monitored and, as it remained stable, the amount of extension prevented by the splint was reduced by 10 degrees each week from 3 1/2 weeks after injury, with close monitoring maintained. Figure 6
managed non-operatively. Splinting is directed towards neutralizing deforming forces and pain control while remembering the position of safe immobilization; the MCP joints are held in full flexion in combination with wrist dorsiflexion.19 The splint can be
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removed as soon as the patient is comfortably able to move the hand and this should not be later than 3 weeks following the injury. In fact the immediate mobilization of fifth metacarpal neck fractures yields excellent results in spite of high degrees of angulation.20
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Metacarpal head fractures Articular fractures of the metacarpal head are often as a result of direct trauma. Non-operative management is indicated for those which are minimally displaced and stable to active stress testing. Non-operative treatment consists of splint immobilization for 2e3 weeks followed by early protected motion. ORIF is indicated when there is significant loss of articular congruency or instability with active stress.21 Collateral ligament avulsion injuries are difficult to reduce and hold with closed methods, meaning that ORIF is often required. Fixation may be with K-wires, screws or interosseus wires. The metacarpal head is approached dorsally with a tendon splitting approach. Early rigid fixation is important in order to allow early mobilization and prevent extensor mechanism tethering. Screw fixation is possible if the fragment diameter is greater than three times the diameter of the screw hole; movement within a few days is important with this technique. Ideally the fixation devices should be clear of the joint surface (Figure 7). If the fracture configuration means that fixation implants would cross the articular cartilage, either well counter-sunk headed screws or
small headless compression bone screws should be used to ensure no metal is exposed within the joint. Fixation by K-wires results in a stable but non-rigid form of fixation, thus movement must wait until around the 2- week mark. Metacarpal neck fractures Rotational deformity must be corrected and the degree of acceptable angulation depends on the digit involved. Less than 15 degrees of angulation may be tolerated in the index and middle finger metacarpals due to the rigid CMCJs. The more mobile ring and little finger metacarpals can tolerate more angulation with 35 and 45 degrees accepted respectively.22 Treatment is symptomatic and mobilization is begun as early as possible; if needed, splint immobilization involves holding the MCP joints in 90 degrees of flexion with around 30 degrees of wrist extension, while the PIPJs are left free to allow immediate motion. Indications for surgical intervention include the inability to achieve or maintain a satisfactory reduction where one is required. Rotational malalignment is unacceptable,
a, b and c. Pre and post-operative radiographs of a distal metacarpal fracture treated with ORIF. Figure 7
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a and b. The use of an IM K wire to stabilize an angulated fifth metacarpal shaft fracture. Figure 8
while excessive angulation and marked palmar comminution are relative indications for surgery. Intra-medullary (IM) K-wire stabilization is the surgical treatment of choice for most single metacarpal fractures; the use of multiple diverging contoured wires will give rotational control23 e the so-called bouquet technique, although the authors prefer to use direct reductionabsolute stability techniques (ORIF) where the injury is rotationally unstable. Other techniques include the use of crossed K-wires and transfixion to adjacent intact metacarpals. Anatomic reduction is not essential for injuries where there is no mal-rotation and a relative stability fixation technique has been
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used. The indications for ORIF include multiple fractures, open injuries, irreducible fractures and injuries that are rotationally unstable. The techniques available for ORIF include K-wires in combination with tension bands and specifically designed hand plates with screws. Metacarpal shaft fractures Less angular deformity can be tolerated in metacarpal shaft fractures in comparison to metacarpal neck fractures due to the longer lever arm that will deliver the metacarpal head into the palm. Transverse, short oblique, oblique and spiral fractures fracture
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a, b and c. An open metacarpal fracture with significant bone loss treated with bridge plating without bone-grafting, radiographs at the 7 month follow up demonstrate bony union. Figure 9
patterns may be seen. Of note oblique and spiral types are particularly prone to acquiring rotational deformity as they shorten. Acceptable angulation is less than 10 degrees for the index and middle finger metacarpals, and less than 20e30 degrees in the ring and little finger metacarpals respectively; no rotational deformity is acceptable, while up to 5 mm of shortening can be tolerated. A moulded splint not including the MCP joints can be employed for shaft fractures proximal to the neck; the splint is discontinued after
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around 4 weeks. Indications for surgical intervention include the inability to achieve or maintain a satisfactory reduction, open fractures, multiple fractures and fractures with bone loss. Again a multitude of techniques have been described in the literature, with IM K-wires being increasingly popular (Figure 8). The biomechanical strength of K-wire fixation has been shown to be significantly inferior to plates and screws. The interfragmentary lag screw is extremely effective in resisting loading forces, but two or more
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should be used unless a neutralization plate is applied as well. Plates function most effectively as tension bands (applied on the dorsal surface); with the availability of locking plates, fractures with marked bone loss or segmental fragmentation can be successfully treated with bridge plating techniques without the need for bonegraft in many cases (Figure 9).
CRPP can involve direct pinning at the fracture site or the splintage of the fracture site by securing the metacarpal to the adjacent metacarpal both proximally and distally. It may be difficult to control rotation without ORIF. Interfragmentary lag screw fixation is the treatment of choice for spiral fractures, screw fixation alone is acceptable as long as the
a and b. A Bennett’s fracture treated with ORIF. Figure 10
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fracture length is at least three times the diameter of the metacarpal and at least two screws are used.24 Short oblique fractures can be treated with a lag screw in combination with a dorsal neutralization plate. The complications of ORIF are not infrequent but its great benefit is to allow early mobilization. Thumb metacarpal shaft fractures Thumb metacarpal fractures are common and account for around 25% of all metacarpal fractures. Most fractures are proximal in which the distal fragment is adducted and supinated; the injury may be partial articular, complete articular or epi-basal in nature. Reduction is therefore performed using longitudinal traction with pronation and abduction to correct the angulation, a well-moulded cast is then applied for 3e4 weeks. The thumb CMCJ’s mobility means that angulation is well tolerated and surgical fixation is often not required for nonarticular injuries. Intra-articular fractures of the thumb base The most common of this type is Bennett’s fracture-dislocation. Bennett’s fracture-dislocation is a partial articular injury, involving a volar ulnar portion of the articular surface that is held in place by the volar oblique ligament and the remaining metacarpal fragment, which is displaced dorsally and into supination by the pull of abductor pollicis longus (APL) (Figure 10a). A true lateral and hyperpronated AP view, also known as ‘Robert’s’ view, may be used to best visualize this injury. Due to the articular involvement and unstable nature of the injury, closed reduction and CRPP are indicated on most occasions. Reduction is achieved using longditudinal traction with a combination of extension, abduction and pronation with direct pressure onto the base of the metacarpal, following by percutaneous pinning of the shaft fragment to the trapezium or index finger metacarpal. CRPP is followed by immobilization with a short arm thumb spica cast for around 6 weeks. If attempted closed reduction results in greater than 2 mm of joint surface displacement then open reduction is indicated. Lag screws or pinning may be used depending on the surgeon’s preference (Figure 10b). Rolando’s fracture-dislocation is a complete articular injury and in addition to the palmar fragment found in Bennett’s fracture, it is characterized by a larger dorsal fragment with varying degrees of comminution. Treatment options include closed reduction and casting, soft dressing with early motion, skeletal traction and early motion, and ORIF. Some authors advocate the use of skeletal traction with early motion as the treatment of choice.25 Traction is applied from an obliquely applied metacarpal wire to an outrigger device, while active motion is begun immediately and maintained for 6 weeks. Other authors prefer pinning the thumb metacarpal to the index metacarpal in order to distract the comminuted metaphyseal zone as it is allowed to heal,6 or using an external fixator. ORIF has the advantage of allowing early motion, but runs the risk of devascularizing fracture fragments with an already precarious blood supply and may be technically difficult in the presence of significant comminution. As a result ORIF is best reserved for the irreducible fracture or those with minimal comminution16 (Figure 11).
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a and b. A Rolando’s fracture treated with ORIF. Figure 11
Carpo-metacarpal fracture-dislocations The little finger CMC joint is the most commonly affected. The concern is that with no treatment the persistent subluxation and incongruity leads to pain and reduced grip strength. Undisplaced injuries can be managed with cast immobilization and regular checks for the maintenance of reduction. Displacement necessitates operative treatment. To determine if the joint is dislocated, either a CT or use of the intra-medullary axis convergence technique (described by Shewring26) can be used (Figure 12a). CRPP is the treatment of choice providing closed reduction can be achieved. Manual reduction is followed by the placement of K-wires through the metacarpal shaft and into the carpal bones and the adjacent stable metacarpals (Figure 12b). Open reduction is indicated if closed reduction is not possible, and also in cases of excessive swelling, cases of delayed presentation and open
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injuries27; this may also be preferred if there is a single, large fragment off the dorsal lip of the carpus, reduction and stabilization of which would restore stability and allow early motion. Index finger CMC joint dislocations more commonly require open
reduction because of extensor carpi radialis brevis interposition. Open reduction is generally accompanied by K-wire fixation. Whether open or closed reduction is employed, cast immobilization follows and the wires are removed at 4e6 weeks.
a and b. a The intra-medullary axis covergance technique, note that the ring and little metacarpal lines do not meet the index and middle lines at a point in the distal radius suggesting joint dislocations. b demonstrates this injury treated with CRPP. Figure 12
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Conclusions
11 Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000; 8: 111e21. 12 Pun WK, Chow SP, So YC, et al. Unstable phalangeal fractures. Treatment by AO screw and plate fixation. J Hand Surg 1991; 16A: 113e7. 13 Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint: treatment with the force couple splint. Clin Orthop Relat Res 1987; 214: 101e12. 14 Williams RM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 2003 Sep; 28: 856e65. 15 Stern PJ, Roman RJ, Kiefhaber TR, et al. Pilon fractures of the proximal interphalangeal joint. J Hand Surg 1991; 16A: 844e50. 16 Scewring DJ, Thomas RH. Avulsion fractures from the base of the proximal phalanges of the fingers. J Hand Surg Eur Vol February 2003; 28: 10e4. 17 Abrahamsson S, et al. Diagnosis of displaced ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg Am May 1990; 15: 457e60. 18 Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop Relat Res; 1993 Jul: 165e71. 19 Burkhalter WE. Closed treatment of hand fractures. J Hand Surg 1989; 14A: 390e3. 20 Bansal R, Craigen MA. Fifth metacarpal neck fractures: is follow-up required? J Hand Surg Eur Vol 2007 Feb; 32: 69e73. Epub 2006 Nov 27. 21 McElfresh EC, Dobyns JH. Intraarticular metacarpal head fractures. J Hand Surg 1983; 8: 383e93. 22 Ashkenaze DM, Ruby LK. Metacarpal fractures and dislocations. Orthop Clin North Am 1992; 23: 19e33. 23 Foucher G, Chemorin C, Sibilly A. A new technic of osteosynthesis in fractures of the distal 3d of the 5th metacarpus. Nouv Presse Med 1976 Apr 24; 5: 1139e40. 24 Lee SG, Jupiter JB. Phalangeal and metacarpal fractures of the hand. Hand Clin 2000; 16: 323e32. 25 Breen TF, Gelberman RH, Jupiter JB. Intraarticular fractures of the basilar joint of the thumb. Hand Clin 1988; 4: 491e501. 26 Hodgson PD, Shewring DJ. The ‘Metacarpal Cascade Lines’; use in the diagnosis of dislocation of the Carpometacarpal joints. J Hand Surg Eur Vol June 2007; 32: 277e81. 27 Rawles Jr JG. Dislocations and fracture dislocations at the carpometacarpal joints of the fingers. Hand Clin 1988; 4: 103e12.
Fractures and dislocations of the hand are a complicated and diverse group of injuries. Despite this complexity and diversity they share a common theme in management. The hand is a delicate and sensitive organ that requires both flexibility and stability in order for optimal function. Therefore the individual surgeon must tailor treatment in order to achieve an optimal functional outcome for the patient. This may be with splinting for a stable injury, or with CRPP or ORIF for an unstable injury. A good general rule to remember is that the more aggressive the surgical intervention has been, the more aggressive the rehabilitation regime must be. A successful outcome also involves trying to avoid the potential complications such as nerve hypersensitivity and infection. Finally the management of the patient’s expectations are also important: it is crucial that the patient is aware that fractures and dislocations of the hand produce swelling, stiffness and pain that frequently take more than a year to overcome. A
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