The Management of Phalangeal and Metacarpal Fractures

Symposium on Trauma

The Management of Phalangeal and Metacarpal Fractures

Paul W. Brown, M.D. *

Some fractures of the phalanges and metacarpals of the hand represent relatively minor injuries whose mechanism of injury is simple, whose recognition is obvious, whose treatment is easy, and whose end results are quite satisfactory. There are others which cause great difficulty for both patient and physician. Hand fractures which are unrecognized or ignored by either patient or physician or those in which improper treatment has been given may result in hands whose total function is noticeably impaired and whose appearance is altered, and, as a result, patient dissatisfaction is extremely high. These exceptions are common enough to make it necessary for the physician who treats injured hands to be fully familiar with all types of hand fractures and to recognize those which respond well to simple treatment and those in which more elaborate measures are necessary. It is also important that the physician be able to inform his patient early in the course of treatment what the probable outcome will be to avoid disillusion and disappointment with the final result. Too often patient and physician may consider the injury a minor one because of the small size of the bone involved, but a poor result will not appear so minor to the patient and as the hand will be constantly before his eyes he will be ever aware of any deformity or functional impairment that is present. Expectations regarding the end result must be realistic, or seemingly minor complications will later assume major proportions in the patient's appraisal of the result.

GENERAL PRINCIPLES Mechanism of Injury Careful history taking brings rewards which make it worth the effort, particularly in cases where compensation claims or litigation are possibilities. Hands as busy, active tools are many times each day placed in pre"Professor of Orthopedic Surgery and Director of Division of Hand Surgery, University of Miami School of Medicine, Miami, Florida

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carious situations and are frequently abused, being used as hammers, . weapons, vises and shields, and protectors. They are also used to express rage and frustration, and the patient who in anger strikes a wall with his hand is often the recipient of a fractured metacarpal. In athletics, hands are stepped on, pummeled, and wrenched. Working in and about industrial or farm machinery, hands are often placed in situations where they may be crushed or mangled. In both love and war, hands may be fractured. In the former, fingers may be wrenched or wenched with ensuing fractures and dislocations, and in war the types and variations of hand fractures are limitless. An accurate history may be impossible to obtain if the fracture was incurred under embarrassing or guilty circumstances. Deliberate falsification of the mechanism of injury by the patient may occur: he may claim an on-the-job injury to the hand when, in truth, the hand was injured several days before while he was working on his car. Most patients presenting with a "boxer's fracture" of the fifth metacarpal claim it was. caused by a fall, whereas most of these fractures are incurred by striking someone or something with a clenched fist.

Recognition Most phalangeal and many metacarpal fractures are obvious enough. Those whose external signs are more obscure often cause the patient to seek treatment days or weeks after the time of injury and this delay in treatment may cause future functional trouble quite out of proportion to the initial pathology. Where history taking is not possible, as in drunken and unconscious patients, or in those patients whose other injuries demand more immediate attention, fractures of the hand frequently escape notice for periods long enough to complicate both treatment and result. Often the patient who has suffered head or thoracoabdominal injury, or the patient with obvious fractures of the larger bones, is discovered some weeks later to have less apparent fractures of dislocations of the phalanges and metacarpals. Ironically, it is these relatively minor injuries which may be the cause of disability continuing for long after the residuals of the major injuries have disappeared. Reduction The dynamics and balance of the tendons and intrinsic muscles of the hands are such that phalangeal and metacarpal fractures are often displaced or angulated. When bony stability is lost, certain muscles and muscle tendon units tend to overpull their antagonists and cause overriding or bowing at the fracture site (Fig. 1). To reduce these requires that one temporarily overpower these deforming forces and this is most commonly accomplished by manipulation of the fracture by the physician. Fractures which are reducible by manipulation respond best to the first manipulation; if that fails, the chances of success from 'second and subsequent manipulations fall off rapidly. Manual traction may be useful during the actual manipulation, but sustained traction on fingers may be disastrous, and though illustrated in many texts and handbooks, its use is very limited and is potentially dangerous. Sustained traction on the

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METACARPAL FRACTURE: Dorsal Angulation Figure 1.

Angulation due to muscle overpull.

fingers may lead to complications worse than those that would be incurred if the fracture were never treated. Open reduction should be freely resorted to if the fracture cannot be reduced by manipulation and if the fracture deformity is unacceptable. When closed reduction has failed, the frustrated surgeon and the unsympathetic patient are then faced with an operative procedure and there is often a natural tendency to cut corners to make up for lost time, to save expense and to save face. This line of reasoning results in the open reduction being done in the emergency room with inadequate anesthesia, lack of tourniquet, lack of proper instruments and a host of other disadvantages. An open reduction of the fracture of the hand, though it mayor may not be simple to do, is still a major surgical procedure and requires a proper operating room set-up. Patients will frequently resist the move to the operating room, particularly if the procedure can't be done until the following day or two, but few will persist in their objection if given an explanation of the facts. Time is an important factor in the reduction of hand fractures. It is . accurate to say that the sooner it is done after injury, the easier it will be, but only if it can then be properly done. It will certainly be easier to do by either closed or operative means if reduction is done within a few days of the time of injury. Beyond the first week the task becomes increasingly difficult and after the second week it may even be impossible to accurately reduce some hand fractures without doing irreversible damage to the hand. Prolonged deformities tend to congeal, muscles and tendons tighten, and fractures start to heal in a position of malalignment after 2 weeks. Nevertheless, the surgeon may be confronted with hand fractures several weeks or months old, fractures which have been ignored by the patient or poorly handled elsewhere. The dilemma then is whether or not to accept the deformity or to decide if the malunion can be satisfactorily corrected without detriment to the rest of the hand. Some fractures of the hand, though impressive on x-ray, interfere little with hand function even if left to heal in an unreduced position. Such fractures tend to settle into a stable position and heal thus without compromised balance or function of the hand. This type of fracture, described in the following text, usually requires only splinting support for 2 or 3 weeks, after which active motion of the injured digit and hand can

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be resumed. Some, particularly interarticular fractures which are inoperable, should be treated with active motion from the time of recognition. Passive exercise, i.e., outside force, has little place in the early treatment of hand fractures though it may be necessary to use dynamic splinting or gentle active assistance exercises for late residuals manifested by joint contractures. Active assistive exercise, which is really a judicious compromise between active and passive force, may be helpful in getting the timid or reluctant patient to start on truly active exercise.

Anesthesia Anesthesia is an absolute necessity for satisfactory reduction of fractures of the hand. It may be administered at the fracture site by injection of 1 or 2 ml. of 1 per cent Xylocaine into the fracture site. Injection of the common digital nerves just proximal to the web space is a simple method for anesthetizing a finger with phalangeal fractures. Local block anesthesia is easily and safely administered by injection of 2 to 5 ml. of Xylocaine around any of the three major nerves of the hand. The median can be blocked on the volar aspect of the wrist and is usually found just to the ulnar side of the flexor carpi radialis. The ulnar nerve can be blocked in the ulnar groove at the elbow and the radial nerve blocked by subcutaneous infiltration of Xylocaine around the radial side of the wrist. In seeking the nerve with the needle, one should try to obtain paresthesias in the nerve distribution but avoid injection of the anesthetic directly into the nerve .

.Retention of Reduction Fractures of the phalanges and metacarpals can be maintained in reduction in three ways. First, the inherent stability of some fractures makes them stable enough that they need not be supported or protected, or one may use external immobilization in the form of splints, braces, or plaster casts. The third method is to use internal stabilization in the form of Kirschner wires. The goal in stabilization of a fracture is to hold it in reduction long enough to allow early union to occur and yet to allow the remainder of the hand to function as normally as possible. Early union is that time in fracture healing when the fracture fragments are stuck together enough so that displacement will not occur with conservative . use of the hand, i.e., when the hand can be safely used for routine, daily activities without extraordinary precaution or support. This point in healing occurs long before x-rays show evidence of healing and though there is no exact.way in which this time can be accurately determined, we have several criteria which are useful in this regard. The patient's opinion as to when it is safe to use the hand is usually fairly accurate and should be considered. The absence of tenderness or other symptoms at the fracture site also has some significance. Stability of the fracture site with gentle manipulation is helpful. X-rays which show early callus and no disp.lacement of the fragments are reassuring but in most cases active motion of the injured part should have been started before these relatively late signs are apparent. Last and most useful is our past experience with similar frC!;ctures-e"xperience which tells us that similar fractures when supported are sticky ~nd stable after a

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certain number of days or weeks. Putting all these criteria together gives no exact answer but should give an accurate approximation of when to proceed to the final step in the treatment of fractures. Restoration of Function Experience gives one a "feel" for the proper time to mobilize the healing part and many unpredictable factors must be considered-fracture healing and stability, patient reliability, vocational requirements, motivation for recovery, and effects of pending litigation. It is the physician's ultimate responsibility to see the injured part through to the point where as near normal function as possible is recovered. The end result is not the healing of the fracture but the function of the hand, and the patient's understanding and acceptance of any malfunction or disability resulting from the fracture. The physician must treat the hand and the patient and not act solely as a bone setter. Restoration of motion of stiffened joints may be a long and discouraging process for the 'patient and if the physician discharges the patient during the rehabilitative process or manifests disinterest, such an attitude will foster resentment on the patient's part. In such an environment, many patients tend to magnify disabilities and symptoms and it is in this milieu that most malpractice charges arise. The patient generally expects that there will be no deformity or disability resulting from hand fractures and yet it may be necessary to accept some in favor of treating the entire hand properly. Comfort, appearance and function are all involved and some compromise with any of these may be necessary for the best possible overall result. The patient must understand this from the beginning and it is during the rehabilitative period that these points must be frequently reemphasized. If the patient is convinced that the physician is working with him toward the goal of the best possible result, he will usually cooperate with instructions and be more inclined to accept with satisfaction the end result, whatever it may be. Again, it must be emphasized that active motion of the stiffened or reluctant hand is the usual course to pursue. Squeezing a tennis ball repeatedly is dull work and it is far more productive to instruct the patient to, return the hand to useful work such as washing dishes, housework, gardening, and similar tasks. This is occupational therapy in its best sense. Basket-weaving and similar pursuits have little place in rehabilitating most fractures of the hand. The proper role of the occupational therapist is to instruct and guide the patient in the use of his hand in the .activities of daily living, and usually the physician can fulfill this role without recourse to other specialized services.

OPEN FRACTURES OF THE HAND The fate of the open wound ofteI). determines the fate of the fracture uI1derlying it and the management of open fractures of the hand must begin with proper management of the wound. There has been a lot of nonsense dissipated about the necessity - even the obligation! - to close such wounds promptly. It is argued that primary closure or coverage will

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discourage the development of infection and will hasten healing of the fracture. While it is true that healing by primary intention is preferable when it can be safely attained, it is also true that if a wound is closed prematurely and then breaks down, the resulting situation is far more detrimental to the hand and any fractures it may contain, than if the wound had been more safely closed at a later date. Whether or not a wound overlying a fracture should be closed depends on the nature and circumstances of the injury, the degree of contamination, the amount of tissue damage, the time elapsed between injury and treatment, and the effectiveness with which debridement can be done. Closure should not be done solely because there is an associated fracture. Quite the contrary - if there is a fracture underlying the wound, this would be reason enough to defer closure. The basic principles of management of a wound in the hand are no different from wounds elsewhere in the body. Proper debridement by surgical removal of foreign material and devitalized tissue, followed by effective and copious lavage or irrigation must be the first step. If all factors are favorable, the wound can be closed but only if this can be done without tension. If it cannot be closed without tension, then closure must be deferred or coverage with a skin graft, pedicle flap, or local rotation flap must be done. Where a skin graft or flap coverage is required, it is usually safer to do so later when there is no obvious need for redebridement or any danger of wound breakdown. Delayed primary closure, i.e., from 2 to 7 days after injury, allows one to reinspect the wound with an eye to re-debridement if necessary, and such delayed closure will give just as satisfactory healing as primary closure and is much safer for wounds present over a fracture. Closure delayed beyond the first week, i.e., secondary closure, is advisable if contamination of tissues deep in the hand has been great or if re-debridement has not been as thorough as one would have wished. Experiences with war wounds of the hand have demonstrated conclusively that the more severe the injury, the more important it is to defer closure until it is obvious that the hand will safely accept closure or coverage. In Vietnam it has been shown in thousands of severe hand injuries, most of which have had one or more fractures, that the policy of delayed closure resulted in far fewer wound breakdowns, infection, loss of skin or other tissue, osteomyelitis, and non-union of fractures. There was less edema in hands so treated and the total time required to get suc'h hands in shape for future reconstructive procedures was less than in hands whose wounds were closed primarily. The presence of a wound in conjunction with a fracture does not mean that treatment of the fracture should be deferred. Manipulation and reduction of the fracture should be promptly accomplished and the reduction retained by appropriate splinting. Internal fixation with Kirschner wires is not only feasible but may be mandatory for grossly unstable or extensive fractures (Fig. 2). Open reduction and internal fixation in open fractures is a safe and recommended practice only if the wound is closed at a later time, and it is also important that proper dressings and free drainage of the wound be maintained. Primary internal fixation, followed by primary closure often ends in disaster.

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Figure 2. A, All metacarpals shattered by high velocity missile. B, Skeletal stability reconstituted by primary internal fixation.

It can be said then that some wounds overlying fractures may be safely closed on the day of injury, but for the majority a later time for closure is the much safer course. The only cost of deferring closure is some inconvenience to the patient and to the surgeon, whereas if the closure has been premature and the wound breaks down, the cost to both is very great. A simple doctrine would be: "If in doubt, don't close."

FRACTURES OF THE BASES OF MET ACARP ALS 2 TO 5 Fractures of the bases of metacarpals 2 to 5 are usually the result of direct trauma and are frequently combined with dorsal displacement of the metacarpus on the carpus. Metacarpals 4 and 5 are more commonly involved than meta.carpals 2 and 3 as the latter form the stable, central portion of the hand, whereas the ring and small finger metacarpals are relatively mobile and move more freely on the carpus. Fractures of the bases of any cif these metacarpalS generally show little displacement and tend to settle into a stable position requiring no reduction and no immobilization. Because they are stable and because they result in no disruption of the arches of the hand or of the function of the hand, immediate, active motion is the only treatment required. The initial discomfort and .s~elling disappear after a week or two and by this time the patient has returned the hand to normal function with no residual disability. This is not the case where there is dorsal displacement of the metacarpal bases on the carpus. This injury is a frequent concomitant to more·obvious and more severe injuries incurred in automobile accidents and often they are not'detected for some weeks after the other injuries are urider control. Often fractures of the bases of the metacarpals are as-

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Figure 3. A, Fracture dislocation of base of metacarpals 3, 4 and 5. B, Reduction by manipulation and retention of reduction with Kirschner wires. C, Normal function attained 4 months later. The fractures of the bases of the metacarpals were of no significance.

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sociated with this dislocation. They are difficult, if not impossible, to reduce after the second week and permanent disability may thus result. The dorsally displaced metacarpal bases produce an unsightly and sometimes painfullu:r;np or boss on the dorsum of the hand, and there is also a reciprocal shortening of the metacarpus and a volar depression of the shaft and head of the metacarpal which distorts the normal longitudinal arch of the hand and leads to hyperextension of the metacarpophalangeal joints of the involved fingers as well as some imbalance and weakening of the interossei. The dorsal displacement of the metacarpal bases may not be obvious if there is much dorsal swelling of the hand. The deformity is not evident on an- anteroposterior x-ray but is quite apparent on the lateral view. Reduction is easily accomplished by manual pressure on the displace-

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Figure 4. Kirschner wire fixation. A, Power drill: one handed operation, less wobble and better control. B, Hand operated drill: less accurate and less precise.

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ment but the deformity promptly recurs when this pressure is released. It is impossible to maintain this reduction force with plaster and further. more it is dangerous to attempt it as continued pressure by plaster is an invitation to skin necrosis. The proper method of retaining reduction is to transfix the bases of the displaced metacarpals with Kirschner wires which are then directed into the carpus and clipped off just below the skin (Fig. 3). This subcutaneous location of the ends of the wires makes removal under local anesthesia an easy matter a few weeks later. With "this type of percutaneous fixation, external splinting is unnecessary and active use of the hand can be resumed immediately. In placing the Kirschner wires, it is best to avoid piercing the extensor tendons of the fingers though dorsal swelling may obscure their location. If the skin is entered on the ulnar border of the hand, the wires can transfix the base of both metacarpals and the tendons are generally avoided. The displacement and the fractures are stable after 4 weeks, at which time the wires can be removed. The use of a drill powered by electricity or gas simplifies placement of the Kirschner wires and with such equipment the reduction can be maintained with one hand while the other hand operates the drill. With such equipment there is less tendency for lateral wobble of the Kirschner wire and the wire will have less play in the bone and will give better fixac tion (Fig. 4).

SHAFT FRACTURES OF MET ACARP ALS 2 TO 5 Transverse Transverse fractures of the shaft are occasionally stable, nondisplaced, and nonangulated and are treated quite simply in a short arm plaster cast for about 4 weeks. If the cast is unpadded and molded to. conform to the transverse metacarpal arch, there is usually no need to immobilize the finger of the same metacarpal and active motion of all fingers may be allowed (Figs. 5 and 6). Occasionally some angulation may occur during the first week and it is wise to x-ray the hand again at the end of this week. If angulation is apparent, it is easily corrected by manipulation after an injection of 1 to 2 ml. of Xylocaine into the fracture site, after which the same type of cast is applied, but this time with a volar aluminum splint for the associated finger or fingers. Transverse fractures which present with initial angulation often tend to promptly resume their angulation after reduction. In these it is usually simpler to open the fracture through a short, dorsal, longitudinal incision and transfix the fracture with two nonparallel or criss-crossed Kirschner wires, which then eliminates the necessity of external immobilization (Fig. 7). In placing nonparallel Kirschner wires, the bone fragments must be held firmly in contact with one another as they tend to be pushed apart as the second wire crosses the fracture site. If a power drill is not available and the wires must be inserted with a hand drill, it is generally better to use only one wire placed in as longitudinal a direction as possible, preferably avoiding entry through the joint. The wires should either be left protruding approximately 3 mm. from the skin or buried

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Figure 5. Metacarpal cast: short arm plaster, non-padded and closely moulded to maintain transverse metacarpal arch.

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Figure 6. A, Transverse midshaft fracture of third metacarpal. Fracture easily reduced by manipulation under local anesthesia. Metacarpal cast for 4 weeks. B, Fracture healed in excellent position at 6 weeks.

OBLIQUE

TRANSVERSE

COMMINUTED

METACARPAL SHAFT FRACTURES Figure 7.

Kirschner wire fixation of metacarpal shaft fractures.

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Figure 8. A, Crush injury with fractures of second and third metacarpals and proximal phalanx of thumb. B, Primary internal fixation of third metacarpal and proximal phalanx of thumb. Index finger damaged beyond salvage and therefore removed.

under the skin deep enough to prevent irritation and breakdown of the overlying skin. Care should be taken to place the wires so that they do not transfix or irritate the extensor tendons (Fig. 8).

Oblique Oblique fractures of the shaft tend to both shorten and to angulate. Manipulativ~ reduction is often not possible and if the shortening or angulation is minimal, it is permIssible to accept some small deformity (Fig. 9). Where shortening is more than 3 or 4 mm., it is a wiser course to open these fractures and to stabilize them with two nonparallel Kirschner wires and this is usually a simple matter when done in the first few days. It may be quite' difficult or even impossible to reduce these fractures after the first week without considerable stripping of the periosteum and origin of muscles. Comminuted Comminuted fractures of the shaft are usually quite unstable and if there is more than a small amount of displacement, shortening or angulation, open reduction and internal fixation is indicated. With severe comminution it may be necessary to utilize an intramedullary Kirschner wire. Such a wire should be introduced into the metacarpal head on either side of the extensor digitorum communis and at the origin of the collaterallig-

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Figure 9. Oblique non-displaced fracture of second metacarpal without rotational deformity. Treated simply and successfully by immobilization for 3 weeks in a short arm metacarpal cast.

ament, and should be driven across the fracture and into the base of the metacarpal. It is not advisable to drive the wire out the dorsum of the hand or wrist as it may cause difficulty with the extensor tendons and will also cause considerable pain and limitation of finger and wrist motion while it is in place. If the distal portion of the wire at the metacarpophalangealjoint is allowed to protrude through the skin, it may be easily removed in 3 weeks, at which time the fracture is generally stable. Often an intramedullary wire is not sufficient to maintain reduction and, therefore, another oblique or transverse wire will be required. As with all metacarpal fractures, it is not enough to correct angulation, overriding, or shortening, but it is also necessary to correct and control any rotational deformity. As this may not be readily apparent, one should examine the entire hand, looking at the fingers extended and flexed from the dorsal view, and also at the fingers from an end-on view. Comminuted Fractures with Bone Loss Gunshot, high explosive, and some types of mangling, industrial injuries to the hand may result in loss of portions of the metacarpal shaft or of several shafts. Such injuries are always accompanied by extensive soft tissue injury and frequently with loss of skin, muscle, tendon, or nerve. There is always a large degree of contamination in these injuries and foreign material and debris are blown or ground into the tissues around the wound and often into tissues a surprising distance from the wound.

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The initial problem is one of adequate debridement with the challenge of removing all that is harmful or devitalized and preserving all that is potentially useful. Next comes the problem of restoring and maintaining skeletal alignment and stability to the hand, for if the deformed and distorted hand is allowed to heal in an uncorrected position, function will be badly impaired. It is imperative to realign and stabilize the hand very promptly. If metacarpal shortening is accepted for as short a time as 1 week, it may not then be possible to regain length and alignment. If a portion of the metacarpal is missing, there is an inexorable tendency for the

Figure 10. Metacarpal bone loss. Use of Kirschner wires to retain length until bone grafting can be done.

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Figure 11. A, Multiple metacarpal fractures from high velocity missile. B, Primary internal fixation. Extensive wounds left open. Note Kirschner wire "spacer" used to maintain gap in fifth metacarpal.

~ length of the ray to shorten, which in turn will throw the rest of the ha'nd out 'Of balance. Ultimately, the bone loss will have to be made up by bone grafting, but as this is not feasible until a healed wound has been obtained, it is necessary to find some other way to prevent shortening. Skeletal traction on the involved finger is sometimes successfully used but is generally a failure and is also dangerous as it may cause harm to tendons and joints and result in a stiff finger. Cross-pinning the proximal and distal metacarpal fragments to an intact, adjacent metacarpal is also occaSionally successful but placement of the pins accurately may be quite difficult (Fig. 10). Simpler, safer, and more effective is the application of "Kirschner wire spacers" which are simply Kirschner wires bent in variou's bayonet and angular forms and inserted while flexed into the two major metacarpal fragments. Upon release the wire tends to straighten exerting a longitudinal traction force which gives good immobilization and maintains a corrected position. When the wound is healed and the hand mobilized, the stage is set for reconstruction of the hand and the spacer wire can be easily removed and replaced by a bone graft (Fig. 11). It must be emphasized that the time to maintain the length of the metacarpals and to apply the proper internal splinting is at the time of initial debridement. To procrastinate is to forever lose the opportunity. Once shortening has occurred it is seldom reversible.

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METACARPAL NECK FRACTURES Fractures of the metacarpal neck constitute the most common metacarpal fracture and are generally incurred by striking an unyielding object with a clenched fist. Most commonly fractured are the necks of metacarpals 4 and 5, and though these are called "boxer's fractures," a trained boxer will more often incur a fracture of the necks of metacarpals 2 and 3, inasmuch as his blow will more often be a direc.t thrust with the more stable 2nd and 3rd metacarpals acting as a direct extension of the forearm, brachium, and shoulder girdle. Metacarpal neck fractures show varying degrees of angulation with the head depressed volarward into the palm. The angulation generally varies between 30 and 60 degrees and often there is considerable impaction, which makes manipulative reduction difficult or impossible. Reduction should be accomplished by pushing upward on the acutely flexed proximal phalanx or by pulling on the finger and attempting to push the metacarpal end dorsally, but if one or two good attempts. do not succeed, there is no point in persisting as the only result will be further trauma to the joint and surrounding tissue. Open reduction will then be necessary followed by cross-pinning with Kirschner wires. If manipulation does

Figure 12. Metacarpal neck fractures. A, Fracture is impacted and irreducible by manip· ulation. If treated" with early motion, function will be excellent. B, Proximal neck fracture. If left to heal in this position, function will be good but there will be some residual hyperextension at the metacarpophalangeal jOint. Better to reduce and pin with Kirschner wire.

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succeed, the fracture can be satisfactorily immobilized by use of a short arm cast with an aluminum extension splint holding the finger in mild flexion. Do not immobilize with a finger acutely flexed as is so often illustrated. Joint stiffness, skin sloughs, and boutonniere. deformity may result (Fig. 12). If the fracture is irreducible by dosed means or if the fracture is more than a few days old, it is often a better course to accept the deformity in the case of metacarpals 4 or 5. Even with an angulation of 60 degrees and depression of the metacarpal head into the palm, there is enough"mobility of these two ulnarward metacarpals to accommodate for the palmar protuberance in most functions of the hand. There is not much impairment in function except for some tenderness on tightly gripping hard objects and there will be some visible depression of the knuckle and a slight claw deformity. Such deformity is not acceptable for metacarpals 2 and 3, as fixed depression of their heads will result in a painful grasp and open reduction should be done for these metacarpals if closed reduction is not successfuL

METACARPAL HEAD FRACTURES Fractures of the heads of the metacarpals are interarticular and generallyare either extensions of shaft and neck fractures or may be entirely distal to the collateral ligaments of the metacarpophalangeal joint, in

Figure 13. Metacarpal head fracture. Reduction is difficult but should be attempted. Instability requires internal fixation.

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which case they are usually comminuted. Such fractures have a poor prognosis as there is often no satisfactory way to reduce or maintain them. They should be molded together as well as possible, splinted for only P/2 or 2 weeks and then started on active motion. If there are only • t~o or three fragments, open reduction and Kirschner wire fixation may be feasible. The patient .should be warned of the likelihood of a stiff or painful joint and subsequent arthritic changes (Fig. 13).

FRACTURES OF THE THUMB MET ACARP AL The first metacarpal moves through a wide arc, stands apart from the other four and acts independently of them. Thus, it can tolerate greater deformity or distortion without significant impairment of function. Due recognition must be given to the greater importance of the thumb ray, but despite this, the wide range of motion possible at the trapeziometacarpal joint compensates for angulation deformities of up to 20° and rotational deformities of up to 10 without greatly hindering prehension, whereas the same deformity in any of the other metacarpals would be reflected in loss of balance in the hand, malrotation of a finger, or weakness in grasp. Fractures of the shaft of the first metacarpal are more commonly transverse and tend to angulate dorsally with the distal fragment flexing toward the palm. Such fractures are usually easily reduced by manipulation and adequately immobilized in a plaster thumb spica (Fig. 14). If the fracture is very unstable, percutaneous pinning with two or three Kirschner wires is advisable. Fractures through the proximal shaft are frequently comminuted and often impacted and quite stable (Fig. 15). -If-stability can be demonstrated, it is better to treat such fractures with immediate mobilization, instructing the patient to move the thumb through as wide an arc as is comfortable but avoiding any strenuous use of the hand for the first 3 or 4 weeks (Fig. 16). These fractures, especially when comminuted, often extend into the trapeziometacarpal joint and in some cases considerable distortion of the articular base of the metacarpal is present. These, too, are best treated with early motion and avoidance of splinting. Though 0

Figure 14. Plaster thumb spica. Wrist is in 30 0 of extension and thumb is in neutral: midway between abduction and adduction and midway between flexion and extension. Plaster extends to tip of thumb.-

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* Figure 15. Fracture through proximal shaft of first metacarpal. This is a stable fracture without significant displacement and was treated successfully with a thumb spica for 4 weeks. Normal appearance and function resulted.

painful at first, the patient rapidly regains nearly full range of motion and though there may be permanent distortion of the trapeziometacarpal joint, seldom do degenerative or painful changes occur in this joint. Immobilization of such intra-articular fractures for the 4 to 6 weeks usually prescribed for them, often results in painful stiffness of the joint and this may persist for a prolonged period or permanently. In many such fractures treated by immediate mobilization, I have not seen any increase in deformity or significant loss of the arc of rotation of the thumb, though there has occasionally been a slight limitation of full extension of the metacarpal on the carpus (Fig. 17).

Bennett's Fracture This is a specific type of fracture through the base of the metacarpal in which the ulnarward "hook" of the base of the metacarpal is left in place and the remainder of the first metacarpal is displaced radially, dorsally, and proximally, resulting in considerable disruption of the trapeziometacarpal joint. It is really a fracture dislocation of the base of the thumb metacarpal (Fig. 18). The fracture is usually incurred by forcible extension and/or abduction of the thumb. If recognized early it can generally be reduced by manual traction on the thumb and this. reduction can be retained by percutaneous pinning with a Kirschner wire introduced through the radial aspect of the mid portion of the shaft an!! drilled across the trapeziometacarpal joint. Transfixion of both fragments is ideal but often the ulnar fragment is too small a target to hit with a wire, in which

THE MANAGEMENT OF PHALANGEAL AND METACARPAL FRACTURES

1413

case the wire can simply be drilled through the major distal fragment and into the carpus (Fig. 19). If reduction by manual traction and manipulation is not possible, the ... fracture should be opened and reduced under direct visualization. Inter- . nal fixation is accomplished by Kirschner wires and it is usually possible to get at least one Kirschner wire through both fragments. The simplest approach is a volar curved incision starting over the mid portion of the metacarpal shaft and curving proximally and transversely over the base of the metacarpal. Following reduction and pinning of the fracture by open or closed means, the plaster thumb spica is worn for about 4 weeks, after which the Kirschner wires are removed and the thumb mobilized. Various forms of sustained traction have been prescribed for the treatment of Bennett's fractures, with traction applied by means of a skeletal pin through the proximal phalanx and the force maintained with a rubber band affixed to an outrigger attached to a plaster cast. This usually will not reduce the fracture well nor retain reduction satisfactorily. It also distracts the metacarpophalangeal joint of the thumb and may lead to problems with that joint. This is a less satisfactory and more uncomfortable method of management than transfixing the fracture percutaneously or by open reduction. Intra-articular fractures involving the base of the metacarpal take many forms of which the Bennett's fracture is only one. There may be only a single fracture line with little or no displacement, or the fracture

Figure 16. Noncomminuted fracture through base of thumb metacarpal. Treatment with immediate active motion resulted in normal function.

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Figure 17. A, Stable, comminuted, displaced fracture of base of thumb metacarpal treated with immediate motion. B, Normal function demonstrated at 4 weeks. Arthritic changes will occur in the trapeziometacarpal joint but they will not necessarily cause symptoms.

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1415

* Figure 18. Bennett's fracture.

r

."-

\

DISPLACEMENT. ) . LlGAMENf INTACT

K-WIRE

*

Figure 19. Bennett's fracture treated by A, manipulation (manual traction) and E, transfixion with one Kirschner wire.

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may be comminuted with considerable distortion of the metacarpal base or its articular surfaces. There may be separation of the fragments or impaction. If the base is grossly distorted and there are numerous fragments, anatomic reduction by either closed or open means is not feasible, but as such fractures are usually quite stable, treatment by early mobilization will give less disability than by immobilization. Often there is much pain and swelling in the region of the fracture at first and a patient may be more comfortable and cooperative if the thumb is immobilized in a spica or plaster splint for a week or so before active motion is started.

FRACTURES OF THE PROXIMAL PHALANX Base The most common fractures of the base of the proximal phalanx involve epiphyseal separation in children and this is also one of the most common types of fractures of the hands in children and adolescents. Most commonly involved is the small finger. There may be only a slight epiphyseal displacement or a metaphyseal fracture associated with the displacement, or in severe cases, the epiphysis as well as the metaphysis may be fractured. Manipulative reduction under adequate anesthesia usually succeeds in correcting both the angulatory and the rotational deformity (Fig. 20). Immobilization in a short arm plaster cast with an alu-

Figure 20. Epiphyseal fractures of the proximal phalanx. A, Displacement of this degree requires reduction. B, Displacement is acceptable but not the rotational deformity.

THE MANAGEMENT OF PHALANGEAL AND METACARPAL FRACTURES

*

1417

Figure 21. This short arm plaster cast incorporating a padded aluminum splint is suitable for many types of metacarpal and proximal phalangeal fractures .

minum splint for 2 or 3 weeks should be followed by resumption of normal activity (Fig. 21). It is wise to caution the parent that growth discrepancies or deformities may appear later and this is especially true if the epiphysis itself has been fractured. The metacarpophalangeal joint is fairly tolerant of joint incongruity and good function may be anticipated even if reduction of the articular surface is not perfect. An occasional epiphyseal fracture displacement will be unstable following reduction or reduction itself will not be possible by closed means. In such cases an open reduction and Kirschner wire fixation must be done if a deformed finger is to.be avoided. Transverse fractures of the base of the proximal phalanx whkh do not extend into the metacarpophalangeal joint tend to angulate with the distal fragment pulled dorsally; i.e., with the apex of the angulation pointing volarward. This position is caused by the intrinsics and extensor mechanism which overpull the flexors. When impacted, closed manipulation may not succeed in correcting the angulation and if the angulation is severe or has a lateral component, open reduction is necessary. Angulation of up to 20 may be accepted in the anteroposterior plane with little finger disability (Fig. 22). 0

Shaft Volar angulation of transverse shaft fractures of the proximal phalanx may be pronounced and require reduction if interference with both extensor and flexor mechanisms is to be avoided. When reduced they are. usuaI.lY stable enough that external splinting will hold them without recurrence of deformity, and with such splinting the most stable position is the position of function in which the wrist is held in extension and the finger in moderate flexion (Fig. 23). Oblique fractures of the shaft of the proximal phalanx seldom are angulated but there is usually a certain amount of shortening. If the shortening is in the neighborhood of 3 mm. or less it may be accepted, but

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Figure 22. Comminuted fracture of the base of the proximal phalanx. Position is acceptable. Treat with cast and splint for only 3 weeks 'and then start active exercise.

if greater than that, or if there is a rotational deformity as well, correction can usually only be attained by open reduction and Kirschner wire fixation (Fig. 24). The sooner this is done, the easier and less traumatic it will be. After a week the task becomes increasingly difficult and after the second week it may be impossible to reduce such fractures despite extensive surgical release of soft tissue attachments on the fragments (Fig. 25). Spiral fractures of the proximal phalanx usually have some rotational deformity which is often correctable by manipulation and they may then be held with percutaneous Kirschner wire pinning. Comminuted fractures of the shaft may demonstrate angulation, rotation, and shortening and with these unstable fractures, open reduction and Kirschner wire fixation is necessary for stabilization. The preferred surgical approach to the proximal phalanx is through a longitudinal mid-dorsal incision. The extensor mechanism is easily split down the midline, allowing each half to be retracted and giving excellent exposure of most of the phalanx. Care must be taken to preserve the extensor insertions on the dorsal base of both the proximal and middle phalanges. Kirschner wires can be introduced directly into the bone if the orientation of the fracture line permits and the wires may be clipped off flush with the bone and left permanently. It may be necessary to pierce the skin on the sides of the phalanx in order to place the wires properly, and where this is done the wires are

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1419

Figure 23. A and B. Typical deformity of transverse shaft fractures of the proximal phalanx. Requires reduction and pinning.

Figure 24. Stable oblique fracture of proximal phalanx. No significant shortening. Treat with cast and splint.

Figure 25. A, Unstable oblique fracture of proximal phalanx. Angulation and rotation not compatible with good function. B, Open reduction and pinning done at 3 weeks. Too late! Rotation was corrected but angulation was not. A poor: result.

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*

Figure 26. A and B, Intercondylar fracture of distal portion of proximal phalanx. Treated successfully by accurate reduction, Kirschner wire fixation, and immediate active motion.

left to protrude approximately 3 mm. and then can be removed when the fracture has attained early union. Most fractures through the distal end of the proximal phalanx are longitudinal or oblique and demonstrate displacement of one or both condyles. The displacement requires accurate reduction and Kirschner wire fixation to avoid angulation at the proximal interphalangeal joint (Fig. 26). This joint tolerates deformity poorly and small discrepancies in joint alignment may be followed by joint stiffness, pain, and later degenerative changes. The condylar fragment of these fractures may be quite small and reduction very difficult, particularly if reduction is not done within a few days of the injury. If stabilization with two Kirschner wires can be obtained, it is wise to start active motion of this joint within a week of injury. Conversely, if the fracture is so comminuted as to be irreducible, it is often wise to ignore the fracture and immediately mobilize the joint. In active and highly motivated patients, such fractures treated by immediate immobilization will retain satisfactory function despite considerable distortion and malalignment of the joint surfaces. Such function may be lost in the ensuing yea~s as degenerative changes progress, in which case arthroplasty or arthrodesis may be necessary (Fig. 27).

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Figure 27. A, A large caliber pistol bullet passed transversely through the proximal portion of the finger. B, Distal end of the proximal phalanx was shattered. Injury was treated by debridement and immediate motion. C and D, Good function shown here 6 months after injury. Wounds of entrance (dorsal) and exit (volar) were allowed to close by secondary intention. Ultimate fate of proximal interphalangeal jOint is unpredictable.

FRACTURES OF THE MIDDLE PHALANX Fractures of the shaft of the middle phalanx are. similar to those of the proximal phalanx and are treated in much the same manner. In the simpler ones, external splinting over an aluminum splint works well and generally the splint need not be incorporated into a short arm cast (Fig. 28). The less stable fractures of the middle phalanx require internal fixation with Kirschner wires, and if open reduction is necessary, the simplest approach is the midline dorsal longitudinal incision which allows easy retraction of the lateral bands of the extensor mechanism (Fig. 29). Here, too, care must be taken not to disturb the attachment of the central slip of the extensor digitorum communis on the dorsal tubercle on the base of the middle phalanx, lest a boutonniere deformity result. In pinning transverse, oblique, or spiral fractures of the proximal phalanx it is best to avoid transfixing either the distal or proximal interphalangeal joints, but in the more difficult or grossly comminuted fractures it may be necessary to do so. In such cases the wires crossing the joints should be removed after 2 or 3 weeks and by then the fracture will have enough stability so that an external splint will be adequate to re-

THE MANAGEMENT OF PHALANGEAL AND METACARPAL FRACTURES

Figure 28.

1423

Aluminum splint for fractures of middle phalanx.

tain the reduction (Fig. 30). The splint can be removed several times a day to allow the joint to be gently exercised, and then only by active exercise. A fracture dislocation of the proximal interphalangeal joint is a specific type of injury and a rather common one. The middle phalanx is displaced dorsally after avulsion of the volar plate of the capsule, often carrying with it a portion of its bony insertion in the middle phalanx. The size of the fragment may be so small as to appear as a fleck of bone on the

Figure 29. Oblique fracture of middle phalanx. Position compatible with fairly good function but result would be better with open reduction and Kirschner wire fixation.

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c Figure 30. A, Band C. Unstable oblique fracture of middle phalanx with angulation and rotational deformity. Poor functional and cosmetic result. Should have been opened and pinned.

lateral x-ray, or the fragment may constitute a significant portion of the articular surface of the base of the middle phalanx, often as much as a quarter or a third of the total surface. There may be some tearing of the collateral ligaments of the proximal interphalangeal joint, but usually the joint will be stable to lateral stress. The external appearance of the finger shows only mild deformity and reduction is deceptively simple. Even though the middle phalanx is easily pushed down into proper relationship with the proximal phalanx, the deformity occurs as soon as digital pres-

THE MANAGEMENT OF PHALANGEAL AND METACARPAL FRACTURES

1425

RUBBER . . BAND TRACTION SHORT ARM

( ,/

.

/1

"

! '

VERTICAL WIRE BANJO SPLINT ~ ~~ ~~ ~'~ ~~'-

/-,

f

/

/

,/ ,/

,/

,

-

Figure 31.

Robertson traction.

sure is released on the middle phalanx. In reducing the middle phalanx there is a "rubbery" feel of mild resistance and not the distinctive, satisfying feeling of a solid relocation of a joint. If the deformity is accepted, or one attempts to treat it with simple splinting, the dislocation will ,remain and within 2 weeks become irreducible, and the net result is a stiff, painful, and arthritic joint followed ultimately by fibrous ankylosis. There are orily two satisfactory methods of treatment of a fracture dislocation of the proximal interphalangeal joint. The first is Robertson skeletal traction, which is one of the few instances in which skeletal traction applied to a finger is acceptable. Traction forces are exerted in three different directions, through transverse Kirschner wires fastened by rubber bands to a vertical banjo splint incorporated in a short arm cast. One vector pulls the proximal phalanx dorsally, a second pulls the middle phalanx volarward, and a third applies longitudinal traction to the digit. Though successfully used by some, it is complicated to apply and difficult to maintain with the proper balance of the three-force vectors (Fig. 31).

A preferable method is open reduction of the proximal interphalangeal joint through a mid-lateral longitudinal incision which allows reduction of the dislocation and of the fracture, following which the small fragment is pinne~ to the middle phalanx and the joint is transfixed with a second Kirschner wire, which then acts as an internal splint to prevent recurrence of the dislocation (Fig. 32). These wires can be removed in 3 to 4 weeks and active motion should then be started. If the bony fragment to which the volar plate is attached is too small to transfix with a Kirschner wire, a wire pullout suture may be used, the suture passing dorsally through the phalanx and tying over a button on the dorsum of

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*

Figure 32. A, Fracture dislocation of proximal interphalangeal joint. B, Open reduction and Kirschner wire fixation. The Kirschner wire crossing the joint can be removed in 3 weeks and active motion started.

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the middle segment of the finger. The suture must not be tied too tightly on the button or gauze pad, lest it cause pressure necrosis of the underlying skin and extensor mechanism.

FRACTURES OF THE DISTAL PHALANX Tuft Fractures These fractures are usually incurred by smashing the finger tip with a heavy object or crushing it in a door. They are usually comminuted and accompanied by considerable bleeding into the distal finger pulp. The tough; fibrous septa of the finger pulp allow little room for distention and the growing hematoma develops increasing pressure which causes these injuries to be extremely painful. Immersion in ice water for a few minutes - not over 5 minutes - if done within an hour or two of the injury is a safe and effective way of controlling pain. If a subungual hematoma is apparent, release of the blood from under the fingernail by burning a hole in the nail with the end of a hot paper clip also gives considerable relief of pain. The fingernail should not be removed even if partially avulsed, as the nail acts as a good splint for the fracture. Often these fractures are extremely comminuted and there may be considerable distortion of the original shape of the tuft, but reduction is neither feasible nor necessary as such fractures heal uneventfully. If there is separation of the fragments, union may take up to a year and non-union of small fragments occasionally occurs. Fingers with this type of fracture are frequently tender for long periods after the injury but the pain is a residual of the crushing of the soft tissues and not due to small chips of bone which have not united. Surgical removal of such fragments will not relieve the fingertip sensitivity but only make matters worse. A volar aluminum gutter splint over the tip of the finger serves as a protector of the tender fingertip but is unnecessary for the fracture itself. Transverse Fractures of the Shaft of the Distal Phalanx U ndisplaced transverse fractures of the shaft of the distal phalanx heal quickly and simply when protected with an aluminum gutter splint taped to the middle and distal phalanges for 3 to 4 weeks. However, if they are comminuted or open or displaced, deformity and non-union may occur and internal fixation with Kirschner wires is advisable.

Avulsion Fractures of the Distal Phalanx Avulsion fractures of the extensor tendon insertion results in a mallet or baseball finger deformity with a loss of approximately 50° of active extension of the distal interphalangeal joint. These common injuries result from force applied against the tip of the extended finger and may involve an avulsion of only the tendon or the tendinous insertion may carry with it a fragment of bone varying in size from a tiny chip to a sizeable portion of the articular base of the distal phalanx. Most such injuries, with or without a fracture, can be successfully treated in the cooperative

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LARGE BONE FRAGMENT

.. DYNAMIC or STATIC SPLINT Figure 33.

WIRE PULLOUT SUTURE Mallet finger.

patient with a dynamic safety pin splint which holds the joint in slight hyperextension. Internal splinting with a Kirschner wire driven through the tip of the finger and across the fully extended joint will give' fairly good results, as will a static gutter or ski tip splint holding the joint in a few degrees of hyperextension, but these static methods of immobilization will not give quite as good active extension following healing of the injury as will the dynamic splint (Figs. 33 to 35). Opening the fracture and careful anatomic reduction of large fragments may be indicated in patients such as musicians for whom full return of active and distal interphalangeal joint motion is imperative. Fixation is then attained with Kirschner wire fixation or with a wire pullout suture.

* A Figure 34. A, Safety pin splint for mallet finger. B, Ski tip splint for mallet finger.

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*

Figure 35. A, Typical mallet finger. B, Avulsion fracture of base of di~tal phalanx. C, Good functional result obtained with safety pin splint.

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COMPLICATIONS OF HAND FRACTURES Malunion Fractures of either the phalanges or metacarpals may heal in such a distorted manner as to interfere significantly with hand function and appearance. Such malunions are easier to prevent than to correct and they may be manifested by persistent angulation, rotational deformity, shortening, extraneous bone formation, or by combinations of any of these. It has already been mentioned that the most important digit, the thumb, paradoxically can tolerate more residual deformity than any of the other digits, but even with the bones of the thumb, careful attention to detail in the reduction and fixation of fractures is necessary. Malrotation is most likely to occur with shaft fractures of the me. tacarpals and the proximal or middle phalanges. When they occur they are usually the result of a surgeon concentrating too much on the fracture site itself and failing to note the appearance of the injured digit in relationship to the remainder of the hand. Prior to reduction, during reduction, and after reduction, the entire hand should be examined from several views, the dorsal, volar, and end-on views. If the fracture has been stabilized enough to allow the fingers to be flexed, the hand should be examined with the injured finger flexed singly as well as with the other fingers, and the inspection should be done in the three different views. Malrotation of 5° or more should be apparent in at least one of these. The end-on view of the fingernails with all digits fully extended may often show rotational deformity not otherwise apparent. Each of the fingers, when flexed individually, should point toward the navicular tubercle at the base of the thenar eminence. Deviation from this results from either angulation or rotation at the fracture site (Fig. 36). Angulation may result from any fracture of the metacarpal or phalanx but is most likely to occur in the dorsal volar plane in the case of diaphyseal fractures and is most likely to be a lateral deviation in fractures involving the joints. An exception to this is the fracture dislocation of the carpometacarpal joint in which the bases of the metacarpals are displaced dorsally. Oblique fractures of the metacarpophalangeal and interphalangeal joints with proximal displacement of one condyle are particularly troublesome, and though easy to recognize, are often very difficult and sometimes impossible to correct. Shortening of fractured bone often results from fractures in which there is extensive comminution or actual bone loss. The bone loss may be caused by bone fragments being blown out of the hand at the time of injury or, more commonly, by overenthusiastic and iriexpert debridement. Though debridement of devitalized or badly compromised soft tissue is absolutely essential in open wounds, bone fragments must be preserved wherever possible. If a bony defect is present, immediate steps must be taken to preserve length of the' bone with spacer wires. Once shortening has occurred and has been allowed to persist for as short a period as a week, it is usually impossible to make up for the shortening. Scarring, muscle contracture and fibrosis, tightening of ligaments, and

THE MANAGEMENT OF PHALANGEAL AND METACARPAL FRACTURES

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Figure 36. A and B, Fracture of proximal phalanx of ring finger treated 2 years previously with splint. Fracture well united. X-ray picture and gross appearance are deceptively good. C, Rotational deformity is apparent on making a fist, with significant functional loss and poor cosmetic result.

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Figure 36. Continued. D. Deformity is apparent on end-on view of fingers. E, Deformity corrected by derotation osteotomy, Kirschner wire fixation, and immediate motion.

other forces all conspire to stubbornly retain the shortening. The amount of shortening which can be tolerated without detriment to hand balance and function varies from bone to bone. It is most serious in the central metacarpals 3 and 4 and shortening of either of these of as little as 5 mm. will give a poorly balanced hand with some impairment of strength and grasp (Fig. 37). Metacarpals 2 and 5 tolerate shortening more readily-and the thumb metacarpal has the greatest latitude. Shortening of the proximal or middle phalanges of the fingers may cause an imbalance of the extrinsic and intrinsic flexors and extensors with impaired range of motion and strength. Extraneous bone formation occurs from the healing of displaced comminuted fragments in their position of displacement and such protruding spikes of bone may interfere with adjacent tendon or joint action, or if protruding into the palm may cause pain when grasping unyielding objects. Such deformities are most likely to occur with fractures of the

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metacarpals and they are prevented by accurate reduction and may be later corrected by surgical removal of the bony protuberance. Malunions of any type, if severe enough to appreciably impair function or appearance, can only be corrected by surgical osteotomy. Splinting is of no avail and closed osteotomy will give poor results. Correction of angulation may be done with either an opening wedge or a closing wedge. In an opening wedge the bone is transsected, the angulation corrected, and the resulting wedge defect is filled with a bone graft. Iliac cancellous bone is best for bone grafts in the hand. It is stable enough, it incorporates rapidly, and it readily converts to cortical bone on its periphery. Stabilization of the osteotomy should be done with two or more nonparallel Kirschner wires. The closing wedge is less often used as it will result in shortening. A wedge of bone is removed from the malunion site, the angle of the wedge being the same as the deformity. The closing wedge has the advantage of allowing firm abutment of the two fragments without the necessity of a bone graft. Rotational deformity is corrected by transverse osteotomy and rotation of the malplaced fragment-usually the distal one-and transfixing with crossed Kirschner wires. Malrotation may stubbornly resist correction even after the osteotomy is done and considerable stripping of soft tissue may be required, in which case very solid internal fixation is mandatory lest non-union occur.

Figure 37. A, Bone loss from third metacarpal secondary to gunshot wound. Shortening should have been prevented by a spacer wire. B, Bone loss filled in by iliac cancellous graft. The shortening of the third ray could not be corrected and function of the middle finger was impaired.

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Corrective osteotomies are accomplished more easily, more precisely, and less traumatically with power equipment, preferably a small, gas driven, oscillating saw. The metacarpals and phalanges of the hand are small tubular bones which are hard and brittle and attempts to cut through them with bone cutters, rongeurs, or hand saws often cause a splintering and fragmentation of the bone. Kirschner wires for internal fixation are more easily and accurately placed with a power drill than with a hand operated drill. The hand drill requires the use of both of the surgeon's hands, the Kirschner wire revolves too slowly for effective penetration, and the wire tends to wobble, giving it less effective fixation in the bone. With a power drill only one hand is required for its operation, the wires are more firmly seated in the bone, and the control of their placement is much more precise.

Non-Union Non-unions of metacarpal and phalangeal fractures, though unusual, are no rarity and their occurrence may cause enough discomfort or deformity in the hand to badly impair total hand function. They are generally the result of neglected or inexpertly treated closed fractures. The most obvious type of non-union is that in which bone loss has occurred as a result of high explosive or high velocity missile injuries of the' hand (Fig. 38). Replacement of the missing bone with iliac cancellous bone may successfully salvage an otherwise useless digit. Such replacement of bone can only be successful if soft tissue healing is complete and if the

Figure 38. A and B, Non-union of middle phalanx secondary to gunshot wound and inadequate treatment,

II

•

THE MANAGEMENT OF PHALANGEAL AND METACARPAL FRACTURES

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FORCE FIT

o 0 'Z

LATERAL VIEW

*

FORCE FIT

TRANSVERSE VIEW DORSAL VIEW Figure 39.

Matchstick inlay graft for delayed or non-union.

original length of the digit has been maintained until such time as bone grafting is feasible. Rotational and angulatory deformities may exist at the non-union site and surgical correction of these deformities should be done when the non-union is dealt with. The most effective treatment is bone grafting and rigid internal fixation with Kirschner wires. Sclerotic bone margins and interposed soft tissue should be removed from the non-union and the defect in the bone made up with a cancellous graft followed by Kirschner wire fixation. Occasionally a key or inlay graft of a matchstick of cortical bone, taken from the proximal ulna and force-fit into a longitudinal slot cut across the non-union, will assist in stabilization of the non-union and also act as a further aid to osteogenesis. The cutting of such a graft and its corresponding slot again requires the use of precision instruments, preferably a power oscillating saw (Fig. 39). When bone loss includes loss of the epiphyseal end of the bone and its

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joint surfaces, replacement of the missing bone can never result in a functional or satisfactory joint. In such a situation, amputation of the finger should be considered and if this is not acceptable, then the bone may be replaced and arthrodesis to the adjoining bone performed at the same stage. Infection If the bone fragments or the surrounding soft tissue of the fracture site become infected before the fracture is healed, the appropriate treatment is to open the infected area, allow it to drain freely, culture it, and treat the causative organism with the appropriate antibiotic. Establishment and maintenance of good circulation is imperative. Swelling is a deterrent to good circulation and is best controlled by elevation of the exrcemity and by active exercise of the fingers. Active motion or active use of the hand is the best stimulus to improving circulation and this is generally quite possible if the fracture has been securely fixed with Kirschner wires or with a cast or splint. The wires should not be removed until the fracture is united. Fragments of bone should not be removed until after the fracture has healed and they appear as sequestra. X-ray appearance can be misleading as the osteoporosis of disease simulates osteomyelitis. As a criterion for healing, rely instead on the clinical appearance and symptoms. Tendon Adherence Extensor tendons rarely adhere to metacarpal or phalangeal fractures unless the fracture is open or there is extensive soft tissue trauma or laceration of the tendons themselves. If after healing of the fracture there is no progress or mobility for several months, a tendolysis may be necessary. If the tendon is adherent to bone it may be advisable to interpose silas tic sheeting between the tendon and bone until full motion is gained, after which the sheeting is removed. Flexor tendons may adhere to fractures of the proximal and middle phalanges and they will require tendolysis and silas tic sheeting. Do not consider tendolysis unless it is definitely established that despite con- . tinued exercise by the patient, there is no progress in motion of the joints distal to the fracture. Following tendolysis gentle, active motion is started within 1 week. Progress may be slow but improvement may continue for up to 1 year. Dynamic splinting and passive exercise will seldom be effective in freeing adherent tendons. Tendon adherence is more easily prevented than cured and the best prophylaxis is good reduction and solid fixation of the fracture followed by early, active motion of the fingers. Joint Stiffness Normal joints, if immobilized without strain, will tolerate prolonged immobilization without becoming stiff. Damaged joints quickly stiffen if not moved early. Joint stiffness may be caused by adherent tendons proximal to the joint, damage to the joint or its associated structures, or

THE MANAGEMENT OF PHALANGEAL AND METACARPAL FRACTURES

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prolonged traction across a joint. Stiff joints are best avoided by early mobilization and active motion. Stiff joints will not respond to force applied by manipulation under anesthesia, passive forcing by a physiotherapist, or powerful dynamic splints. Instead, persistent, active motion and time and patience are required. Capsulectomy and tendolysis may be required in severe cases but only when persistent, conservative measures have failed.

SELECTED READINGS Boyes,J. H.: Bunnell's Surgery of the Hand, 5th ed. Philadelphia, J. B. Lippincott Co., 1970. Howard, L. D.: Fractures of the Small Bones of the Hand. Instructional Course, American Academy of Orthopaedic Surgeons, 1960. Milford, L.: The Hand. In Campbell's Operative Orthopaedics, 5th ed. St. Louis, C. V. Mosby Company, 1971. Robertson, R. C., Calley, J. J., and Farris, A. M.: Treatment of fracture dislocation of the interphalangeal jOints of the hand. Amer. J. Surg., 50:563, 1938. P.O. Box 875 Biscayne Annex Miami, Florida 33152