General principles
Hand fractures should be assessed for:
- open injury
- neurovascular injury
- tendon injury
- rotation
- angulation
- shortening
- intra-articular extension
Rotational deformity is poorly tolerated and must always be checked clinically by observing finger convergence during flexion.
Metacarpal fractures
Shaft fractures
Stable fractures without malrotation can often be treated non-operatively. Tolerance of angulation increases from radial to ulnar metacarpals because the ring and small-finger carpometacarpal joints are more mobile.
Operative fixation is considered for:
- rotational deformity
- unacceptable angulation or shortening
- multiple unstable fractures
- open fracture
- displaced intra-articular fracture
- irreducible or unstable injury
Metacarpal neck fractures
The fifth metacarpal neck is the commonest site. The deformity is usually apex dorsal. Reduction may be performed using the Jahss manoeuvre.
The acceptable amount of angulation depends on the ray and functional requirement. Rotation is not acceptable.
Base fractures
Base fractures may involve the carpometacarpal joint and may be unstable, particularly at the fourth and fifth rays.
Phalangeal fractures
Proximal and middle phalanx
Stable extra-articular fractures with minimal angulation and no rotation may be treated with splintage or buddy strapping followed by early motion.
Indications for fixation include:
- rotational deformity
- unacceptable angulation or shortening
- unstable fracture pattern
- displaced intra-articular fracture
- irreducible fracture
Distal phalanx
Most distal phalanx fractures are treated non-operatively. Associated nail-bed injury must be recognised and treated appropriately.
PIP fracture-dislocation
Stability depends on the size of the articular fragment and the degree of comminution. Treatment ranges from extension-block splintage to fixation, dynamic external fixation or reconstructive procedures in severe injuries.
Thumb injuries
Ulnar collateral ligament injury
A displaced UCL avulsion with interposition of the adductor aponeurosis is a Stener lesion and usually requires operative treatment.
Bennett fracture
An intra-articular fracture-dislocation of the base of the first metacarpal. The volar-ulnar fragment remains attached while the shaft is displaced by deforming forces.
Diagram
References
- Orthobullets. Metacarpal Fractures.
- Orthobullets. Phalanx Fractures.