Clinical priorities
The most important deformity to detect is rotation.
Examine:
- cascade of fingers in flexion
- nail-plate alignment
- extensor lag
- open wounds and fight-bite injuries
- tendon and neurovascular function
Radiographs define angulation, shortening, rotation indirectly, joint involvement and CMC alignment.
Metacarpal fractures
Acceptable angulation varies by ray because ulnar metacarpals have greater CMC mobility than index and middle metacarpals.
Operate when there is:
- unacceptable rotation
- unstable displacement
- open fracture requiring formal treatment
- significant intra-articular incongruity
- multiple unstable fractures
- CMC fracture-dislocation
Tolerance of angulation varies by ray because the mobile ulnar carpometacarpal joints compensate more than the index/middle rays.
Shortening can reduce extensor efficiency and alter knuckle contour. Rotation is generally unacceptable.
Neck fractures of the fifth metacarpal are common. Management depends on:
- rotation
- angulation
- stability
- occupation
- skin
- patient function
Fifth-metacarpal neck fracture
Many can be treated non-operatively when there is no rotation and function is acceptable. Do not operate solely because an X-ray looks angulated.
Bennett fracture
An intra-articular fracture-dislocation at the base of the thumb metacarpal. The volar-ulnar fragment remains attached to the trapezium while the shaft displaces under muscle forces.
Unstable displacement usually requires reduction and fixation.
Rolando fracture
A comminuted intra-articular fracture of the thumb metacarpal base. Treatment is determined by fragment size and reconstructability.
Phalangeal fractures
The priority is maintaining tendon glide and early motion while preserving alignment.
Prolonged immobilisation risks stiffness and adhesions. Fixation is used when stable early movement cannot otherwise be achieved.
The deforming forces depend on fracture level relative to tendon insertions. This explains characteristic angulation patterns.
Treatment aims to maintain:
- length
- rotation
- joint congruity
- tendon glide
Excessive immobilisation rapidly causes stiffness and adhesions.
General assessment
Hand fractures require attention to function, not radiographs alone.
Assess:
- open injury
- tendon injury
- rotation
- digital cascade
- neurovascular status
- skin and nail bed
- joint involvement
Rotational deformity is poorly tolerated and can cause finger overlap during flexion even when the radiograph appears acceptable.
Base and CMC injuries
Metacarpal-base fractures may be associated with CMC instability and can be missed on poor-quality films. Oblique/lateral imaging or CT may be needed.
Bennett and Rolando fractures involve the thumb metacarpal base and are mechanically unstable because of muscle pull and joint involvement.
Intra-articular fractures
Step-off, instability and joint subluxation are particularly important. Fixation should be stable enough to permit early motion where possible.
Operative methods
Options include:
- K wires
- screws
- mini-plates
- external fixation for selected comminuted injuries
The least disruptive construct that restores stable alignment is often preferable because soft-tissue scarring can be as disabling as the fracture.
Complications
- stiffness
- tendon adhesion
- malrotation
- non-union
- infection
- CRPS
- hardware irritation
FRCS synthesis
For every hand fracture, state the rotation, stability and tendon/soft-tissue condition. Early movement after stable fixation is a major objective.