General Treatment Principles
- “Fight-bite” injuries: Any short, curved laceration overlying a joint in the hand, particularly the MCP joint, must be suspected of having been caused by a tooth. These injuries must be assumed to be contaminated with oral flora and should be addressed with broad-spectrum antibiotics (ampicillin sulbactam [Unasyn, Pfizer, New York, New York] is the initial drug of choice). Please consult with local infectious disease specialist to see if additional methicillin-resistant Staphylococcus aureus coverage is required such as sulfamethoxazole/trimethoprim (Bactrim DS, Caraco Pharmaceutical Laboratories, Ltd., Detroit, Michigan) and irrigation and debridement.
- Animal bites: Antibiotic coverage is needed for Pasteurella and Eikenella (similar to human bite coverage).
- There are essentially six major treatment alternatives for closed phalangeal and metacarpal fractures:
- Immediate motion
- Temporary splinting
- Closed reduction and percutaneous pinning (CRPP)
- Open reduction and internal fixation (ORIF)
- Immediate reconstruction
- External fixation
- The general advantages of entirely nonoperative treatment are lower cost and avoidance of the risks and complications associated with surgery and anesthesia. The disadvantage is that stability is less assured than with some form of operative fixation.
- CRPP is expected to prevent overt deformity but not to achieve an anatomically perfect reduction. Pin tract infection is the prime complication that should be mentioned to patients in association with CRPP, unless Kirschner wires (K-wires) are buried.
- Open treatments are considered to add the morbidity of surgical tissue trauma, titrated against the presumed advantages of the most anatomic and stable reduction.
- Critical elements in selecting between nonoperative and operative treatment are the assessments of rotational malalignment and stability.
- In general, the goal in treatment of hand fractures is restoring a functional range of motion, not necessarily anatomic alignment. Slight angulation and shortening can be acceptable if the clinical exam shows that a functional range of motion and stability exists. Rotational malalignment is not tolerated well.
- Rotational discrepancy can be identified with careful clinical exam. Differentiate between scissoring (actual crossover of digits when flexing) and slight rotational malalignment.
- Defining stability is somewhat more difficult. Some authors have used what seems to be the very reasonable criterion of maintenance of fracture reduction when the adjacent joints are taken through at least 30% of their normal motion.
- Contraction of soft tissues begins approximately 72 hours following injury. Motion should be instituted by this time for all joints stable enough to tolerate rehabilitation.
- General indications for surgery include:
- Open fractures
- Unstable fractures
- Irreducible fractures
- Multiple fractures
- Fractures with bone loss
- Fractures with tendon laceration, neurovascular injury, or soft tissue injury requiring coverage.
- Treatment of stable fractures:
- Splinting is performed, with repeat radiographs in 1 week.
- Initially unstable fractures that are reduced and then converted into a stable position: external immobilization (cast, cast with outrigger splint, gutter splint, or anteroposterior splints) or percutaneous pinning, which prevents displacement and permits earlier mobilization
- Buddy taping can be used for some stable avulsion-type fractures but not for the initial treatment of diaphyseal or unstable articular fractures. Buddy taping is appropriate during the rehabilitation phase of treatment after the fracture has achieved some initial stability.
- Treatment of unstable fractures:
- Unstable fractures that are irreducible by closed means or exhibit continued instability despite closed treatment require CRPP or ORIF, including K-wire fixation, interosseous wiring, tension band technique, interfragmentary screws alone, or plates and screws.
- Fractures with segmental bone loss
- These continue to be problematic. The primary treatment should be directed to the soft tissues, maintaining length with K-wires or external fixation. These injuries usually require secondary procedures, including bone grafting.
Management of Specific Fracture Patterns
Metacarpals
Metacarpal Head
- Fractures include:
- Epiphyseal fractures
- Collateral ligament avulsion fractures
- Oblique, vertical, and horizontal head fractures
- Comminuted fractures
- Boxer’s fractures with joint extension
- Fractures associated with bone loss
- Most require anatomic reduction (if possible) to reestablish joint congruity and to minimize posttraumatic arthrosis.
- Stable reductions of fractures may be splinted in the “protected position,” consisting of metacarpal–phalangeal flexion >70 degrees to minimize joint stiffness (Fig. 24.1).
- Displaced metacarpal head fractures usually require ORIF with K-wires or headless compression screws.
- Early range of motion is essential if a stable fixation can be achieved.
Metacarpal Neck
- Fractures result from direct trauma with volar comminution and dorsal apex angulation. Most of these fractures can often be reduced closed, but maintenance of reduction can be difficult (Fig. 24.2).
- The degree of acceptable deformity varies according to the metacarpal injured:
- Less than 10 degrees of angulation for the second and third metacarpals
- Less than 30 and 40 degrees of angulation for the fourth and fifth metacarpals, respectively
- Unstable fractures require operative intervention with either percutaneous pins (may be intramedullary or transverse into the adjacent metacarpal) or plate fixation.
Metacarpal Shaft
- Nondisplaced or minimally displaced fractures can be reduced and splinted in the protected position. Central metacarpal fractures (third and fourth) are usually more stable due to the deep transverse intermetacarpal ligaments and the interosseous muscles.
- Operative indications include rotational deformity and apex dorsal angulation >10 degrees for second and third metacarpals and >20 degrees for fourth and fifth metacarpals.
- Generally, malrotation is not acceptable. Ten degrees of malrotation (which risks as much as 2 cm of overlap at the digital tip) should represent the upper tolerable limit.
- Operative fixation may be achieved with either intermetacarpal CRPP or ORIF with interfragmentary screws, intramedullary nails, or plate and screws.
Metacarpal Base
Fingers: Carpometacarpal Joint Dislocations and Fracture-Dislocations
- Dislocations at the finger CMC joints are usually high-energy injuries with involvement of associated structures, including neurovascular injury.
- Overlap on the lateral x-ray obscures accurate depiction of the injury pattern. A 30-degree pronated view from lateral will help elucidate.
- When fracture-dislocations include the dorsal cortex of the hamate, computed tomography may be necessary to better evaluate the pathoanatomy.
- Most thumb CMC joint injuries are fracture-dislocations rather than pure dislocations. Terms associated with these fracture-dislocations are Bennett (partial articular) and Rolando (complete articular) fractures.
- Dorsal finger CMC fracture-dislocations cannot usually be held effectively with external splints/casts alone. CRPP versus ORIF is the treatment of choice.
- Fractures of the bases of the second through fifth metacarpals may be associated with CMC fracture-dislocations. In addition to a posteroanterior radiograph, it is important to get a true lateral and a 30-degree pronated from lateral view. If the fractures are extra-articular than some angulation, displacement may be acceptable and closed treatment in a cast or splint can be undertaken. Displaced and articular fractures require CRPP versus ORIF.
- The reverse Bennett fracture is a fracture-dislocation of the base of the fifth metacarpal/hamate.
- The proximal metacarpal fragment is displaced proximally by the pull of the extensor carpi ulnaris.
- This fracture often requires surgical intervention with CRPP versus ORIF.
Thumb
- Extra-articular fractures: These are usually transverse or oblique. Most can be held by closed reduction and casting, but some unstable fractures require CRPP. The basal joint of the thumb is quite forgiving, and an anatomic reduction of an angulated shaft fracture is not essential; 30 to 40 degrees can easily be tolerated.
- Intra-articular fractures(Figs. 24.3and24.4):
- Type I:Bennett fracture: Fracture line separates major part of metacarpal from volar lip fragment, producing a disruption of the first CMC joint. The distal metacarpal is displaced proximal, radial, and dorsal by APL and extensor pollicis longus (EPL). The APL pull also supinates the metacarpal. The adductor pollicis displaces the metacarpal head into the palm)
- Type II: Rolando fracture: It requires greater force than a Bennett fracture; presently used to describe a comminuted Bennett fracture, a “Y” or “T” fracture, or a fracture with dorsal and palmar fragments
- Treatment: Both types I and II fractures of the base of the first metacarpal are unstable and should be treated with CRPP or ORIF.
Proximal and Middle Phalanges
Intra-articular Fractures
- Condylar fractures: single, bicondylar, osteochondral
- They require anatomic reduction; CRPP versus ORIF should be performed for any displacement. Consider CRPP for nondisplaced fractures because they are frequently unstable and difficult to assess maintenance of reduction in a splint or cast.
- Comminuted intra-articular phalangeal fractures should be treated with reconstruction of the articular surface, if possible. Severely comminuted fractures that are deemed nonreconstructible may be treated closed with early protected mobilization. The surgeon should discuss with the patient the possibility of secondary procedures.
Proximal Interphalangeal Fracture-Dislocations
- Volar lip fracture of middle phalangeal base (dorsal fracture-dislocation)
- Treatment is controversial and depends on percentage of articular surface fractured.
- Hyperextension injuries without a history of dislocation with <30% to 35% articular (nondisplaced) involvement: dorsal block splint and early mobilization with weekly radiographs including a perfect lateral for 3 weeks and then buddy tape active and active assisted range of motion
- 40% or more articular involvement: usually unstable. Dynamic external fixator (Suzuki/Slade with 0.045 in K-wires and rubber bands). Add ORIF or CRPP (with percutaneous reduction aided by pointed reduction clamps and stabilized with K-wires placed anterior to posterior through the flexor tendons) if fragments need further reduction. If too comminuted or chronic and 40% to 50% articular involvement: volar plate arthroplasty versus hemi-hamate arthroplasty; >50% articular involvement: hemi-hamate arthroplasty
- Dorsal lip fracture of middle phalangeal base (volar fracture-dislocation)
- Usually, this is the result of a central slip avulsion.
- Fractures with <1 mm of displacement: may be treated closed with splinting (PIP in full extension), as in a boutonnière injury
- Fractures with >1 mm of displacement or volar subluxation of the PIP joint: Operative stabilization of the fracture is indicated; CRPP versus ORIF
- Pilon fractures (Suzuki/Slade with 0.045 in K-wires and rubber bands). Add ORIF if fragments need further reduction.
Extra-articular Fractures
- Shaft fractures: If displaced or unstable, CRPP versus ORIF. Epibasilar proximal phalanx fractures are usually apex volar. Consider CRPP with trans-MCP joint pin while flexing MCP joint.
- Fractures at the base of the middle phalanx tend to angulate apex dorsal, whereas fractures at the neck angulate the apex volarly owing to the pull of the sublimis tendon (Fig. 24.5). Closed reduction should be attempted initially with finger-trap traction followed by splinting.
- Fractures in which a stable closed reduction cannot be achieved or maintained should be addressed with CRPP or ORIF with mini-fragment implants.
Distal Phalanx (Fig. 24.6)
Intra-articular Fractures
- Dorsal lip
- A mallet finger may result from a fracture of the dorsal lip with disruption of the extensor tendon. Alternatively, a mallet finger may result from a purely tendinous disruption and may therefore not be radiographically apparent.
- Treatment remains somewhat controversial.
- Some recommend nonoperative treatment for all mallet fingers with full-time extension splinting for 6 to 8 weeks including those with a significant articular fracture and joint subluxation.
- Others recommend CRPP for displaced dorsal base fractures with subluxation. Various closed pinning techniques are possible, but the mainstay is extension block pinning.
- Pinning can also be considered for those who cannot tolerate splinting (e.g., health care workers who need to constantly wash hands).
- Volar lip
- This is associated with flexor digitorum profundus rupture (“jersey finger”: seen in football and rugby players, most commonly involving the ring finger).
- Treatment is primary repair, especially with large, displaced bony fragments.
Extra-articular Fractures
- These are transverse, longitudinal, and comminuted (nail matrix injury is very common).
- Treatment consists of closed reduction and splinting.
- The splint should leave the PIP joint free but usually needs to cross the distal interphalangeal (DIP) joint to provide adequate stability. Aluminum and foam splints or plaster of Paris are common materials chosen.
- CRPP is indicated for shaft fractures with wide displacement because of the risk for nail bed incongruity and later nail plate nonadherence.
- A special case is a Salter-Harris Type 1 displaced fracture in a child where the nail bed is interposed.
Nail Bed Injuries (Fig. 24.7)
- These are frequently overlooked or neglected in the presence of an obvious fracture, but failure to address such injuries may result in growth disturbances of the nail.
- Acute subungual hematomas may be evacuated with cautery or a hot paper clip.
- If the nail plate has been avulsed at its base, it should be removed, cleansed with povidone-iodine, and retained to replace under the eponychium.
- Nail bed disruptions should be carefully sutured with 6-0 absorbable suture under magnification.
- Recent evidence indicates 2-octyl cyanoacrylate (Dermabond) is a viable method of nail bed repair with the advantage of being a faster procedure.
- The aluminum suture package material may be used if the original nail plate is not usable as a biologic dressing.
Metacarpophalangeal Joint Dislocations (Fig. 24.8)
- Dorsal dislocations are the most common.
- Simple dislocations are reducible and present with a hyperextension posture.
- They are really subluxations because some contact usually remains between the base of proximal phalanx and the metacarpal head.
- Reduction can be achieved with initial hyperextension followed by distal translation and simple flexion of the joint; excessive longitudinal traction on the finger should be avoided because this could interpose the volar plate. Wrist flexion to relax the flexor tendons may assist reduction.
- The other variety of MCP joint dislocation is a complex dislocation, which is by definition irreducible, most often the result of volar plate interposition.
- Complex dislocations occur most frequently in the index finger.
- A pathognomonic x-ray sign of complex dislocation is the appearance of a sesamoid in the joint space.
- Most dorsal dislocations are stable following reduction and do not need surgical repair of the ligaments or volar plate.
- Volar dislocations are rare but are particularly unstable.
- Volar dislocations are at risk for late instability and should have repair of the ligaments.
- Open dislocations may be either reducible or irreducible.
Thumb Metacarpophalangeal Joint Dislocations
- The thumb MCP joint, in addition to its primary plane of flexion and extension, allows abduction–adduction and a slight amount of rotation (pronation with flexion).
- With a one-sided collateral ligament injury, the phalanx tends to subluxate volarly in a rotatory fashion, pivoting around the opposite intact collateral ligament.
- The ulnar collateral ligament may have a two-level injury consisting of a fracture of the ulnar base of proximal phalanx with the ligament also ruptured off the fracture fragment.
- Of particular importance is the proximal edge of the adductor aponeurosis that forms the anatomic basis of the Stener lesion. The torn ulnar collateral ligament stump comes to lie dorsal to the aponeurosis and is thus prevented from healing to its anatomic insertion on the volar, ulnar base of the proximal phalanx (Fig. 24.9).
- The true incidence of the Stener lesion remains unknown because of widely disparate reports.
- Nonoperative management (thumb spica cast vs. splint for 6 weeks) is the mainstay of treatment for partial thumb MCP joint collateral ligament injuries.
- If the MCP joint opens >30 degrees or >15 degrees from the contralateral side, tested at 30 degrees of flexion, it is a complete thumb MCP joint collateral ligament injury, and surgery is indicated for the ulna collateral ligament and is controversial for the radial collateral ligament. The ligament can be repaired with a bone suture anchor. If the injury is chronic, and there is no adequate ligament to repair, a free tendon graft through bone tunnels may be employed.
Proximal Interphalangeal Joint Dislocations
- Dislocations of the PIP joint have a high rate of missed diagnoses that are passed off as “sprains.”
- Although large numbers of incomplete injuries occur (especially in ball-handling sports), complete disruptions of the collateral ligaments and the volar plate are also frequent (50% occur in the long finger followed in frequency by the ring finger).
- Congruence on the lateral radiograph is the key to detecting residual subluxation.
- Residual instability is quite rare in pure dislocations, as opposed to fracture-dislocations, in which it is the primary concern.
- Recognized patterns of dislocation other than complete collateral ligament injury are dorsal dislocation, pure volar dislocation, and rotatory volar dislocation.
- Dorsal dislocations involve volar plate injury (usually distally, with or without a small flake of bone).
- For pure volar dislocations, the pathologic findings are consistently damage to at least one collateral ligament and the central slip. The volar plate may remain intact.
- Volar or lateral dislocations may be irreducible if the head of proximal phalanx passes between the central slip and the lateral bands, which can form a noose effect and prevent reduction.
- In pure dislocations, stiffness is the primary concern. Stiffness can occur following any injury pattern.
- Chronic missed dislocations require open reduction with a predictable amount of subsequent stiffness.
- Treatment
- Once reduced, rotatory volar dislocations, isolated collateral ligament ruptures, and dorsal dislocations congruent in full extension on the lateral radiograph can all begin immediate active range of motion with adjacent digit strapping.
- Dorsal dislocations that are subluxated on the extension lateral radiograph require a few weeks of extension block splinting.
- Volar dislocations with central slip disruptions require 4 to 6 weeks of PIP extension splinting, followed by nighttime static extension splinting for 2 additional weeks. The DIP joint should be unsplinted and actively flexed throughout the entire recovery period.
- Open dorsal dislocations usually have a transverse rent in the skin at the flexion crease. Debridement of this wound should precede reduction of the dislocation.
Distal Interphalangeal and Thumb Interphalangeal Joint Dislocations
- Dislocations at the DIP/interphalangeal joint are often not diagnosed initially and present late.
- Injuries are considered chronic after 3 weeks.
- Pure dislocations without tendon rupture are rare, usually result from ball-catching sports, are primarily dorsal in direction, and may occur in association with PIP joint dislocations.
- Transverse open wounds in the volar skin crease are frequent.
- Injury to a single collateral ligament or to the volar plate alone at the DIP joint is rare.
Nonoperative Treatment
- Reduced dislocations that are stable may begin immediate active range of motion.
- The rare unstable dorsal dislocation should be immobilized in 20 degrees of flexion for up to 3 weeks before instituting active range of motion.
- The duration of the immobilization should be in direct proportion to the surgeon’s assessment of joint stability following reduction.
- Complete collateral ligament injuries should be protected from lateral stress for at least 6 weeks.
- Should pin stabilization prove necessary because of recurrent instability, a single longitudinal K-wire is usually sufficient.
Operative Treatment
- Delayed presentation (>3 weeks) of a subluxated joint may require open reduction to resect scar tissue and to allow tension-free reduction.
- Open dislocations require thorough debridement to prevent infection.
- The need for fixation with a K-wire should be based on the assessment of stability, and it is not necessarily required for all open dislocations.
- The duration of pinning is usually 4 weeks, and the wire may be left through the skin for easy removal.