Hand Fractures: A Review of Current Treatment Strategies

doi:10.1016/j.jhsa.2013.02.017

The Journal of Hand Surgery

Volume 38, Issue 5, May 2013, Pages 1021-1031

https://doi.org/10.1016/j.jhsa.2013.02.017 Get rights and content

Fractures of the tubular bones of the hand are common and potentially debilitating. The majority of these injuries may be treated without an operation. Surgery, however, offers distinct advantages in properly selected cases. We present a review of hand fracture management, with special attention paid to advances since 2008. The history and mechanisms of these fractures are discussed, as are treatment options and common complications. Early mobilization of the fractured hand is emphasized because soft tissue recovery may be more problematic than that of bone.

Section snippets

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History

Rudimentary care of hand fractures (eg, rest and elevation) is presumably as old as humans themselves. Upright posture may have contributed to an increase in these injuries, and today, falls from standing height remain a major source of hand injuries. The ancient Egyptian Imhotep described reduction and immobilization of fractures in 3000 bc. Hippocrates in 200 bc and Galen in ad 160 recommended prolonged immobilization of broken bones and frequent dressing changes. More durable, plaster-based

Epidemiology

Hand fractures are among the most common skeletal injuries. As is the case with many orthopedic injuries, young men and elderly women are most susceptible. Modes of injury in different age groups are predictable: children and young adults are frequently injured in sports-related activities, middle-age manual laborers are prone to work-related injuries, and older patients may experience hand trauma as the result of a fall or motor vehicle collision. The distal phalanx is the most commonly

Diagnosis

Diagnosis of hand fractures begins with a thorough patient interview. The patient should describe the mechanism of injury because this may suggest certain reduction maneuvers, assist in identifying secondary injuries, and reveal pathological fractures. A very low-impact injury leading to fracture, for instance, should raise the suspicion of osteoporosis or enchondroma. In addition to a history of the injury, it is important to note the patient's handedness, their functional status, occupation,

General principles

Most hand fractures are well managed without surgery. This was known to ancient physicians; however, today we better appreciate the dangers of prolonged immobilization.⁷ Stiffness, pressure sores, and, rarely, compartment syndrome may result from mismanaged casting or splinting, and in this sense, “conservative” treatment may be particularly risky. Surgery is indicated when early mobilization of soft tissues is critical, when the fracture is otherwise unreducible, in instances of polytrauma or

Complications

Stiffness is a far more common and difficult to treat complication of metacarpal and phalangeal fractures than are malunion, nonunion, and arthrosis combined. Each of these complications may occur with or without an operation, and each is more easily prevented than treated. Strictly surgical complications—hardware prominence, hardware infection, and wound breakdown—are often primarily related to technique. Management of complications lies on a broad spectrum from the simple to the complex. A

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Cited by (88)

Choosing the proper implant for extra-articular fractures of proximal phalanges: A study on 75 cases
2024, Injury
Phalangeal fractures are the most common fractures of the hand and in particular the proximal phalanx of the long fingers is the most involved. These fractures can ben conservatively managed but, when the fracture pattern is considered unstable, surgical treatment is recommended. However, there is no consensus in literature about the proper surgical option for extra-articular proximal phalanx fractures.
We compared clinical and radiographical results after treatment of 75 cases of extra-articular proximal phalanx fractures using three different surgical techniques: closed reduction and internal fixation (CRIF) with Kirschner wires (G1 group), open reduction internal fixation (ORIF) with plates and screws or lag screws (G2 group), and closed reduction and intramedullary screw fixation (CRIMEF)(G3 group).
We found no significant differences in term of union rate and time to fracture healing between the three groups. However, we found a significant reduction in time to return at work and in TAM at the final follow-up examination in G3 group (treated with CRIMEF) when compared with both G1 and G2. No differences in complications rate were found between three groups.
The surgical variability in the management of extra-articular phalanx fractures create lacks on standard guide for treatment.
In conclusion, our results showed good clinical and radiographical results with all the three surgical options. However, the closed reduction and internal fixation with intramedullary screws (CRIMEF) seems to be better in terms of time to return to work and TAM at the final follow-up, probably due to good primary stability and little risk of soft tissue adherence development.
Trends in the Management of Fifth Metacarpal Neck Fractures
2024, Journal of Hand Surgery
To describe management trends of fifth metacarpal neck (5MCN) fractures within a large health care system. We aimed to define patient and surgeon factors associated with nonsurgical versus surgical treatment, as well as to identify factors associated with receiving care only in the emergency department (ED).
We identified all 5MCN fractures within our system for the years 2012–2020 and recorded baseline demographics for cases. Injury, treatment, and fracture characteristics were all recorded. For fractures treated nonsurgically, we determined the type of immobilization used (if any) and recorded whether patients were seen only in the ED or received subsequent outpatient follow-up. Demographic comparisons were made between groups, and adjusted logistic regression models were generated to predict the odds of having a surgical 5MCN fracture or being seen in the ED only.
There were 611 5MCN fractures over an 8-year period, of which 10% were treated surgically. During the first half of the study period, 8% of isolated cases were treated surgically compared with 7% of cases in the second half. Soft dressings were increasingly used. There were no nonsurgically managed cases that underwent subsequent surgical procedures for symptomatic nonunion or malunion. Twenty-one percent of patients were seen only in the ED. Fracture angulation, associated injuries, insurance status, and treatment by a hand surgeon were all significantly associated with an increased likelihood of surgery.
Of the 611 5MCN fractures identified, 90% were treated nonsurgically. Patient and surgeon factors were associated with increased odds of surgery. Of patients who sought care for 5MCN injuries, >20% received no follow-up care outside of the ED. These data can be used to assess future changes in management trends and suggest that nonunion and symptomatic malunions are uncommon occurrences.
Prognostic IV.
“Review of contemporary non-surgical management techniques for metacarpal fractures: Anatomy and rehabilitation strategies”
2024, Orthoplastic Surgery
This comprehensive study explores the various aspects of metacarpal fractures, a prevalent condition in hand injuries. We delve into the anatomy of the metacarpals, elucidating how their structural characteristics influence fracture mechanics and treatment options. Special attention is given to the diverse types of fractures, particularly the differing tolerances for angular, shortening, and rotational deformities. The manuscript extensively reviews conservative treatment approaches, emphasizing the efficacy of non-surgical methods like modified braces and active mobilization techniques. Additionally, we provide a nuanced understanding of specific fracture types, such as neck fractures, highlighting their unique healing dynamics. This research offers valuable insights for orthopedic and plastic surgery practitioners, advancing the understanding and management of metacarpal fractures.
Risks of Reoperation in Surgically Treated Fractures of the Proximal Phalanx
2024, Journal of Hand Surgery Global Online
The objective of this study was to determine the risk factors and the rate of reoperation after closed reduction percutaneous pinning (CRPP) of isolated closed single-digit proximal phalanx fractures.
A retrospective cohort study was conducted for patients who underwent CRPP of non–thumb closed proximal phalanx fractures between 2010 and 2020 at two level-I trauma centers and two community teaching hospitals. Demographics, fracture, and treatment characteristics were collected. The primary outcome measure was reoperation. Secondary outcome measures were complication and reoperation specifically for digital stiffness.
Of the 115 patients who underwent surgical treatment, 46 patients (40.0%) had a complication and 13 patients (11.3%) underwent reoperation at a mean of 6.7 months—most of which (84.6%) were for digital stiffness.
Surgeons and patients may be aware that CRPP of closed extra-articular proximal phalanx fractures carries considerable rates of complication and reoperation.
Therapeutic III.
Outcomes Following Fully Threaded Intramedullary Nailing of Metacarpal Fractures
2024, Journal of Hand Surgery Global Online
Intramedullary screw fixation has emerged as a popular approach for the treatment of displaced metacarpal fractures. The purpose of this study was to investigate the functional and radiographic outcomes of a newly designed, headless noncompressive fully threaded intramedullary nail (TIMN) for the treatment of metacarpal fractures.
A retrospective chart review was performed on patients who were treated with the INnate TIMN (ExsoMed) at a single academic institution with a minimum of 1-year follow-up. Patient-reported functional outcomes included Quick Disabilities for the Arm, Shoulder, and Hand (QuickDASH) questionnaires, return to work and physical activity time, and overall satisfaction. Radiographs were retrospectively reviewed to determine radiographic union, change in angulation, and metacarpal shortening.
A total of 49 patients (58 fractures) with a mean age of 36 years (range: 17–75 years) were included. The mean follow-up time was 2.7 years (range: 1.4–4.3 years). Overall, the mean patient satisfaction rating was 4.9 of 5 (range: 3–5). The mean return to work time was 7.2 weeks (range: 0.14–28 weeks), and the mean return to sport or activity was 8.3 weeks (range: 1–28 weeks). Average QuickDASH scores across all patients were 4 (range: 0–56.9). The median radiographic healing time was 6.1 weeks (range: 4.7–15.4 weeks). Mean postoperative shortening in the fifth metacarpal fracture was 3 mm (range: −4.2 to 8 mm) at the initial postoperative visit and 3.6 mm (range: −3.3 to 7.9 mm) at the final radiographic follow-up. Subgroup analysis showed that postoperative shortening was similar, regardless of the fracture pattern. The following four complications were reported: one case of persistent pain and stiffness, one case of carpal tunnel syndrome, one nonunion, and one fractured intramedullary nail.
Our findings suggest that the TIMN allows for a reliable return to work and physical activity, high patient satisfaction, low complication rate, and minimal shortening at the final radiographic follow-up.
Therapeutic IV.
Osteosynthesis by intramedullary headless screw in digital fractures: A retrospective scannographic and anatomical study
2023, Annales de Chirurgie Plastique Esthetique
Les fractures du squelette des doigts longs sont des lésions fréquentes. Dans les formes déplacées, le traitement chirurgical est de rigueur. Avec l’avènement des vis canulées sans tête, la technique s’est simplifiée et permet d’obtenir une réduction dans les deux plans. L’objectif de notre étude était d’évaluer la récupération fonctionnelle des patients opérés par cette technique.
Nous avons mené une étude monocentrique rétrospective entre 2019 et 2022. Onze patients ont été suivis et 12 fractures analysées. Un suivi radioclinique était réalisé à 1 mois, puis au dernier recul avec une évaluation des amplitudes articulaires et un score de qualité de vie (QuickDash, QD). Le délai de reprise des activités professionnelles et sportives et la douleur (EVA) étaient recueillis. Une évaluation anatomique/scanographique était réalisée pour évaluer l’atteinte tendineuse et cartilagineuse.
Au dernier recul, on objectivait une flexion moyenne globale de 266° et une extension globale complète, un score de QD moyen de 15,9 et une force au Jamar de 106 % par rapport au côté sain. La reprise des activités physiques et professionnelles était précoce et la douleur rapidement tolérable. Aucun déplacement secondaire n’était objectivé et l’ensemble était consolidé au dernier recul, sans cal vicieux. Aucun patient n’avait été opéré secondairement.
Cette technique semble être un moyen sur et non traumatique dans les fractures des métacarpiens et de P1. Il permet un retour plus rapide aux activités sportives et professionnelles avec des complications moindres et une absence de nécessité d’ablation du matériel.
Long finger skeletal fractures are common injuries. In displaced forms, surgical treatment is required. With the advent of headless cannulated screws, the technique has been simplified and allows reduction in both planes. The objective of our study was to evaluate the functional recovery of patients operated on by this technique.
We conducted a retrospective single-center study between 2019 and 2022. Eleven patients were followed and 12 fractures analyzed. A radio-clinical follow-up was carried out at 1 month then at the last follow-up with an evaluation of the articular amplitudes and a quality of life score (QuickDash, QD). The time to return to professional and sporting activities, pain (EVA) was collected. An anatomical/scannographic evaluation was performed to assess tendon and cartilage damage.
At the last follow-up, the average global flexion was 266° and the extension was total. An average QD score of 15.9 and a Jamar force of 106% compared to the healthy side were observed. The return to physical and professional activities was earlier and the pain quickly tolerable. No secondary displacement was objectified and all were consolidated at the last follow-up, without malunion. No patient had been operated on secondarily.
This technique seems to be a safe and non-traumatic. It allows a faster return to sports and professional activities with fewer complications and no need to remove the material.

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Current conceptsHand Fractures: A Review of Current Treatment Strategies

Section snippets

CME Information and Disclosures

History

Epidemiology

Diagnosis

General principles

Complications

J Hand Surg Eur Vol

Chin J Traumatol

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

Chir Main

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Br

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

Fractures of the metacarpals and phalanges

Fractures, dislocations, and ligamentous injuries

Hand fractures and dislocations

Fractures and dislocations of the hand

Les debuts de l'osteosynthese en Belgique

Chirurgie: operatoire des fractures

History of fracture fixation of the hand and wrist

Clin Orthop Relat Res

Current concepts
Hand Fractures: A Review of Current Treatment Strategies