Hand and finger fractures
Background
- Splinting is used in initial immobilization of, and often is definitive tx for, metacarpal fractures
- Maintenance of MCP joint in flexion is important to avoid immobility contractures of collateral ligaments
Thumb Fracture
Classification
- Type I (Bennett's Fx)
- Fx-dislocation of the base of the metacarpal (intraarticular)
- Type II (Rolando's Fx)
- Comminuted version of a Bennett's fracture (intraarticular)
- Type III
- Extraarticular (transverse or oblique)
- Type IV
- Extraarticular pediatric fx involving the proximal physis
Diagnosis
- Examination
- Important to distinguish tenderness at base of 1st MC from injury to scaphoid, trapezium, or distal radius
- If pain or ecchymosis occurs more distally at the MCP (particularly on the ulnar side) consider ulnar collateral ligament injury (Game Keeper's Thumb)
- Imaging
- AP, lateral, oblique
Treatment
- Splinting
- Type I, II - Thumb-spica with the IP joint free and wrist in 30 deg of extension
- Type III - Short arm thumb-spica extening to the IP joint and wrist in 30 deg of extension
- RICE
- Significant swelling or overly aggressive icing to radial side of thumb may result in temporary palsy to the superficial radial nerve (numbness over the dorsum of the thumb)
- Reduction
- Indicated for:
- Angulated extraarticular fx if clinician is comfortable with the procedure
- Indicated for:
Disposition
- Refer within 3-5 days:
- All intraarticular fractures warrant referral (most require sx)
- Extraarticular fractures that cannot be adequately reduced
Non-Thumb Metacarpal Head Fracture
- Intra-articular Fx
- Examination
- Swelling, decreased ROM, and TTP of MCP joint
- Assess for rotational alignment (rotational malalignment is not tolerated)
- Assess for skin integrity (r/o fight bite)
- Imaging
- AP, lateral, oblique
- Angulation assessed on lateral view
- Consider "Brewerton" view if collateral ligament avulsion fx suspected
- AP, lateral, oblique
- Treatment
- Ulnar or radial gutter splint
- MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
- Ulnar or radial gutter splint
- Dispo
- Almost always refer b/c are intraarticular and typically comminuted
- Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises
Non-Thumb Metacarpal Neck Fracture
- Examination
- TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
- Loss of the normal knuckle contour
- Due to dorsal angulation of fracture apex due to pull of the interosseous muscles
- Assess angulation
- Head-to-neck angle of the metacarpals is normally 15 degrees
- Fracture angulation = measured angle minus 15 deg
- Angle toleration (below which there is no adverse functional outcome)
- 2nd MC < 10 deg
- 3rd MC < 20 deg
- 4th MC < 30 deg
- 5th MC < 30 deg
- Head-to-neck angle of the metacarpals is normally 15 degrees
- Assess rotational alignment
- Assess extensor apparatus
- Assess skin integrity
- Treatment
- Gutter splint
- MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
- Acute reduction indicated:
- Pseudoclawing
- Significantly angulated 4th or 5th MC fx
- Gutter splint
- Dispo
- Refer for:
- Comminution
- Rotational malalignment
- Refer for:
Non-Thumb Metacarpal Shaft Fracture
- Examination
- TTP along affected metacarpal
- Flexion at MCP is difficult
- Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
- Assess angulation
- >10 deg in 2nd and 3rd and >20 deg in 4th and 5th metacarpal shaft fractures requires reduction
- Assess rotational alignment
- Imaging
- Oblique fx are more prone to shorten and rotate
- Transverse fx generally stable (particularly isolated 3rd or 4th MC shaft fx)
- Treatment
- Gutter splint
- Acute reduction indicated if there is pseudo-clawing or significant angulation
- Closed reduction generally corrects angulation but typically does not restore length
- Dispo
- Refer:
- Malrotation
- Comminution
- Shortening > 5mm (refer all shortening if not familiar with fx management)
- 2 or more metacarpal fractures
- Unacceptable angulation
- Long oblique fractres
- Refer:
Non-Thumb Metacarpal Base Fracture
- Examination
- Movement at the wrist elicits pain
- Assess for ulnar deficits (finger abduction/adduction)
- Assess for rotational alignment
- Imaging
- AP, lateral, oblique
- 30 deg obliques pronated and supinated if usual films unable to visualize the MC bases
- Consider CT if index of suspicion high for occult fx despite "negative" plain films
- Treatment
- Dorsal and volar splints with the wrist in 30 deg of extension and MCP joints free
- Dispo
- Refer for:
- Intraarticular fx
- Extraarticular fx with malrotation
- Dislocation of metacarpal base CMC joint;
- Ulnar nerve injury
- 5th metacarpal base fx (typically require sx)
- Refer for:
See Also
Source
UpToDate