Hand Fractures

A fracture is a break in the bone. Fractures in the hand are some of the most frequent in the upper extremity.

Pathology

A fracture is a break in the bone. Fractures in the hand are some of the most frequent in the upper extremity. Males between 10 and 40 years of age are most commonly affected. Historically, some fractures are named after the doctor who first described the fracture or the condition that caused it. An example of this is the Bennett’s fracture that represents a fracture at the base of the thumb that extends into the carpometacarpal joint, or the Boxer’s fracture that involves the neck of the fifth metacarpal when punching improperly with the fist on a hard surface. The thumb and small fingers are the most frequently injured digits and are referred to as the border digits which puts them at higher risk of injury because of their proximity to objects when using the hands.

All fractures can be broadly described as closed fractures in which the skin is intact, or Open fractures which involve wounds that communicate with the fracture site, creating contamination and a potential risk for injection. Open fractures therefore require immediate surgical attention. Fractures are also classified according to their radiologic appearance by the geometry and direction, number of fracture fragments, angulation of the fracture fragments, displacement, or compression of the fragments. Fractures are further classified as intra-articular (break through the joint) or extra-articular (outside of the joint). These factors will determine if a fracture is stable or unstable and whether a cast vs surgery is required for definitive treatment.

Fractures that are not separated (displaced), significantly shortened or angulated can often be treated with a splint or cast that takes into consideration the correct alignment of the fracture but also the proper positioning of the other joints not involved in the break in order to avoid stiffness. The fracture usually gains strength around 4-6 weeks after injury and gentle active range of motion exercises can be started at that time or earlier, if the x-rays demonstrate sufficient fracture healing has occurred. The consultation of a therapist will assist in preventing the hand from becoming stiff and will guide the therapy protocol until the best level of activity is achieved.

Fractures of the hand can be complicated by deformity from no treatment, stiffness from prolonged immobilization, and both deformity and stiffness from improper treatment.

Treatment

When the fracture fragments are separated, open, significantly shortened, angulated, or contain multiple small fragments (comminution), the fracture is often unstable meaning it will not hold a reduction after splinting. In this instance surgery is required for proper healing in the optimal position to occur and full function to return. Different methods of fixation and stabilization have been described that can be used independently or in combination and include: Pins, Wires, Headless screws, External fixation and Plates and Screws. More recently, these fractures are also fixed with the use of modern plates and screws that incorporate new technology that lock the screws to the plate and hold the fragments together until the bone heals. These newer designs increase the rigidity of the fixation allowing earlier motion and may have an advantage in treating fractures when the quality of the bone is poor, severely compacted or severely fragmented risking potential collapse. The selection of the type of fixation depends on the fracture type, the availability of these systems to the surgeon, bone quality, patient co-morbid conditions and the surgeons training and expertise in the use of these systems. Severe fractures may have associated conditions like tendon, nerve or vessel injuries. A wide combination of associated fractures or dislocations can be observed, specifically in high energy injuries which demand a comprehensive evaluation and treatment.

After fracture fixation, the patient can start immediately with active motion of the fingers to prevent stiffness while in a removable splint. The patients are regularly evaluated at about 1 week postoperatively for the initial follow up. They are started as early as 48 hrs in a formal therapy program and are placed in a protective brace that allows for intermittent removal of the brace for hygiene and hand exercises. It may take up to 2-3 months to recover optimal motion and strength.