This document summarizes principles for the management of hand fractures presented by Dr. REJUL K RAJ. It discusses anatomy of the hand bones, common fracture patterns, mechanisms of injury, signs and symptoms, imaging, classification systems, treatment principles including splinting and various operative fixation methods, and postoperative care. Key points covered include fracture patterns of the distal phalanx, middle phalanx, proximal phalanx and metacarpals as well as treatment approaches for each. Studies on outcomes of K-wire fixation versus ORIF for metacarpal fractures are summarized.

1. JOURNAL CLUB - 12.01.17
PRINCIPLES OF MANAGEMENT
OF HAND FRACTURES
Presentor- Dr. REJUL K RAJ
CMCH LUDHIANA

2. REFERENCES
• ROCK WOOD AND GREENS,
FRACTURES IN ADULTS – VIII th Edition.
• Campbell’s Operative Orthopaedics, XII th Edition.

3. ANATOMY
• 27 bones
• Carpals (8), metacarpals (5) and phalanges(14).
• The shaft of each metacarpal is curved - characteristic cup
shape.
• MCPJ- Condyloid joints , flexion and extension of the digits,
as well as a very small degree ofabduction and adduction
when the digits are extended.
• Phalanges - has a base, shaft, neck and head that is formed
from two condyles.
• PIPJ, DIPJ - Hinge joints, flexion and extension.

5. • The joint capsule is reinforced on its volar
aspect by the thickened ligament known as
the volar plate that prevents hyperextension
of the joint.

10. INTRODUCTION.
• One of the most commmon encountered
injuries.
• Phalangeal (23%) and metacarpal (18%)
fractures to be the second and third most
common fractures below the elbow.

11. • PREVALENCE AND DISTRIBUTION OF HAND FRACTURES
E. B. H. Van Onselen, R. B. Karim, J. Joris Hage And M. J. P. F. Ritt
Journal of Hand Surgery (British and European Volume, 2003) 28B: 5: 491–495

12. Injury Mechanisms
• The mechanism of injury description should include ,
– magnitude
– direction
– point of contact
– type of force

13. 1. Axial load or “jamming” injuries -
– shearing articular fractures or metaphyseal compression
fractures-
– catching a falling object-
2. Bending –
– Diaphyseal fractures and joint dislocations-
– ball-handling sports or when the hand is trapped
3. Torsional –
– spiral fractures
– Individual digits can easily be caught in clothing, furniture, or
workplace equipment
4. Crushing
– Bending + shearing + torsion-
– with significant soft tissue injury.

14. Injuries associated.
• Open injuries.
– Greatest challenge is thin and supple soft tissue
coverage.
• Tendons.
– Dislocations.
• Nerves and vessels.
• Massive hand trauma.
• Bone loss

15. Signs and symptoms
• Pain, swelling, deformity, stiffness, weakness,
and loss of coordination.
• Numbness and tingling - nerve involvement
• Signs - tenderness, swelling, ecchymosis,
deformity, crepitus, and instability.

16. Assessment of rotation.

19. Total active movement: TAM
• by sum of the angles formed by MCP, PIP and DIP joints in maximum
active flexion,
• minus total extension deficit at the MCP, PIP and DIP joints during active
finger extension.
• MCP joint can flex up to 85°
• PIP joint can flex up to 110°
• DIP joint can flex up to 65°.
• If the finger is capable of full extension, the loss of extension is 0°.
• As a result, TAM is measured as 260° (260°-0°: 260°).
• In a normal first finger, the MCP joint - 85° and the IP joint - 90°.
• TAM is measured as 175°.

20. FUNCTIONAL STABILITY
• Pun WK, Chow SP, So YC, et al.
A prospective study on 284 digital fractures of the hand.
J Hand Surg Am. 1989;14(3):474-81.
• fractures as functionally stable
• if patients could actively move the adjacent joint more
than 30% of the expected range while the alignment of
fracture remained within acceptable range.
• Unstable fracture
• If the patient was not able to move the adjacent joint
more than 30% of the expected range or
• movement resulted in malalignment.

21. IMAGING
• Anteroposterior
• Lateral
• Splay lateral views
– varying amounts of flexion to prevent phalangeal override
– best show only one digit in a true lateral projection.
• Oblique views -assessing reduction of articular fractures.
• True lateral views - ring and small finger MCs- 10 degrees of
supination
• Index and middle fingers - 10 degrees of pronation.

22. Description of fractures
• Location within the bone
– (HEAD, NECK, SHAFT, BASE)
• Direction of the fracture plane
– (TRANSVERSE, SPIRAL, OBLIQUE, COMMINUTED)
• Degree of displacement.
• Dislocations -direction the distal segment travels
– (DORSAL, VOLAR, ROTATORY)
• Capacity for closed reduction –
– SIMPLE OR COMPLEX

23. PRINCIPLES
• Negative effects of surgery on the tissues should not exceed
the negative effects of the original injury.
• Difficult decision making centers on management of the soft
tissues.
• The injured part must not be considered in isolation.

24. AIM
1. Sufficient stability of the bone or joint injury
2. To permit early motion rehabilitation
3. Without resulting in malunion or residual
instability
• The preferred treatment option is the least
invasive technique that can accomplish these
goals.

25. 5 major treatment alternatives
1. Immediate motion
2. Temporary splinting
3. CRIF
4. ORIF
5. Immediate reconstruction
• External fixation is a variation.

26. NON operative treatment.
• Advantages
– lower cost
– avoidance of the risks and complications
• Disadvantage
– is that stability is less assured

27. Closed reduction internal fixation.
• Prevent overt deformity
• Not to achieve an anatomically perfect
reduction.
• Pin tract infection is the prime complication.

28. Nonoperative Treatment- Principles
• Assessments of rotational malalignment and stability.
• Stability- 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
• Motion should be instituted by this time for all joints stable
enough to tolerate rehabilitation.

29. • Elevation and elastic compression.
• The more aggressive the surgeon’s management of the injury has
been, the more aggressive must be the rehabilitation.
• Low-energy isolated injuries have far less risk of stiffness.
• If the injury is reducible at all, gentle manipulation will accomplish
the reduction far more successfully than forceful longitudinal
traction.
• The principle is relaxation of deforming forces through proximal
joint positioning such as MP joint flexion to relax the intrinsics or
wrist flexion to relax the digital flexor tendons. part.

30. • Splints should immobilize the minimum number of joints
• Wrist immobilization - 25 to 35 degrees of extension.
• “Wounded paw” - wrist flexion + MP joint extension–
interphalangeal (IP) joint flexion (the position).
• Full motion of the IP joints should be encouraged
throughout.
• The total duration of immobilization - 3 to 4 weeks.
• Stable enough by this time to tolerate active range of
motion (AROM) with further remodeling by 8 to 10 weeks.

33. Open reduction internal fixation.
• Add the morbidity of surgical tissue
trauma.
• Titrated against the presumed advantage of
achieving the most anatomic and stable
reduction

34. Introduction to Distal Phalanx (P3) Fractures
• Terminal point of contact.
• Soft tissue coverage is limited.
• Soft tissue injury is of greater significance
• Hematoma can be seen beneath the nail plate- Open fracture.
• Mechanism – crushing.
• Radiographs - isolated views of the injured digit.

36. PATHOANATOMY
• Fractures in three primary regions:
– the tuft, shaft, and base
• The two mechanisms .
– sudden axial load (as in ball sports)
– crush injury

38. • Crush fractures of the tuft are often stable.
• Proximally, the digital flexor and terminal extensor
tendons insert on the volar and dorsal bases of the
distal phalanx.
• Majority of bone flakes at the volar base P3 are FDP
tendon ruptures

39. Distal Phalanx Fracture- Treatment Options
CONSERVATIVE.
• Digital splints
• should leave the PIP joint free
• needs to cross the DIP joint simply to gain enough
foundation

48. Middle Phalanx (P2) Fractures
• Intra-articular fractures that occur at the base of the middle
phalanx.
• Most functionally devastating of all fractures.
• the most technically difficult to treat.
• head, neck, shaft, and base.

49. Axial loading patterns ,
• Unicondylar or bicondylar fractures of the head.
• Intra-articular fractures of the base.
• Partial articular fractures
– Dorsal base
– Volar base
– Lateral base
• Complete articular fractures
– “pilon” fractures. “
– Unstable in every direction including axially.

50. Pathoanatomy and Applied Anatomy

53. Middle Phalanx Fracture- Treatment Options
• Static Splinting.
– Crushing- comminution with no significant displacement.
• Dynamic Extension Block Splinting.
– Volar base of P2 - less than 40% of the articular surface
• Condylar fractures
– CRIF- converging or diverging.
• Unstable shaft fractures
– CRIF – K wiring
– ORIF – Lag screw fixation – if rotational instabiity.
– Plate and screw fixation – if axial instability.

54. • Temporary Transarticular Pinning for Partial Articular Base
Fractures.
• Volar Base Fractures
– CRIF /ORIF
• Pilon fractures.
– Highly unstable,stifness of PIPJ.
– Dynamic traction / dorsal spring mechanism.
– The general principle is to establish a foundation at the center
of rotation in the head of P1.
– traction (adjustable or elastic) is applied along the axis of P2
to hold the metaphyseal component of the fracture out to
length
– while allowing early motion to remodel the articular surface

70. Proximal Phalanx (P1) Fractures
• Head - Intraarticular fractures
– partial or complete articular
• Neck - extra-articular fractures
– (extreme PIP limitation)
• Base - extra-articular and intra-articular.
• Shaft extra-articular fractures
– transverse, short oblique, long oblique, or spiral

73. PATHO ANATOMY – P 1 #
• sheet-like extensor mechanism with a
complex array of decussating collagen fibers

75. Intrinsic plus position

76. P 1 – Treatment options.
• Non operative.
– Stable proximal fractures, Transverse shaft.
– Dorsal splinting with the MP joint in flexion.
– discontinued at 3 weeks, followed by AROM .
– Stable + undisplaced – immediate AROM with
buddy strapping.
– Weekly folllow up.
• Operative – CRIF/ORIF

77. Closed Reduction + Internal Fixation.
• Reducible but unstable isolated fractures.
• For long oblique and spiral fractures
– three K-wires- perpendicular to the fracture
• For neck fractures-
– retrograde pinning may be necessary
• For short oblique and transverse fractures,
– longitudinal K-wires .

81. Open Reduction and Internal Fixation
• Indications :
– Open fractures
– multiple fractures
– intra-articular fractures with displacement
– Spiral fractures
• lag screws
• to achieve precise control over rotation.

91. Postoperative Care – P 1 #
• Non operative –
– Restrict splinting to 3 weeks followed by AROM.
• CRIF –
– pin removal at 3 weeks strat AROM.
• ORIF –
– AROM should begin within 72 hours of surgery
and edema control

92. • Prospective study - 43 fractures
• Inclusion criteria
– Functionally unstable fractures
– Unacceptable radiographic alignment (>10° in both AP and lat)

97. • RESULTS.
– Good function - 35 patient
– Fair – 6
– Poor – 2 (TAM less than 180)
• Nail traction with digital splint is an effective
and safe technique

100. Acceptable Reduction- criteria
1. <10º axial angulation – AP
2. <15º axial angulation - lateral view
3. No rotation
4. No collapse

101. • 32 patients.
• Inclusion criteria
– (1) single-digit, closed, proximal phalangeal
– fracture;
– (2) displaced, extra-articular involvement;
– (3) non-pathological, fresh (<1 week) injury
– (4) noassociated injuries
• The results were excellent in 72%, good in 22%, and poor in
6%.
• Skeletal stability, not rigidity, is necessary for functional
movements of the hand.

103. • 32 patients.
• Used splint only when the fracture line was stable.
• In case of unstable fractures - K-wire.
• TAM scores of 20 fingers were perfect (≥220°
• for D2-5, ≥150° for D1), for 7 fingers were good (180-
• 220° for D2-5, 120-150° for D1), and for 5 fingers were
• either moderate or poor.
• Kirschner wire fixation is a reliable and simple method of treating
unstable proximal phalangeal fractures.
• In stable proximal phalanx fractures, splints provide sufficient
treatment.

104. METACARPAL FRACTURES- INTRODUCTION
• Fracture patterns - head, neck, and shaft.
• Transverse Neck and shaft fractures - apex dorsal angulation.
• normal anatomic neck to shaft angle of 15 degrees.
• Evaluation of rotation .
• Ten degrees of malrotation ( 2 cm of overlap at the digital tip)
is the upper tolerable limit.

109. Pathoanatomy and Applied Anatomy
• formation of the three arches of the hand.
• 20% thicker volar cortex.
• bound to each other by strong interosseous ligaments at their
bases and by the deep transverse intermetacarpal ligaments
distally.
• 2 mm of metacarpal shortening, 7 degrees of extensor lag
• In the sagittal plane, the primary deforming forces are the
intrinsic muscles
– counteracted through MP joint flexion,
– reduction maneuver

110. Treatment - Nonoperative Management
• Intra-articular fractures of the head and base
– stable and minimally displaced.
• dorsal splint in full MP joint flexion.
• Greater degrees of angulation are tolerable in neck
• Greater angulation is tolerable in the ring and small metacarpals
than in the index and long metacarpals
– because of the increased mobility of the ulnar-sided CMC joints.
• 30 degree at small MT.

111. Closed Reduction and Internal Fixation
• Isolated metacarpal fractures not meeting the criteria for
nonoperative.
• Extra-articular and intra-articular fractures
• anatomically reducible and stable to the stress of motion

114. Intramedullary Fixation
• Transverse and short oblique fracture patterns
• large diameter rod such as a Steinmann pin, an expandable
intramedullary device, multiple prebent K-wires

118. Open Reduction and Internal Fixation
• Indications :
– Intra-articular fractures that cannot be reduced
– multiple fractures without inherent stability
– open fractures especially when associated with tendon
disruptions.
• Internal fixation can be accomplished with
– intraosseous wiring,
– composite wiring,
– screws only, or
– Screws and plates

125. Post op care- MT #.
• The importance of early motion must be considered in direct
proportion to the magnitude of the injury or the surgical
procedure performed.
• When internal fixation has been required, one must anticipate
the development of an extensor lag at the MP joint.

130. • The degrees of angulation for each digit that may for surgical
fixation are
– - 15 for the index finger
– - 25 for the long finger
– - 35 for the ring finger
– - 45 for the small finger

131. • A systematic review.
• Five non-comparative studies were found.
– Two studies reported on 36 ORIF-treated patients.
– Three studies reported on 65 K-wire-treated patients

133. • Complications
– 8 ORIF-treated patients (22 %)
– 23 K-wire-treated patients (35 %)
• Functional outcome
– functional impairment requiring reoperation was reported
in 6 ORIF-treated patients (17 %) and in none ofthe K-
wire-treated patients.
• Conclusions
– ORIF to be a less favorable technique for single, closed
metacarpal shaft fractures

134. Carpometacarpal (CMC) Fractures
• The normal ROM at the thumb CMC joint
• 50 degrees of flexion-extension
• 40 degrees of abduction-adduction
• 15 degrees of pronation-supination.

149. THANK YOU

153. Ten Years Stable Internal Fixation of Metacarpal and Phalangeal
Hand Fractures—Risk Factor and Outcome Analysis .
Journal of Trauma-Injury Infection & Critical Care
Bannasch, Holger MD; Heermann, Anne K. MD; Iblher, Niklas MD;
Momeni, Arash MD; Schulte-Mönting, Jürgen Dr. rer. nat;
Stark, G. Bjoern MD
March 2010 - Volume 68 - Issue 3 - pp 624-628
• 365 patients treated during the last 10 years
• Results: Uneventful bony consolidation was observed in 91.2%.
• The functional results were excellent to acceptable in 85.2%, whereas in
14.8% (n = 54), the result was unsatisfactory, the latter group
presenting with concominant soft tissue injury.
• Conclusion:
• These results confirm that most patients with open metacarpal and
phalangeal fractures can be treated by stable internal fixation.

154. • Clinical Orthopaedics & Related Research:
• April 2006 - Volume 445 - Issue - pp 133-145
• doi: 10.1097/01.blo.0000205888.04200.c5
• SECTION I: SYMPOSIUM: Problem Fractures of the Hand and Wrist
• Extraarticular Hand Fractures in Adults: A Review of New Developments.
• Freeland, Alan E MD*; Orbay, Jorge L MD†
• Section Editor(s): Meals, Roy A MD, Guest Editor; Harness, Neil G MD, Guest Editor
• Abstract
• This report cites new developments in the treatment of extra-articular hand fractures in adults. Recent reports
confirm that small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment.
Unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal
joint facilitates proximal phalangeal fracture exposure and may improve functional recovery. Results using open
mini screw fixation of oblique extra-articular metacarpal and phalangeal fractures may be comparable to those
of percutaneous Kirschner wire fixation. Bicortical self-tapping mini screw fixation of extra-articular oblique
metacarpal and phalangeal fractures simplifies screw insertion and provides stability comparable to that of
fractures fixed with lag screws. Percutaneous intramedullary wire fixation may afford suitable fixation for
unstable extra-articular oblique as well as transverse metacarpal fractures. Locked intramedullary nails may offer
similar advantages. Unicortical screw fixation of mini plates securing transverse extra-articular metacarpal
fractures affords stability comparable to that of bicortical screw fixation while creating less bone damage. The
dissection required for plate fixation and the small surface area of transverse fractures delay and occasionally
impair bone healing. Primary bone grafting of diaphyseal defects in clean stable wounds may shorten and
simplify treatment and decrease morbidity. As little as 1.7 mm of flexor tendon excursion during the first 4 weeks
after reduction or repair may substantially diminish peritendonous adhesions at the fracture site. Synchronous
wrist and digital exercises may also reduce peritendonous fracture adhesions. Early motion of adjacent joints in
closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting
fracture alignment and leads to earlier return to work.
• Level of Evidence: Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of
evidence.

155. • Journal of Trauma-Injury Infection & Critical Care:
• March 2002 - Volume 52 - Issue 3 - pp 535-539
• Original Articles
• Complications of Plate Fixation in Metacarpal Fractures
• Fusetti, Cesare MD; Meyer, Henning MD; Borisch, Nicola MD; Stern, Richard MD; Santa, Dominique
Della MD; Papaloïzos, Michael MD
• Abstract
• Background : The objective of this study is to assess the complications after open reduction and
plate fixation of extra-articular metacarpal fractures.
• Methods : We retrospectively reviewed the clinical and radiologic records of 129 consecutive
patients with 157 metacarpal fractures treated by open reduction and internal fixation with plates
between 1993 and 1999. Intra-articular fractures and fractures of the thumb metacarpal were
excluded. Eighty-one patients (64 men and 17 women) with 104 fractures were available for
review, at an average follow-up of 13.6 months (range, 6–27 months).
• Results : Twenty-eight patients (35%) and 33 fractures (32%) had one or more complications,
including difficulty with fracture healing (12 patients [15%]), stiffness (eight patients [10%]), plate
loosening or breakage (seven patients [8%]), complex regional pain syndrome (two patients), and
one patient who developed a deep infection.
• Conclusion : Despite technical advances in implant material, design, and instrumentation, plate
fixation of metacarpal fractures remains fraught with complications and unsatisfactory results.