This document provides an overview of the management of hand fractures. It discusses the goals of treatment which include restoring anatomy, reducing malrotation and angulation, maintaining reduction with minimal surgery, and rapid mobilization. Most closed hand fractures can be treated with closed reduction and splinting, while unstable or intra-articular fractures often require operative fixation techniques like K-wiring, tension band wiring, plating, or external fixation. Common fractures of the hand including metacarpals, phalanges, and thumb are described along with appropriate treatment options and techniques. Potential complications of treatment are also outlined.

1. MANAGEMENT OF HAND
FRACTURES
DR. MUJTUBA PERVEZ KHAN
RESIDENT PLASTIC AND RECONSTRUCTIVE
SURGERY

2. GOALS OF MANAGEMENT
1. Restoration of articular congruity
2. Reduction of Malrotation
3. Reduction of Angulation
4. Maintenance of reduction with minimal
surgical intervention
5. Rapid mobilization

3. PRINCIPLES OF FRACTURE
TREATMENT
• The majority of closed hand fractures can be
effectively treated by closed reduction and splinting
• Stable, undisplaced fractures can be treated by
splinting or buddy taping alone
• Unstable fractures are to be reduced, stabilized and
splinted
• Varying degrees of angulation of fracture is acceptable
• No degree of malrotation is acceptable

5. INDICATIONS FOR OPERATIVE
FIXATION
• Irreducible fractures
• Malrotation
• Intra articular fractures
• Open fractures
• Segmental bone loss
• Multiple fractures
• Fractures with significant soft tissue defects

6. TECHNIQUES OF BONE FIXATION
• Most frequently used
• Provides stability, but does not add compression on the
fracture
• Single K-wire alone cannot provide rotational stability,
therefore, at least two wires in different planes are
necessary to prevent rotation
• Disadvantages: lack of rigidity, pin loosening, pin tract
infection, and the necessity for additional immobilization
K- Wires (Kirschner Wires)

7. • Typically 1.0 – 1.3 mm K wires sufficient
for almost all hand fractures. For children
0.9 mm are more appropriate
• Steps of insertion
• Confirmation by Fluoroscopy
• Additional POP/Splint may be necessary
• Pre and Post op X-rays are important

8. • Interfragmentary
compression with wire loops
around the k-wire
• Provides compression
• Steel wire is guided in a
figure of 8 fashion and
tightened dorsally
counteracting the strong pull
of flexor tendons.
• Provides early motion
Tension Band Wiring

9. • Used for Transverse fracture
of the phalanges, joint
fusion, osteosynthesis in
replantation
• K wire inserted for guide
dorsal to palmar, dental wire
is tightened circumferentially
Interosseous Wiring

10. • Suitable for transverse
fractures
• Steinmann pins (similar to K-
Wire but with larger
diameters) or multiple k
wires are used
• Disadvantages: Rotational
instability, pin migration
Intramedullary Fixation

11. • Lag screws can be used in
oblique and spiral fractures
• Compression can be
applied between the
fracture fragments using
the lag screw
Compression Screws

12. • Main benefits are Rigid
Fixation and Maintenance
of bone length
• Indicated in metacarpal
fractures, reconstruction of
malunion and nonunion
• Plate fixation is associated
with a higher rate of
extensor tendon adhesion
formation
Plate Fixation

13. • For Complex Fractures,
highly comminuted
fractures with bone loss,
gunshot wounds, fractures
with severe soft tissue loss
and contamination
• Bridges across the fracture
• Stabilizes the fragments
until soft tissue healing
occurs
• Preservation of vascular
External Fixation

14. METACARPAL FRACTURES
• Most common location of metacarpal
fracture
• Referred as Boxer’s fractures, results
from fist striking the wall or human face
• Most frequently in the 4th and 5th
metacarpals
• Majority of these fractures are treated
by closed reduction and cast
immobilization in 70° flexion of MCPJ
for 4wks
• Modified Jahss maneuver for reduction
Metacarpal Neck Fractures

15. • If unstable after closed reduction, K
wiring in retrograde or in a
transverse manner to the adjacent
metacarpal may be necessary
• Transverse method allows active
exercise after 1week and shows
excellent outcomes.

16. Modified Jahss Maneuver
• Flexion of MCPJ of the fractured
digit at 90°
• Middle phalynx is pressed
dorsally
• Volarly directed counter pressure
on the metacarpal body

17. • Stable, undisplaced fractures are
treated with a cast for 4 weeks after
closed reduction
• If unstable, go for K wiring
• Comminuted fractures favor open
reduction and plate fixation
• Oblique fractures can be treated by
lag screws
• Multiple fractures can lead to
compartment syndrome
• Fasciotomy: Two longitudinal
incisions are made over the 2nd and
4th metacarpal bases
Metacarpal Shaft Fractures

19. • Due to high energy trauma
• May involve dislocation of the
carpometacarpal joint
• If reduction cannot be
accomplished with closed
reduction, K-wire fixation or plate
fixation is required.
• Intra articular base fracture of the
5th metacarpal is called Reverse
Bennett Fracture, unstable due to
the pull of ECU
Metacarpal Base Fractures

21. • Base fractures are much more
common than shaft fractures. MC
head fractures are rare
• Most fractures can be treated by
closed reduction and casting
• Fracture is immobilized for 4-6wks in
a thumb spica cast
• Bennett fracture: Intra articular
fracture of the metacarpal base. MC
bone is displaced due to the pull of
APL
• Closed reduction with K wire is the
choice of treatment
• K wire is anchored into the trapezium
or the base of 2nd metacarpal
Metacarpal Thumb Fractures

22. • Lag screws and plates can also be
used
• Rolando Fractures: Comminuted
fracture of the base, at least 3
fragments. T or Y shaped.
• Treatment of choice is open reduction
with condylar plates or K wires
• Even with excellent surgical
technique, posttraumatic arthritis of
the carpometacarpal joint may result
over time.

24. PROXIMAL AND MIDDLE PHALANGEAL
FRACTURES
• Proximal and Middle phalangeal
fracture have similar properties
• Stable fractures are ideal for dorsal
splinting with 70° MCPJ flexion
• Any fracture showing rotational
deformity requires ORIF
• Condylar fractures are unstable and
require an open approach
• Stabilization is achieved by K wires,
screws and T plates

25. • Fracture dislocation are complex
and may lead to stiff, painful and
arthritic joint
• Treatment options: Screw fixation, K
wire, external fixator and
arthroplasty

26. DISTAL PHALANGEAL FRACTURES
• Most common hand fractures
• Result of direct trauma
• Classified into Tuft, Shaft and Base
fractures
• Commonly accompanied by nail bed
injuries and subungual hematoma
• Volar splint is used to immobilize
DIPJ for 2-3wks
• K wires are used
• Mallet fractures: deformity of the
finger caused when the extensor
tendon is damaged, FDP pulls the
distal fragment

27. COMPLICATIONS
• The most common complication is Pin Tract infection after K
wiring. Administer antibiotics and removal of the wire is the
only reasonable treatment
• Tendon adhesion and rupture, infection, malunion, nonunion,
plate prominence and joint stiffness may be associated with
plating and hardware usage
• Infection. Common bacteria are Staphylococci and
Streptococci
• Malunion may occur after internal fixation with one longitudinal
pin
• Angulated metacarpal fractures may result in pseudoclawing
and pain while gripping. Wedge osteotomy is sufficient for
correction

28. THANKYOU