Hand Fractures

More than half of all hand fractures are related to occupational injuries.  Fractures of the hand can include fractures of the metacarpal bones or the phalanges.  The breakdown of hand fractures include the following:
  • Distal phalanx—45 percent
  • Metacarpal—30 percent
  • Proximal phalanx—15 percent
  • Middle phalanx—10 percent
There are greater numbers of hand fractures in males when compared to females, in part because of an increase in sports injuries and occupational exposure to those things that can cause hand fractures.
 
Mechanism of Injury

There are a wide range of mechanisms that can cause hand fractures.  Some of these include “jamming” injuries in sports, such as when trying to catch a ball.  Dislocations and diaphyseal injuries occur when there is a bending of the hand as part of the injury, such as when the hand is trapped by an object and can’t move with the rest of the arm.  Individual fingers can get caught in clothing or equipment, resulting in a spiral fracture or a complicated dislocation of the finger.  Crushing injuries happen in the workplace, which can fracture just about any bone in the hand.
 
Evaluation of Hand Fractures
 
A careful history of the mechanism of injury needs to be undertaken to make sure there isn’t evidence of an open fracture of the hand such as can occur with a bite or barnyard injury to the hand.  The circulation of the distal finger must be assessed, including having capillary refill of the nail bed of less than 2 seconds.  Neurological status distal to the fracture must also be assessed by using two-point discrimination.  Rotational deformities must be assessed as these can greatly impact the outcome.  Comparing the alignment of the fingernails is a good way to see if there is any rotational deformity to the fracture.

X-ray using AP and lateral x-ray views are usually all that is required although oblique views might be necessary to define the fracture.  Injured fingers should be evaluated separately on lateral view so there is minimal overlap of the other fingers onto the injured finger.
 
Classification of Hand Fractures

Hand fractures are identified as being open or closed, specific location, fracture pattern (comminuted, spiral, vertical split or transverse), the presence or absence of any type of displacement of the bone and the presence or absence of a rotational or angulation deformity.  Some fractures involve the joints; some are stable and some are not stable.
 
Treatment of Hand Fractures
 
Make sure that the fracture is not open. Any laceration or tooth mark in the hand might indicate the presence of an open fracture.  Animal bites need antibiotic coverage for the common pathogens found in the mouths of animals.

There are five types of treatment alternatives for hand fractures. These include:
  • Immediate motion of the hand
  • Temporary splinting of the hand
  • Closed reduction of the fracture
  • Open reduction and internal fixation of the hand
  • Reconstruction of the hand
Ideally the fracture should be treated without surgery to avoid surgical complications and anesthetic complications.  Contraction of the soft tissues of the hand can occur beginning at 72 hours post injury so that movement of the non-injured part of the bones must be undertaken as soon as possible.

Surgery is done for these kinds of hand fractures:
  • Unstable fractures
  • Open fractures
  • Fractures that cannot be reduced externally
  • Fractures with loss of bone
  • Multiple fractures of the hand
  • Fractures that include tendon lacerations.
If the fracture is stable, then buddy taping or splinting is appropriate with follow up x-rays taken at one week post-injury.  Unstable fractures that are reduced and turned into stable fractures can be immobilized in gutter splints, casting, splinting with anterior or posterior splints or percutaneous pinning of the fracture.  Unstable fractures need closed reduction with pin placement to hold the hand fracture together; alternatively open reduction and internal fixation can be done using wiring or tension bands to hold the fracture in place.  If bone is lost, surgery with bone grafting may be necessary.
 
Complications of Hand Fractures
 
These can include malunion, in which there is a loss of balance of the hand due to angulation or rotation of the finger affected.  Nonunion is rare but can occur with open fractures that are contaminated or with fractures involving a great degree of soft tissue injury.  Other complications include infection of the hand in open fractures, joint contractures, loss of hand motion and post traumatic arthritis of the hand.
 
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