Hand and finger fractures

Background

• Splinting is used in the initial immobilization of, and often is the definitive treatment for, metacarpal fractures
• Maintenance of the MCP joint in flexion is important to avoid immobility contractures of the collateral ligaments

Thumb metacarpal Fx

• 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
• 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
• Dispo
  • Refer within 3-5 days:
    • All intraarticular fractures warrant referral (most require sx)
    • Extraarticular fractures that cannot be adequately reduced

Non-Thumb Metacarpal Head Fx

• 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
• 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
• 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 Fx

• 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
  • 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
• Dispo
  • Refer for:
    • Comminution
    • Rotational malalignment

Non-Thumb Metacarpal Shaft Fx

• 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

Non-Thumb Metacarpal Base Fx

• 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
    • Etraarticular fx with malrotation
    • Dislocation of metacarpal base CMC joint;
    • Ulnar nerve injury
    • 5th metacarpal base fx (typically require sx)

Source

UpToDate