Hand and finger fractures

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

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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� of extension
  - Type III - Short arm thumb-spica extening to the IP joint and wrist in 30� 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

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� flexion, wrist in 20-30� extension, PIP and DIP joints in 5-10� 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

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� in 2nd and 3rd and >20� 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

Examination
- Movement at the wrist elicits pain
- Assess for ulnar deficits (finger abduction/adduction)
- Assess for rotational alignment
Imaging
- AP, lateral, oblique
- 30� 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� 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)

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