6 Fractures, Dislocations, and Ligament Injuries of the Hand

Richard Samade and Hisham Awan

Abstract

This chapter will provide the reader a concise overview of various traumatic injuries that are commonly encountered in the hand. The osseous structures of interest described in this section include the metacarpals and phalanges. For each pathology summarized, emphasis is placed on descriptions of the mechanism of injury, relevant anatomy, clinical presentation, appropriate imaging, and recommended treatments. Figures with radiographs are also provided to illustrate key pathologies and treatments. This chapter is designed to provide an easily readable reference that will aid the orthopaedic practitioner in determining appropriate treatment for a traumatic pathology encountered during consultations in the emergency department, inpatient ward, or outpatient clinic. Thus, it will ideally be a useful resource for orthopaedic residents, advanced practitioners, and practicing orthopedic surgeons. References for the core material outlined here are listed at the end of this chapter and contain further information on each topic presented for the interested reader.

Trauma – fracture – dislocation – intra-articular – extra-articular – ligament – tear

6 Fractures, Dislocations, and Ligament Injuries of the Hand

I. Fractures of the Metacarpals

A. Thumb Metacarpal Base Fractures

Mechanism of injury
- Trauma (e.g., fall or punch) with axial loading and partial flexion of the thumb metacarpal. ¹ , ²
Relevant anatomy and epidemiology
- Fractures can be extra-articular, intra-articular with a stable volar-ulnar fragment (a Bennett’s fracture), or intra-articular with comminution (a Rolando’s fracture, see ► Fig. 6.1a).
- Deforming forces: Adductor pollicis, abductor pollicis longus, and extensor pollicis longus.
Clinical presentation
- Pain, swelling, and limited range of motion (ROM) at the base of the thumb.
Imaging used for diagnosis
- Thumb X-ray series is best for diagnosis and to evaluate for intra-articular extension.
Treatment
- Nonoperative: Stable, extra-articular, and <30 degrees of angular deformity can be splinted.
- Operative: If unstable or intra-articular, then proceed with open reduction internal fixation (ORIF) versus closed reduction percutaneous pinning (CRPP) (► Fig. 6.1b).

**Fig. 6.1 (a)** A lateral radiograph of a hand with a comminuted intra-articular base of thumb fracture (Rolando variant) with associated soft tissue swelling. **(b)** Rolando’s fracture shown in **(a)** after open reduction and percutaneous pinning.

B. Metacarpal Base Fractures Other than the Thumb

Mechanism of injury
- Direct trauma (e.g., from punch) is the mechanism ofall non-thumb metacarpal fractures. ¹ , ² , ³ , ⁴
Relevant anatomy and epidemiology
- May be extra-articular or intra-articular, usually apex dorsal due to intrinsic forces.
- It is important to evaluate for concomitant carpometacarpal (CMC) joint dislocation.
Clinical presentation
- Pain and swelling in middle hand present, sometimes with open wounds or tenting of skin.
- Evaluate all metacarpal fractures for malrotation by confirming that the cascade of fingertips, when the patient makes a closed fist, points to the scaphoid.
Imaging used for diagnosis
- Usually, a full hand X-ray series suffices to diagnose all metacarpal fractures.
Treatment
- Nonoperative: Treat with reduction and splinting in intrinsic plus position for:
  - A nondisplaced intra-articular fracture.
  - An extra-articular fracture with no malrotation and with acceptable angulation (10 degrees for index [IF], 20 degrees for long [LF], 30 degrees for ring [RF], and 40 degrees for small [SF] fingers).
- Operative: If none of the above, consider proceeding to ORIF with plate versus CRPP.

C. Metacarpal Shaft Fractures

Relevant anatomy and epidemiology
- Fractures may have transverse or oblique orientation, with the latter prone to shortening. ¹ , ² , ³ , ⁴
Treatment
- Nonoperative: Can do closed reduction and immobilization if no malrotation and acceptable angulation (10 degrees for IF, 20 degrees for LF, 30 degrees for RF, and 40 degrees for SF).
- Operative: Consider ORIF with plate/screws versus CRPP for oblique fractures (► Fig. 6.2).

**Fig. 6.2** An anteroposterior (AP) radiograph of a hand demonstrating an unstable oblique metacarpal shaft fracture of the ray of the ring finger, stabilized with four screws.

D. Metacarpal Head and Neck Fractures

Relevant anatomy and epidemiology
- Head fractures commonly lead to joint incongruity if displaced or comminuted. ¹ , ² , ³ , ⁴
Treatment
- Nonoperative: Can be treated with reduction and splinting in intrinsic plus position for nondisplaced intra-articular head or extra-articular neck fractures (with no malrotation and acceptable angulation of 10-15 degrees for IF and LF, up to 40 degrees for RF, and up to 60 degrees for SF).
- Operative: If none of the above, consider ORIF with plate/screws versus CRPP versus head arthroplasty (if a high degree of comminution is present).