14
Hand and Wrist Fractures and Dislocations
The Hand
Physical Examination
A complete physical examination to determine the integrity of the neurovascular, musculoskeletal, and cutaneus system is warranted. Dedicated hand series radiographs should include AP, true lateral, and oblique views. In selected cases of carpal fractures and wrist injuries, a CT scan may be indicated.
Fracture Classification
• Open versus closed
• Displaced versus nondisplaced
• Transverse versus oblique versus spiral versus comminuted or avulsion
• Traumatic versus pathologic
• Adult versus pediatric
In pediatric patient: Green stick versus epiphyseal plate
In epiphyseal plate: Salter-Harris classification
Fracture Treatment
In general, hand fractures can be treated in the emergency room with closed reduction and splinting. However, if the fracture is open, displaced, unstable, or if the angulation is not acceptable, then operative treatment may become necessary.
Open Fractures
• Perform a finger or wrist block
• Culture and irrigate open fractures profusely
• Administer IV antibiotics (ER treatment or inpatient)
Ampicillin 500 g IV q8h + gentamycin 3 to 5 mg/kg q.d. divided 8 hours (check peak and through serologic levels)
Vancomycin 1 gm IV q 12h + Ceftriaxone 1 to 2 gm IV q24h
Outpatient prophylactic antibiotic for patients with plan for later surgery includes Bacitracin DS and PO b.i.d.
• Irrigate the wound and splint the patient in preparation for operative reduction
Phalangeal and Metacarpal Fractures
Indications for Operative Treatment
• Intraarticular fracture
• Irreducible fractures
• Malrotation
• Subcapital phalangeal fractures
• Open fracture if displaced or angled
• Bone loss
• Multiple fractures
• Fractures with soft-tissue injury
Phalangeal Fractures
Distal Phalanx Fractures
Distal phalanx fractures are the most common fractures in the hand. The thumb and middle finger are most likely involved. Patients present with tuft fractures, shaft fractures, and intraarticular injuries due to crush.
Tuft Fractures
Open Fractures
• Perform finger or wrist block
• Remove nail
• Irrigate
• Repair nail bed with 6.0 to 7.0 chromic and stent the nail matrix (see Chapter 17, Fig. 17–2)
• Immobilize DIP joint in extension with tongue blade or aluminum splint for 3–4 weeks with PIP free
• In cases of severe comminution, soft-tissue repair is adequate for splinting fractures
• Treat with Bacitracin DS and PO b.i.d. × 5 days
Closed Fractures
• Perform finger or wrist block
• If a hematoma is present under the nail, drain it with a drill (sterile 18-gauge needle tip), heated paper clip, or electrocautery
If the hematoma >50% of nail bed, likely nail bed injury
Remove and repair nail bed and splint with piece of foil from chromic package or use the nail itself (see Chapter 17, Fig. 17–2)
• Splint finger for 2 weeks
• Treat with outpatient antibiotics × 5 days
Shaft Fractures
• Nondisplaced
Repair soft tissue
Splint 3 weeks
Bacitracin DS and P. O. b.i.d.
• Displaced
Likely nail bed laceration
Repair nail matrix (see Chapter 17, Fig. 17–2)
Stabilize fracture with K-wire or 18-gauge needle
Splint finger with PIP free for 3 weeks
Outpatient antibiotics × 5 days
Intraarticular Fractures
• Open fracture
Repair nail bed
Splint DIPJ in extension for 6–8 weeks
Outpatient antibiotics
• Closed fracture
Splint DIPJ in extension
Dorsal Base
An intraarticular fracture of the dorsal base (mallet fracture) is a hyperflexion injury in which a portion of the dorsal bone breaks off with extensor mechanism. It causes extensor lag with a mallet finger deformity. Treatment requires strict patient compliance. In pediatric population this may require a K-wire through DIPJ.
• Treat with splint in extension for 6 to 8 weeks
Volar Base (FDP Avulsion)
An intraarticular fracture of the volar base is a hyperextension injury in which the flexor digitorum profundus (FDP) pulls off the distal phalanx.
• Treat with ORIF because FDP may retract into palm
• Splint hand in emergency room with tongue blade or aluminum splint
• If open, wash out, repair nail bed, start antibiotics, and splint
Middle and Proximal Phalanx Fractures
Middle and proximal phalanx fractures are caused by crushing forces rather than direct blow, twisting, or angular forces. If these fractures are nondisplaced or stable, simply buddy tape or splint with IP extended for 3–4 weeks. A comminuted, displaced fracture of the middle or proximal phalanx proximal to the articular surface is called a pilon fracture.
Articular fractures
• In ER setting
Fracture of single digit: ensure involved joint is in extension
Aluminum or tongue blade splint
Multiple fractures: Splint hand in intrinsic plus
Follow up in clinic for operative management
• Non-displaced: Inherently unstable.
Operative management using either closed or open reduction and fixation by multiple k-wires or screws or a combination.
If non-operative management chosen then close follow up required
• Displaced
Dorsal base fractures of middle phalanx
ORIF to avoid Boutonniers defect
Dorsal base fractures of proximal phalanx
Requires ORIF
• Unicondylar (Displaced)
Inherently unstable either closed or open reduction and fixation with multiple K-wires or screws
Extension splint 2–3 weeks
• Bicondylar
Requires ORIF
Non-comminuted
Fix condyle to condyle first then to the shaft with K-wires or screws
Comminuted
Difficult to treat
DIPJ:
• Minimal displacement: Closed reduction.
Splint 2 weeks in extension
Physical therapy in 2 weeks
• Displaced:
ORIF with K-wire/screw fixation
Early motion at 2 weeks
PIPJ:
• Skeletal traction of the middle phalanx for 3–4 weeks with forearm splint.
• Active flexion of PIPJ immediately
Nonarticular fractures
• Shaft
Non-displaced and stable- not rotated, angulated, or comminuted
Splint the finger in extension with an aluminum splint
Must cover proximal and distal joint
Duration of 1 week
• Once pain and swelling resolve then buddy tape to adjacent finger and begin range of motion
Displaced but amenable to stable closed reduction
Usually transverse fractures not oblique or spiral
Attempt reduction and stabilization
Perform digit block (See Chapter 13, Fig. 13–1)
Flex MPJ maximally
Flex distal fragment to correct volar angulation
Dorsal splint in intrinsic plus position
Plaster should be placed dorsally for extension blocking. MP 90°, IP extended, include adjacent digits in splint for stabilization
Splint for 3 weeks, then buddy tape for additional 2 weeks
Unstable—if potential for rotation or angulation exists
Open, oblique, spiral, comminuted fractures
Radiographically angulated
Assess by having patient flex finger
Fingers overlap
Plan closed reduction with percutanous pinning with in 3–4 days
Use 0.035–0.045 inch
Unstable transverse fractures
Intramedullary longitudinal fixation through metacarpal head with k-wire
Extension block splint in intrinsic plus position with IP joints free for 3–4 weeks
Comminuted fractures
Require operative management
External fixation device often indicated
Preserves length
Assists with management of soft tissue injuries
For unsuccessful percutaneus pinning perform ORIF with plates or interaosseous wireing
Base fractures of proximal phalanx
• Extraarticular
Angulation of 25° in adults and 30° in children requires treatment
To reduce:
Flex MP maximally
Flex distal fragment to correct volar angulation
Splint in intrinsic plus (dorsal plaster) for 3 weeks
Failed closed reduction
K-wire fixation
Metacarpal Fractures
Head Fractures
• Open fractures 2° to closed-fist injury (fight bite)
Wrist or local block
High-pressure irrigation and débridement
Leave wound open
Delay fixation until sign of fixation subsided
Full access? Get Clinical Tree
