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Chapter 25
Hand Fractures and Dislocations

Bill Rhodes and Louis Carter

Preface

This chapter is included for those surgeons who have the time, knowledge,
expertise and equipment to handle hand fractures. Many general surgeons
in remote hospitals may not have the time to treat hand fractures, even
though it is important to the individual patient to have a functional hand. If
the surgeon is comfortable in treating fractures, then this chapter will enable
one to treat fractures of the hand in district hospitals in the Sub-Saharan
area. Most closed hand fractures will be splinted or casted with or without
attempted manipulation. With most closed fractures closed treatment is best
and allows for good and rapid healing. This chapter is written to give
guidelines for those closed fractures that are grossly displaced, angulated or
rotated and for the treatment of open fractures. Common dislocations will
also be covered. Attempt will be made to give the surgeon a simple method
for treating these injuries with the equipment and technology that is available
in district hospitals. Hand anatomy and hand incisions are shown in basic
texts that most hospitals will have available. These should be available your
operating room before you begin surgery.

Introduction
Traumatic injuries to the hand present a significant challenge to the general
surgeon because of the complex anatomy and the endless number of possible
traumatic scenarios. Injuries can range from simple closed fractures to
complex open wounds that involve both fractures and injuries to tendon and
neurovascular structures. The goal of this chapter will be to describe the
common fractures/dislocations and treatment options within a clinical context
that has limited diagnostic and treatment capabilities (e.g., C-arms with
fluoroscopy and small plates and screws).

There are several factors that are especially relevant when considering
fractures/dislocations of the hand in the developing world context:

1) Delay in seeking medical attention

2) Delay in treatment because of other life or limb threatening injuries
3) Forced dependency on physical exam with the lack of specialized
diagnostic capabilities
4) The lack of available internal and external fixation devices for
stabilization of hand fractures/dislocations (Indian suppliers of these
can be found across Africa now).
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5) Non-compliance in postoperative follow-up for wound care and physical

therapy
6) The general lack of trained therapists for rehabilitation after hand
injuries

Even the best surgical intervention can be undermined by the non-compliance

of the patient during the postoperative phase as well the inability to provide
timely and effective hand therapy to restore function. The surgeon must take
a realistic approach in the management of hand fractures to deliver the best
result possible. While there are few actual hand therapists in the Sub-
Saharan Africa, there are many physical and occupational therapists.
Unfortunately, few of these have actual hands on experience in hand therapy
and very few of these are in district hospitals.) Thus, the doctor must also be
his therapist in these hospitals.

Because of the lack of fluoroscopy (C-arms) many fractures/dislocations that

potentially could be treated by closed methods must be treated by open
reduction for direct visualization and simple percutaneous pinning with
Kirschner wires. Actually even with a C-arm, percutaneous pinning with K-
wires can be a very difficult procedure which often requires a lengthy learning
curve.

(Editor’s Note: Open reduction and internal fixation should only be

carried out for the most severe of closed hand fractures. Open reduction
is not without complications and scarring after open reduction will often
leave the patient’s hand stiffer than it would have ever been—maybe
reduced but non-functional. A painful non-union in a hand that moves is
better and easier treated than a painless union in a stiff hand. If the
wound is already open, then one should go ahead and fix significantly
displaced or angulated fractures and dislocations.)

Initial Evaluation

All fractures and dislocations involving the metacarpals and phalanges should
be assessed in a thorough and thoughtful manner. An appropriate history
and physical exam must be performed. Concerns include:

♦ The time since the injury occurred, hours, days, weeks, or even months
♦ Specific site of pain, tenderness, swelling, deformity, and if there is an
open wound
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♦ Determine if inability of movement is secondary to pain, fracture, tendon

or nerve injury
♦ Determine if there are other associated upper extremity injuries
involving elbow or shoulder
♦ Review appropriate x-rays to evaluate any fracture/dislocation.
• The basic hand views are AP, lateral and oblique. Often oblique x-
rays are not taken but some oblique, spiral and small intra-
articular fractures may be missed unless oblique views are also
taken.
• X-ray technicians must learn to take films of an individual finger
alone and not the entire hand when only a single finger is injured.
A full hand x-ray often does not show a finger deformity clearly.
• There are special x-rays to help diagnose certain fractures when
clinical exam suggests a fracture and routine x-rays fail to
demonstrate an abnormality. These will be mentioned below.

Fig 1 Fig 2
Importance of oblique views—see base of ring proximal phalanx
Fracture difficult to see on PA view but obvious on oblique

Initial Care

Prompt attention to cleaning all wounds or open fracture sites is a priority.

This may require sedation with local or regional anesthesia or even general
anesthesia. Hand and upper extremity wounds can be débrided and closed if
< 24 hours old. Ideally tendon, nerve and bony injuries will be treated
acutely. If someone with the expertise to repair these structures is not
available, then débridement and copious irrigation should be followed by loose
closure (see chapter on Wound Closure—“Clean Closed Wound Concept.”) The
hand should be elevated at all times postop. Definitive repair can be
performed later as this is now a clean closed wound. DO NOT just dress an
open wound with the thought of definitive surgery the following day. It is
always best to loosely close the wound immediately if adequate débridement
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has been carried out since no one can predict the operating room schedule the
next day. Ideally delayed repair should be done as soon as possible but a
delay of 7-10 days is not harmful. Systemic antibiotics should be given in
cases of open fractures and where there has been contamination.

With injuries presenting after 24 hours, repeated débridements may be

necessary for several days before the wound can be safely closed. Sometimes
the use of a VAC will be necessary. Since soft tissues of the hand are well
vascularized, minimal débridement is usually sufficient along with removal of
all obviously necrotic tissue and foreign bodies. In the rare case that a wound
cannot be closed, it is important to keep the wound moist and the extremity
elevated between débridements.

Basic Nomenclature of fractures and dislocations

♦ Angulation: The position of the apex of the fracture determines whether
the angulation is dorsal or volar. Metacarpal fractures often have an
apex dorsal angulation whereas proximal phalanx fractures have an
apex volar angulation due to muscle forces.
♦ Rotation: Common in oblique and spiral fractures and can be diagnosed
by actively or passively flexing the fingers into the palm. Overlap of the
fingers is seen. Rotation can also be identified by comparing the plane
of adjacent fingernails. Rotation must be corrected as 5° of rotation at
the metacarpal level can result in 1.5 cm of overlap of the fingers.
♦ Dislocation: The position of the distal bone determines whether the
dislocation is dorsal or volar.
♦ Displacement: When the bone fragments on each side of the fracture
are not in alignment with each other.
♦ Comminuted: When there are multiple fracture fragments.

Anesthesia
The choice of anesthesia depends on what is available in your hospital. For
adults, an axillary block or Bier block is fine for all hand injuries. A wrist or
digital block will be satisfactory for finger injuries. Ketamine is also sufficient
for closed reductions and especially for children. A tourniquet should be used
with any open fracture or open procedure. General anesthesia may sometimes
be required.

Once x-rays have been taken and the diagnosis confirmed, a hematoma block
with lidocaine in the casualty department or operating room will give good
anesthesia for an early reduction and casting/splinting of some fractures.

When closed pinning is suggested below, this can be done either in the OR
(theatre) with a portable x-ray or even better in the x-ray department if safe
anesthesia and sterile conditions can be maintained.
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Resources
Keep an anatomy book in your OR at all times and refer to it on the cases
below.

Metacarpal Base (CMCJ) Fractures and dislocations

Thumb

Special x-ray view of Thumb CMCJ: Robert’s view—forearm pronated,

shoulder internally rotated and thumb abducted against the film.

♦ CMCJ dislocation of the thumb without a fracture on AP, lateral and

oblique views of the thumb: An isolated CMCJ dislocation is usually
dorsal. If closed reduction is successful, a spica plaster should be
applied for 6 weeks, before range of motion is initiated. If closed
reduction is unsuccessful, then an incision can be made along the
radial border of the thumb with a palmar extension along the distal
wrist crease (Wagner) and open reduction and pinning with K-wires
carried out. One must preserve the dorsal branches of the radial nerve
in this incision. The thenar muscles are reflected volarly off the
metacarpal in order to better visualize the joint.

♦ Bennett’s fracture is an oblique intraarticular fracture of the

metacarpal base with the undisplaced ulnar fragment attached to the
anterior oblique ligament or metacarpotrapezial ligament. The large
radial shaft fragment is displaced dorsally, proximally and radially with
the pull of the abductor pollicis longus tendon. Though this is an
unstable fracture pattern, closed reduction may be attempted by
traction on the thumb with abduction and pressure over the radial side
of the thumb base while applying a thumb spica cast which includes the
wrist joint and the thumb MP joint. If it is difficult to hold reduction,
one or two K-wires may be passed from the thumb metacarpal base
blindly into the carpus before the spica cast is applied.

Fig 3 Fig 4
Bennett’s Fracture showing pull of adductor ulnarly and APL proximally
(Courtesy of eORIF.com)
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♦ If followup x-rays show reduction, the patient should be followed weekly

to ensure reduction is maintained.
If the fracture cannot be reduced or reduction maintained, an
incision as described above is used. The fracture site is exposed, the
metacarpal reduced and two .045 in. Kirschner wires are inserted from
the radial thumb metacarpal shaft into the ulnar fragment or proximal
trapezium and carpal bones. If the ulnar fracture fragment is large
enough, direct pinning into it with two K-wires can be done. A thumb
spica radial gutter splint is applied. The pins are removed at 3 weeks
and the splint is continued for a full six weeks. Range of motion is then
begun.

Fig 5 Method to reduce Bennett’s Fig 6 Other methods of fixation

fracture: traction, abduction, pressure (Courtesy of eORIF.com)
at base
(Courtesy of eORIF.com)

♦ Rolando fracture is a rare comminuted intraarticular, V-shaped

fracture of the metacarpal base. Closed reduction with or without
pinning is rarely successful. Open reduction and pinning is difficult but
can be attempted if there are large displaced fragments. External
fixation with traction on a distal pin may be best—pins through the
trapezium or carpus and a distal pin through the distal metacarpal or
proximal phalanx. Skeletal traction can be performed by placing these
K-wires and incorporating the wires in a thumb spica cast while
applying traction. If these techniques are not possible, simply placing
the thumb in a spica splint or cast for 3 weeks and then beginning
range of motion exercises early may be best that can be done.

(Editor’s Note: It cannot be over emphasized that closed reduction

with splinting or casting is best if one does not have experience
with this surgery and is not certain of hand anatomy.
Immobilization for 3 weeks followed by early exercises will often
result in a functional hand.
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Fig 7 Fig 8
Rolando Fracture PA and Lateral views
(Courtesy of eORIF.com)

♦ Open fractures of the thumb CMCJ will be treated the same way after
adequate cleansing and débridement.

Metacarpal Dislocations of other digits

♦ The most common CMC joint fracture/dislocation involves either the

ring or small finger or both. The best x-ray to ascertain these fracture
dislocations is with the hand held in 30 degrees pronated from a fully
supinated position. The fracture dislocation of the small finger is similar
to the Bennett’s fracture of the thumb. The distal fragment is
dislocated dorsally and proximally by the pull of the extensor carpi
ulnaris tendon. Stabilization of these fractures may be difficult to
maintain with simply closed reduction and splinting/casting. Two K-
wires can be passed blindly after reduction into the carpus and/or ring
finger. If this is not possible it is acceptable to treat these with splinting
and early range of motion rather than an open reduction and pinning.

Fig 9 Fracture dislocation small CMC joint

(Courtesy Dr. Jason Rehm)
♦ CMC fracture dislocation involving the index, long, ring or small finger
can be suspected by significant swelling over the dorsum of the hand.
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These are due to high energy injuries. These are usually dorsal and
often there may be fracture fragments present. The best x-ray to
ascertain these fracture dislocations is with the hand held in 30 degrees
pronated from a fully supinated position. With these fracture
dislocations it is difficult to maintain stabilization with closed reduction.
Blind retrograde pinning from the metacarpal into the carpus is possible
once swelling has subsided. The sure option is by open reduction
through a dorsal incision with direct visualization and insertion of K-
wires in a retrograde manner. If these dislocations are open, reduction
and pinning as above will be more easily performed.

Fig 10 Fig 11
Fracture dislocation base small finger If severely displaced, treat with pins as above but casting
will work fine in most cases if one lacks experience and x-ray control

♦ Volar dislocations result from significant force and are rare and
frequently missed. Open reduction is indicated after swelling has
subsided. In any CMCJ dislocation, associated fractures may cause
rotation and before and after pinning, great care should be taken to rule
out rotation by flexing the fingers into the palm.

Fig 12 Fig 13
Carpometacarpal fracture dislocations are rare and usually dorsal. Both dorsal and
volar are due to high energy forces and are often associated with other severe injuries.
There is significant soft tissue swelling and surgery should be delayed until swelling
subsides with elevation. (Courtesy of eORIF.com)
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(Editor’s Note: These are severe injuries with significant swelling.

Reduction and pinning is not easy and without experience these
may be splinted and early motion begun.)

Fig 14 Fig 15 Fig 16

Non-intraarticular fracture of metacarpal base: Treat closed unless
open fracture. If significant angulation, above pinning is an excellent
method of stabilization. One will need x-ray control for pinning.

Metacarpal Fractures:

♦ Metacarpal fractures may be at the base, in the shaft or at the neck.

They can occur in transverse, spiral, or oblique fracture patterns.
Shortening at an isolated fracture site of up to one centimeter may be
acceptable if there is no rotational deformity. Angulation may be
accepted if the angulation is less than 10° in index and long, less than
20° in ring and less than 25° in small. Rotational deformity of even a
few degrees is unacceptable. If closed reduction is performed, great care
must be taken to ensure stability without rotational deformity. Many
shaft fractures can managed by close reduction and casting for 4 weeks
with the wrist extended 20-30° and MP joints flexed. The cast is
extended out to the PIP joints but these are left free to move. Fingers
can be buddy-taped together to help correct and prevent rotation.
Transverse fractures are often angulated with the apex dorsal.
Reduction is accomplished by traction, flexion of MP joints and dorsal
pressure over the metacarpal shaft while applying the cast. (Jahss
Maneuver)

♦ A single metacarpal fracture should be treated with closed reduction

and casting. Rarely will it be necessary to open a single metacarpal
fracture. If closed reduction is possible but maintenance of
stabilization is not possible in a border metacarpal, percutaneous closed
pinning may be attempted but it is difficult without a C-arm. This can
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be accomplished by maintaining reduction and placing several K-wires

transversely across the metacarpals pinning the fractured metacarpals
to normal ones above and below the fracture site.

Fig 17 Fig 18 Fig 19

Metacarpal shaft fracture with 60 degrees apex dorsal angulation
(Courtesy of eORIF.com)

♦ Open reduction may be needed in the following situations:

• there are multiple fractures
• the fracture(s) is significantly displaced and bony approximation
cannot be corrected by closed reduction,
• rotation cannot be corrected
• open displaced or rotated fractures.
• Spiral, oblique central metacarpal (long and ring) fractures require
closed correction of rotation. Shortening will not be significant
and does not require open reduction.

For all hand fractures, if a C-arm is NOT available, a portable x-ray in the
theatre can be used. If a portable x-ray is unavailable, then the patient
can be given a regional block and taken to x-ray where serial x –rays can
be taken after each attempt at reduction. The patient should be closely
monitored by anesthesia personnel. If pinning is performed in the x-ray
department, great care must be taken to maintain a sterile environment.

♦ Methods of ORIF-open reduction and internal fixation

1. Transverse K-wires above and below fracture into normal
metacarpals (percutaneous and closed if possible—recommended)
2. Crossed K-wires, bent, inserted antegrade from base of
metacarpal (this may be difficult without experience)
3. Crossed K-wires passed retrograde through MC head (usually
requires x-ray control and experience)
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Fig 20
K-wires above and below the fracture and into adjacent normal metacarpal
(Courtesy of eORIF.com)

4. Crossed K-wires passed antegrade from the fracture site

through the distal fragment until they emerge through the distal cortex
and then passed retrograde into the proximal fragment—when open
reduction.

Fig 21
Crossed K-wires—ORIF only if fracture open
(Courtesy of eORIF.com)

5. One K-wire through the fracture and one or two interosseous

24 gauge steel wire for oblique border metacarpals
6. One K-wire through the fracture and cerclage steel wires—if
the fracture is oblique or spiral
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Fig 22
Spiral metacarpal fractures: Index fracture appears stable in this view.
There is likely minimal shortening of ring and long. If closed but angulated these
fractures would be best treated with K-wires from small to ring and long under x-ray
control. If this is not possible or if angulation is minimal, closed treatment with casting
in position of protection is best—MPJs flexed and IPJs extended. If these fractures are
open, then they may be treated with interosseous wires, cerclage wires or small
interfragmentary compression screws if available

7. 90:90 stainless steel 24 gauge wire sutures—excellent

stabilization, if one must open a fracture or if the fracture is open. Use
0.045 K-wires to make horizontal and vertical drill holes through both
ends 5 mm from fracture. (K-wire is passed from 3 to 9 and 12 to 6 at
each end.) A 19 gauge needle is passed through the drill holes and a
wire suture or stainless steel wire is inserted through the needle. The
wire is pulled through, needle removed, and then the wire is passed
back through another needle in the opposite fragment drill hole. The
sutures can then be twisted down. This method is ideal for an unstable
transverse fracture.
• If there is rotation of a transverse fracture, the first or last
two techniques will likely be necessary.
• Towel clips are excellent to temporarily stabilize the spiral or
oblique fracture
• Open, rotated spiral fractures may be treated with K-wires
into adjacent stable metacarpals or K-wires or interosseous
wires across the fragments

Pinning methods above should be carried out with .028, .035 or

.045 K-wires according to the size of the metacarpal. If possible K-wires
should be left just outside the skin so they can be removed at 3 weeks.
If not, they can be left beneath the skin without difficulty
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Casting these fractures in the “protective position” is necessary as

none of the above techniques will give rigid fixation except the 90:90
wiring.

Exposure for metacarpal fracture fixation is through the

laceration or through longitudinal incision along one side of an extensor
tendon. Adjacent metacarpals can be approached by an incision
midway between them.

Protective position: Wrist slight extended, MPJ flexed 80-90° and IPJ
extended

Fig 22 Fig 23
Casted in protective position. Note buddy-taping between
ring and long to help prevent rotation (Courtesy of eORIF.com)

Protective position: Wrist slight extended, MPJ flexed 80-90° and IPJ
extended

Editor’s Note: Many will not have expertise in this surgery and many
metacarpal fractures will be treated closed with casting. Just be certain
that rotation has been corrected and motion is started after 3—4 weeks.
A volar splint or gutter splint is worn when not exercising during the
next 3 weeks. Rotation can be determined by flexing the fingers into a
fist to ensure there is no overlap and by ensuring the fingernails are
parallel. All the fingers tips should point to the scaphoid—see below.
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Fig. 24 Fig 25
Finger tips should point to scaphoid. Note overlapping between
the small and ring finger tips on the right.

♦ Comminuted fractures or those with segmental loss are best treated

with transmetacarpal K-wires above and below the comminution and
into normal metacarpals as described above or using a mini-external
fixator if only one metacarpal involved. Home-made external fixators
can be constructed using two K-wires above and below the fracture and
held together with plaster or methylmethacrylate—an endotracheal tube
filled with methylmethacrylate is a good “external fixator.” As the
methylmethacrylate is hardening, the K-wires are stuck through the
tube as the fracture is distracted and aligned. If segmental loss, bone
grafting can be carried out as a second stage. If open with segmental
loss, a K-wire can also be used as an intramedullary pin to hold the
metacarpal out to length. Two right angle turns are made at each end
and placed in both fractured ends of the bone. Severely crushed
metacarpals can be casted and early motion started at 3-4 weeks.

Fig 26
K-wires with right angle turns to maintain length when there is segmental
loss. K-wires can be placed above and below with an “external fixator” as described above
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♦ Metacarpal neck or Boxer’s fractures

These are one of the more common hand fractures that generally result
from the person striking an object in a longitudinal fashion with a
closed fist. These generally result in apex-dorsal angulation. The
amount of acceptable angulation is dependent upon the digit involved.
As a general rule, the index and long finger can only tolerate 10 to 20
degrees of angulation. The commonly involved ring and small fingers
can generally tolerate up to 50-60 degrees of angulation in metacarpal
neck fractures. These fractures warrant an attempt at closed reduction
in the acute setting with a hematoma block. The Jahss maneuver is
used: Flex the MP joint while applying upward pressure through the
proximal phalanx directed toward the metacarpal head. This can more
easily be accomplished by flexing the PIPJ and pushing dorsal through
the PIPJ. Care must be taken to prevent rotation of the metacarpal.
This can be clinically achieved by comparison of the plane of the
fingernails. Casts should include the wrist in slight extension, the MP
joints flexed to 90° and the PIPJ extended. The PIPJ can be held in
extension for two to three weeks and then allowed to flex. X-rays
should be repeated at weekly for two weeks as these fractures are
unstable.

Fig. 27 Jahss Maneuver

Fig 28
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Fig 29 Fig 30
Fig 27-29 Metacarpal neck fracture: note dorsal angulation with head in palm.
Reduced by Jahss Maneuver and casted in position of protection
with MPJ flexed and IPJs extended

If the fracture is severely angulated (see Editor’s Note below) and cannot
be held in reduction with the cast, then attempted closed fixation with
crossed K-wires through the MC head. The K-wires are placed from the
either side of the head down into the proximal fragment. Alternatively,
K-wires may be placed from the MC head into an adjacent stable MC
head. A gutter splint is applied with the MPC’s flexed, the PIP’s
extended for three weeks at which time range of motion is begun, and
protective splinting continued for two to three more weeks. Closed
pinning will be difficult without fluoroscopy.

Fig 31 Fig 32 Fig 33

Metacarpal neck fractures: If necessary to pin (see below) these are two methods, crossed K wires
through the MC head or K-wires from the fractured MC into the normal metacarpal while reducing the
fracture with the Jahss maneuver. These methods are best done with a C-arm or portable x-ray.

(Editor’s Note: Important Information--Some would only reduce

these if the MC head was palpable in the palm or if there was
pseudo-clawing deformity with extension of the proximal phalanx at
the MP joint. Sometimes an angulation up to 75° will do fine and
can be accepted.)
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♦ (Gutter splint: a curved splint from dorsal to palmar around a border

digit)

♦ If the metacarpal neck fractures cannot be successfully reduced and

stabilized by closed methods, open reduction and percutaneous pinning
may be necessary for significantly displaced/angulated fractures. This
will be unusual, but untreated significantly angulated neck fractures in
the index and long fingers that are left unreduced may cause significant
pain in the palm. Open reduction is achieved through a longitudinal
incision over the dorsal aspect of the affected metacarpal, retraction of
the extensor tendon and longitudinal retrograde pinning through the
metacarpal head. Pins are removed at 3 weeks and exercises begun.
(The extensor tendons may be separated in midline to gain exposure,
but this may lead to adhesions.)

Fig 34 Fig 35 Fig 36

Angulation of third MC neck fracture with retrograde pinning:
Pinning was performed in this case since it was in the third metacarpal where
the head in the palm is not as well tolerated.
(Courtesy of eORIF.com)

♦ Care must be taken to rule out an open fracture from a human bite
wound.

Position of Protection: wrist slightly extended, MPJs flexed 80-90° and

IPJs extended. This will prevent extension contractures of MPJ and
flexion contractures of PIPJ.

♦ Intraarticular fractures of the metacarpal head require exact

reduction if possible to maintain the metacarpal phalangeal joint.
Minimally displaced articular fragments may be treated conservatively
with protective splinting and careful early range of motion after 2-3
weeks. Closed reduction with molding and pinning of displaced intra-
articular fragments can be attempted but if there is a residual 2-3 mm.
step-off, these ideally require open reduction. Closed reduction and
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pinning maybe tried on border digits. Open reduction can be

accomplished via a curvilinear incision made over the MCP joint. A
careful incision through the sagittal band leaving a cuff for later repair
will provide good exposure to the joint surface. On occasion, the saggital
band and extensor tendon may be retracted with percutaneous pinning
of the articular surface with small K-wires to achieve satisfactory
stabilization. The MCP joint should be held in position of protection to
maintain maximum collateral ligament length. Once again, great care
must be taken to rule out human bite injuries.

(Editor’s note: The above recommendations are somewhat

theoretical. General surgeons in most district hospitals will find
this open surgery difficult if not impossible. Therefore closed
reduction and splinting in position of protection is maybe best with
early range of motion exercises at 2-3 weeks. Splinting is
continued for 6 weeks when not exercising. Stability and proper
alignment of these fractures at the MPJ has been found to be more
important than perfect articular reduction.

Special x-ray view: Brewerton for metacarpal head fractures—

fingers on the film with palm up, MCP flexed 65°, and x-ray taken from 15°
ulnar to the vertical.

Metacarpal phalangeal joint (MPJ) Dislocations:

Thumb
♦ Ulnar collateral ligament injury
♦ This is the most common type of dislocation at the thumb MPJ
and is secondary to a sudden radial deviation of the thumb at the
metacarpal phalangeal joint with a tear of the ulnar collateral
ligament. The ligament usually avulses from the base of the
proximal phalanx. This injury is seen acutely but more often it is
seen late and is known as a Gamekeeper’s thumb. When seen
late it is often associated with a Stener’s lesion where the
completely ruptured ulnar collateral ligament is found proximal to
the adductor pollicis aponeurosis. When the aponeurosis is
interposed between the ligament and the base of the proximal
phalanx, the ligament cannot heal.
♦ On exam there is swelling and if seen acutely there is tenderness
and ecchymosis. When the joint is stressed radially, the joint is
considerably more lax than the contralateral thumb. This test is
best done with the MPJ flexed 30-40 degrees which limits the
stabilizing effect of the volar plate in full extension. (When testing
is done acutely, a local digital anesthetic block may be helpful to
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relieve pain and give a better evaluation both for the clinical exam
and stress x-rays as seen below.)
♦ X-rays should be taken to rule out a fracture at the base of the
proximal phalanx.
♦ It is important to compare findings to the uninjured thumb.

Fig 37
Stress view showing significant laxity of the thumb UCL
Note 40-45° angle (Courtesy of eORIF.com)

Fig 38
Avulsion ulnar base of thumb
proximal phalanx—Gamekeeper’s thumb

♦ Indications for surgery:

- If less than 30° laxity or less than 15° differential from the
contralateral thumb when stressed, then acute injuries may
be treated conservatively with a thumb spica cast with the
MPJ slightly flexed for 4 weeks.
- If greater than 30° laxity or greater than a 15° differential
from the contralateral thumb, then operative repair is
recommended.
- Several surgical techniques have been described
– If the patient is seen soon after injury then direct
repair or repair using a bone anchor is possible
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– For fractures at the base of the proximal phalanx,

these will usually heal if not widely displaced and if
casted for 6 weeks—or thumb spica splint.
Otherwise open reduction is necessary with pins or
preferably small screws.
– Chronic injuries can be repaired with either adductor
advancement or a tendon graft
– One is referred to operative textbooks for description
of these procedures.

(Editor’s Note: It is recognized that in many of our hospitals these

injuries, if recognized, will be treated with casting or splinting. If
there is not a Stener lesion, the ligament/fracture will likely heal
back. If one feels a mass over the proximal ulnar side of the MPJ,
then a Stener lesion is probable and adequate healing of the
ligament may not occur with splinting alone.)

Fingers
• Metacarpal phalangeal joint dislocations can occur either in a dorsal or
volar position. Dorsal dislocations are much more common from
forceful hyperextension and can be divided into simple and complex.
These occur commonly in thumb and index finger.
• A simple dorsal dislocation is reducible when the phalanx remains in
contact with the metacarpal head and the volar plate is not trapped
within the joint.
• These simple dislocations are usually quite obvious with
significant angulation—more prominent than a complex
dislocation.
• Reduction is achieved by maintaining contact of the MCP joint
while pushing the base of the proximal phalanx distally along the
dorsum of the metacarpal.
• Hyperextension or traction is not useful and is contraindicated.

Fig 39
Simple dislocation of MPJ
(Courtesy of eORIF.com)
 21

♦ A complex dislocation occurs when the volar plate ruptures from the
metacarpal and becomes entrapped between the head of the metacarpal
and base of proximal phalanx.
• Puckering of the volar skin may be seen at the level of the
metacarpal neck and this always indicates a complex dislocation.

Note “puckering”

Fig. 40
Complex thumb MPJ dislocation

• The proximal phalanx lies dorsally in the same direction as the

metacarpal—“bayonet appearance.”
• The metacarpal head is caught in a “noose” between the flexor
tendons and the lumbrical muscles in the index and the flexor
tendons and thenar muscles in the thumb.
• The volar plate is avulsed from the metacarpal and often trapped
in the joint
• X-rays may show the sesamoid bones in a widened joint.
• Closed reduction is rarely successful and especially when the
patient presents late.

Fig 41
Complex dislocation of index MP joint
with bayonet appearance: required open reduction.
This dislocation could be easily missed
 22

• Open reduction should be carried out from a volar approach.

- This allows identification and protection of the radial digital

nerve which is tented up next to the skin by the metacarpal
head.
- The flexor tendons are identified on the ulnar side of the
metacarpal head and the A-1 pulley is divided. Usually this
allows reduction.
- In chronic cases that present late, a dorsal approach may
also be needed to release the collateral ligaments from the
metacarpal head and reduce the volar plate by splitting it in
the midline and passing each side back around the
metacarpal head.
- The ligaments will reattach and do not need to be repaired.
- The MPJ is held in 20-30° flexion for 2 weeks and then
exercises are begun while the last 10° of extension is
blocked.

Fig 42 Fig 43
Chronic dislocation of thumb MPJ:
Required volar and dorsal approach

Phalangeal Fractures and Dislocations

♦ These are always serious injuries in those who use their hands from
musicians to surgeons and to manual laborers. The flexor and extensor
tendons lie close to the bone and are susceptible to injury and later
stiffness.

♦ Intra-articular fractures at the base that are closed and minimally

displaced can often be treated with manipulation, buddy-taping, and a
dorsal splint with the MP joints flexed and early range of motion at 3
weeks. Significantly displaced with a 3 mm. step off or open intra-
articular fractures (uncommon) can be opened through the dorsal
 23

midline and pinned with small K-wires. However, stability and

alignment are more important than a perfect articular reduction. If
necessary and one has experience operating in this area, the extensor
tendon is divided longitudinally in the midline or through the open
injury. Approaching these laterally is possible if the fracture extends
distally, but a lateral approach is difficult for fractures at the base of the
proximal phalanx because of the lateral bands. One lateral band may
be divided for exposure and then repaired at the end of surgery or
sacrificed, but this is difficult surgery for the non-hand surgeon. If
there is severe comminution, then a K-wire can be placed through the
distal proximal phalanx or through the distal phalanx and traction
applied. This pin can be incorporated into a cast while traction is
placed on the MPJ. Traction should be discontinued and exercises
begun at 3 weeks.

Fig 44 Fig 45 Fig 46

Base of proximal phalanx fractures: Treated by Eaton-Belsky technique below.
(Courtesy of Dr. Jason Rehm)

Fig 47
Eaton-Belsky technique: Pin through metacarpal head, fracture alignment,
and pin passed into distal cortex of proximal phalanx
 24

Fig 48 Base fracture—best treated Fig 49 Fig 50

with Eaton-Belsky technique Shaft fracture—note apex volar angulation—
Attempt Eaton-Belsky technique, otherwise
treat closed in position of protection

♦ Closed or open transverse fractures through the base or shaft of the

proximal phalanx: Proximal phalanx shaft fractures are most often
have an apex volar angulation secondary to the volar flexion of the
phalanx base by the intrinsic tendons and the extension of the distal
end by the extensors at the central slip insertion. These can be best
stabilized with flexion of the distal fragment and volar to dorsal pressure
over the site of angulation so that it will line up with the flexed proximal
fragment. If closed reduction is not stable with a cast, then the Eaton-
Belsky pinning technique should be used. After the fracture fragments
are reduced and aligned as best possible, two K-wires are passed
through the metacarpal head and into the proximal phalanx with the
MPJ flexed. The pins are inserted until resistance is reached at the
distal cortex. This is excellent fixation for these fractures which should
be attempted even if you do not have a C-arm. This procedure requires
patience as one passes the K-wire through the metacarpal head and up
to the fracture site, then though the distal fragment while manipulating
it into reduction, and until resistance is felt distally. This technique
gives rigid fixation as the fracture is stabilized proximately with the pin
through the metacarpal head and distally by the pin engaging the distal
cortex, but not into the PIP joint. If there is significant displacement,
possibly from intervening soft tissue, or if the fracture is open, the
Eaton-Belsky technique can be easily carried out under direct vision.
These pins can be removed at 3 weeks and motion began. The PIPJ
should never be splinted or casted in the flexed position. Proximal
phalanx shaft fractures often lead to tendon adhesions.

♦ If a closed shaft fracture is displaced or rotated, then traction with

manipulation, MPJ flexion, volar to dorsal pressure at the fracture site
to correct the angulation and then splinting or casting with the PIPJ
 25

extended will help align the fractures. The involved finger can be
splinted together with the adjacent normal finger.

(Editor’s note: If the Eaton-Belsky technique is not possible and

closed reduction and casting/splinting does not result in perfect
alignment, further exploration with open pinning or wiring of the
fracture is NOT recommended unless the fracture is open. See
below.)

♦ Closed oblique or spiral fractures of the proximal phalanx should NOT

be opened unless severely displaced or open. If a closed fracture is
displaced or rotated, then traction with manipulation, MPJ flexion, and
volar to dorsal pressure at the fracture site will help align the fractures.
Also the involved finger can be buddy taped and splinted together with
the adjacent normal finger. These fractures often lead to both flexor
and extensor tendon adhesions as the tendons are close to the bone. If
there is shortening at the fracture site, an extensor lag at the PIPJ may
result, but opening these injuries even with the ability to rigidly fix and
even with good postop therapy will often lead to stiffness and loss of
motion.

♦ Open proximal phalanx fractures should be irrigated and debrided and

an attempt to stabilize with the Eaton-Belsky technique. This may be
possible even with obliques and spiral fractures. With the pins in place
the hand should be casted in position of protection with the PIP joints
extended and immobilized. If this is not possible for transverse
fractures, two small K-wires may be passed antegrade and obliquely
from the fracture site through the medullary canal until they emerge
laterally at the MC neck. When they penetrate the skin, they may be
passed retrograde into the proximal fragment to hold the fracture. The
wires are left through the skin distally for easy removal at 3 weeks. If
stabilization of open spiral fractures is not possible with the above
techniques, two or three K-wires may be placed transversely across
fracture with or without a cerclage wire. Early motion with proximal
phalanx fractures is much more important than rigid fixation. If the
fracture is comminuted, external fixation as described above may be
attempted.
 26

1. Terminal extensor tendon

2. Triangular ligament
3. Oblique retinacular ligament
4. Transverse retinacular
ligament
5. DIP joint
6. PIP joint
7. Lateral Slip
8. Central Slip
9. Lateral Band
10. Sagittal Band
11. MCP joint
12. Extensor digitorum
comminus tendon
13. Lumbrical
14. Volar interossei
15. Dorsal interossei

Fig 51
Note the close association of the tendons and the phalanges—this is the cause for
adhesions and stiffness postoperatively and especially if the fracture is open of if open
reduction is carried out. (Courtesy of eORIF.com)

♦ Distal transverse condylar neck fractures in proximal or middle

phalanges are especially seen in children. These are dorsally displaced
and sometimes rotated 90° with the articular surface pointing dorsally.
These can be frequently missed, especially if a good lateral x-ray is not
taken. Closed reduction can occasionally be accomplished early with
traction and downward and distal pressure applied over the distal
fragment. Since these fractures are unstable, once the fragments are
reduced, K-wires should be placed through the head of the proximal
phalanx into the shaft and left 4 weeks to maintain reduction.
Because these fractures have little chance to remodel even in a child,
open reduction may be necessary if closed reduction is not successful.
A dorsal incision should be made and the fracture approached from
below or volar to the lateral band. If the fracture involves the middle
phalanx, after reduction a K-wire can be placed from the tip of the finger
through distal phalanx and DIP joint and into the middle phalanx to
hold the fragment reduced. The author has found 18-21 gauge
hypodermic needles especially useful to pin these in children. The
 27

needles can be easily twisted down the shafts of the bones for
stabilization and one is usually sufficient.

Fig 52 Fig 53 Fig 54 Fig 55

Condylar neck fracture, initially missed, required ORIF

♦ Distal oblique intraarticular condylar proximal phalanx fractures

are difficult to treat when closed without a C-arm. While it is important
to reduce and stabilize intra-articular fractures when there is a
significant step off of 2-3 mm, rigid fixation is difficult without small
screws. One potential closed method when there is a significant step
off at the articular surface is to use one or more towel clips to attempt
reduction. After x-rays are taken, a digital block is given in the x-ray
department (or in the OR with a portable x-ray machine) and a towel clip
is used to grasp each fragment and attempt to reduce the fracture
fragments. Repeat x-rays are taken to visualize the reduction. Several
attempts can be taken before opening the joint. If it must be opened, a
dorsal incision is made, and the articular surface visualized though an
incision between the lateral band and extensor tendon (central slip). A
small towel clip can now be used under direct vision to approximate the
fracture fragments. Once reduced closed or open, the fracture can be
pinned percutaneously with two or three small 0.028 K-wires,
depending on the length of the fracture. PIPJ surgery is not without
complications whether opened or closed. If a fairly good closed
reduction and fixation can be accomplished with manipulation, and a
towel clip and K-wires, then this fracture may be casted or splinted
closed with the MPJ in flexion and PIPJ in extension. Comminuted
fractures should be treated in traction as described below.

PIP Joint Dislocations

♦ These are commonly seen and often poorly cared for. The most common
dislocation is a dorsal dislocation with the middle phalanx dorsal to the
proximal phalanx. They occur by hyperextension and axial loading.
 28

♦ If the there is a volar plate disruption at the base of the middle

phalanx—without a fracture, then the dislocation can be reduced and
held in 30° flexion for three weeks with a dorsal block splint and then
15° flexion for an additional two to three weeks. PIP joint flexion is
allowed during this dorsal block splinting.

Fig 56
Dorsal PIPJ dislocation

♦ These dislocations often include a fracture of the volar lip of the middle
phalanx which is attached to the volar plate.
♦ If this intra-articular fracture involves less than 40% of the articular
surface, dorsal block splining should be used. The collateral ligaments
are still attached to the distal dorsal fragment and reduction is possible.
This hand based splint holds the MPJ in flexion and the PIPJ in
sufficient flexion to reduce the fragment—up to but not more than 40°.
♦ Patients must be closely followed and x-rays taken on a regular basis to
ensure the reduction is not lost.
♦ The reduction should result in congruent dorsal articular surfaces of the
phalanges. If there is a dorsal “V” shaped deformity on lateral views,
then the reduction is not adequate.

(Editor’s note: Excellent technique below: (courtesy of Dr. Bill

Bourland)—this technique will require some x-ray control, either a C-
arm or portable x-ray: “Hyperextend the PIP and drive a 0.035 K-wire
under the volar fracture lip fragment (from the volar side) through the
proximal phalanx and withdraw it dorsally until the volar pin just blocks
the volar lip fragment. Then flex the PIP joint until the dorsal fragment
reduces with the volar pin preventing the volar lip fragment from
moving. Then drive a 0.035 K-wire dorsal to the dorsal lip of the middle
 29

phalanx into the proximal phalanx. Cut the pins beneath the skin.
Splint for three weeks. Remove the pins under local and begin protected
ROM with a dorsal blocking splint.”

Fig 57
Treatment for fracture-dislocation of PIPJ
(Courtesy of Dr. Bill Bourland)

♦ When the middle phalanx fracture fragment involves greater than 40-
50% of the articular surface, dorsal block splinting will not work. The
collateral ligaments are no longer attached to the dorsal distal fragment
and closed reduction will not be stable. The angle of the dorsal block
would have to be increased and this would lead to a stiff, flexed PIPJ.
♦ In these situations, when a dorsal block splint is unsatisfactory, then
open reduction or an external traction is necessary. The editor would
attempt the technique above.
- A volar and sometimes a “shot gun” approach is best as it gives
good visualization of the fracture fragment and attached volar
plate, though it requires some experience and knowledge of
anatomy around the PIPJ.
- A volar zigzag incision (Bruner) is made across the PIPJ. Care is
taken to identify and not damage the neurovascular bundle on
either side. The A-3 pulley is divided and the flexor sheath
 30

opened from A-2 to A-4 pulleys. The flexor tendons are retracted
to one side and the joint inspected.
- If better exposure is necessary, the collateral ligaments may be
divided at their origin and the joint opened with hyperextension
(shotgun approach). Once the volar fragment is reduced, small K-
wires may be placed obliquely across the fragment into the middle
phalanx. If the fragment is small or comminuted, another
technique involves passing a suture/small steel wire through the
volar plate at its insertion into the avulsed fragment and then
passing the suture/wire through a drill hole in the middle
phalanx and twisted down. With either technique, the joint
should be immobilized in slight flexion for 3 weeks. K-wires
should be removed at 3 weeks and gentle ROM exercises carried
out. The collateral ligaments will reattach and do not need to be
repaired.
(Editor’s note: PIPJ surgery is difficult. I recommend
splinting and early range of motion or traction with pins
above and below the PIPJ for fracture dislocations
involving > 40% of the articular surface. The “shotgun”
approach above is difficult even for the accomplished hand
surgeon and stiffness will result no matter the how accurate
the reduction and fixation.)

♦ Volar dislocations are the result of a rupture of the central slip or a

dorsal lip fracture with the central slip attached to the fragment. If an
extensor tendon/central slip avulsion, this may be treated closed or
open with repair of the central slip insertion. The easiest treatment is
placing a pin through the PIPJ to hold it in extension for 6 weeks. If the
fragment is large and the reduction is not stable, then an open approach
may be carried out with pinning of the fragment to the middle phalanx
with one or two small K-wires and with an additional K-wire through the
PIPJ to ensure compliance in keeping the PIPJ extended at 0°.

♦ Rotatory dislocations are rare but also possible. These may be looked
up in a major text.

♦ Comminuted fractures in jammed fingers at the base of the middle

phalanx are also frequently seen—a pilon fracture. These occur with
significant axial loading and include both dorsal and volar lip fractures
with a destroyed middle phalanx articular surface. In district hospitals
these injuries should be treated with splinting and early range of
motion. If one has significant experience in hand surgery, one may try
the dynamic PIPJ traction method shown above.
 31

Fig 58 Fig 59
Pilon fracture dislocation of PIPJ (Courtesy eORIF.com)
Treated with dynamic PIP
joint external fixation (Badia
A, J Hand Surg 2005;
30A:154)

1. 0.045in K-wire
placed transversely
through center of the
head of the prox
phalanx
2. 0.045in K-wire
placed through
center of the head of
the middle phalanx
3. Proximal K-wire is
bent 90 degrees to
be parallel to middle
phalanx
4. End of proximal
phalanx K-wire is
bent >90 degrees
dorsally and again
>90 degrees volarly
to make S
configuration at tip
5. Traction applied and
distal K-wire is
engaged and bent 90
Fig 60 Method of dynamic PIPJ external fixation for traction (Courtesy eORIF.com)
(For dynamic fixator technique: see Ruland RT, J Hand Surg 2008; 33:19)
 32

Unfortunately, no matter what the treatment is for these PIPJ

injuries, arthritis and stiffness will likely be a final result.

Middle Phalanx Fractures

♦ Closed shaft fractures are rare and most will be treated closed with early
range of motion. If opened and fixed significant stiffness will result.
These should only be treated open when there is an open injury. Intra-
articular fractures through the head of the middle phalanx may be
treated as for the proximal phalanx but a stiff joint will likely result
regardless of the technique.

Distal Phalanx Fracture/Dislocations

♦ Most common these are apex dorsal dislocations of the DIPJ—Mallet

finger. These can be tendinous with an avulsion of the extensor tendon
or bony with a fragment of the dorsal lip of the distal phalanx avulsed
off with the tendon. Tendinous injuries are best treated with a K-wire
to hold the DIPJ in extension for 6 weeks followed by splinting in
extension for another 6 weeks while allowing gradual increase in
exercises during the day but constant splinting in extension at night.
Bony avulsions if less than 50 % of the joint surface may be treated the
same way. Some would pin the dorsal lip fragment for >50% of the
joint surface involved while many would continue with the closed
pinning in extension. An excellent technique to reduce and hold this
dorsal lip fracture is with the insertion of the K-wire through the distal
extensor apparatus into the distal dorsal articular surface of the middle
phalanx while the DIPJ is held in flexion. (See figure below.) The distal
phalanx is then extended and pinned in extension. The “extensor block
pinning” allows the fragment to be reduced and held in reduction by the
pins. This avoids causing potential comminution of the fragile fracture
fragment when attempting to insert a K-wire directly into the fracture
fragment. These dorsal lip fractures may be comminuted. Splinting the
DIPJ alone may be used but compliance is a major factor. Without
treatment there will be an extensor lag with subluxation of the volar
fragment, but this is only of cosmetic importance as it rarely will affect
function.
 33

Fig 61
See actual method of fixation below.
(Courtesy eORIF.com)

Fig 62
Extensor block splinting for bony Mallet fracture-dislocations:
The pin through the middle phalanx is inserted first with DIPJ in flexion.
Distal phalanx is then extended and a pin passed from the distal tip of the
distal phalanx into the middle phalanx. (Courtesy of Dr. Bill Bourland)

Epiphyseal fractures

♦ These occur in 5 types and the classification can be found in major

texts. The author would treat all these closed with fracture
manipulation and reduction except the grossly displaced or angulated.
 34

If acceptable reduction cannot be accomplished, then open reduction

and pinning can be carried out. If possible reduction and pinning with a
portable x-ray machine in surgery or in the x-ray department would be
better than opening these fractures in children. Open epiphyseal
fractures are rare. One important epiphyseal fracture not to be missed
is the dorsal angulation fracture at the base of the distal phalanx, so-
called Seymour fracture. This occurs through the nail bed which should
be repaired after the fracture is reduced and pinned. One must ensure
that the nail bed is not trapped in the fracture site. A #18-#21
hypodermic needle may be used to pin this fracture with the pin passed
from the tip of the finger into the middle phalanx.

Fig 63 Seymour fracture through epiphysis of distal phalanx

♦ It is important to take x-rays of the opposite normal hand with all

questionable fractures, especially epiphyseal fractures in children.

Final Thought

Bottom Line: Most closed hand fractures, up to even

90%, will do well if recognized and treated with an appropriate
cast or splint—CLOSED!