MANAGEMENT OF

HAND FRACTURES
Fransisca
Mentor: dr. Arif Tri Prasetyo, M.Ked.Klin, SpBP-RE
 INTRODUCTION

Fractures of the metacarpals

and phalanges: frequent
• 41% of all upper extremity fractures in
US
Goal of hand fracture treatment:
• Restoration of articular congruity,
• Hand reduction of malrotation and
angulation,
• Maintenance of reduction with minimal
surgical intervention
• Rapid mobilization
 FOCUS EXAMINATION OF THE HAND

1. A thorough history
2. Inspect the injured and the contralateral
3. Assess swelling, tenderness, open wounds/
4. Gentle palpation locates tender point
5. Assess circulation and sensation of the hand,
integrity of tendon and ligaments
6. Ask patient to maximally extend and flex the
fingers to detect malalignment/ rotational changes
7. Open fracture  cleanse and disinfect first, do not
deep probe the fracture through the wound in an
emergency setting
8. Order plain radiographs in 3 planes (PA, lateral, and
oblique)
 PRINCIPLES OF FRACTURE
TREATMENT
 Majority of closed hand fractures can be effectively
treated by closed reduction and splinting
 Each fracture has its own “personality," depending on
the time from injury, the fracture pattern, the
amount of cortical versus cancellous bone at the
fracture site, and the muscle/tendon forces acting on
the fractured parts.
 Stable, non-displaced fractures can usually be treated
by splinting and/or buddy taping (taping to the
adjacent digit) alone.
 Unstable fractures may be reduced, converting them
to a stable position for splinting.
 If the reduction is not stable in post-reduction
radiographs, then the position should be secured by
percutaneous pinning or other means of fixation.
 PRINCIPLES OF FRACTURE TREATMENT

Irreducible fractures are candidates for open reduction and internal fixation
(ORIF).
Open fractures  wound is irrigated and debrided urgently in the operating
room. The fracture is treated by internal fixation or k-wire fixation during the
same session if the wounds are clean.

Adequate soft tissue cover is essential for proper bone healing.

Administer prophylactic IV antibiotics

 K-WIRES
 (KIRSCHNER WIRES)
The most versatile & frequently used
method
 To minimize trauma, the wires can be
introduced percutaneously under
fluoroscopic guidance after closed
reduction of the fracture.
 If closed reduction is not possible, the
fracture can be reduced via an open
approach and then stabilized with
JC-wires.
 At least two wires in different planes
are necessary to prevent rotation.
 Do not add a compressive component
on the fracture.
 The disadvantages: lack of rigidity,
possible pin loosening, pin tract
 TENSION BAND WIRING

 Principle of this technique: to maintain the

alignment of the fracture fragments with K-
wires and to apply inter- fragmentary
compression with wire loops around the K-wire.
 K-wires of 0.035 or 0.045 inch diameter are
driven across the fracture line.
 Care is taken not to position the wire ends
directly underneath a tendon.
 A 24G or 26G monofilament steel wire is
guided in a figure of eight fashion and
tightened dorsally, counteracting the natural
pull of the flexor tendons.
  The 90° to 90° interosseous wire fixation
can also provide stability and compression
with minimal soft tissue dissection.
INTRAOSSEOUS WIRING  Mainly used for transverse fractures of the
phalanges, for joint fusion, and for
osteosynthesis in replantation.
 Requires 0.045 inch K-wires, an 18G
needle, and 24G or 26G dental wire.
 Drill holes are made using a 0.045 inch K-
wire through both bone fragments, dorsal
to palmar, and radial to ulnar.
 An 18G needle is inserted through the drill
holes to serve as a temporary guide for the
insertion of a 24G or 26G dental wire.
 After circumferential engagement of the
wire, it is tightened carefully to avoid wire
breakage. Alternatively, instead of using
interosseous wires in antero- posterior and
lateral planes, both loops can be positioned
in a dorsal to volar direction.
INTRAMEDULLARY FIXATION

 The use of intramedullary

fixation may be suitable for
transverse fractures. Steinmann
pins or multiple K-wires are
used.
 The devices are completely
intraosseous and their removal
is not necessary.
 Potential disadvantages are
rotational instability and pin
migration.
 Difficult to apply in spiral or long
oblique fractures.
  Compression can be applied
between the fracture fragments
COMPRESSION SCREWS using the lag screw principle.
 Done by using screws with a small
length of thread at the tip and a
smooth shank between the
threaded portion and the tip. Fully
threaded screws can also act as
lag screws if the proximal cortex is
over-drilled so that the proximal
hole acts as a glide hole.
 Compression of two bone
fragments with lag screws can be
applied in long oblique and spiral
fractures, where the fracture
length is at least twice the bone
width.
 PLATE FIXATION

 The main benefits of osteosynthesis with plates and

screws: rigid fixation and maintenance of bone
length.
 Indication: metacarpal fractures, esp. with multiple
fractures, and for the reconstruction of malunion and non-
union.
 Tightening the screw in an eccentrically placed drill hole
creates a force vector in the longitudinal direction. The
screw head progressively pulls the plate along with already
fixed fracture portion toward the other fragment.
 Due to the need for extensive dissection, plate fixation is
associated with a higher rate of extensor tendon adhesion
formation, often necessitating tenolysis.
 Despite the development of thinner plates, some bulkiness
remains and plates may require removal.
 EXTERNAL FIXATION

External fixation is used in complex fractures where anatomic reconstruction

is not feasible.
• For example, highly comminuted fractures with bone loss, gunshot wounds, and fractures with
severe soft tissue damage and/or contamination
The external fixator bridges across the fracture, thus stabilizing the bone
fragments and maintaining length until soft tissue healing occurs.

As the manipulation of the fracture site is minimal, preservation of the

vascular supply is possible.

The high stability of external fixator systems permits early mobilization.

METACARPAL NECK FRACTURES

Most common location of metacarpal fractures;

referred to as boxer's fractures .

Occur most frequently in the fourth and fifth

metacarpal; are angulated with their apex
dorsally

When reducing metacarpal neck fractures, a

modification of the jahss maneuver is applied

Majority of metacarpal neck fractures can be

treated by closed reduction, followed by cast
immobilization in 70° to 90° flexion of the
metacarpophalangeal joint
 METACARPAL SHAFT FRACTURES

 The stability and healing of metacarpal shaft

fractures depends on the fracture pattern.
 Transverse fracture may be unstable and slow to heal
because of the small amount of cortical bone at the
fracture site.
 Oblique and spiral fractures of the metacarpal shaft
have more bony surface area for stability and healing,
but malrotation needs to be corrected.
 Non-displaced and stable fractures after closed
reduction are treated with a short arm cast for 3 to 4
week.
 Long oblique fractures can be stabilized with lag screws
 Multiple metacarpal fractures can lead to a critical
rise of pressure in the muscle compartments.
 consider fasciotomy of the interosseus spaces
 METCARPAL BASE FRACTURES

 Usually the result of high-energy trauma and may

involve dislocation of the carpometacarpal joints.
 Thorough evaluation of carpal involvement is necessary.
 U reduction cannot be accomplished with closed
reduction alone, K-wire fixation or open reduction and
plate fixation is required.
 Intra-articular base fractures of the fifth metacarpal are
referred to as "reverse Bennett” fractures and are
unstable due to the pull of the extensor carpi ulnaris
tendon, which inserts onto the base of the fifth
metacarpal.
 Fracture dislocations of the other carpometacarpal joints
of the fingers may be multiple and represent high-
energy injuries. It is critical to consider compartment
syndrome.
  Fractures of the thumb metacarpal are mostly
divided into shaft and base fractures.

METACARPAL FRACTURES  Full visualization of the base of the thumb

metacarpal and the trapeziometacarpal joint is
OF THE THUMB obtained with the Robert's view (PA view with hand
30° short of full pronation and maximal ulnar
deviation of the wrist).
 Most shaft fractures can be treated by closed
reduction and casting because the plaster can
be effectively molded around this solitary
metacarpal.
 Bennett fracture: the most common fracture of the
thumb metacarpal base; an intra-articular fracture
through the volar-ulnar aspect of the metacarpal
base.
 Closed reduction after traction and pronation of the
thumb with percutaneous pinning is the first choice of
treatment.
 Rolando fracture: resulting mostly from high-energy
trauma, are frequently comminuted and difficult to
treat.
 Treatment of choice: open reduction with fixation
using condylar plates or K-wires.
 PROXIMAL AND MIDDLE
PROXIMAL AND MIDDLE PHALANGEAL FRACTURES FRACTURES
PHALANGEAL

 Transverse fractures of the proximal

phalanx tend to angulate volarly.
 Stable proximal phalangeal fractures are
ideal candidates for dorsal splinting with
flexion of the metacarpophalangeal joint
 Condylar fractures that are not
amenable to closed treatment require
an open approach.
 Do not to injure the collateral ligaments,

 Unicondylar fractures can be reduced by

a midaxial approach. The goal is to
achieve rigid fixation and allow early
movement of the joint
 PROXIMAL AND MIDDLE
PHALANGEAL FRACTURES
Non-displaced shaft fractures can be
buddy taped to an adjacent uninjured
finger.
PIP joint fracture dislocations are
complex and often result in a stiff,
painful, arthritic PIP joint.
• The treatment is based on the size of the
volar middle phalanx base fragment and
the amount of subluxation or dislocation of
the middle phalanx.
• Treatment options: fragment screw fixation,
dorsal block pinning, and dynamic external
fixator placement to salvage operations,
such as volar plate arthroplasty and hemi-
 FRACTURES OF THE DISTAL PHALANX

Distal phalangeal fractures are the most common fractures in the

hand.
• classified into tuft, shaft, and base fractures.
• frequently accompanied by nail bed injury and subungual hematoma.

To avoid irregularities of the new nail, meticulous repair and splinting

of the nail bed is required.
• An extension splint is used to immobilize the DIP joint for 2 to 3 weeks.
Closed reduction is mostly sufficient with repair of the nail bed, if
present. Distal phalangeal fractures may result in non-union but they
are rarely symptomatic.
 OUTCOMES

Treatment outcomes after hand fractures are variable

Excellent results are reported after screw and/ or

plate fixation of metacarpal and phalangeal fractures
with 92% displaying more than 220° range of motion
Favorable outcomes also follow fixation of metacarpal
and phalangeal fractures with K-wires and
intramedullary rods.
Only 27% of of unstable phalangeal fractures treated
by plates and/or screws achieved excellent outcomes
(at least 210° arc of motion)
 COMPLICATIONS

Key for maximizing functional outcome while minimizing complications is the selection of
the best treatment modality for each given case.

Major complications in 36% of injuries are: stiffness, plate prominence, non-union,

infection, and tendon rupture. Complications were observed more frequently in open
fractures and phalangeal fractures.

The primary factors influencing stiffness = soft tissue damage and the age of the patient.
Infection (the most common bacteria isolated from open hand fractures were
staphylococci and streptococci)

Malunion is more likely to occur after closed reduction and splinting or internal fixation
with one longitudinal pin.
Postoperative scarring may result in tendon adhesions after internal fixation.

The indication for extensor tenolysis and dorsal capsulotomy is judged cautiously and
should be performed after an interval of at least 3 months to allow for softening of the
tissues
 CONCLUSIONS

It is important to understand not only the anatomical and

pathomechanical basis of the injury but also the three-
dimensional pattern of the fracture.
The simplest method that will allow adequate reduction and
immobilization will have the best outcome.

The period of immobilization should be kept to the

minimum so that motion can be restored in a timely fashion.
MANAGEMENT OF
MUTILATING
INJURIES OF THE
UPPER EXTREMITY
“Mangled” or “mutilating” injuries:
devastating
At least 3 of 4 following tissue groups:
• Integument/ soft tissue, nerve, vasculature, bone

The Mangled Extremity Severity Score

(MESS) can be applied to the upper extremity, although infrequent
•  7: indication for amputation in lower
extremity
• Lower extremity injuries  lower threshold for
amputation due to the life threatening
consequences.
• Better predictor of limbs that will not require
amputation than of those that will.
 ETIOLOGY

Combat population:

• ballistic missiles
• blast injuries
• motor vehicle accidents (MVA)

Civilian populations:

• all mechanisms of trauma

• industrial and agricultural injuries
• firearm and blast-related trauma
 EVALUATION
EVALUATION
Control of hemorrhage
• gauze packing Secondary survey:
Standard ATLS • pressure dressing with determine the
protocol extremity elevation presence of more
• tourniquet
• clamping of vessels 
specific injuries
discouraged

Standard pulse
Observations of gross X-ray of the affected
examination may be
deformity and digital portion, as well as the
aided by using hand-
cascade joints proximal & distal
held doppler
 PHYSICAL EXAMINATION

Observation of digital cascade; identify tendon injuries, joint dislocations,

and fractures

Note the exposed tissues and the nature of contaminants

Perform vascular and neurologic exams, pulse palpated and compare

with uninjured arm

Document the color, warmth, CRT.

Look for compartment syndrome

 RADIOGRAPHIC MANAGEMENT

Any suspicion of injury to an extremity  X-ray!

• Hand / wrist: 3 views; Forearm: 2 views; Elbow: 2 views

Suspicion of major vascular injury who has clinical evidence

of vascular insufficiency  angiographic evaluation

Severe upper extremity trauma  administrate:

• Immunization for tetanus immediately.
• Antibiotic prophylaxis within 3 hours of injury
 Stable and not life threatening patients:
OPERATIVE debridement, stabilization, wound
MANAGEMENT temporization.

Goal: earlier wound debridement for all

mangled upper limb injuries.

Initial management in the OR is

dictated by the extent of vascular
compromise. Critical warm ischemia
times vary from tissue to tissue.
Recent RCT of open lower extremity
fractures:
• Castile soap: superior to irrigation with a
standard antibiotic & fewer wound healing
problems
 Initial soft tissue management: debriding devitalized or heavily
contaminated tissues
If vascular reconstruction is still required, the surgeon may consider
whether this should be performed before or after bony fixation
Revascularization may be performed safely prior to fracture fixation and
may help avoid fasciotomy for those injuries with shorter ischemia times.
Tendon loss may be treated by tendon grafts or tendon transfers.

It is preferable to achieve a clean wound and perform bone, tendon,

and nerve reconstruction at the same time as flap coverage
For isolated tendon loss, tendon grafts may be taken
from the palmaris longus (PL) or plantaris tendons if
present, from a section of the flexor carpi radialis (FCR)
tendon, or long toe extensor tendons.
If the patient does not have available plantaris,
palmaris, or other tendon donor sites but still has intact
muscular motors, allograft tendons may be considered.
Tendon grafts should not be performed under skin grafts
or have skin grafts placed upon them, due to poor graft
and wound healing combined with poor expected
tendon excursion.
Free and pedicled fasciocutaneous flaps, skin grafted
fascia flaps, and skin grafted muscle free flaps, such
as the serratus free flap, have been used successfully
for dorsal hand coverage.

Forearm and upper arm defects may be covered with

regional flaps or free flaps.

Large wounds requiring broad areas of coverage may

necessitate free flap coverage utilizing muscle flaps
with skin grafting, such as the latissimus dorsi with or
without the lower four to five slips of serratus anterior
via the serratus branch.
ANTIBIOTIC
USE

Should be administrated within 3 hours of injury

No benefit in the use of antibiotics in elective / traumatic hand surgery when

meticulous wound care and debridement was performed

“Barnyard” or “farmyard” injuries: Penicillin  protect against anaerobes

(clostridium)
COMPARTMENT SYNDROME/ FASCIOTOMY

Independent risk factors of Diagnosis is based upon clinical

fasciotomy: suspicion: 5P!
• Penetrating injuries • Pain
• Vascular injuries • Pulselessness
• Combiner arterial and venous • Pallor
injuries • Paralysis
• Elbow dislocation • Paresthesias
• Open fracture
• High blood product transfusion
requirements
• Male gender
 CONCLUSION
Mangled upper extremity injuries are complex and require
reconstruction simultaneously & adequate multidisciplinary team.

The risk/benefit ratio of aggressive salvage operations is different for

each patient based on: age, comorbidities, concomitant injuries, and
reasonable expectations for outcome.
The threshold for amputation of the upper extremity should be
higher than a lower extremity, and salvage guidelines (MESS) should be
used with caution
Earlier definitive reconstructions yield better results in functional
recovery, earlier time to rehabilitation, earlier time to full functional
recovery, and fewer operations.
Familiarity with the myriad techniques available for bony fixation,
vascular, nerve, and soft tissue reconstruction is paramount to success
because no two mangled upper extremities are identical.
 REFERENCES

• Choi MSS, Chang J. Management of hand fractures. In: Thorne CH, Chung KC, Gosain
AK, Gurtner GC, Mehrara BJ, Rubin JP, et al. Grabb and Smith’s Plastic Surgery. 7 th ed.
Philadelphia: Lippincott Williams & Wilkins; 2014. p.758-766.
• Shores JT, Lee WPA. Management of mutilating injuries of the upper extremity. In:
Thorne CH, Chung KC, Gosain AK, Gurtner GC, Mehrara BJ, Rubin JP, et al. Grabb and
Smith’s Plastic Surgery. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. p.
833-7.
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