Treatment

What treatments should I consider?

Treatment options for hand fractures include simple protection of stable fractures which will heal without intervention, closed reduction and splinting, closed reduction and pin fixation, closed reduction and external fixation, and open reduction with internal fixation (ORIF) or pin fixation.

Stable Fractures

Tuft fractures of the distal phalanges, minimally displaced phalangeal and metacarpal fractures and many fractures of the carpal bones will heal and permit normal function of the hand without intervention. The goal of treatment therefore is to reduce the pain, protect the hand from further harm and prevent stiffness from developing. These aims are usually accomplished by splinting the finger or the hand in the position of function.

Finger tip injuries are often protected by a padded metal splint which can be taped to the finger. The position of function for the finger is extension at the interphalangeal joint. For injuries to most other parts of the hand it is supported by a splint which goes from the forearm below the elbow to the fingertips of the affected digit and its neighbors. The splint holds the wrist at approximately 50° extension (up) and the metacarpophalangeal joints at 70° flexion. The interphalangeal joints are usually held straight. In this position the collateral ligaments of the various joints are kept slightly stretched so there is less risk of them contracting. It's not always necessary to include all the fingers in the splint; keeping them free and encouraging movement of the free fingers helps reduce the chance of stiffness. A splint that includes only the thumb side of the hand is called a radial gutter splint. Likewise, a splint that includes only the little finger side of the hand is called an ulnar gutter splint.

Non-displaced fractures of the scaphoid and the thumb are normally treated in a thumb spica cast. This cast extends from the forearm, below the elbow, to the tip of the thumb preventing movement at the wrist and carpo-metacarpal joints. Some surgeons prefer to include the elbow in the cast to prevent rotation at the wrist.

Some non-displaced stable fractures of the middle and proximal phalanges can be treated by buddy taping. This is a form of splinting in which the finger is taped to its nextdoor neighbor but allowed to move. The good finger keeps the broken bone straight and keeps the fracture relatively still; movement ensures that the tendons keep gliding in the tendon sheaths and do not stick down.

All these fractures which do not need reduction must be watched closely in case they displace before healing is completed. X-rays are taken at intervals to make sure this is not happening.

Some hand fractures are displaced by the force that cause the injury but are inherently stable. An example would be the Boxer's fracture or an oblique fracture of the middle phalanx. When the fracture is manipulated back into position (reduced) and splinted in an appropriate position there is little risk that the fracture will re-displace. These fractures can then be treated with buddy taping, splints or casts as above. It is very important to come for follow-up of these fractures as the decision that the fracture pattern is stable is a judgment call by the surgeon. If it is not stable and shifts out of position it is best to know about it early.

Reduction of the fracture is usually accomplished under local anesthetic. This is often done by infiltration of xylocaine or another local anesthetic drug into the region around a nerve. Fractures of the fingers can be made numb by injecting local into the web-space which affects the digital nerves or a ring-block in which local anesthetic is injected all around the base of the finger. Another technique is an intravenous block; a tourniquet is applied to the arm and a larger volume of dilute local anesthetic is injected into a vein. The whole arm below the tourniquet is made numb as the local anesthetic spreads through the veins.

Unstable fractures

These fractures need more aggressive treatment to make sure they stay reduced. By definition they either have, or are likely to have, an unacceptable position. Even if closed reduction would accomplish a good position and a good cast or splint is applied, the alignment is likely to be lost over time. All these injuries require general or local anesthesia for the manipulation and fixation procedures.

Closed Reduction and Percutaneous Pin Fixation

Where a good reduction can be obtained by closed manipulation, it can often be held by one or two smooth metal pins driven through the skin and across the fracture. Generally the positions of the fracture and the pins are checked by x-ray during the procedure. This is a common way of treating unstable fractures of the phalanges and fractures of the metacarpal neck and shaft. Since it depends on accurate reduction using manipulation alone and on the bone fragments giving some support, it can not be used in all situations. It is important that you follow all advice for follow-up x-rays at frequent intervals. Once there are signs of healing the pins will be removed. Since they are smooth this procedure is easy and only slightly uncomfortable. It is usually done in the office without anesthetic.

Closed Reduction and External fixation

This technique is rarely used. Where a fracture is very unstable or there are multiple fragments it may be better to put pins into the normal bone above and below the fracture and simply distract the fracture site. This has the effect of pulling everything straight like beads on a string. The pins are attached to an external metal frame that maintains the distraction. The metal frame can be adjusted to improve the alignment.

This apparatus needs to be checked at frequent intervals after the procedure to make sure (on x-ray) that the fracture alignment is still satisfactory and to examine the pin sites for signs of infection. It is important that you attend these follow-up visits. Once there is x-ray evidence that the fracture is healing with new bone formation bridging across the fracture, the external fixation frame will be removed. This procedure is done in the office or out-patient department and can be uncomfortable. Local anesthetic is not usually offered for this procedure because the injection of anesthetic is as painful as the pin removal.

Open Reduction and Internal Fixation (ORIF)

Many fractures treated by closed means. Intra-articular fractures and shattered (comminuted) fractures are common examples. Open fractures also need surgery to clean up the wound and this is often followed by fixation of the fracture. Other reasons for using ORIF include difficulty stabilizing the fracture by percutaneous pins and failure of other methods of treatment. It is generally true to say that the surgeon takes the option to open up the fracture and operate on it because he/she judges that other methods of treatment run a greater risk of a poor result.

Typical fractures which may be treated by ORIF include displaced scaphoid fractures, fractures associated with dislocation, intra-articular fractures such as condylar fractures of the phalanges or mal-aligned fractures of the metacarpal shaft. Fixation may be quite simple if the main problem was obtaining the reduction. An oblique fracture of the proximal phalanx may be held with two screws. More elaborate fixation using plates and screws is sometimes required by the nature and location of the fracture.

In most cases the hardware used for ORIF of hand fractures is designed to be left in place, buried under the tissues of the hand. The implants are small and thin so they do not take up a lot of space in the hand. Occasionally, they do cause irritation or interfere with the gliding of a tendon. Sometimes there is a vague ache in the hand which is eliminated by removal of the hardware. Where the situation suggests that removal of the hardware would improve things, this operation is done as a day surgery procedure under local or general anesthetic. Patients are often worried that hardware removal will hurt as much as the original injury and surgery. This is hardly ever the case because the bone and muscle is healed and the only pain is from the surgical cut. Most people who were apprehensive about hardware removal are now very pleased that it was done.