CME Common Fractures and Dislocations of the Hand Neil F. Jones, M.D. Learning Objectives: After reading this article, the participant should be able Jesse B. Jupiter, M.D. to: 1. Describe the concept of early protected movement with Kirschner-wired Donald H. Lalonde, M.D. finger fractures to the hand therapist. 2. Choose the most appropriate method Orange, Calif.; Boston, Mass.; and of fracture fixation to achieve the goal of a full range of motion. 3. Describe the Saint John, New Brunswick, Canada methods of treatment available for the most common fractures and dislocations of the hand. Background: The main goal of treatment of hand and finger fractures and dislocations is to attain a full range of wrist and nonscissoring finger motion after the treatment is accomplished. This CME article consists of literature review, illustrations, movies, and an online CME examination to bring the participant recent available information on the topic. Methods: The authors reviewed literature regarding the most current treat- ment strategies for common hand and finger fractures and dislocations. Films were created to illustrate operative and rehabilitation methods used to treat these problems. A series of multiple-choice questions, answers, discussions, and references were written and are provided online so that the participant can receive the full benefit of this review. Results: Many treatment options are available, from buddy and Coban taping to closed reduction with immobilization; percutaneous pins or screws; and open reduction with pins, screws, or plates. Knowledge of all available options is important because all can be used to achieve the goal of treatment in the shortest time possible. The commonly used methods of treatment are reviewed and illustrated. Conclusions: Management of common hand and finger fractures and disloca- tions includes the need to focus on achieving a full range of motion after treatment. A balance of fracture reduction with minimal dissection and early protected movement will achieve the goal. (Plast. Reconstr. Surg. 130: 722e, 2012.) he majority of metacarpal and phalangeal bone loss, and multiple fractures, and relatively fractures can be treated nonoperatively.1,2 indicated for intra-articular fractures and malro- Optimal treatment will depend on whether tated fractures that cannot be corrected by closed T 3 the fracture can be reduced (reducible or irre- reduction. ducible) and whether the reduction can be main- tained (stable or unstable). Closed reduction and percutaneous fixation or open reduction and in- ternal fixation of metacarpal and phalangeal frac- tures is indicated for irreducible fractures, open Disclosure: The authors have no financial interest fractures, associated soft-tissue injury, segmental in any of the products or devices mentioned in this article. From the Department of Orthopedic Surgery, University of California, Irvine Medical Center; Harvard Medical School, Department of Orthopedic Surgery, Massachusetts General Related Video content is available for this ar- Hospital; and Dalhousie University. ticle. The videos can be found under the “Re- Received for publication January 5, 2012; accepted April 17, lated Videos” section of the full-text article, or, 2012. for Ovid users, using the URL citations pub- Copyright ©2012 by the American Society of Plastic Surgeons lished in the article. DOI: 10.1097/PRS.0b013e318267d67a 722e www.PRSJournal.com Volume 130, Number 5 • Common Hand Fractures and Dislocations INTRA-ARTICULAR FRACTURES OF of anatomical reduction of intra-articular frac- THE BASE OF THE THUMB tures, finding little evidence of symptomatic post- METACARPAL traumatic arthritis 10 years after nonoperative Bennett fracture is a two part fracture-disloca- treatment of Bennett fractures.12 tion in which the entire thumb metacarpal is sub- luxated dorsally, radially, and proximally by the pull ULNAR METACARPAL BASE FRACTURE of the abductor pollicis longus4–7 (Fig. 1, left). If the DISLOCATIONS metacarpal base can be reduced and Kirschner In reverse (baby) Bennett13 fractures, approx- wired closed, or if the fragment is less than 20 per- imately 25 to 30 percent of the radial base of the cent of the articular surface, closed reduction and small finger metacarpal remains articulating with percutaneous fixation are preferred (Fig. 1, center). the hamate, but the entire small finger metacarpal Longitudinal traction, adduction, and pronation is subluxated proximally and dorsally because of are applied to the base of the thumb metacarpal the pull of the extensor carpi ulnaris tendon. One under fluoroscopy, and the base of the metacarpal study showed that the majority of patients treated is Kirschner wired to the index metacarpal or tra- by immediate range of motion were asymptomatic pezium. The pins are removed after 4 weeks. If 4½ years later.14 Another study showed that 38 there is an articular stepoff greater than 2 mm percent of patients are symptomatic 4 years later after attempted closed reduction and percutane- regardless of the treatment.15 Most agree that resto- ous fixation, open reduction and internal fixation ration of articular congruity should be attempted is performed through a Wagner incision with 2.4- either by closed reduction and percutaneous fixa- or 2.0-mm lag screws8 or Kirschner wires (Fig. 1, tion or open reduction and internal fixation.16 right). Long-term follow-up has confirmed supe- Longitudinal traction is applied to the small rior results in terms of pain, mobility, strength, finger and pressure is applied to the dorsal aspect and radiographic signs of arthritis in patients who of the base of the small finger metacarpal followed underwent closed reduction and percutaneous by passive wrist extension and closed Kirschner Kirschner wiring or open reduction and internal wire fixation under fluoroscopy. If treatment has fixation if there was less than 1 mm of articular been delayed, closed reduction and percutaneous stepoff after reduction.9 Conversely, patients with fixation is not successful, multiple carpometacarpal articular incongruity after reduction had a higher joint fracture dislocations are present, or there is an incidence of symptomatic arthritis in long-term associated dorsal shear fracture of the hamate,17 follow-up.10,11 One study contradicts the principle open reduction and internal fixation is indicated Fig. 1. (Left) Intra-articular Bennett fracture of the base of the thumb metacarpal showing proximal and radial displacement of the entire thumb. (Center) Closed reduction and percutaneous Kirschner wire fixation of a Bennett fracture. (Right) Open reduction and internal fixation of a Bennett fracture with two 2.0-mm lag screws. 723e Plastic and Reconstructive Surgery • November 2012 through a dorsal longitudinal incision. Fixation is An alternate method of percutaneous pinning of achieved with oblique and transverse Kirschner a metacarpal shaft fracture is to use the “bouquet wires or by longitudinal intramedullary Kirschner arrangement” of multiple intramedullary Kirsch- wires first passed antegradely down the metacarpal ner wires inserted antegradely from the base of the shaft and then passed retrogradely back into the metacarpal.22–24 hamate. Open reduction and internal fixation of meta- carpal shaft fractures is indicated for unsuccessful METACARPAL SHAFT FRACTURES closed reduction and percutaneous fixation, or for (1) significantly displaced transverse fractures or The geometry of metacarpal shaft fractures fractures that have residual angulation of greater may be transverse, oblique, spiral, or comminuted. than 10 degrees in the index and middle fingers, Transverse metacarpal shaft fractures exhibit apex 20 degrees in the ring finger, and 30 degrees in the dorsal angulation caused by the deforming force small finger; (2) spiral or oblique fractures with of the interosseous muscles (Fig. 2). Closed re- residual malrotation and scissoring; (3) multiple duction is indicated for 10 degrees of apex dorsal metacarpal shaft fractures when multiple Kirsch- angulation in the index and middle fingers, ner wires may not allow early movement after sur- greater than 20 degrees in the ring finger, and gery; (4) open metacarpal shaft fractures; or (5) greater than 30 degrees in the small finger. Most segmental metacarpal bone loss. metacarpal shaft fractures are inherently stable Metacarpal shaft fractures are exposed through and do not require fixation after closed reduction. a longitudinal incision to one side of the extensor Immobilization should not be continued longer tendon. The most simple fixation technique is to than 3 weeks; otherwise, stiffness may result.18,19 insert a Kirschner wire longitudinally down the med- Closed reduction and percutaneous fixation is in- ullary cavity of the metacarpal. The Kirschner wire is dicated if the fracture is unstable. Under fluoro- introduced antegradely at the fracture site into the scopic control, a single 0.062-inch Kirschner wire distal fragment and drilled out through the radial or can be inserted retrogradely into the metacarpal ulnar aspect of the metacarpal head and then drilled head to the radial or ulnar side of the extensor back retrogradely after the fracture has been re- tendon and then across the fracture site into the duced into the proximal fragment and even into the proximal metacarpal or even into the carpus.20,21 carpus. Longitudinal intramedullary Kirschner wire Metacarpal shaft fractures of the border digits, the fixation is an excellent solution for multiple open index and small