Hand Fractures and Dislocations

Reduction maneuvers should not cause added tissue
trauma. If the injury is reducible at all, gentle manipulation will
accomplish the reduction far more successfully than forceful
longitudinal traction. The principle is relaxation of deforming forces
through proximal joint positioning such as metacarpophalangeal (MP)
joint flexion to relax the intrinsics or wrist flexion to relax the
digital flexor tendons. Often, a gentle back-andforth rotatory maneuver
is necessary to free a bony prominence from soft tissue entrapment. The
mobile distal part is then reduced to the stable proximal part.

Splints should immobilize the minimum number of joints
possible and allow unrestricted motion of all other joints. One
controversial point concerns the need to immobilize the wrist. Setting
appropriate length-tension relationships in the extrinsic motors (in
cases where they are deforming forces) is most easily accomplished
through immobilization of the wrist in 25 to 35 degrees of extension.
This is extremely helpful in patients with low pain tolerance who tend
to place the hand in a characteristic dysfunctional posture of wrist
flexion-MP joint extension-interphalangeal (IP) joint flexion (the
“wounded paw” position). Other patients who are capable of avoiding
this position on their own often do not need wrist immobilization. A
simple splint that is useful for injuries ranging from the
carpometacarpal (CMC) joints proximally to P1 fractures distally
consists of a single slab of plaster or fiberglass applied dorsally.
With a foundation at the forearm, the splint runs out to the level of
the proximal interphalangeal (PIP) joints distally with the wrist
extended and the MP joints fully flexed. Full motion of the IP joints
should be encouraged throughout the healing process. The total duration
of immobilization should rarely exceed 3 to 4 weeks. Hand fractures are
stable enough by this time to tolerate active range of motion (AROM)
with further remodeling by 8 to 10 weeks.¹⁵

The integument is easily damaged, and open fractures are
common. Open wounds should not be probed in the emergency department;
doing so only drives surface contaminants deeper and rarely yields
useful information. The need for prophylactic antibiotics in open hand
fractures is controversial. The previous standard administration of
Ancef no longer appears applicable with methicillin-resistant Staphylococcus aureus
(MRSA) dominating most community-acquired infection profiles.
Clindamycin, vancomycin, Bactrim, and the quinolones are useful agents
against MRSA. Aminoglycosides are added for contaminated wounds, and
penicillin for soil or farm environments. No hard evidence exists to
support continuation of antibiotics beyond the initial 24 hours. The
exception to this may be bite wounds, whose potential for osteomyelitis
is significant if the tooth directly penetrates the cortex, allowing
the saliva into the cancellous structure. Aggressive and early surgical
debridement is needed for all bite wounds.

The distal phalanx directly supports the nail matrix.
With substantial displacement of the dorsal cortex, nail matrix
disruption should be expected and direct repair planned. Reconstruction
of residual open wounds overlying skeletal injury sites requires the
use of flaps. Frequently transposition flaps will suffice. Less
frequently, pedicle or free flaps will prove necessary.⁷⁵,⁷⁶
The greatest challenge in the hand, and particularly the digit, is to
achieve both thin and supple tissue coverage. A fascial flap covered
with a split-thickness skin graft provides this combination of
features, except at the volar pulp, where a directly innervated
glabrous cutaneous flap is needed (Fig. 28-1).

Closed extensor tendon ruptures near insertion points
may accompany dislocations. Prime examples are terminal tendon ruptures
sustained in association with distal interphalangeal (DIP) joint
injuries and central slip ruptures sustained in association with PIP
joint injuries. Initial examination of the traumatized hand must
include a survey that inventories each potential tendon injury. Apart
from these, tendon damage usually only occurs with an associated
laceration or in open combined injuries.

Apart from open combined injuries, these tissues are
rarely injured as part of simple fractures and dislocations of the
hand. In major open hand trauma, there is usually a significant zone of
injury. Appropriate treatment includes excision of the devitalized
tissues in the zone of injury including nerve and vessel tissues
followed by reconstruction with autogenous grafts or adjacent transfers.

The term combined refers to the association of a hand
fracture with injury to at least one of the soft tissues listed above.
These are most often open injuries with the soft tissue component of
greatest significance being the injury to flexor tendons, extensor
tendons, or both. The occurrence of this combined pattern of injury
directly impacts the treatment strategy for the fracture itself. Many
fracture patterns presenting as an isolated injury would be best cared
for nonoperatively or with closed reduction and internal fixation
(CRIF) using smooth stainless steel Kirschner wires (K-wires). The open
wound leading to the fracture site automatically changes the surgical
approach to open reduction, usually with internal fixation (ORIF). The
presence of an adjacent tendon repair site necessitates achieving
skeletal stability sufficient to withstand the forces of an immediate
tendon glide rehabilitation program. This often means the use of rigid
internal fixation (Fig. 28-2). In a study
limited to ORIF of intra-articular fractures, comminution and an
initial open injury were identified as independent variables leading to
a worse prognosis.¹⁵⁴ Only 6 of 16
patients in another study of comminuted phalangeal fractures and
associated soft tissue injuries achieved greater than 180 degrees of
TAM.²⁹ The remainder of this chapter
describes the most appropriate techniques for managing fractures and
dislocations of the hand as isolated injuries. The term combined injuries
will be found associated with the more stable fixation options as part
of the “Indications for Treatment” tables listed throughout the chapter.

The comprehensive planning required for treatment of
massive hand trauma merits a textbook in its own right and is beyond
the scope of this chapter. The majority of the complex decision-making
in these injuries occurs with respect to the strategy chosen for the
soft tissues (Fig. 28-3). With true degloving injuries and exposed bone and tendon, either pedicle or free flaps are required for coverage.⁷⁵,⁷⁶ Pedicle flaps are simpler and faster but are limited in size and reach and are associated with

a higher complication rate than thin fascial free flaps that can cover a defect of any size and shape.⁷⁵,⁷⁶
Clinical evaluation of these injuries is quite difficult because the
patient is often unable or unwilling to do very much with respect to an
interactive examination. Much of the determination regarding the extent
of injury is made intraoperatively. Good-quality radiographs are rarely
obtained initially and usually consist of semioblique views of the hand
with a high degree of bone overlap. Every effort should be made within
the scope of total patient management to obtain additional radiographic
views that can be set up properly so that associated injuries are not
missed. More often than not, the opportunity for these views first
presents itself in the operating room. A very easy pitfall is to draw
attention to the most obvious radiographic findings without taking the
time to search for more subtle injuries. Radiographic evidence of
foreign matter embedded in the hand should be sought as well as its
absence at the conclusion of the debridement.

The Gustilo classification of open fractures has been
modified for the hand by reducing the 10-cm wound length threshold to 2
cm. The validity of the classification is supported by 62.5% normal
hand function found after type I injuries compared with 21% following
type III fractures.¹¹¹ Another series found 92% poor results associated with grade III B and C injuries.³⁹ From a series of 200 open hand fractures, Swanson¹⁵¹
differentiated type II wounds from type I wounds by three criteria:
contamination at initial presentation, open for more than 24 hours
before treatment, or in patients with systemic illness. Type II wounds
are not recommended for primary closure.

Both internal and external fixation may be appropriate
in massive hand injuries. Standard indications for external fixation
include gross contamination of the original wound, segmental bone loss
or comminution, or the lack of availability of good

soft tissue coverage.³⁷
The biomechanics of external fixation in the hand are the same as
elsewhere in the body with pin diameter constituting the chief
determinant of fixator stiffness. Four pins, two proximally and two
distally, are sufficient for most hand applications. A given hand
injury may best be fixed by all internal, all external, or a
combination of the two methods of fixation. An improved understanding
and a wider array of elegant soft tissue coverage techniques have
overcome previous concerns regarding exposure of hardware with internal
fixation.⁷⁵,⁷⁶

Whenever the injury involves the first web space
(especially with crush injuries), the thumb and index metacarpals
should be pinned into abduction to prevent a first web space
contracture. No matter how the injury is managed, the strategy should
plan for rehabilitation to begin, unobstructed by bulky external
dressings, by 72 hours after surgery. In one series, 72 metacarpal and
phalangeal fractures with severe associated soft tissue injury were
treated with plates and screws yielding 46% good, 32% fair, and 22%
poor results by the American Society for Surgery of the Hand (ASSH)
criteria of total active motion.²¹
The overall results for treatment of these severe injuries are most
closely related to the soft tissue component rather than the status of
the skeletal injury.⁶⁵ In 245 open
injuries studied prospectively, extensor tendon injury alone had 50%
poor results, but flexor tendon or multiple soft tissue injuries
produced 80% poor results.²⁴ A
series of 140 open fractures demonstrated better results at the
metacarpal compared with the phalangeal level with the worst outcomes
occurring for injuries at the P1 and PIP level, especially when
associated with an overlying tendon injury.³⁹

Segmental bone loss is a frequent finding in massive
hand injuries. Once the wound has been rendered clean through either a
single or multiple débridements, bone grafting is appropriate using
corticocancellous iliac crest, shaped and sized to match the curvature
of the missing segment. If only mild comminution is present without
loss of structural stability, cancellous graft alone is sufficient.
Stable fixation is achieved with either internal plate (Fig. 28-4)
or external fixator application. With proper débridement, immediate
primary bone grafting is safe. A series of 12 patients with type III
open fractures and another 20 patients with low-velocity gunshot
phalangeal fractures both demonstrated 0% infection rates with the use
of an immediate autograft.⁶²,¹³³
If delayed bone grafting is planned, a temporary spacer may be used to
preserve the volume that will later be occupied by the graft (Fig. 28-5).
Bone loss that includes the articular surface represents an entirely
different and much more complex problem. Strategies that have been
advocated include autografts of metatarsal head, second, and third CMC
joints; immediate Silastic prosthetic replacement; osteoarticular
allografts; primary arthrodesis; and free vascularized composite whole
toe joint transfer.⁸⁷

Critical elements in selecting between nonoperative and
operative treatment are the assessments of rotational malalignment and
stability (Fig. 28-6). If carefully sought, rotational discrepancy is relatively easy to determine.¹⁴⁰
Defining stability is somewhat more difficult. Some authors have used
what seems to be the very reasonable criterion of maintenance of
fracture reduction when the adjacent joints are taken through at least
30% of their normal motion.²⁴
Contraction of soft tissues begins approximately 72 hours following
injury. Motion should be instituted by this time for all joints stable
enough to tolerate rehabilitation.²⁸ Elevation and elastic compression promote edema control.¹⁰⁹
The more aggressive the surgeon’s management of the injury has been,
the more aggressive must be the rehabilitation. Low-energy isolated
injuries have far less risk of stiffness than those created by
high-energy trauma with large zones of injury.

Plain radiographic evaluation includes at least two
projections with the beam centered at the level of interest. A third
oblique view is often quite instructive, revealing displacement not
evident on the standard posteroanterior (PA) or lateral. Rarely are
other imaging studies necessary in evaluating fractures and
dislocations of the hand. In complex periarticular fractures, such as
“pilon” fractures at the base of P2, computed tomography (CT) scans
assist some surgeons with operative planning. Foreign bodies may not
always be detected by standard radiographic projections. Glass or
gravel is best seen with soft tissue technique. CT scans may detect
plastic, glass, and wood. Ultrasound can detect objects that lack
radiopacity. Magnetic resonance imaging (MRI) remains a more expensive
backup for all types of foreign materials.

Unfortunately, the literature regarding these injuries
has not been written in accordance with any defined classification
scheme, and true comparisons are difficult to make. Descriptions

of
fractures have been based largely on the location within the bone
(head, neck, shaft, base) and further modified by the direction of the
fracture plane (transverse, spiral, oblique, comminuted) and the
measurable degree of displacement. Dislocations have been described by
the direction the distal segment travels (dorsal, volar, rotatory) and
further modified by the capacity (simple) or incapacity (complex) for
closed reduction. In the sections that follow regarding each injury, it
will be assumed that the above-stated designations are in effect unless
specific exceptions are noted.

If the dorsal surface of the distal portion of the
phalanx that supports the nail matrix has a significant step-off,
especially with a concomitant nail plate avulsion, the fracture should
be restored to a level surface and pinned to render support to the
surgical repair of the nail matrix. Conversely, if the nail plate has
maintained its seal at the hyponychium and the dorsal surface of the
distal phalanx is level, formal removal of the plate to perform a nail
matrix repair is not necessary despite any measured percentage of
hematoma occupying the area under the nail. Matrix defects should be
split-thickness grafted from the adjacent or a distant nail bed.
Following repair, the dorsal nail fold should be stented to prevent
adherence to the matrix but still allow fluid drainage. The patient
should be warned of the potential for nail deformity and the time
required (4 to 5 months) for regrowth.

Most shaft fractures have limited enough displacement
that nonoperative management is appropriate. Active motion of the DIP
joint can be pursued from the outset since the forces of the flexor
digitorum profundus and the terminal extensor tendon are not acting
across the fracture site. Only externally applied forces such as pinch
will deform the fracture. Shaft fractures with wide displacement are
headed for a nonunion without closer approximation of the fragments.
CRIF is usually sufficient for these fractures unless there is
interposed tissue blocking the reduction (Fig. 28-10).
Kirschner wire fixation may also be preferable (0 of 5 malunions)
compared with splinting (3 of 18 flexion malunions) when the fracture
is transverse, extra-articular, and located at the base of the distal
phalanx.⁴

CRIF is the treatment of choice for true displaced dorsal base fractures, comprising over 25% of the articular surface (Fig. 28-11). A variety of closed pinning techniques are possible, but the mainstay is extension block pinning⁸⁰,¹²³ (Figs. 28-12 and 28-13). Twenty-three patients treated with extension block pinning for fragments comprising an average of 40% of the joint

surface had mean flexion of 77 degrees with a four-degree extensor lag and two losses of reduction.⁸⁰
The difficulty in comparing the published outcomes for these injuries
is that the literature has usually failed to distinguish between dorsal
fractures that are merely bony variants of terminal tendon injuries and
those that are the more significant intra-articular fractures discussed
in this section.

Dorsal base fractures may rarely require ORIF. Although
subluxation has been cited as a reason to perform ORIF, a biomechanical
study showed that subluxation was not seen whenever the smaller
fragment carried less than 43% of the articular surface.⁸⁴ Thirty-three patients with K-wire ORIF had a mean arc of 4 to 67 degrees of final motion.¹⁵³
As an alternative method of ORIF, nine patients were treated with a
custom “hook plate” formed by cutting a 1.3-mm modular straight plate
and achieved an average of 64 degrees of ROM at the DIP joint with no
extensor lag.¹⁵⁵ One method of
avoiding the complications potentially associated with open DIP joint
surgery (0 of 19) might be the 5 weeks of external fixation employed in
19 patients resulting in 70 degrees of flexion with a two-degree
average extensor lag.⁸⁸

ORIF is the treatment of choice for highly displaced volar base fractures that have a large intra-articular fragment and loss of

FDP functional integrity. If the volar FDP fragment is large enough, it
may be fixed with a compression screw. Extension block pinning is
another rarely used alternative. The remainder of small bone flakes
located at the volar base of the distal phalanx are tendon avulsions
and should be treated in accordance with modern principles of flexor
tendon reinsertion.

Healing at this level of the digit is often prolonged.
Transverse shaft fractures may take 3 to 4 months before being able to
resist maximum pinch force. For stable tuft and longitudinal fractures,
splints may be removed and functional use of the hand instituted as
soon as tolerated. Dorsal base fractures usually have the Kirschner
wires removed by 4 weeks with continued external protection for 2 to 3
more weeks when using traditional pinning techniques. The dorsal base
extension block method works through the institution of passive
extension exercises beginning at 4 weeks and coinciding with wire
removal. The more distal the injury is in the digit, the more
hypersensitivity to surface contact the patient is likely to have.
Desensitization through progressively more stimulating contact is the
earliest component of the rehabilitation program, with the goal of
reincorporating the fingertip into as many activities of daily living
as possible.

Reduced dislocations that are stable may begin immediate
AROM. The rare unstable dorsal dislocation should be immobilized in 20
degrees of flexion for up to 3 weeks before instituting AROM. The
duration of the immobilization should be in direct proportion to the
surgeon’s assessment of joint stability following reduction. Complete
collateral ligament injuries should be protected from lateral stress
for at least 4 weeks. When splinting at the level of the DIP/IP joint,
extreme caution must be exercised with regard to the vascularity of the
dorsal skin between the extension skin crease and the dorsal nail fold.
It is not only direct pressure but merely the angle of hyperextension
that can “wash out” the blood supply to this skin, potentially
resulting in full-thickness necrosis. This complication is thought to
occur at an angle representing 50% of the available passive
hyperextension of the DIP joint and can be identified by blanching of
the skin (Table 28-2).

It is possible that the degree of postreduction
instability is great enough to require a brief period (3 to 4 weeks) of
0.045-inch K-wire stabilization across the joint (Fig. 28-20). The need for added stabilization occurs primarily when aggressive rehabilitation is required for adjacent hand injuries.

Delayed presentation (more than 3 weeks) of a subluxated
joint may require open reduction to resect scar tissue and permit a
congruent reduction, but can result in additional postoperative
stiffness. In one study, 10 patients with chronic dorsal
fracture-dislocations of the DIP and IP joints (average, 8 weeks)
underwent a volar plate arthroplasty with 4 weeks of K-wire fixation
yielding a 42-degree average arc of motion for finger DIP joints and 51
degrees for thumb IP joints with an average flexion contracture of 12
degrees.¹²⁶ Open dislocations
require thorough débridement to prevent infection. The need for
fixation with a K-wire should be based on the assessment of stability
and fixation is not necessarily required for all open dislocations. The
wire may be placed either longitudinally or on an oblique path. The
duration of pinning should not be longer than 4 weeks. The advantage of
longitudinal pinning is the absence of any lateral wire protrusion to
contact adjacent digits. The advantage of oblique pinning is the
ability to remove both sections of the wire should breakage across the
joint occur. When open reduction of the joint is required, a transverse
dorsal incision

at
the distal joint crease from midaxial line to midaxial line provides
ample exposure. Should additional exposure be required, midaxial
proximal extensions can be made.

Many P2 fractures can be effectively managed entirely nonoperatively (Tables 28-3, 28-4 and 28-5).
The presence of comminution alone does not necessitate surgery. When
crushing is the mechanism of injury, the periosteal envelope may remain
relatively intact as long as fracture displacement is not significant.
Degree of displacement is more related to inherent stability than the
direction or number of fracture planes. Nevertheless, certain patterns
are more stable than others. Transverse fractures are more stable than
long oblique or spiral fractures, both of which tend to shorten and
either laterally deviate or rotate to cause interference patterns with
neighboring digits. Splinting is confined to the digit alone with
dorsally applied aluminum and foam or custom orthoplast splints. Motion
rehabilitation should be initiated by 3 weeks postinjury with interim
splinting until clinical signs of healing are present (but not longer
than 6 weeks).²⁰ Side strapping to an adjacent digit usually provides sufficient protection from external forces after the first 3 weeks.

A nonoperative technique used specifically for volar
base fractures is extension block splinting. Fractures at the volar
base of the middle phalanx that involve less than 40% of the articular
surface can usually be managed effectively with extension block
splinting. The key to success with this treatment is absolute
maintenance of a congruent reduction, avoiding the hinge motion that
occurs with dorsal and proximal subluxation of the major fragment.
Correct application of a dorsal extension block splint requires
maintenance of contact between the dorsum of the proximal phalangeal
segment and the splint. If the digit is allowed to “pull away” from the
splint volarly, the PIP joint can extend beyond the safe range,
subluxate, and negate the desired effect of the splint. Once the splint
is in place, weekly follow-up with a true lateral radiograph of the PIP
joint is mandatory to monitor the advancement of extension at a rate of
around 10 degrees per week (see later for details of extension block
splinting).

Displaced unicondylar or bicondylar fractures of the head of the middle phalanx require a transverse wire to be placed across

the condyles to maintain a level distal articular surface at the DIP
joint. A second wire passed obliquely to the diaphysis of the opposite
cortex will prevent lateral migration of the condylar fragment along
the smooth shaft of the first wire, which would create an articular gap
(Figs. 28-26 and 28-27).
This second wire also controls the rotation of the fragment in the
sagittal plane that can occur with single-wire fixation alone. If the
patient presents late or soft tissue lies interposed in the fracture
plane between condyles, achieving an accurate closed reduction is
unlikely and open reduction may be required. Once opened, the
opportunity for threaded lag screw fixation exists as opposed to smooth
K-wire fixation. If the condylar fragment does not have a diaphyseal
extension, then the location for lag screw placement is directly
through the collateral ligament, which may negate the screw’s
theoretical advantage over two diverging K-wires in terms of early
motion.

CRIF is usually accomplished with 0.035-inch K-wires depending on patient size (Fig. 28-28).
Kirschner wires that cross in the middle of the shaft produce a less
stable pattern of fixation particularly if the fracture is located at
the level where the wires cross. For transverse or short oblique
patterns, K-wire placement other than the crossing pattern may be
difficult to achieve without violating either the DIP or PIP joint or
directly penetrating a tendon (Fig. 28-29).
Long oblique or spiral shaft fractures are amenable to relatively
transverse placement of K-wires without joint or tendon penetration.
When rotational alignment cannot be effectively

restored
by closed means, interfragmentary lag screw fixation is usually quite
effective for spiral fractures. When comminution or axial instability
is present, a limited number of P2 fractures may actually be most
appropriately treated with plate and screw fixation (Fig. 28-30).

Extension block pinning is an effective strategy for dorsal and volar base fractures (Figs. 28-31 and 28-32).
An average PIP joint ROM of 91 degrees was achieved following CRIF of
dorsal base fractures despite an extensor lag of over 10 degrees in 5
of 9 patients.¹²⁷ Extension block
pinning for 3 weeks or even longer to treat volar base fractures has
been used with success in limited numbers of patients.¹⁶²,¹⁶⁷
Ten patients with 16-year follow-up of transarticular pins for 3 weeks
with 2 additional weeks of extension block splinting achieved an
average 85-degree arc of motion with an 8-degree flexion contracture
and no severe degenerative changes.¹¹⁵
Another study compared transarticular fixation (eight patients) to ORIF
with lag screws (six patients) or ORIF with cerclage wires (five
patients). At 7-year mean follow-up, cerclage wires produced the
smallest arc of motion (median, 48 degrees) compared with pinning

(median, 75 degrees). Eleven of the 19 total patients healed with some degree of incongruence or frank subluxation.²

A closed fixation strategy uniquely designed for volar
base fractures is a force couple device that works to dynamically
reduce the tendency for dorsal subluxation of the middle phalanx¹⁷ (see Table 28-4).
Acute volar base fractures involving more than 40% of the joint surface
and those with subacute or chronic residual subluxation can be treated
with volar plate arthroplasty.³⁶
Seventeen patients followed at 11.5 years demonstrated a TAM of 85
degrees when operated on within 4 weeks of injury and 61 degrees when
operated on later than 4 weeks from injury.³⁶
A series of 56 patients with volar base fracture-dislocations treated
by either volar plate arthroplasty (23 of 56) or ORIF (33 of 56)
yielded at 46-month follow-up minimal pain in 83% but radiographic
evidence of degenerative changes in 96%.³⁴

Lag screw fixation is an excellent option for large volar fragments without comminution (Fig. 28-33).
Seven patients undergoing lag screw fixation within 2 weeks of injury
achieved an average PIP joint ROM of 100 degrees with a similar group
of seven patients operated after 2 weeks achieving an average of 86
degrees.⁶⁶ Another 12 digits followed-for an average of 8.7 months after lag screw ORIF demonstrated combined PIP

and DIP motion arcs that averaged 132 degrees.⁹⁶
When followed at an average of 42 months from surgery, 9 similar
patients demonstrated an average PIP range of 70 degrees with a
14-degree flexion contracture.⁶⁸
Even displaced fractures more than 5 weeks from injury can be carefully
corrected at the articular surface and supported by bone graft using
the volar “shotgun” exposure.³² An interesting alternative procedure offered by Weiss¹⁷²
and performed through the same “shotgun” volar exposure is that of
cerclage wiring of the base of the middle phalanx, which resulted in an
average PIP ROM of 89 degrees for 12 patients. When comminution is
excessive, restoration of the volar buttress with true hyaline
cartilage is possible using a hemi-hamate osteochondral autograft.
Thirteen patients treated with this strategy at an average of 45 days
postinjury for comminution of the volar 60% of the the middle phalanx
base had an average PIP 85-degree arc of motion at 16-month follow-up.¹⁷⁵

The most functionally devastating injuries to the PIP
joint are “pilon” fractures that involve the complete articular surface
combined with metaphyseal compaction (Table 28-5).
These are highly unstable injuries refractory to standard surgical
techniques. Although other adverse events such as pin tract infection
may intercede, the primary complication is stiffness. Unique forms of
treatment have been devised for these injury patterns involving
“dynamic traction.”⁸,⁴²,¹⁰⁶,¹²⁹,¹³⁴,¹⁵²,¹⁵⁷ An alternative design uses a dorsal spring mechanism.⁴⁵
The general principle is to establish a foundation at the center of
rotation in the head of P1. From this foundation, traction (adjustable
or elastic) is applied along the axis of the middle phalanx to hold the
metaphyseal component of the fracture out to length while allowing
early motion to remodel the articular surface (Fig. 28-34).
Dynamic traction with pins and rubber bands in 14 patients followed for
2.5 years produced average PIP motion of 74 degrees and a TAM of 196
degrees.¹⁰⁶ Dynamic fixation with
wires but not elasticity in eight patients yielded a final average
motion of 12 to 88 degrees following wire removal at 6 weeks.⁸⁵ Ideally, the patient should begin treatment acutely compared with delayed

application of the device.²³ Many types of device constructs are possible (Fig. 28-35).
The simplest constructs involve only K-wires and rubber bands.
Thirty-four patients from the armed services achieved a final average
arc of motion at the PIP joint of 88 degrees and the DIP joint of 60
degrees using such a device with eight pin tract infections.¹²⁹ Another group of nonmilitary personnel achieved average PIP arcs of 64 degrees and DIP arcs of 52 degrees.¹⁵⁷
With the traction left in place for only 3.5 weeks on average, an
average PIP arc of 94 degrees and thumb IP arc of 62.5 degrees was
achieved in six total patients.¹³⁴
Another six patients having the device removed between 3 and 4 weeks
achieved average PIP range from 5 degrees to 89 degrees with two pin
tract infections.⁸ In another
series, by an average of 26 months postoperatively, five of eight
patients already demonstrated step-off deformities or arthritis.⁴²

Isolated volar plate injuries can be managed with only 7 to 10 days of splinting followed by 6 weeks of “buddy taped”

(strapped to an adjacent digit) AROM (Table 28-6).
Fortunately, the majority of hyperextension injuries remain congruent
even at full extension and do not require extension block splinting.
However, one must consider that the distal volar plate is poorly
vascularized, and a lack of early healing may lead to chronic
hyperextension laxity. Lower-profile digitally based splints or buddy
taping may effectively prevent the full extension that could threaten
sound volar plate healing. When formal extension block splinting is
chosen (usually only in the situation of fracture-subluxation), the
rate of progression each week is determined by the severity of the
initial injury but should reach full extension no later than 4 weeks
from injury.

With pure volar dislocations, central slip disruption
occurs and will result in a boutonnière deformity if not treated
properly. Careful examination consisting of PIP extension against
resistance from a starting position of full flexion will prevent
missing the diagnosis of a central slip disruption. Limitation of
passive DIP flexion is an early sign of a developing boutonnière
deformity. Even when identified late, the treatment of choice is
extension splinting at the PIP joint with immediate active DIP blocking
exercises. Active DIP flexion pulls the whole extensor mechanism
(including the ruptured central slip) distally through the intact
lateral bands. The duration of PIP extension splinting is usually 4 to
6 weeks with a transitional period of night splinting for several
additional weeks.

Rotatory volar dislocations where the head of P1 is
trapped between the central slip and lateral band may be difficult to
reduce owing to the noose effect exerted by these two soft tissue
structures. The key to closed reduction (if it is possible at all) is
to relax both structures. Wrist extension relaxes the extrinsic
component, and full metacarpophalangeal joint flexion relaxes the
intrinsic component. A gentle rotating maneuver that avoids excessive
longitudinal traction stands the highest chance of success. A few of
these dislocations remain irreducible even in the most skilled hands.
When a reduction can be achieved, early mobilization is then instituted
with buddy taping to an adjacent digit (usually the more radial) in an
attempt to prevent stiffness.

There are two indications for open treatment of PIP joint injuries: an open injury or an irreducible dislocation.¹¹⁸ Lateral dislocations may also be irreducible because of interposition of a torn collateral ligament (Fig. 28-43).
A midaxial (or dual midaxial) incision allows for management of both
dorsal and volar dislocations. Controversy remains as to the need for
direct repair of complete collateral ligament ruptures and volar plate
injuries. Direct repair is probably only functionally necessary in the
long term for the radial collateral ligament of the index finger.
Chronic reconstruction of collateral ligament deficiency is an even
more technically demanding procedure with a high propensity

for generating stiffness but may be accomplished by a variety of techniques.

Fracture of the proximal phalanx may well be one of the most frustrating hand injuries to manage.⁹¹,⁹⁷
The prime reason is the local soft tissue anatomy. While the metacarpal
has only a cordlike extensor tendon running well dorsal to it, the
proximal phalanx is closely invested by a sheetlike extensor mechanism
with a complex array of decussating collagen fibers (Fig. 28-45).
Surgical disturbance of the fine balance between these fibers can
permanently alter the long-term function of the digit. The operative
approach to P1 can be either dorsal or lateral. The dorsal approach may
be technically simpler but transgresses the extensor mechanism. The
lateral midaxial approach allows the fracture to be fully exposed and
hardware placed in its proper lateral position (if hardware is
indicated) without directly violating the extensor mechanism.⁷³
If prominent hardware is to be placed, the intrinsic tendon on that
side (usually ulnar) may be resected. The proximal phalanx is not a
cylinder but rather highly elliptical (in fact, tunnel shaped) in cross
section, with a thicker dorsal cortex.

At the proximal phalangeal level, both intrinsic and
extrinsic tendon forces deform the fracture. They result in a
predictable apex volar deformity for transverse and short oblique
fractures. These forces can be used with benefit during rehabilitation.
If the MP joints are maximally flexed (the intrinsic plus position),
the intrinsic muscle forces acting through the extensor mechanism
overlying P1 create a tension band effect that helps to maintain
fracture reduction (Fig. 28-46). Active PIP
joint motion will heighten this effect and forms the basis for
nonoperative fracture management. Spiral and long oblique fractures
tend to shorten and rotate rather than angulate. These fractures also
have more complex patterns of deformity that are not so easily
controlled through the joint positioning just described.

One can expect 12 degrees of extensor lag at the PIP
joint for each millimeter of shortening and 1.5 degrees of extensor lag
for each degree of apex palmar fracture angulation.¹⁶³

Transverse and short oblique proximal phalanx shaft
fractures deform through apex volar bending. Laboratory investigation
has shown the biomechanical inefficiency of dorsally applied plates in
an apex volar bending model that correlated with the clinical forces
experienced at the P1 level.¹⁰³ Even with plate fixation, the soft tissue envelope has been shown to add stability under load application.¹²⁰ This is particularly true in the most proximal 6 to 9 mm at the base of P1.¹⁷⁴
The most valuable foundation in a fixation paradigm is a well placed
lag screw across a noncomminuted fracture interface, although some
surgeons have bypassed the step of lagging the screw in favor of less
labor intensive bicortical screws.¹²⁸
Long oblique and spiral proximal phalanx fractures demonstrate less
angular deformity than transverse fractures, instead shortening and
axially rotating.

This is the preferred treatment for many phalangeal
fractures that are either minimally displaced or easily rendered stable
by reduction (Table 28-7). Transverse fracture
patterns will generally prove to be stable after reduction compared
with oblique, spiral, or comminuted fractures. Stable proximal
phalangeal fractures are ideal candidates for dorsal splinting with the
MP joint in flexion. Only 4 of 45 patients treated in intrinsic plus
splints failed to achieve full motion by 6 weeks.⁴¹
The splint should be able to be discontinued at 3 weeks and followed by
AROM exercises without resistance. Stable, nondisplaced fractures may
even be treated by a program of immediate AROM, protected only with
adjacent digit strapping. The take-home message for nonoperative
management is that a carefully formed splint and/or adjacent digit
strapping can effectively maintain an existing and reasonably stable
reduction. What splints and strapping cannot accomplish is a reduction
in their own right. In case this fact is not appreciated at the initial
encounter, all patients undergoing nonoperative management should be
seen back in the office at a week to verify maintenance of reduction
radiographically.

This is the treatment of choice for the category of
reducible but unstable isolated fractures, both extra-articular and
some intraarticular. A higher degree of care must be exercised when
pursuing CRIF in the phalanges compared with the metacarpals because

of
the close investment by the broad extensor mechanism. Pin entry sites
should be chosen carefully to minimize tethering of the extensor
mechanism. In the proximal two thirds of P1, this is virtually
impossible. As one approaches the distal third, a direct lateral
approach can be made volar to the interosseous tendon. For long oblique
and spiral fractures, three K-wires (0.045 or 0.035 inch) are placed
perpendicular to the fracture plane (Fig. 28-47). For neck fractures, retrograde pinning may be necessary (Fig. 28-48). For short oblique and transverse fractures, longitudinal K-wires (0.045-inch) are placed through the MP joint (Fig. 28-49).
Twelve patients achieved an average TAM of 265 degrees with two
longitudinal pins placed across the MP joint and down the shaft of the
proximal phalanx.⁸¹ Trocartipped
K-wires rather than diamond-tipped or surgeon-cut wires should be used.
The wire should be passed through the soft tissues and down to bone
before activating the wire driver. Pins should be cut just below the
skin surface to prevent pin tract infection or left protruding for ease
of removal at the surgeon’s discretion. Absolute parallelism of the
K-wires for oblique fractures risks the fracture displacing as it
slides along the wires. Some degree of convergence or divergence of the
wires will help to prevent this consequence of using smooth wires. The
procedure of CRIF is made more difficult than it may initially appear
by the challenge of obtaining a truly accurate reduction by closed
means. Commercially available devices have been specially designed for
closed intramedullary rodding of the phalanx (Fig. 28-50).
Routinely, pins should be removed by 3 weeks. When this is done, any
final limitations of motion are most likely because of the injury
itself rather than the pins. In 35 fractures of the proximal phalanx
treated by percutaneous pinning, 32% developed a PIP flexion
contracture averaging 18 degrees.⁴³ A slight variation on the theme is “intrafocal” pinning used in five patients to achieve an average PIP range of 90 degrees.²⁷

ORIF is the technique of choice for severe open
fractures with multiple associated soft tissue injuries and for
patients with multiple fractures (within the same hand or polytrauma
patients). It is also the technique of choice for intra-articular
fractures with displacement in P1. In a series of 38 distal unicondylar
fractures of P1, five of seven initially nondisplaced and unfixed
fractures and four of ten fixed with a single K-wire went on to
displace.¹⁷³ Displaced fractures at
the intra-articular base of P1 with more than 20% articular involvement
should be internally fixed. Using a volar A1 pulley approach, 10
patients had fixation of lateral base fractures with full motion
recovery, good stability, and over 90% contralateral grip strength.⁹²
The role of ORIF for an isolated, noncomminuted, extra-articular
fracture of the phalanx is clearly defined only for the rare
irreducible fracture. Spiral fractures may benefit from ORIF with lag
screws to achieve precise control over rotation, provided that surgeons
experienced in this specific technique can minimize soft tissue
disruption. Most surgeons will be more comfortable with CRIF for those
fractures that can be reduced. The 40-month follow-up of 32 patients
prospectively randomized to percutaneous pinning versus lag screw
fixation for long oblique and spiral shaft fractures found no
differences in function, pain scores, ROM, or grip strength, but with a
mean loss of active extension of 8 degrees in the pinning group and 27
degrees in the screw fixation group.⁸²
Surgical technique was such that there were 8 malunions of the 15 lag
screw patients using screws as large as 2.0 mm. Three of the 17 K-wire
patients required subsequent formal extensor tenolysis for tethering
but none of the lag screw patients did.⁸² ORIF with screws and/or plates is

considerably more technically demanding than in the metacarpal for a
number of reasons including the proximity of the extensor mechanism,
the origins of the fibro-osseous flexor tendon sheath, and the size and
consistency of the bone. More than just the technical complexity of
ORIF is the problem of the postoperative response of the surrounding
soft tissues to the surgical dissection and the presence of hardware.

Options for ORIF include intraosseous wiring, composite wiring, screw-only fixation, or screw and plate fixation²²,²⁹,⁵⁸,⁶²,⁷²,⁷³,⁷⁴,¹³²,¹³³,¹⁵⁰ (Figs. 28-51 and 28-52).
The familiarity of the surgeon with the specific technique is probably
the most important factor in the selection of a method. Of 30 patients
followed for 2.3 years after tension band wiring, 17 had a TAM of over
195 degrees and 13 had a TAM of between 130 and 195 degrees.¹³² More recently, attention has increasingly turned to the use of screw and plate technology (Figs. 28-53 and 28-54).
The relative bulkiness of plates at the phalangeal level compared with
the metacarpals can result in the need for their removal even with
initially excellent results. The results of internal fixation are
intimately related to the associated injuries present. The gravest
danger, however, occurs when the surgeon elects ORIF but is then unable
to secure rigid fixation of the fracture. In this situation, the
patient has been subjected to the “worst of both worlds,” and a poor
outcome can be reliably predicted.

Two intra-articular patterns are seen distally at the
phalangeal head, unicondylar (partial articular fracture), or
bicondylar (complete articular fracture). The condylar fragments
usually are extremely small, can be fragile, and receive their blood
supply from the attached collateral ligament. Fixation of a single
condyle is most rigid when accomplished with a compression screw placed
transversely, entering near the collateral ligament origin (Fig. 28-55). This can be quite challenging technically, and the bone stock may only tolerate K-wire or composite wiring techniques (Fig. 28-56).
When the unicondylar fragment has a solid extension to the shaft level
cannulated microsized headless compression screws can be used.⁵⁸ Triplane fractures of the head of the proximal phalanx are

well managed with 1.2-mm lag screws (Fig. 28-57).²²
Complete articular fractures can be fixed with screws only if one of
the two condyles has an extended spike. If not, minicondylar or locking
plate fixation may be necessary to achieve excellent rigidity. Again,
the bone stock may not tolerate the application of this device, and
wiring techniques remain an alternative strategy.

The final group of articular fractures are those seen at
the lateral corner of the phalangeal base, which are particularly
amenable to the technique of tension band wiring (see Fig. 51C). An
alternative is a volar approach to lateral base P1 fractures using a
single lag screw for fixation to achieve full motion by 3 weeks.¹³⁷
Comminuted intra-articular fractures of the proximal phalangeal base
can be stabilized by a small volar plate placed through the A1 pulley
approach.⁷² A specific subset of
proximal phalangeal base fractures that are purely impactions by nature
may be treated by supporting the impacted fragments with packed
cancellous bone only; in one series of 10 patients followed for 32
months, there was no secondary displacement and an average PIP joint
flexion of 88 degrees was achieved.¹⁵⁰

Nonoperative management should restrict splinting to 3
weeks followed by AROM that can include adjacent digit strapping if
necessary. Similarly, CRIF should allow for pin removal at 3 weeks,
with AROM beginning no later than this time. If ORIF is chosen, AROM
should begin within 72 hours of surgery and edema control should be
foremost in the treatment plan using cohesive elastic bandages.⁵³
AROM alone may be insufficient to counteract extensor lag at the joint
distal to the site of fixation. Rapidly accelerating the extensor
tendon concentrically without resistance best limits local adhesion
formation⁷⁷ (Fig. 28-58).
These exercises can be supplemented with the use of electrical muscle
stimulation during outpatient therapy sessions. Night splinting with
the PIP joint in extension can be helpful but will not in and of itself
overcome an extensor lag.

The thumb MP joint, in addition to its primary plane of
flexion and extension, allows abduction-adduction and a slight amount
of rotation (pronation with flexion). The range of flexion and
extension has a wide natural variation that may be related to the
flatness of the metacarpal head and may also play a role in
predisposition to injury for those with less motion. With a one-sided
collateral ligament injury, the phalanx tends to subluxate volarly in a
rotatory fashion, pivoting around the opposite intact collateral
ligament. The ulnar collateral ligament may have a two-level injury
consisting of a fracture of the ulnar base of P1 with the ligament also
rupturing off the fracture fragment.⁵⁹
Of particular importance is the proximal edge of the adductor
aponeurosis that forms the anatomic basis of the Stener lesion. The
torn UCL stump comes to lie dorsal to the aponeurosis and is thus
prevented from healing to its anatomic insertion on the volar, ulnar
base of the proximal phalanx (Fig. 28-71). The
true incidence of the Stener lesion remains unknown because of widely
disparate reports. The abductor pollicis brevis also sends fibers to
the extensor mechanism, but a discrete edge capable of preventing
healing of the radial collateral ligament does not

exist;
therefore, there is no correlate to a Stener lesion on this side of the
joint. Radial collateral ligaments injuries have been found to occur at
the phalangeal insertion in 13 of 38 cases and at the metacarpal origin
in 25 of 38.²⁶

For reducible dorsal dislocations and collateral ligament injuries, nonoperative management is the treatment of choice (Table 28-8).
Collateral ligament injuries should be immobilized in incomplete
flexion (50 degrees) for 3 weeks followed by AROM while the digit is
strapped to an adjacent digit to resist lateral deviation stress. Even
with fracture fragments constituting up to 25% of the width of the
phalangeal base, early active mobilization using side strap protection
led to normal motion and grip strength in 6 of 7 patients with a mean
DASH score of 3.1.¹³⁵ Dorsal
dislocations will normally prove stable during early AROM. Only in an
exceptional case would the use of extension block splinting of 20
degrees or so for 2 to 3 weeks be required. In a high-demand patient
the radial collateral ligament of the index MP joint should be
considered for operative repair.

Nonoperative management is the mainstay of treatment for
thumb MP joint injuries. Only the complete UCL injury with a Stener
lesion and volar dislocations require more aggressive treatment. The
standard treatment consists of 4 weeks of static MP joint
immobilization with the IP joint left free. Management in the presence
of a fracture at the ulnar base of P1 is more controversial. Nine
patients with less than 2-mm displacement of such a fragment treated
nonoperatively all had chronic pain with pinch strength rated at 36% of
normal. Following operative treatment, pinch improved to 89% of normal
with symptom resolution.³⁵
Conversely, 28 patients with ulnar base fractures but with a joint
clinically assessed as stable to stress testing were managed
nonoperatively resulting in equivalent grip and pinch strengths to the
contralateral side and 93% were pain free despite a 60% rate of fibrous
union.¹⁴² Radial collateral ligament
disruptions and pure dorsal dislocations can be successfully managed by
a 4-week period of MP joint immobilization. Sesamoid fractures also are
managed primarily by 3 to 4 weeks of immobilization in partial flexion.

Volar dislocations, complex dorsal dislocations, and
collateral ligament disruptions associated with large bone fragments
should be treated with open reduction and repair (Fig. 28-72).
Radial collateral ligament injuries repaired late risk a higher
incidence of pinch weakness and should be attended to promptly. Open
repair or reconstruction with a free tendon graft may also be required
in chronic cases with persistent symptoms following initial
nonoperative management. Of 33 patients with MP collateral ligament
avulsion fractures from the base of the proximal phalanx, the eight who
were treated nonoperatively

initially all went on to symptomatic nonunion requiring subsequent surgery.¹³⁷
In a similar series of 19 patients with the avulsion occurring at the
metacarpal head, successful results occurred in the 11 displaced
fragments internally fixed through a dorsal approach but 3 of 7
initially nondisplaced fragments went on to symptomatic nonunion
requiring surgery.¹³⁸ Volar MP
dislocations should have repair of the collateral ligaments and volar
plate to prevent late instability. Either a dorsal or a volar approach
is acceptable, and the one that provides access to the major pathology
should be chosen based on the individual patient’s preoperative
findings. Dorsally, a midline longitudinal incision provides good
access to manage any associated osteochondral fractures. One may have
to split the volar plate longitudinally and draw it around the sides of
the metacarpal head to accomplish a reduction. The volar approach
avoids splitting the volar plate but risks injury to digital nerves
which are tented over the deformity and lying directly under the
dermis. Volarly, the volar plate can be pulled back out of the joint
and reduced without splitting it.

The duration of immobilization should be in direct
proportion to the surgeon’s assessment of instability following
reduction. While most patients may begin AROM immediately, those
injuries that demonstrate an extra degree of instability during the
postreduction assessment should be immobilized in partial flexion for 3
weeks. Whether simple or complex, the dislocations should be
immobilized in only partial (50-degree) flexion to allow ligament
healing under appropriate tension. After 3 weeks, AROM is progressed
until 6 weeks, when full passive motion including hyperextension is
allowed.

Surgical management of thumb MP joint injuries is
largely limited to UCL disruptions with a Stener lesion and volar or
irreducible MP dislocations.⁸³ The results of acute repair of the radial
collateral ligament equal those of chronic reconstructions. This makes
a very weak case for early operative repair considering that no Stener
lesion exists on the radial side of the joint. Determining the presence
of a Stener lesion on the ulnar side of the joint remains an inexact
science; therefore, open management can be argued to be the treatment
of choice for all widely unstable ulnar-sided disruptions. Pure
ligamentous midsubstance ruptures can be repaired by direct suture. The
usual site of disruption is distally at the phalangeal insertion where
bone anchors can be used for ligament reinsertion. Thirty-six patients
with suture anchor repairs healed with loss of 10 degrees of MP joint
motion and 15 degrees of IP joint motion.¹⁷⁰
Overtensioning should be avoided as insertion sites malpositioned
volarly or distally on the proximal phalanx will cause loss of motion.⁹ Arthroscopic reduction of the Stener lesion has been reported in eight patients.¹³⁰
With bony avulsion fragments, tension band wiring, intraosseous wiring,
or fragment excision with ligament anchorage may all be used at the
surgeon’s discretion.

Cases presenting late with residual instability (after
degeneration of the tendon substance has occurred) may require
reconstructive methods.⁴⁷ Twenty-six
patients with tendon reconstruction for the thumb UCL followed for 4.5
years had 85% normal ROM and key pinch strength equal to the opposite
side at 20 pounds.⁶⁰ High-grade
radial collateral ligament tears that are widely unstable may benefit
from direct soft tissue advancement and repair with 38 patients at
10-month follow-up achieving 92% of normal pinch and 87% were symptom
free.²⁶

Careful inspection of the dorsal aspect of the
metacarpal head should identify any chondral or osteochondral
fractures. There are three strategies to manage these fractures. If the
fragment is small and extremely unstable, it should be excised. If the
fragment has a large subchondral bone base, it can be fixed with a
countersunk screw. If fixation is not possible but the fragment can be
stably trapped in its bed by the congruent opposing joint surface, it
can be further restrained with fine resorbable sutures. For collateral
ligament injuries associated with bone fragments, there are two
options. If the bone fragment is both large and solid enough to receive
definitive fixation, ORIF may be performed with a tension band wire or
lag screw. Twenty-five patients with base of P1 ligament avulsion
injuries were reported to have recovered full motion by 3 weeks
following volar approach single lag screw fixation.¹³⁷
If the bone fragment is too small or too comminuted, the bone can be
excised and the end of the ligament reinserted to the cancellous bed of
either the metacarpal head or the base of the proximal phalanx. This
can be accomplished with a mini-bone anchor (many models are currently
available) or by transosseous suture. Surgery may not always be
necessary to achieve grip and key pinch strength in avulsion fractures
of the lateral base of P1. For example, 27 of 30 nonoperatively treated
patients achieved clinical stability despite a 25% incidence of
radiographic nonunion, but with only 19 of 30 reporting no pain.⁹⁵

Many metacarpal neck and shaft fractures can be treated nonoperatively (Table 28-9).
Twenty-seven small finger metacarpal fractures with initial angulation
of 40 degrees were reduced and treated in a short hand cast for 4 weeks
with only 3 patients losing reduction beyond 15 degrees.³⁰
Intra-articular fractures of the head and base may also be treated
nonoperatively provided the fracture plane is both stable and minimally
displaced. Metacarpal fractures with significant rotation or shortening
cannot be effectively controlled through entirely nonoperative means.
An externally applied splint exerts indirect (but not direct) control
over fracture position through positioning and reduction of
myotendinous deforming forces. A splint is able to preserve a fracture
position that is inherently stable but is not capable of reducing and
maintaining an unstable position. The stability of a metacarpal
fracture is determined primarily by the adjacent structures
(periosteum, adjacent metacarpals, deep transverse intermetacarpal, and
proximal interosseous ligaments) as well as the degrees of initial
displacement and comminution. Splinting should be directed at pain
control and neutralization of deforming forces. Surface contact should
be as broad as possible with an appropriate amount of padding. The
splint may be discontinued as soon as the patient can comfortably
perform ROM with the hand and not later than 3 weeks. Interphalangeal
joint motion should begin immediately following injury. A dorsal splint
in full MP joint flexion meets the patient’s needs well but may be more
than is required. Even less restrictive methods of functional bracing
have been advocated. Compared to simple adjacent digit strapping in 73
patients, a molded metacarpal brace for less than 40-degree angulated
fractures of the small finger metacarpal neck yielded similar clinical
results with less pain.⁷⁰ Extending this concept, some have advocated functional mobilization for metacarpal fractures without splinting at all.¹⁴
Defining the acceptable limits of deformity for each injury location is
the subject of much controversy. Functionally, pseudoclawing is
unacceptable. Also, the patient may be troubled by the appearance of a
dorsal prominence at the fracture site or a shift in the metacarpal
head from its dorsally visible position toward the palm. Only rarely
will the shift toward the palm create a functional problem. Each
patient may have different degrees of deformity that he or she is
willing to tolerate. A correlation between deformity and symptoms has
not been clearly established. Greater degrees of angulation are
tolerable in neck fractures than in shaft fractures. Greater angulation
is tolerable in the ring and small metacarpals than in the index and
long metacarpals because of the increased mobility of the ulnar-sided
CMC joints. Biomechanically significant decay in flexor tendon
efficiency because of slack in the flexor digiti minimi and third volar
interosseous occurs with angulations over 30 degrees in the fifth
metacarpal neck, the site of greatest allowable angulation.³,¹²

CRIF is the mainstay of treatment for isolated metacarpal fractures not meeting the criteria for nonoperative treatment (Fig. 28-82).
Twenty-five patients with small finger metacarpal fractures achieved
excellent functional results following stabilization with 3 transverse
K-wires and demonstrated no shortening, appreciable angulation, or
complications.⁵⁶ A comparison
between transverse and intramedullary K-wires in 59 patients failed to
show any differences in outcome with no complications in either group.¹⁷⁶
CRIF may be used for both extra-articular and intra-articular fractures
provided that the fracture is anatomically reducible and stable to the
stress of motion with only K-wire fixation (Fig. 28-83). CRIF is the minimum treatment necessary for metacarpal base fractures that cannot be held reduced by nonoperative means.

Intramedullary fixation strategies are best matched with
transverse and short oblique fracture patterns and include a single
large-diameter rod such as a Steinmann pin, an expandable
intramedullary device, multiple prebent K-wires, or specially
manufactured devices inserted at the metacarpal base designed

to achieve three-point intramedullary fixation⁵²,⁶³,⁶⁴,¹⁰²,¹⁰⁷,¹¹⁶ (Fig. 28-84).
A single Steinmann pin may be inserted open through the fracture site
with the two fragments then impacted over it. Rotational control is
achieved by fracture fragment interlock, and motion can be started
immediately. The strategy of multiple, stacked prebent wires has
received broader acceptance than the other two strategies, perhaps
owing to the closed technique used for introduction.⁵²,⁶⁴,¹⁰²,¹⁰⁷
The wires are to be prebent such that three-point contact is obtained
dorsally at the proximal and distal ends of the metacarpal and volarly
at the mid-diaphysis (Fig. 28-85). This bow
opposes the natural dorsal convexity of the metacarpal and is the basis
for the apparently secure fixation achieved with this technique. The
pins are to be stacked into the canal, filling it and imparting
improved rotational control; as many as three to five 0.045-inch
K-wires may be required. Excellent results with multiple wires have
been reported primarily for fractures at the metacarpal neck level.⁵²,¹⁰⁷ One series of 20 patients with 5-year follow-up reported essentially no complications.¹⁰⁷
Another series of 66 patients with 4.5-year follow-up noted eight
incomplete reductions (average 18-degree deformity) and 12 patients
with MP joint extensor lags of 10 to 15 degrees.⁵²

ORIF is the treatment of choice for intra-articular
fractures that cannot be reduced and held by closed means. Internal
fixation is also required for multiple fractures without inherent
stability and for open fractures especially when associated with tendon
disruptions.⁵⁴ Internal fixation can be accomplished with intraosseous wiring, composite wiring, screws only, or screws and

plates (Fig. 28-86).
Wiring techniques have traditionally held the advantage over plate and
screw application in terms of technical ease and availability of
materials. However, with the modular plating systems now available
specifically for use in hand surgery, lower profile fixation can be
achieved with greater rigidity (Fig. 28-87).
The most important consideration is that the surgeon should choose the
method of internal fixation with which he or she is the most
comfortable.

For partial articular metacarpal head fractures,
screw-only fixation is the treatment of choice. If sufficient interlock
of bone spicules occurs, a single 1.2- to 1.5-mm countersunk screw can
control rotation of the fragment. If interlock is not effective, two
screws are preferred even if this means downsizing the screw diameter
to accommodate both of them in the fragment without causing comminution
(Fig. 28-88). For complete articular head
fractures, the condylar blade plate used to be required, but it is the
most technically demanding plate to apply. It is applied laterally with
the blade dorsal and the condylar screw hole volar. The drill hole for
the blade is round but the blade is rectangular in cross-sectional
area. This makes manual insertion of the blade into its hole difficult,
and a fine touch is required to not further comminute the metacarpal
head. More importantly, the exact angle of the drill path for the blade
must be determined in advance relative to the cortical surface of the
more proximal shaft against which the plate will be applied. The
condylar screw hole of the plate usually needs to be bent to avoid
prominence on its volar edge. Since the last edition of this text,
locking plate technology has become available in the size range for
small hand fracture plates. This allows fixed angle support of
comminuted periarticular fractures with the ability to contour the
plate first and avoid the complexity associated with inserting the
blade plate (Fig. 28-89).

The importance of early motion must be considered in
direct proportion to the magnitude of the injury or the surgical
procedure performed.¹¹² The more
tissue damage that is present, the more aggressive must be the motion
program. One frequently overlooked factor that greatly confounds
progress in therapy is edema control. External compression wraps to the
zone of injury with cohesive elastic bandages work to minimize the
presence of edema from the outset. When internal fixation has been
required, one must anticipate the development of an extensor lag at the
MP joint. Specific attention should be given to extensor tendon gliding
in zone VI to overcome a developing lag. Rapid tendon activation has
been successful in breaking free developing adhesions between the
peritendinous tissues and their surroundings⁷⁷ (Fig. 28-90).
Patients should be allowed to use the hand for light activities
throughout the healing period. Light resistance activities can begin at
6 weeks. Extremely forceful use patterns should be deferred until 3
months.¹⁵

Stability at the finger CMC joints is provided by a
system of four ligaments. There is a high degree of variation with
dorsal, multiple palmar, and two sets of interosseous ligaments (only
one between the long and ring metacarpals).⁴⁰,¹¹⁴
The interosseous ligaments are the strongest and have a V-configuration
with the base of the V oriented toward the fourth metacarpal. Range of
motion of the index and long CMC joints is limited to less than 5
degrees, with 15 degrees at the ring, and up to 25 to 30 degrees at the
small finger. Small finger CMC motion is reduced 28% to 40% when the
ring finger is immobilized.⁴⁴ The
axis of motion is located near the base of the metacarpal. The index
metacarpal has a particularly stable configuration through its
wedge-shaped articulation with the trapezoid. The small finger CMC
joint is the only joint not having a gliding configuration but instead
is a modified saddle-shaped joint. The increased mobility on the ulnar
side of the hand may predispose to its greater frequency of injury.
Critical soft tissue relationships to appreciate during treatment of
injuries to the CMC joints are the positions of the motor branch of the
ulnar nerve directly in front of the fifth CMC joint and the deep
palmar arch in front of the third CMC joint. Of all hand fractures and
dislocations, injury at the CMC level requires the highest degree of
vigilance regarding associated neurologic injury. The high-energy
mechanism of these injuries and profound degrees of swelling may lead
to worsened outcomes through residual long-term nerve compression.

Branches of both the lateral antebrachial cutaneous and
superficial radial nerve ramify throughout the region of the thumb base
on the radial side. Three tendons pass through this region: the
abductor pollicis longus (APL), extensor pollicis brevis (EPB), and
extensor pollicis longus (EPL). The radial artery passes beneath the
APL and EPB on its course to the first web space and lies just proximal
to the CMC joint. The joint anatomy includes reciprocal saddle-shaped
surfaces of the distal trapezium and proximal metacarpal. The axis of
this concavoconvex joint is then itself curved in a third plane with
the convexity lateral. The normal ROM at the thumb CMC joint is around
50 degrees of flexion-extension, 40 degrees of abduction-adduction, and
15 degrees of pronation-supination. There is consensus as to which
ligaments are anatomically present at the trapeziometacarpal joint (Fig. 28-98). They are the superficial

anterior oblique, deep anterior oblique (beak), ulnar collateral, intermetacarpal, posterior oblique, and dorsoradial ligaments.¹⁰
A point of confluence exists at the palmar ulnar tubercle of the first
metacarpal base. There was a period of disagreement regarding the
primary stabilizing ligament in preventing dislocation between the deep
anterior oblique and the dorsoradial ligament. Although the deep
anterior oblique was previously considered the primary stabilizer, more
recent research has effectively demonstrated that the dorsoradial
ligament is the prime restraint to dislocation. The dorsoradial
ligament is the shortest ligament in the group and the first to become
taut with dorsal or dorsoradial subluxation.¹⁰ Selective ligament sectioning showed that deficiency of the dorsoradial ligament led to the greatest degree of subluxation.¹⁶⁴
Dorsal dislocation usually occurs through rupture of the dorsal
ligaments with a sleevetype avulsion of the anterior oblique ligament
as it peels off the volar surface of the first metacarpal.¹⁴⁸
Supination may also play a significant role in the mechanism of this
injury. Deformation of fractures at the base of the thumb metacarpal
occurs with a complex motion (Fig. 28-99). The
distal metacarpal is adducted and supinated by the adductor pollicis.
At the same time, the APL pulls the metacarpal radially and proximally.
Reduction maneuvers must attempt to counteract each of these forces.
Probably the most difficult aspect of the reduction to maintain through
splinting is the radial displacement of the base.

Closed reduction is usually possible early but may be difficult later following injury (Table 28-10).
Dorsal finger CMC fracture-dislocations usually cannot be held
effectively by external means alone. Although usually acceptable as the
least invasive method of treatment for most injuries, entirely
nonoperative management of pure thumb CMC dislocations does not provide
sufficient stability for accurate healing of the ligaments. It is not
possible through external means to completely maintain control over the
reduction of a widely displaced intra-articular fracture-dislocation at
the base of the thumb throughout the entire period of healing. However,
the need to achieve anatomic union in these fractures has been
questioned. Although no one study is definitive, the risk of
significant malunion when managing an initially widely displaced
intra-articular fracture is too great to warrant entirely nonoperative
management.

For those injuries that can be accurately reduced, CRIF
is the treatment of choice. The technique involves restoration of
anatomic length to the shortened and dislocated metacarpals through the
combined application of traction and direct pressure at the metacarpal
bases. Manual reduction is then followed by placement of 0.045-inch
K-wires across the metacarpal shaft and into either the carpal bones or
into adjacent stable metacarpals (Fig. 28-100).
Adequacy of reduction as well as stability should be evaluated both
radiographically and clinically. Pins should remain for 6 weeks. Unlike
most other hand fractures, residual instability rather than stiffness
is the risk with this injury.

Initially
open fractures and those with tissue interposition preventing reduction
will require ORIF. Open reduction is much more likely to be required in
cases presenting late and may be accomplished as long as three months
after the initial injury (Fig. 28-101).
The stabilization strategy is the same as for CRIF with the open part
of the procedure being used strictly for reduction purposes.⁵¹,¹³⁶
Excellent long-term stability without pain is achieved in the majority
of cases. In more severe cases, immediate arthrodesis of the CMC joints
may be required.⁶⁹

Surprisingly, even the results of CRIF have not been
sufficient to consistently prevent long-term symptoms of instability
and arthritis in pure thumb CMC dislocations. In a series of eight
dislocations pinned for 6 weeks and immobilized for a total of 7.4
weeks, four required ligament reconstruction (three for symptomatic
instability and one for progression of early posttraumatic arthritis).¹³⁹
Based on these poor results, the same authors subsequently treated the
next nine patients with early ligament reconstruction, resulting in no
late symptoms, full motion, and normal grip strength¹³⁹ (Fig. 28-102).

Closed reduction and internal K-wire (0.045-inch)
stabilization is the treatment of choice for nearly all Bennett
fractures and some Rolando fractures (Fig. 28-103).
A series of 32 patients followed for 7 years with intra-articular
step-offs of less than 1 mm found no difference between closed pinning
and ORIF for Bennett’s fractures with the exception of a higher
incidence of adduction contracture in the pinning group.¹⁰⁵ Advocates of internal fixation may choose to manage less comminuted Rolando’s fractures and some Bennett’s fractures with ORIF.¹⁰¹
When there are reasonably large fragments that will support purchase of
at least one solid screw per fragment, one may consider plate and screw
stabilization of a Rolando fracture (Fig. 28-104).
However, ORIF of a Rolando fracture is not for the occasional hand
surgeon. Comminution is the rule rather than the exception, and
restoration of normal anatomy is quite difficult. The combination of
limited internal fixation and external fixation to support the length
and unload the articular reduction may be helpful in complex Rolando’s
fractures. A series of ten patients managed this way and followed at 35
months showed 88% key pinch strength compared with the contralateral
side with 9 of 10 patients having good or fair overall satisfaction.¹⁹ While some series have deemphasized the role of anatomic reduction in improving long-term results, others have stressed its

role. Eighteen patients followed to 10.7 years showed a clear
correlation between the quality of reduction and posttraumatic
arthritis.¹⁵⁹
A similar series with over 7-year follow-up demonstrated a clear
correlation between radiographic post-traumatic arthritis and greater
than 1-mm step-off in the final reduction.¹⁵⁸
Twenty-one patients achieved 80% of normal grip strength despite
radiographic signs of degeneration in 16 that did not correlate to
clinical outcome.¹⁶ Thirty-one
patients followed at 7.3 years demonstrated a correlation of both
radiographic signs of osteoarthritis and (more important) symptoms of
pain with the final residual displacement when healing occurred with
more than a 2-mm articular step-off.⁹⁰

Immobilization should last from 6 to 8 weeks in an
orthoplast splint. The primary problem with finger CMC joint injuries
is residual instability, not joint stiffness. The MP joints should be
left free throughout the aftercare period with attention paid to
excursion of the common digital extensor tendons. For thumb CMC joint
injuries, immobilization is continued for 6 weeks in a thumb spica
splint. The IP joint should be left free throughout the postoperative
period. Following cast removal the patient undergoes a standard
progression of ROM exercises that graduates as tolerated into
functional use by 8 to 10 weeks. Forceful pinch loading is avoided for
3 months after surgery.