Hand Fracture

Aka: Hand Fracture, Finger Fracture, Phalanx Fracture, Finger Avulsion Fracture

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II. Epidemiology

  1. Phalanx Fractures account for 10% of all Fractures and 1-2% of all emergency department visits
  2. Distal Phalanx Fractures are most common
  3. Most commonly caused by work injury or Sports Injury

III. Types: Phalanx Fractures

  1. Distal Phalanx Fracture
  2. Middle Phalanx Fracture
  3. Proximal Phalanx Fracture
  4. Metacarpal Fracture
  5. Boxer's Fracture

IV. Types: Finger Avulsion Fractures (Tendon Ruptures)

  1. DIP Extensor Tendon Avulsion (Mallet Finger, Drop Finger, Baseball Finger)
  2. DIP Flexor Tendon Avulsion (Jersey Finger, Flexor Digitorum Profundus Avulsion)
  3. PIP Extensor Tendon Avulsion (Central Slip Extensor Tendon Injury, Boutonniere Deformity)
  4. PIP Flexor Tendon Avulsion (Volar Plate Injury, Jammed Finger, Swan-Neck deformity)

V. Types: Dislocations

  1. Dorsal PIP Dislocation
  2. Lateral PIP Dislocation
  3. Volar PIP Dislocation
  4. DIP Dislocation
  5. IP Joint Dislocation at Thumb
  6. Metacarpal-Phalangeal Dislocation

VI. Exam

  1. See Hand Exam (includes Hand Neurovascular Exam)
  2. Injury exam mantra: "joint above, joint below, circulation, motor function and Sensation, skin and compartments"
  3. Evaluate for flexor and extensor tendon integrity at MCP, PIP and DIP joints
  4. Evaluate for rotational alignment (see below)
  5. Evaluate for open Fracture

VII. XRay

  1. Hand or finger xray
    1. Anteroposterior, lateral and oblique views
    2. Rotational abnormalities may appear on lateral xray as variation in phalanx shaft widths

VIII. Management: General Principles of Hand Fracture Management

  1. See Epiphyseal Fracture (for Fractures in Children)
  2. See Interphalangeal Dislocation
  3. See specific Finger Avulsion Fractures (listed above)
  4. Nerve Block for any manipulation required at time of Splinting
    1. See Digital Nerve Block
    2. See Hand and Wrist Regional Anesthesia
  5. Correct angular malalignment and rotation
    1. Fracture reduction for all unstable, oblique, angulated or displaced Fractures
      1. Obtain post-reduction xrays after reduction and Splinting
    2. Axes of all flexed fingers should point toward Scaphoid Bone or radial styloid (thenar eminence)
      1. OrthoHandPositionFistToScaphoid.jpg
  6. Splinting
    1. Splint in position of moderate flexion
      1. Avoid Splinting fingers in extension (esp MCP)
    2. Avoid over-immobilization (leads to Joint Stiffness and longer recovery)
      1. Stable, non-displaced Phalanx Fractures may be buddy taped with early protected ROM
    3. Gutter splint (Ulnar Gutter Splint or Radial Gutter Splint)
      1. Splint in intrinsic position (30 degrees wrist extension, 90 degrees MCP flexion, IPs in extension)
  7. Evaluate peri-articular Fractures for avulsed tendon
    1. Avulsed fragments are often attached to a tendon or ligament
  8. Outpatient follow-up within 5-7 days
    1. Reevaluate for angulation, rotation or translation

IX. Management: Open Reduction and Internal Fixation (ORIF)

  1. Indications
    1. Malrotation >10 degrees
    2. Unstable displaced intra-articular Fractures
      1. if >25-30% of joint surface involved
  2. Advantages
    1. Avoid excessive manipulation
    2. Avoids prolonged Splinting

X. References

  1. Perkins (2020) Crit Dec Emerg Med 34(10): 10-1
  2. Childress (2022) Am Fam Physician 105(6): 631-9 [PubMed]

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