Fracture stability is a function of fracture configuration, periosteal disruption, muscle forces acting at the fracture site, and additional external forces, such as impact in contact sports. Instability frequently parallels the amount of fracture displacement. Shortening, angulation, and rotation may occur independently or in some combination. The instability can be further complicated in the case of multiple metacarpal fractures [10].

When a single metacarpal is fractured, metacarpal shortening is usually limited to less than 4 mm by intermetacarpal ligaments [11]. Approximately 7° of extensor lag occurs for each 2 mm of residual metacarpal shortening after fracture healing. As extrinsic digital extensor tendons can normally slightly hyperextend the metacarpophalangeal joint; fingers with metacarpal shortening up to 4 mm can maintain complete or near complete metacarpophalangeal joint extension [12].

Metacarpal shaft fractures tend to angulate dorsally because of the unbalanced forces of the extrinsic muscles and extrinsic flexor tendons that tend to flex the distal fragment. The closer the fracture is to the metacarpophalangeal joint, the less obvious the amount of angulation in clinical and radiologic evaluation. Measurement on lateral X-ray may be enough to define the precise amount of angulation [10].

The second and third carpometacarpal joints are rigid, with limited mobility; they form the fixed unit of the hand that is why most authors agree that angular deformities in these metacarpals should not be allowed to exceed 10° in sagittal plane [13].

The fourth and fifth carpometacarpal joints have a mobility of 15 and 30° of flexion/extension, respectively. It means that it is possible to compensate certain angular deformities. This fact has created controversy over the degree of acceptable angulation deformity allowed in these metacarpals. In the extreme case of boxer’s fracture, depending on the authors, from 20 to 70° may be admitted as an acceptable angulation of the fragments. Ali et al. [14], in a biomechanical study in 1999, concluded that 30° was the highest permissible limit of final angulation. Above this, angulation may interfere with normal dynamics tension of intrinsic muscle and begin to cause weakness, loss of endurance, cramping, or clawing, as well as altered dorsal knuckle contour.

The metacarpals may tolerate 10–15° of lateral angulation in the frontal plane and still avoid impingement on an adjacent finger during synchronous flexion. The lateral angular deformity of the metacarpal and its effects may be seen best with the fingers in full extension [10].

The rotational deformity, most commonly seen in oblique and spiral fractures, is poorly tolerated. The border metacarpals (of the index and small fingers) are more likely to became rotated and shortened because they do not have the suspensory effect of adjacent intermetacarpal ligaments acting as supports on both sides. A small amount of rotational deformity may be unnoticed with the fingers extended, whereas it may cause impingement and overlapping when they are flexed to make a fist because this tightens the collateral ligaments of the metacarpophalangeal joint.

Each degree of metacarpal fracture rotation corresponds to approximately 5° of rotational deformity at the fingertips [15]. Rotational deformity is suspected when a gap is seen between the fragments of an oblique or spiral fracture on a frontal view. The oblique fracture configuration is unstable by nature, but real instability only occurs if periosteal disruption is substantial enough to allow fracture displacement.

Initially dorsal and volar splints, in intrinsic plus position that includes all fingers, are the most effective method of immobilization. This is followed by an Orthoplast splint including only the one affected digit and a neighboring one at 2 weeks and then buddy taping and active motion at 4 weeks after injury.

Three to 4 weeks of immobilization are typically required to generate enough healing for initiation of motion, and thus, in this time, it could lead to stiffness due to adhesion formation. Clinical healing, as always, is based on absence of tenderness. The fracture callus may not be visible on X-ray auntil 4–6 weeks after injury. Persistent stiffness of the joint may result from closed reduction and immobilization, but this does not necessarily overrule the advantages of being a low-cost and noninvasive treatment to the patient (Fig. 7.3).

Nondisplaced fractures of the index and middle fingers and minimally displaced fractures of ring and small metacarpals can be treated by external immobilization alone. Fractures that require reduction are difficult to maintain with external immobilization alone, but this may be attempted.

The closed reduction maneuver for neck fractures was described by Jahss [16], in 1938. The reduction is achieved first by disimpacting the fracture by digital traction. The metacarpophalangeal and the interphalangeal joints are then both fully flexed. Dorsally directed pressure is applied axially along the shaft of the proximal phalanx through the flexed metacarpophalangeal joint, and volarly directed pressure is supplied by another digit placed directly over the dorsal apex of the fracture. This takes advantage of the tightness of the metacarpophalangeal collateral ligaments in flexion, which stabilizes the loose metacarpal head fragment.

The fracture should never be immobilized in the Jahss position, as significant interphalangeal joint contractures will ensue. It is immobilized with a short-arm gutter splint with the fingers in the safe position and the wrist in neutral to tighten the dorsal extension mechanism to act as a tension band. The splint is continued for 14 days, followed by active motion with buddy taping to an adjacent digit.

Fractures of the head with minimal to no displacement can be treated by splinting in the intrinsic plus position, but this is an uncommon presentation for this injury [13].

Conservative treatment may be recommended in ball athletes only when there is no or minimal displacement, and the fracture is stable. In athletes, we have to be more demanding than in the normal population; they present three major problems with this treatment: (1) the prolonged recovery time, as the physiotherapy cannot begin until immobilization is removed; (2) malunion is poorly tolerated by athletes; and (3) the stiffness that may occur may have implications on their future careers.

In stress fractures, the only effective solution is to discontinue play or to protect the hand from impact until symptoms resolve [10].

The percutaneous fixation with Kirchner wires is a useful technique that is relatively easy to perform and useful in many types of fractures (unstable neck, long oblique). These are typically crossed or inserted in parallel. The transfixion wires should be inserted with the metacarpophalangeal joints flexed to prevent intrinsic muscle tightness. Two wires are necessary distal to the fracture site. This prevents rotation to the distal fragment on a single wire. However, Kirschner wires do not provide truly rigid fixation, and a period of immobilization must always follow to avoid loss of reduction. Infection at the entrance of the pins may be another problem, when they are left outside the skin. That is why many surgeons leave them buried under the skin, and these are removed after fracture healing (4 weeks or more), in the clinic setting. Nevertheless, many studies have published excellent results with minimal complications for metacarpal fractures fixed with Kirschner wires [17] (Figs. 7.4 and 7.5).

Intramedullary fixation of the metacarpal is another technique described for transverse and short oblique fractures [18]. Although this technique was not very common, there is an increasing number of publications with very good results [19–21].

This technique uses a small incision at the base of the metacarpal and then an awl to create a window in the metacarpal cortex, through which a single central large wire (1.6 mm) or several small wires (0.8 a 1 mm) are inserted. Some authors leave the ends of the wires buried in the metacarpal bone to prevent irritation of the soft tissues. However, they do not provide a rigid fixation or compression and contribute little to control of rotation at the fracture site, which is why there is some debate as to initiating mobilization immediately or after 2–3 weeks of cast immobilization. Intramedullary K-wires is more frequently used in diaphysis and neck fractures of the fourth and fifth metacarpal bones [22, 23].

Tension band wiring also provides relatively rigid fixation and is not as bulky as plate fixation. However, it requires extensive dissection and is not as stable as fixation with plate and screws; that is why most hand surgeons do not perform this technique frequently [13].

Interfragmentary screws are useful in long oblique fractures (at least twice the diameter of the bone) and for capturing large isolated intra-articular fragments. Some studies have demonstrated that fixation with two lag screws provides greater rigidity than either crossed Kirschner wire or dorsal plating [24]. This fact allows for early motion of the fingers, thereby avoiding the postoperative stiffness that often characterizes the use of Kirschner wires. Screw fixation, however, is technically demanding and leaves little margin for error. The surgeon usually gets only one shot with screw fixation [13].

A plate and screws provides a rigid fixation, which permits early mobilization, similar to screw fixation. Due to its buttress support, plate fixation is ideal for comminuted fractures [25]. However, plates require extensive dissection to provide adequate exposure, which could result in extensor lag, and even if we use low-profile plate, prominence of the plate could be a problem. Plate fixation, similar to screws fixation, is technically demanding and, according to many studies, fraught with complications such as contractures, extensor lag, infection, tendon rupture, plate prominence, plate loosening or breakage, and unsightly dorsal scars [26, 27]. Most studies have shown approximately 220° of total active motion after plate fixation, with complication rates approaching 20 % [25].

Bioabsorbable miniplating, although it appears to offer the same resistance to hold the fracture in the beginning and can obtain good healing of the fracture, poses the problem of foreign body reaction, which can cause long-term complications, with follow-up needed at least two years after implant placement [28].

External fixation is another tool that has been used in open fractures and those involving segmental bone loss and or infection. This method avoids extensive dissection and leaves periosteum over fracture fragments to promote healing. As in Kirschner wires, pin entry site is a possibility, and the bulky fixation unit can be bothersome to patients. Other potential complications include osteomyelitis, loosening of the pins, fracture through the pin sites, and damage to the extensor ­tendons [29].

Bone grafting can be useful for obtaining adequate reduction and greatly accelerating healing in high-energy injuries. Cancellous grafts can be obtained from the distal radius or iliac crest; allografting may be considered. Bone grafting has been classically used in secondary reconstruction procedures for complex injuries, but it has gradually gained acceptance for use in primary surgical procedures, with very good results, no infections, and return to original work for all patients as in the series published Saint-Cyr and Gupta [30] in 2006.

As explained above, when making the surgical decision, we must take into account that these fractures are often one unique metacarpal fracture without major soft ­tissue injuries and without much displacement [1, 4].

First metacarpal fractures make up almost 25 % of all metacarpal fractures, and over 80 % of these fractures involve the base of the first metacarpal. The fracture predominates in adult males and usually occurs in the dominant hand. Fractures of the first metacarpals result from rotation, bending, direct blows, indirect forces, or any combination of these forces. Hand injuries are relatively common during sports practice, probably because the hand is characteristically in front of the athlete in most sports and frequently absorbs the initial contact. Fractures of the first metacarpal occur at recreational level or at top athlete level, and initial injury management is crucial. Finger and thumb injuries are common in sports with a high risk of falling, such as skiing, biking, in-line skating, and gymnastics. In many competitive team sports, the thumb is one of the areas most often injured. Football also results in a high percentage of hand and wrist injuries, accounting for 15 % of all injuries. In football, first metacarpal fractures affect mainly the goalkeeper from trauma caused by the ball. Other causes are a fall to the ground and physical contact with other athletes.

On the other hand, finger injuries in volleyball occur mainly during blocking [35].

Patients with thumb injuries classically present with pain and loss of function of the thumb including inability to grip, weak pinch, and reduced range of motion. On inspection, there may be a local swelling, volar, and dorsal ecchymosis (Fig. 7.9). Sometimes the thumb will appear shortened or with an angular deformity. A careful examination will reveal bony crepitus and tenderness to palpation over the first metacarpal.

It is also important to remember to appropriately examine trauma patients for any other injuries. A differential diagnosis with injury to the scaphoid, trapezium, or distal radius should be made.

Imaging should begin with radiographs of the entire hand and should include three views: posteroanterior (PA), lateral, and oblique. Because the thumb sits out of the plane of the rest of the hand and fingers, special radiographic views are necessary for appropriate evaluation. Radiographic assessment of the thumb includes standard posteroanterior (PA), lateral, and oblique views. A true anteroposterior view of the thumb requires that the hand be hyperpronated so that the dorsum of the thumb lies against the radiographic plate (Robert’s view). A true lateral of TM joint (Bett’s view) is where the sesamoids of the thumb MP joint overlap each other. This view can be obtained with the palm on the cassette, and the hand then pronated 15–20° and the tube angled proximally 15°. Both views are helpful when evaluating fracture displacement and joint congruency of TM joint and the three additional articulations of the trapezium with the trapezoid, the scaphoid, and index metacarpal.

Radiographic evaluation of fractures includes the location and direction of the fracture line, the presence or absence of comminution, displacement of the fracture, articular involvement, and associated soft tissue injury. Pay attention to the center of ossification of the base of the metacarpal of the thumb because it unites with the body at about the 20th year.

CT remains the best modality for evaluation of the bony architecture. It is particularly helpful for articular fractures of the head and base that may not be evident on radiographs.

The first metacarpal bone is the shortest and the most mobile. It can be divided into four anatomic regions: a head, a neck, a shaft, and a base (Fig. 7.10). Fractures can be subdivided by these four regions.

The head of the first metacarpal differs from that of the other metacarpals. Fractures are common in the long finger metacarpal but rare in first metacarpal because any longitudinally directed force which might produce this fracture is dissipated at the trapeziometacarpal joint. Distal metacarpal fractures are by definition intra-articular, and most are avulsion fractures with radial collateral ligament injuries. On the other hand, four cases of intra-articular shearing fracture of the radial condyle of the metacarpal head in association with ulnar collateral ligament injury were reported.

Metacarpal neck fractures usually result from direct trauma. The fracture occurs just below the metacarpal head, which is displaced in a volar direction (Fig. 7.11). Injuries such as this commonly occur in throwing athletes, when the thumb strikes an object with a ball.

Metacarpal shaft fractures are uncommon sports injuries. These fractures usually occur at the metaphyseal–diaphyseal junction and are referred to as epibasal ­fractures. The fragments are typically displaced with an apex dorsal angulation. The distal fragment is deviated in supination, flexion, and adduction, per share of ­adductor pollicis, flexor pollicis brevis, and abductor pollicis brevis. The proximal fragment is deflected by the action of the abductor pollicis longus.

The first metacarpal base fractures are classified by Green and O’Brien [36] into four patterns (Fig. 7.12). Types 1 and 2 are intra-articular fractures and types 3 and 4 are extra-articular. Type 1 is the Bennett fracture. It is a fracture–dislocation of the base of the metacarpal. Type 2 is Rolando fracture, a comminuted version of type 1 fracture. Type 3 fracture is either transverse or, less commonly, oblique. Type 4 fracture is an injury involving the proximal physis.

In metacarpal neck fractures, casting or splinting for 3 weeks is helpful to avoid further instability and to promote healing with stability at the fracture site.

Due to the compensatory motion of the trapeziometacarpal joint, some displacement and angulation can be tolerated in the thumb metacarpal shaft fracture. These cases can be treated conservatively.

Since its first description, the treatment of Bennett’s fracture has remained the subject of much debate. Biomechanical studies noted that 2 mm of residual displacement at the articular surface resulted in an overall increase in contact area at the TM joint, with a dorsal shift in contact pressures over the trapezial surface. The authors concluded that a 2-mm articular step-off is acceptable and should be well tolerated as long as the metacarpal was reduced [38].

The treatment of Rolando’s fracture depends on the severity of comminution of the fragments and the degree of displacement. The methods of treatment suggested are soft dressing with early motion, closed reduction and casting, closed reduction and percutaneous Kirschner wire fixation, and oblique traction. The two first described methods are unacceptable in athletes.

The conservative treatment is recommended in type 3 fractures if there is no displacement. The thumb is immobilized for 6 weeks.

The treatment in type 4 fractures is nonoperative, consisting of closed reduction and application of a thumb spica cast including the entire first ray.

Displaced intra-articular fractures of the metacarpal head often require open reduction and internal fixation, particularly if an articular step-off is present. In malunited intra-articular fractures of the metacarpal head, an intra-articular osteotomy and rigid internal fixation was described with significant improvement in the articular anatomy and function. In failed cases, the arthrodesis of the first metacarpal phalangeal joint after fixation with a low-profile titanium plate, using a cup-and-cone technique, gives a high rate of union, a short period of immobilization and rehabilitation, and a reliable position at the site of fusion.

Metacarpal neck fractures that are markedly comminuted or angulated may occasionally require open reduction and internal fixation with Kirschner wires or screw and plates. A plaster cast immobilization is used by for 3 weeks.

Metacarpal shaft fracture with angulation greater than 30° is an indication for reduction. Closed reduction may be accomplished through axial traction, extension, and pronation with direct pressure over the fracture dorsally and skeletal fixation with percutaneous pins. Open reduction and internal fixation with plates and screws is reserved for high-energy trauma, irreducible fracture, fracture with excessive angulation, or multiple fractures. It can be performed through a dorsal longitudinal incision. Careful blunt dissection should be performed to preserve the terminal branches of the superficial radial nerve and radial artery. For adequate exposure of the first metacarpal, the extensor pollicis longus is retracted to the ulnar side and the extensor pollicis brevis to the radial side.

The closed reduction technique for treatment of Bennett’s fracture was described by Wagner. It can be done under adequate analgesia. It involves axial traction on the thumb to pull the metacarpal distally, palmar abduction, and pronation while applying external pressure, with the thumb pulp over the metacarpal base medially to return it to its anatomical position. To hold the reduction, a Kirschner wire is placed through of the metacarpal across the joint and into the trapezium. Subsequently, to prevent shortening and adduction of the thumb, another K-wire with a diameter of 1.5–2 mm is inserted between the metacarpal diaphysis of the thumb and the index finger. Closed reduction and percutaneous fixation with intermetacarpal Kirschner wires can be used. The K-wires are positioned approximately 2 cm apart, through the first metacarpal with a 90° angle and also through the second metacarpal. Edmunds [39] wrote that this practice using the hitchhiker position (to take the pull off the abductor pollicis longus) is based on the myth that the abductor pollicis longus is a deforming force in a Bennett fracture. He considers it to be a grossly incorrect reduction technique. He recommends the passive screw-home-torque technique method of reduction in which the surgeon places the patient’s trapeziometacarpal joint into a full passive opposition and then torques the thumb metacarpal into maximum passive screw-home-torque, such that the plane of the thumb tip pulp is rotated opposite the pulp of the index and long digits in the three-jaw chuck power pinch position. This technique can be performed closed for percutaneous fixation, or it can be performed open with a K-wire in the metacarpal as a “twisting joystick” to aid in the torque before internal fixation of the Bennett fracture. When the proximal fragment is too big, we prefer fixation with a percutaneous cannulated screw.

Open reduction and internal fixation should be considered when the fracture is irreducible or where greater than 2 mm of articular step-off persists despite closed reduction attempts or a Kirschner wire cannot be passed across the fracture into uninjured bone at the base of the thumb.

The open reduction of the metacarpal is performed through a Wagner incision. The incision is made at the junction of the volar skin and dorsal skin over the ­trapezoid–metacarpal joint. Careful blunt dissection should be performed to preserve the terminal branches of the superficial radial nerve and radial artery. The extraperiosteal elevation of thenar muscles is performed to permit exposure of fracture site. The choice of fixation technique depends on the size of the fragment. If the base length of the fragment is greater than 25 % of the length of the first metacarpal base, we can choose the compression screw fixation. If less than 25 %, we should use Kirschner wires.

The decision for open reduction, as opposed to closed reduction and pinning, is still a matter of debate. Lutz et al. [40] studied 32 patients with a Bennett’s fracture who were treated either by open reduction and internal fixation or closed reduction and percutaneous transarticular Kirschner wiring. After a mean follow-up of 7 years, they found that the type of treatment did not influence the clinical outcome or the prevalence of radiological posttraumatic arthritis. The percutaneous group had a significantly higher incidence of adduction deformity of the first metacarpal. This however did not result in an inferior outcome.

On the other hand, Capo et al. [41] showed significant discrepancies in step-off and displacement measurements between fluoroscopic examination and open visualization and in displacement values between radiographic and direct visualization. They recommend open reduction and internal fixation if the reduction is deemed unsatisfactory and if any doubt exists about the residual articular malalignment.

To avoid these problems, the visualization of reduction by arthroscopy is advocated by Culp and Johnson [42]. The surgical technique is not difficult if the surgeon is familiar with the arthroscopic technique and appropriate instruments are available. The patient is placed supine on the operating table under general or regional anesthesia. A single finger trap is applied to the thumb, and 4.5 kg of traction is applied using a traction tower. The 1-radial portal is established just radial to the abductor pollicis longus tendon at the level of the carpometacarpal joint. The 1-ulnar portal is located just ulnar to the extensor pollicis brevis, again at the level of the trapeziometacarpal joint. An 18-gauge needle is inserted into 1-radial portal, and the carpometacarpal joint is inflated with 2–3 ml of normal saline to distend the joint. A small incision centered over the carpometacarpal joint at the 1-radial portal is made, and a small, curved hemostat is used to spread the subcutaneous tissue. After this, the trocar and sleeve are inserted, then the trocar is removed, and the 1.9-mm arthroscope is inserted. The 1-ulnar portal is then established by same steps for 1-radial portal. A 2.0-mm shaver may be used to remove any frayed tissue or cartilaginous fragments. Once the joint is clearly visualized, the fragment is then manipulated using the intra-articular probe, adjustments in traction, and 1.5-mm Kirschner wires. Usually, the metacarpal shaft fragment is extended and supinated. This may be accurately reduced using Kirschner wires as joysticks. Once reduction of the fragment is obtained, fixation is completed using either Kirschner wires or 1- or 1.5-mm screws. A bulky dressing and forearm-based thumb spica splint are applied after portal sites are closed using 4–0 nylon simple sutures.

Cases of simultaneous Bennett’s fracture and trapezium are reported [43] in which open reduction and internal fixation was required to stabilize an unstable first carpometacarpal joint with simultaneous fracture of the trapezium and Bennett’s fracture. The results were good in terms of range of movement and radiological appearance, all of them returning to normal activities, including heavy manual work. We have six unpublished cases (Fig. 7.16). No patient required further surgery.

The Rolando fractures are quite difficult to treat but, fortunately, are a rare type of first metacarpal fracture. When the two fragments are large, without considerable comminution, open reduction and internal fixation with Kirschner wires or lag screws placed through a Y, T, or L plate may be attempted. Again we preferred the Wagner incision.

However, if there is severe comminution, distraction and reliance on ligamentous reduction of the fragments may be necessary, but the treatment of choice is controversial because attempts at operative restoration of the articular surface are frustrating, if not impossible, with ligamentotaxis alone.

Distraction can be achieved with oblique traction pinning, but this method was bulky, required a long period of fixation, and decreased the range of motion. Closed reduction and percutaneous Kirschner wires were used, but the results were satisfactory.

Alternatively, the fracture can be spanned and distracted using external fixation with different configurations described. The use of external fixation for Rolando fracture provides several advantages to alternative techniques for fixation, including ease of insertion with minimal dissection and devascularization of soft tissue and bone, and preservation of bony length.

In cases of displacement, surgical treatment is indicated in type 3 fractures. Internal fixation is performed with intramedullary pinning or intermetacarpal K-wires. These techniques usually require postoperative immobilization for 6 weeks.

Internal reduction should be done via dorsal approach. A Y, T or L plate is placed on the dorsal aspect or lateral edge of the first metacarpal (Fig. 7.17). Careful closure of the periosteum is carried out to protect the extensor system. Skin is closed without a drain. Diaconu et al. [44] reported that T-shaped plates do not provide sufficient strength to allow early mobilization of the thumb after fixation. They thus recommend the use of double-row plates.

Unstable type 4 fractures require K-wire stabilization of the first and second metacarpals across the first web using Iselin’s technique and application of a cast including the thumb.

If secure internal fixation can be achieved, early motion may be initiated in intra-articular fractures of the metacarpal head.

Open reduction and internal fixation of metacarpal shaft fractures restores structural integrity so that early return to sports with a protective splint is often possible. Swelling can be controlled with massage, proper elevation, icing immediately after therapy, and compression gloves. Digital and wrist tenodesis and individual joint-blocking exercises are excellent nonresistive exercises to regain maximum ROM in all joints [45].

In the Wagner technique, a plaster cast immobilization is used by for 4 weeks. Rehabilitation involves early active and passive mobilization of interphalangeal joints. After Kirschner wires are removed, mobilization of carpometacarpal joint is started. Mobilization is early with internal fixation as well. Resistive exercises for strengthening thumb intrinsic and extrinsic muscles, pinch and grip, weight bearing on the palm with thumb in radial abduction, and return to usual routines without a hand-based opponens splint should be considered only when there is evidence of stable fracture healing. Progressive training to full return can be expected at around 4–6 weeks or when the fracture is nontender and shows radiological evidence of union.

In type 3 fractures with internal fixation with plate and screws, the first web is immobilized in a splint for 3 weeks, followed by hand therapy.

Unfortunately, the management of injuries of the thumb in a recreational or professional sports team is sometimes not the best and often leads to detrimental consequences for ball-sport practice.

The estimate for an athlete’s return to sports should be as fast as possible. Surgery may be necessary to reach these goals for athletes because of the demands of their sport. Even with miniplate fixation, the fracture needs protection until there is evidence of healing by fracture callus on X-ray or resolution of local signs of injury on clinical examination. Although many manual laborers who are injured at work are reluctant to return until they are fully healed and pain-free, athletes are different. The desires and motivation of the player, coaches, and parents may pressure the physician to return the patient to play more quickly than is safely possible. Preventing a sports-related hand injury may not always be possible, but there are steps to reduce their impact if they do occur.

Locked metacarpophalangeal joint due to an intra-articular fracture of the metacarpal head was described.

A malunion of a metacarpal shaft fracture will result in compensatory hyperextension at the metacarpophalangeal joint. Open reduction and internal fixation of the metacarpal shaft fracture with plates and screws provides excellent stability but may cause extensor tendon adhesions with a scar on the dorsal aspect of the thumb.

Bennett’s fracture is unstable, and concern exists as to whether inadequate reduction/fixation leads to long-term consequences such as osteoarthritis, weakness, or loss of function of the first carpometacarpal joint. The disadvantage of the Wagner technique is possible exudate from pin site and a pin-tract infection. If it is observed, we recommend oral administration of antibiotics. In severe case, we recommend K-wiring.

Joint instability following Bennett fracture–dislocation is rare. Stability is assumed as long as the fragment is fixed properly to the shaft. If subsequent instability occurs, the rational choice of treatment is the Eaton method because this method, although originally introduced to strengthen and reconstruct the anterior oblique ligament, also has a stabilizing effect on the dorsal radial ligament.

The Rolando fracture can be associated with significant posttraumatic arthritis if there is significant incongruity at the articular surface of the base of the first metacarpal. Marked decrease in hand function can result if proper fixation is not achieved [46].

The complications of type 3 are frequent and include retraction of the first web, persisting pain, decreased thumb mobility, and strength.

Despite the reported incidence of arthrosis and accompanying pain, and limitation of motion in the long term, we have seen few cases.

In our opinion, because of the instability of this fracture and for complications, the closed reduction and plaster casting is an inappropriate treatment for athletes.

The treatment of Rolando fracture depends on the severity of comminution of the fragments and the degree of displacement. Two methods of treatment of Rolando Fracture are unacceptable for treatment in athletes: soft dressing with early motion and closed reduction and casting.

As in all articular fractures, the key to success is anatomical reduction. We believe that reduction of articular fractures of the head and the base of the first metacarpal should be helped by arthroscopy in the future. For this to happen, further development of arthroscopic equipment is needed. The current 1.9-mm scopes are very fragile and break easily. This weakness implies more expensive and difficult access to this treatment.

Extra-articular fractures should be treated so as to enable early motion with a treatment as least aggressive as possible.

Suggested Readings

Culp RW, Johnson JW (2010) Arthroscopically assisted percutaneous fixation of Bennett fractures. J Hand Surg 35A:137–140

Arthroscopic evaluation of reductions has suggested that the joint surface may not be completely reduced. The authors propose a method of arthroscopic reduction and stabilization of Bennett fractures of the first metacarpal base.

Green DP, O’Brien ET (1972) Fractures of the thumb metacarpal. South Med J 65(7):807–814

Green & O’brien in 1972 described a classification to first metacarpal base fractures. This classification is still used nowadays. They listed different methods of treatment for each type fracture.

Lutz M, Sailer R, Zimmermann R, Gabl M, Ulmer H, Pechlaner S (2003) Closed reduction transarticular Kirschner wire fixation versus open reduction internal fixation in the treatment of Bennett’s fracture dislocation. J Hand Surg 28B(2):142–147

The authors compared open reduction and internal fixation with closed reduction and percutaneous transarticular Kirschner wiring. The type of treatment did not influence the clinical outcome or the prevalence of radiological posttraumatic arthritis.

Phalangeal fractures are the most common sports-related hand fractures [47]. Even subtle injuries, such as a simple finger jam, can lead to a phalanx fracture, and therefore, many are initially undiagnosed. An undiagnosed phalanx fracture can significantly affect the athletes’ career.

Even though the thumb plays a fundamental role in different types of gripping and daily activities, the literature on phalangeal fractures of the thumb is very sparse except for avulsion fractures of the collateral ligaments of the thumb metacarpophalangeal joint (MPJ). Thirty percent of all phalangeal fractures occur in sports (including ball sports) injuries, and the thumb phalanges are involved in nearly 19 % of all phalangeal fractures with unicondylar fractures of the proximal phalangeal base being the most frequent type, accounting for 52 % of all thumb phalangeal fractures [107]. Rugby seems to be associated with thumb phalangeal fractures more often than basketball, volleyball, or American football [108]. Published series combine thumb and finger phalangeal fracture treatment and only include few if any cases of thumb phalangeal fractures which are not discussed separately. Detailed treatment recommendations for thumb phalangeal fractures in athletes or typical sport injuries are not described in the current literature.

The type of fracture of the thumb phalanges in ball sports depends on the direction of the impact of the ball: An axial trauma of the ball to the thumb may result in an often-comminuted intra-articular fracture of the phalangeal base. Lateral ­deviation of the thumb may cause a rupture or avulsion fracture of the collateral ligament, eventually with additional unicondylar compression fracture; forced flexion of the extended interphalangeal joint (IPJ) may result in an extensor tendon avulsion ­fracture, and rarely, rotational trauma may result in a spiral or oblique fracture of the phalangeal shaft. Clinical signs are pain, swelling and/or hematoma, and loss of function. As these signs are unspecific, standard anteroposterior (or posteroanterior) and lateral radiographs are mandatory for the diagnosis or exclusion of a fracture. Poorly taken radiographs must not be accepted, and as the position of the thumb is different from the other fingers, correct positioning of the thumb may be problematic and separate thumb views are necessary. Standard radiographs of the whole hand do not show these fractures adequately. Lateral views of the thumb are usually obtained without difficulty, but true AP or PA views may be more difficult. Failure to get proper radiographs with the joint space of the MPJ and IPJ joint projected free of bone overlapping may miss collateral ligament avulsion fractures [109]. If necessary, CT scans are performed to show more details of the fracture pattern (number of fragments, centrally impressed fragments, articular step-off, and displacement) in intra-articular fractures.

Tuft fractures are the result of crushing injuries of the distal phalanx of the thumb. They are thus most often not related to a direct impact of a ball, but rather due to trampling by another player’s shoe especially cleats. The often present subungual hematoma should be evacuated for pain relief, and eventually the nail bed injury has to be repaired using a running suture or fine resorbable sutures. The fracture itself is stable, and an intact or refixed nail plate provides additional stability, so often these fractures do not need any specific treatment and sports activities can be resumed depending on residual pain. With nail bed injuries and nail refixation, a splint should be applied for 3–4 weeks.

Transverse fractures of the distal phalanx are rare but are unstable especially if located proximal to the nail plate (Fig. 7.66). This fracture tends to show a volar apex angulation due to the pull of the flexor pollicis longus tendon. With minimal or no displacement, the thumb should be protected with a Stack-type splint during 4–6 weeks. If there is a relevant gap between the fragments, reduction under ­compression and additional K-wire fixation (eventually driven across the IPJ into the head of the proximal phalanx if the fracture is very proximal) is reasonable [110]. Interfragmentary compression using headless screw fixation has been described [111]. Sports activities can eventually be resumed with the Stack splint firmly fixed to the thumb using a tape bandage.

Avulsion fractures of the collateral ligaments of the IPJ may be treated conservatively with a Stack-type splint (about 2–3 weeks continuously, afterward taping to prevent lateral deviation during sports and daily activities) as the fragments are usually small and minimally displaced. The exact amount of displacement of articular fragments that can be accepted in hand and finger fractures is not known, but open reduction and internal fixation has been recommended if fragments are displaced more than 1 mm at the joint surface or involve more than 25 % of the joint surface [112]. In the case of a displaced and rotated avulsion fragment with clinical instability of the IPJ, open reduction and K-wire or preferably screw fixation if the fragment is sufficiently large is performed. Range-of-motion exercises can be started immediately, but the internal fixation should be protected with a Stack-type splint during 4 weeks, afterward with taping for sport activities.

Dorsal avulsion fractures include the extensor tendon insertion at the distal phalanx; a typical injury mechanism is a forced flexion by a ball while the thumb IPJ is actively extended. With very small fragments, treatment corresponds to closed pure extensor tendon ruptures, and a Stack-type splint is applied for 8 weeks holding the IPJ in slight hyperextension [113]. The splint must be worn 24 h and may only be removed for skin care with the IPJ passively held in extension. Later, the IPJ may be protected against hyperflexion by a ball with taping, and the splint is worn at night until 12 weeks after the injury. With larger fragments, the Stack-type splint is worn during 4–5 weeks until radiographs show adequate bone healing. The indication for internal fixation (preferably by lag screw fixation) is a large avulsion fragment with volar subluxation of the distal phalanx with fragments involving more than one-third of the joint surface in the lateral view. If the fragments do not allow stable fixation due to comminution, volar subluxation can also be treated with closed reduction and K-wire transfixation of the IPJ [114].

Volar fragments at the IPJ (which should not be confused with the volar sesamoid bone which is found in 22–86 % of thumbs examined [115]) correspond to volar plate avulsion fractures in dorsal dislocations of the IPJ. They are rare and do not need any specific treatment in most cases provided that the fragments are small and there is no dorsal subluxation. Repeated hyperextension should be prevented during 6–8 weeks with a splint or taping if necessary. A volar avulsion fragment may be part of impaction fractures of the base of the distal phalanx so X-rays have to be carefully checked. A literature search did not show any reports on flexor pollicis longus avulsion fractures from the distal phalanx of the thumb.

Impaction fractures of the base of the distal phalanx as a result of an axial trauma are very rare and can usually be treated conservatively with a Stack-type splint ­during 4 weeks (Fig. 7.67), and good mobility can be expected even if the X-rays show some malalignment [114]. Open reduction and internal fixation (ORIF) using K-wires or lag screws with possible bone grafting may rarely become necessary if there is relevant lateral deviation or impaction. Postoperatively, a protective splint is used until the X-rays show adequate bone healing.

Fractures of the head of the proximal phalanx are also rare injuries, and treatment depends on fracture type and displacement. Undisplaced fractures can be treated with a full-length thumb cast (but wrist joint not included) with regular radiological controls. Condylar fractures occur in combined axial load and lateral angulation injuries and tend to be very unstable. These unicondylar fractures can be stabilized with K-wires or better with one or more lag screws to allow early functional therapy. In bicondylar inverted Y-shaped fractures with one long condylar fragment, lag screw fixation may be possible, otherwise bicondylar fractures are best treated with stable plate fixation, and a lateral plate position is preferable to reduce extensor tendon adhesions. Reduction is often difficult, but anatomical reconstruction of the articular surface as well as correct longitudinal alignment should be attempted to avoid later degenerative changes. In bicondylar fracture fixation, the use of a reduction forceps with pointed tips often leads to rotation of the articular fragments so reduction and temporary fixation using fine K-wires may be advisable. Correct positioning of the implants is crucial to avoid collateral ligament injury or transfixation, and plates have to be perfectly adapted to the bone surface to avoid redisplacement of fragments when the screws are tightened.

Diaphyseal fractures of the proximal phalanx of the thumb are rarely reported and accounted for only 14 % of proximal phalangeal fractures of the thumb [107]. If they are not or only minimally displaced, conservative treatment with a thumb cast for 4 weeks is possible. Afterward the thumb has to be protected with a removable splint if ball-sport activities are resumed. Due to the very mobile thumb carpometacarpal joint and the fact that there is no overlapping over a neighboring finger, some malalignment is better tolerated than in fractures of the proximal phalanx of the long fingers. However, fractures showing more than 20–30° of angulation in the lateral plane (resulting in an extensor lag of the IPJ) or relevant rotational deformity should be treated with ORIF using lag screws or plates [110]. Depending on the fracture pattern, the surgical approach (and plate position) is chosen laterally or dorsally (Fig. 7.68). Early active mobilization is mandatory to prevent extensor ­tendon adhesions.

Intra-articular fractures of the base of the proximal phalanx of the thumb occur in axial (resulting in comminuted fractures of the base) and lateral deviation traumas (collateral ligament avulsion fractures). ORIF is often necessary in comminuted fractures to reduce eventually impacted fragments, and bone grafting is advocated to buttress articular fragments and promote bone healing. The surgical approach is usually dorsal between the two thumb extensor tendons, and the MPJ capsule is opened to check correct reduction of the joint surface. The first metacarpal head may be used as a template to reduce the depressed articular fragments, and the void distal to the fragments is filled with cancellous bone grafts from the distal radius. The fragments may be stabilized with K-wires or screws, and plate fixation is usually necessary to further buttress the fragments and to fix the articular fragments to the shaft of the proximal phalanx.

Avulsion fractures of the ulnar collateral ligament are frequent and may result in thumb MPJ instability as in ligamentous skier’s thumb injuries. Fragments are of different size and are often displaced and rotated, but it is not possible to determine from radiographs whether a complete rupture or avulsion of the collateral ligament has occurred in addition. Only if the fragment (which may be very small) is displaced proximal to the adductor aponeurosis, a bony Stener lesion can be assumed from the X-ray and open repair with reinsertion and fixation of the fragment and the ulnar collateral ligament is mandatory (Fig. 7.69). In all other cases, stability of the ulnar collateral ligament is tested in 30° of MPJ flexion as there may exist a combination of a minimally displaced fragment and a complete ligament avulsion. With the force exerted during manual testing, no Stener lesion is provoked [116], and if ulnar collateral ligament instability is found open repair is indicated. With less than 30° of radial deviation (or less than 15° difference to the opposite side), nonoperative treatment with a short thumb spica or splint (immobilizing only the MPJ) is initiated even if the fragment is rotated and displaced, as long as it does not exceed 25 % to one-third of the joint surface [112, 117]. Under these circumstances, results after 6 weeks of immobilization and subsequent mobilization have been reported as excellent with return to previous work and normal sport activities, no instabilities, no significant differences in strength, and subjective satisfaction in all 28 patients [117]. Fibrous union is frequently seen with conservative treatment but was not associated to instability, degenerative changes or later surgical interventions. An indication for ORIF of ulnar avulsion fractures therefore exists if the fragment is larger than 25 % to one-third of the articular surface, is displaced proximal to the adductor aponeurosis, or if there is ulnar collateral ligament instability. Taping the MPJ is advisable when ball-sport activities are resumed.

As the impact of the ball on the thumb in ball sports is hardly controllable and the thumb cannot be taped to an adjacent finger, it has to be protected even after stable lag screw or plate fixation. Early active mobilization under supervision of a hand therapist is encouraged following internal fixation, but ball-sport activities should only be resumed if the radiographs taken at 4 weeks show adequate bone healing and a removable splint is recommended during another 3–4 weeks. At that time, radiographs should confirm stable healing of the fracture. Taping may be sufficient for light activities at noncompetition level and is helpful after splint removal.

Suggested Readings

Aitken S, Court-Brown CM (2008) The epidemiology of sports-related fractures of the hand. Injury 39(12):1377–1383

In this retrospective analysis of 1,430 hand fractures, more than 22 % were sports related. Football resulted in the highest number of phalangeal fractures, but in the thumb, rugby accounted for a higher percentage of phalangeal fractures than in the other digits.

Day Charles S, Stern Peter J (2011) Fractures of the metacarpals and phalanges. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds) Green’s operative hand surgery, 6th edn. Elsevier/Churchill Livingstone, Philadelphia

Basic principles of fracture treatment in the hand are discussed in this chapter and details of surgical fixations are shown. One section deals with indications and techniques of thumb phalangeal fractures.

Sorene ED, Goodwin DR (2003) Non-operative treatment of displaced avulsion fractures of the ulnar base of the proximal phalanx of the thumb. Scand J Plast Reconstr Surg Hand Surg 37:225–227

Twenty-eight thumbs with ulnar collateral ligament avulsion fractures that were stable on clinical testing were treated conservatively with a spica cast. At 2.5 years 26 were pain free and no thumb was unstable.