Introduction

One-third of all injuries involve the upper extremity. Phalangeal and metacarpal fractures comprise a significant portion of upper extremity injuries. These are the second and third most common injuries of the hand/forearm, after distal radius fractures. Etiology in young patients includes sports injuries, in middle-aged patients work-related injuries, and in elderly patients falls. These injuries more commonly occur on the border digits.

I. Preoperative

1. 
   

   History

   
   
   
   
   1. 
      

      Age.

      
      
   2. 
      

      Hand dominance.

      
      
   3. 
      

      Pain:

      
      
      
      
      1. 
         

         Onset.

         
         
      2. 
         

         Location.

      
      
   4. 
      

      Activity/occupation:

      
      
      
      
      1. 
         

         Baseline function.

         
         
      2. 
         

         Occupation.

         
         
      3. 
         

         Valued hobbies.

      
      
   5. 
      

      Mechanism of injury:

      
      
      
      
      1. 
         

         Time of injury:

         
         
         
         
         • 
           

           i. Infection risk with open wounds.

           
           
         • 
           

           ii. Finger fractures heal quickly.

         
         
      2. 
         

         Crush injury? Direct trauma (e.g., punch)? Torsional or axial load injury? Open laceration?, etc.

         
         
      3. 
         

         Specific injuries—animal or human bite (tooth injury in punch).

         
         
      4. 
         

         Soft-tissue injury.

         
         
      5. 
         

         Potential for malalignment—originally malaligned and reduced?

      
      
   6. 
      

      Neurologic symptoms:

      
      
      
      
      1. 
         

         Baseline neurologic function.

         
         
      2. 
         

         Any neurologic deficits after injury?

         
         
      3. 
         

         Vascular compromise?

      
      
   7. 
      

      Exposure:

      
      
      
      
      1. 
         

         Especially important in open fractures.

         
         
      2. 
         

         Concerned about exposure to human/animal oral flora, injuries occurring in a barnyard or in dirty water, industrial exposure, etc.

      
      
   8. 
      

      Relevant past medical/surgical history:

      
      
      
      
      1. 
         

         History of rheumatoid or osteoarthritis?

         
         
      2. 
         

         Bone quality?

         
         
      3. 
         

         Skeletally mature?

         
         
      4. 
         

         History of diabetes mellitus or vascular disease?

         
         
      5. 
         

         Previous injuries to affected hand?

   
   
2. 
   

   Physical examination

   
   
   
   
   1. 
      

      Inspection:

      
      
      
      
      1. 
         

         Skin quality:

         
         
         
         
         • 
           

           i. Note ecchymosis, swelling, wounds, etc.

           
           
         • 
           

           ii. Warm, red—consider infection.

           
           
         • 
           

           iii. Cool, dry—consider vascular compromise.

         
         
      2. 
         

         Deformity:

         
         
         
         
         • 
           

           i. Angular.

           
           
         • 
           

           ii. Rotational.

           
           
         • 
           

           iii. Shortening.

      
      
   2. 
      

      Palpation:

      
      
      
      
      1. 
         

         Tender areas merit greater attention and, potentially, radiographs.

      
      
   3. 
      

      Range of motion:

      
      
      
      
      1. 
         

         Note how close the tip of the fingernail gets to the distal palmar crease.

         
         
      2. 
         

         Note any extensor lags.

      
      
   4. 
      

      Neurovascular examination—important in both open and closed injuries.

      
      
      
      
      1. 
         

         Test individual muscle groups in the radial, ulnar, and median distributions:

         
         
         
         
         • 
           

           i. Radial nerve/posterior interosseous nerve (C7):

           
           
           
           
           • 
             

             Test wrist extension.

             
             
           • 
             

             Test metacarpophalangeal (MCP) joint extension.

             
             
           • 
             

             Test thumb interphalangeal (IP) hyperextension and retropulsion.

           
           
         • 
           

           ii. Median nerve/anterior interosseous nerve (C8):

           
           
           
           
           • 
             

             Test thumb IP joint flexion.

             
             
           • 
             

             Motor recurrent branch → test thumb palmar abduction.

           
           
         • 
           

           iii. Ulnar nerve (T1)—test index finger abduction (first dorsal interosseous).

         
         
      2. 
         

         Vascular examination:

         
         
         
         
         • 
           

           i. Test capillary refill (< 2 seconds).

           
           
         • 
           

           ii. Allen’s test—occlude both radial and ulnar arteries, then release one:

           
           
           
           
           • 
             

             If arches are patent—hand should reperfuse with only one artery occluded.

             
             
           • 
             

             If reperfusion does not occur, suspect arterial injury or occlusion.

         
         
      3. 
         

         Test sensation in the digits and in the radial, ulnar, and median nerve distributions (▶ Fig. 29.1 ).

         

         
         
         
         
         • 
           

           i. Radial (C6)—dorsal thumb.

           
           
         • 
           

           ii. Median nerve (C6–C7)—palmar surface of index and middle fingers.

           
           
         • 
           

           iii. Ulnar nerve (C8)—dorsal surface of the fourth and fifth fingers.

           
           
         • 
           

           iv. Two-point discrimination test—ability to determine two separate points of sensation. Use 6 mm as minimum distance.

   
   
3. 
   

   Anatomy

   
   
   
   
   1. 
      

      Metacarpals:

      
      
      
      
      1. 
         

         Comprise the longitudinal and transverse arches of the hand.

         
         
      2. 
         

         Second and third carpometacarpal (CMC) joints are fixed.

         
         
      3. 
         

         First, fourth, and fifth CMC joints are mobile.

         
         
      4. 
         

         Dorsal and palmar interosseous muscles originate from metacarpals.

      
      
   2. 
      

      Phalanges:

      
      
      
      
      1. 
         

         Proximal, middle, and distal phalanges.

         
         
      2. 
         

         Ligaments of fingers important for distal IP (DIP) and proximal IP (PIP) joint stabilization. They contribute to deforming forces in the setting of fracture along with tendons at attachment sites.

      
      
   3. 
      

      Vascular:

      
      
      
      
      1. 
         

         Radial and ulnar arteries supply superficial and deep palmar arch.

         
         
      2. 
         

         Rich collateral blood supply.

         
         
      3. 
         

         Deep arch predominantly supplied by radial artery.

         
         
      4. 
         

         Superficial arch predominantly supplied by ulnar artery.

   
   
4. 
   

   Imaging

   
   
   
   
   1. 
      

      Radiographs:

      
      
      
      
      1. 
         

         Anteroposterior (or posteroanterior), lateral, and oblique.

         
         
      2. 
         

         Oblique X-rays are more difficult to interpret, but may help resolve doubt about subtle findings on the anteroposterior or lateral radiographs.

      
      
   2. 
      

      CT:

      
      
      
      
      1. 
         

         Assess articular pattern and alignment.

         
         
      2. 
         

         Limit use to injuries where it might affect treatment options or prognosis.

      
      
   3. 
      

      MRI:

      
      
      
      
      1. 
         

         Rarely used for fractures.

         
         
      2. 
         

         Role for ligament injuries debated. Also, it can often be misleading.

   
   
5. 
   

   Classification

   
   
   
   
   1. 
      

      Descriptive classification:

      
      
      
      
      1. 
         

         Open versus closed.

         
         
      2. 
         

         Location—bone involved, specific area of bone involved in injury.

         
         
      3. 
         

         Pattern, deformity, and displacement.

         
         
      4. 
         

         Extension into surrounding structures—articular involvement, soft-tissue involvement, etc.

      
      
   2. 
      

      Open hand fractures: Swanson et al classification:

      
      
      
      
      1. 
         

         Type I—clean wound, no significant delay in treatment, no systemic signs of infection.

         
         
      2. 
         

         Type II—includes one or more of human or animal bite and open injury in fresh water.

         
         
         
         
         • 
           

           i. Open injury occurring in a barnyard setting.

           
           
         • 
           

           ii. Contamination of open wound with gross debris.

           
           
         • 
           

           iii. Delay in treatment of over 24 hours.

           
           
         • 
           

           iv. Significant systemic illness that would impact healing/infection risk, such as rheumatoid arthritis, diabetes, etc.

II. Treatment

1. 
   

   Initial Management

   
   
   
   
   1. 
      

      Surgical indications:

      
      
      
      
      1. 
         

         Open fractures.

         
         
      2. 
         

         Some malaligned fractures.

         
         
      3. 
         

         Rotational malalignment that cannot be corrected and maintained with nonoperative treatment methods.

         
         
      4. 
         

         Associated nerve, vessel, or tendon injuries benefiting from treatment.

      
      
   2. 
      

      Adequately aligned fractures that are unlikely to cause problems:

      
      
      
      
      1. 
         

         Includes any fracture that is adequately aligned and stable (unlikely to move), a fracture that was initially displaced, but able to be reduced and remain aligned thereafter.

         
         
      2. 
         

         Fractures with deformity consistent with good function, such as small finger metacarpal neck fractures and small finger proximal phalanx base fractures.

         
         
      3. 
         

         Buddy taping, splinting, or casting.

         
         
      4. 
         

         Selective repeat radiographs based on potential for problematic loss of alignment (routine repeat radiographs not necessary).

         
         
      5. 
         

         Optional return visit for fractures with a good prognosis.

      
      
   3. 
      

      Other considerations:

      
      
      
      
      1. 
         

         Fight bite injuries:

         
         
         
         
         • 
           

           i. Any small crescent-shaped wound near an associated fracture site (particularly MCP) should be considered for possible contamination with oral flora.

           
           
         • 
           

           ii. Needs irrigation and debridement.

           
           
         • 
           

           iii. Consider antibiotic coverage to cover for aerobic and anaerobic bacteria.

         
         
      2. 
         

         Animal bites:

         
         
         
         
         • 
           

           i. Consider antibiotic coverage for Pasteurella.

           
           
         • 
           

           ii. Leave wounds open—do not suture.

           
           
         • 
           

           iii. Wounds with exposed joints, tendons, or nerves should be debrided and irrigated in the operating room.

   
   
2. 
   

   Definitive Management

   
   
   
   
   1. 
      

      Carpal fractures and dislocations:

      
      
      
      
      1. 
         

         Scaphoid:

         
         
         
         
         • 
           

           i. Most commonly fractured carpal bone:

           
           
           
           
           • 
             

             Most common location of fracture: waist.

             
             
           • 
             

             Less common—distal tubercle and proximal pole.

           
           
         • 
           

           ii. Limited blood supply of scaphoid:

           
           
           
           
           • 
             

             Risk of osteonecrosis.

           
           
         • 
           

           iii. Suspected fracture (fall, tender scaphoid, normal radiographs):

           
           
           
           
           • 
             

             Splint and re-examine in 1 to 2 weeks.

             
             
           • 
             

             MRI best for ruling out (high negative predictive value, low positive predictive value), so perhaps useful for return to sport or work.

           
           
         • 
           

           iv. Nonoperative management:

           
           
           
           
           • 
             

             Nondisplaced fractures.

             
             
           • 
             

             Immobilization for 10 weeks is standard, but as little as 6 weeks may be adequate for CT verified, nondisplaced fractures. A cast or splint is preferred. Evidence suggests no benefit to immobilizing the thumb or the elbow.

           
           
         • 
           

           v. Operative management:

           
           
           
           
           • 
             

             Option for nondisplaced fracture in order to avoid a cast or splint: percutaneous screw fixation.

             
             
           • 
             

             Also indicated for fractures with greater than 1 mm gap or any translation or angulation (seen on CT scan). Open or arthroscopic assisted open reduction and internal fixation (ORIF).

         
         
      2. 
         

         Lunate/perilunate injuries:

         
         
         
         
         • 
           

           i. The lunate is known as the “carpal key stone” because of its well-seated location in the lunate fossa, securely attached to the distal radius via volar ligaments.

           
           
         • 
           

           ii. Most common traumatic pathologies are perilunate fracture dislocations:

           
           
           
           
           • 
             

             Carpal bones dislocate around the lunate, which stays in place. The most common is a trans-scaphoid perilunate fracture dislocation. Injury often occurs through the greater or lesser arc of the wrist secondary to an axial load (▶ Fig. 29.2a, b ). Capitate, triquetrum, and radial styloid can also be involved. Pure lunate dislocation can also occur.

             

             
             
           • 
             

             Often dislocates volarly.

             
             
           • 
             

             High association with median neuropathy. Typically acute carpal tunnel syndrome.

             
             
           • 
             

             Reduction is attempted when experts are available.

             
             
           • 
             

             In the absence of acute carpal tunnel syndrome, arrangements can be made for later definitive care even if the wrist cannot be reduced.

             
             
           • 
             

             Operative treatment consists of reduction, realignment, fixation of any fractures, repair, and protection of interosseous ligament injuries. Treatment often consists of CRPP versus open reduction with screw fixation.

           
           
         • 
           

           iii. Clinical evaluation:

           
           
           
           
           • 
             

             Often present with generalized swelling to wrist.

             
             
           • 
             

             Can sometimes detect dorsal carpal bones in case of perilunate dislocation.

           
           
         • 
           

           iv. Lateral radiograph is important for assessing dislocation:

           
           
           
           
           • 
             

             “Spilled tea cup sign” = volar dislocation of lunate (▶ Fig. 29.3 ).

             

           
           
         • 
           

           v. CT scan useful for defining injury pattern and ligamentous injury.

           
           
         • 
           

           vi. Treatment:

           
           
           
           
           • 
             

             Attempt timely closed reduction to limit risk of median neuropathy. It is important to obtain sedation. Longitudinal traction is helpful to relax forearm muscles. Maneuver includes hyperextending wrist with longitudinal traction applied with volar pressure to lunate. Subsequent flexion of wrist over restrained lunate.

             
             
           • 
             

             Prompt surgical intervention is necessary in cases of acute carpal tunnel syndrome.

         
         
      3. 
         

         Trapezium:

         
         
         
         
         • 
           

           i. Fractures often involve articular surface.

           
           
         • 
           

           ii. Commonly associated with trapeziometacarpal (TMC) joint dislocation/subluxation.

           
           
         • 
           

           iii. Result from an axial blow to an adducted thumb.

           
           
         • 
           

           iv. Thumb spica splinting indicated for nondisplaced fractures.

           
           
         • 
           

           v. Surgery for fractures with substantial articular incongruity.

         
         
      4. 
         

         Hamate:

         
         
         
         
         • 
           

           i. Articular surface with CMC fracture-dislocation:

           
           
           
           
           • 
             

             Displaced fractures and fractures with subluxation or impaction are treated operatively.

             
             
           • 
             

             Small marginal fragments associated with dislocation can be ignored and the joint reduced and pinned for a month.

             
             
           • 
             

             Others treated with ORIF.

           
           
         • 
           

           ii. Hook of the hamate:

           
           
           
           
           • 
             

             Direct blow to palm.

             
             
           • 
             

             Athletic activities such as golf or baseball. Deep branch of ulnar nerve closely associated with hook of the hamate.

           
           
         • 
           

           iii. CT scan often best visualizes hamate fractures.

           
           
         • 
           

           iv. Nondisplaced fractures can be treated nonoperatively with activity restriction and cast immobilization for 6 weeks.

           
           
         • 
           

           v. Patients with displaced hook of hamate fractures and established nonunions causing substantial symptoms are offered surgical excision.

      
      
   2. 
      

      Metacarpal head fractures:

      
      
      
      
      • 
        

        i. Range from epiphyseal fractures to metacarpal shaft fractures that extend into the MCP joint.

        
        
      • 
        

        ii. Minimally displaced, stable fractures lead to splint in MCP flexion of greater than 70 degrees:

        
        
        
        
        • 
          

          Shearing pattern—monitor radiographs each week for loss of reduction.

        
        
      • 
        

        iii. Displacement greater than 2 mm leads to open ORIF.

      
      
   3. 
      

      Metacarpal neck fractures:

      
      
      
      
      1. 
         

         Often angulate apex dorsal given force exerted by interosseous muscles.

         
         
      2. 
         

         Closed reduction and casting:

         
         
         
         
         • 
           

           i. Fracture redisplacement common after reduction.

           
           
         • 
           

           ii. Small finger malalignment is mostly aesthetic:

           
           
           
           
           • 
             

             “Lump in palm” feeling.

             
             
           • 
             

             Malrotation extremely uncommon.

           
           
         • 
           

           iii. Immobilize in extension or flexion for 4 weeks.

         
         
      3. 
         

         Operative:

         
         
         
         
         • 
           

           i. Open fractures.

           
           
         • 
           

           ii. People willing to take the risks of surgery for potentially improved aesthetics.

           
           
         • 
           

           iii. Operative techniques:

           
           
           
           
           • 
             

             Closed reduction and percutaneous pinning (CRPP) either antegrade or retrograde.

             
             
           • 
             

             ORIF with plating generally reserved for fractures that cannot be reduced using CRPP.

      
      
   4. 
      

      Metacarpal shaft fractures:

      
      
      
      
      1. 
         

         Closed reduction and splinting:

         
         
         
         
         • 
           

           i. Indications: acceptable angulation:

           
           
           
           
           • 
             

             Less than 10 to 20 degrees in index and metacarpals.

             
             
           • 
             

             Less than 30- to 40-degree angulation in the fourth and fifth metacarpals.

           
           
         • 
           

           ii. Little or no malrotation.

           
           
         • 
           

           iii. Shortening is aesthetic.

           
           
         • 
           

           iv. Most are treated symptomatically (removable splint or wrap).

         
         
      2. 
         

         Operative:

         
         
         
         
         • 
           

           i. Considered for malrotation and angulation more than 10 to 20 degrees.

           
           
         • 
           

           ii. Techniques include CRPP and open reduction with screw or plate and screw fixation.

      
      
   5. 
      

      Metacarpal base fractures:

      
      
      
      
      1. 
         

         Index through small metacarpals:

         
         
         
         
         • 
           

           i. May be associated with CMC joint dislocation.

           
           
         • 
           

           ii. Sometimes overlooked.

           
           
         • 
           

           iii. Common mechanisms: punch or fall.

           
           
         • 
           

           iv. Carpal bones can obscure fracture pattern on standard radiographs → 30-degree anterior oblique radiographs can be helpful.

           
           
         • 
           

           v. CT may aid in diagnosis and delineate intra-articular involvement.

           
           
         • 
           

           vi. Treatment includes CRPP if articular alignment is adequate and ORIF for articular malalignment.

         
         
      2. 
         

         Thumb:

         
         
         
         
         • 
           

           i. Extra-articular fracture treatment:

           
           
           
           
           • 
             

             Closed reduction and spica splint or cast. Quite a bit of angulation consistent with good function (e.g., 30 degrees).

             
             
           • 
             

             CRPP greater angulation.

           
           
         • 
           

           ii. Intra-articular fractures:

           
           
           
           
           • 
             

             Type I: Bennett’s fracture—fracture/dislocation of TMC joint with variable sized volar lip fragment with attached volar oblique ligament. Metacarpal fragment is displaced by adductor and abductor pollicis longus and extensor pollicis longus.

             
             
           • 
             

             Type II: Rolando’s fracture—fragmented articular fracture of the base of thumb metacarpal (▶ Fig. 29.4a, b ). Both fracture patterns are unstable and usually treated operatively: closed reduction/percutaneous pinning versus ORIF.

             

      
      
   6. 
      

      Fractures of the proximal and middle phalanges:

      
      
      
      
      1. 
         

         Very common injury across all age groups.

         
         
      2. 
         

         Proximal phalanges often apex volar:

         
         
         
         
         • 
           

           i. Deforming force—interosseous muscles.

         
         
      3. 
         

         Middle phalanges can displace apex volar or apex dorsal:

         
         
         
         
         • 
           

           i. If fracture is proximal to flexor digitorum superficialis (FDS) insertion, it will displace the apex dorsal.

           
           
         • 
           

           ii. If fracture is distal to FDS tendon insertion, it will displace the apex volar.

         
         
      4. 
         

         Closed reduction and buddy taping:

         
         
         
         
         • 
           

           i. Fractures with acceptable alignment and not likely to lose alignment (either without reduction or after reduction).

           
           
         • 
           

           ii. Extension block casting can work for some fractures at risk for loss of alignment (Burkhalter; ▶ Fig. 29.5 ).

           

           
           
         • 
           

           iii. Movement limits stiffness and prevents rotational malalignment.

         
         
      5. 
         

         ORIF versus CRPP:

         
         
         
         
         • 
           

           i. Substantially angulated, rotated, or shortened fractures.

           
           
         • 
           

           ii. CRPP preferred for closed fractures.

           
           
         • 
           

           iii. ORIF for fractures with wounds or extensive soft-tissue crush. Also for some articular fractures.

      
      
   7. 
      

      PIP fracture dislocations:

      
      
      
      
      1. 
         

         Dorsal PIP fracture dislocation:

         
         
         
         
         • 
           

           i. Volar lip fractures.

           
           
         • 
           

           ii. Treatment based on amount of joint surface involvement:

           
           
           
           
           • 
             

             If less than 40% of joint is involved, it can be treated with closed reduction and splinting. It leads to reduction in flexion. Dorsal extension block splint is commonly used.

             
             
           • 
             

             If greater than 40% of joint surface is involved, surgery is indicated. Extension block pin and transarticular pin are used. ORIF is difficult due to impacted articular fragments. Hemihamate arthroplasty is preferred for much damaged volar lip or for delayed treatment.

         
         
      2. 
         

         Volar fracture dislocation:

         
         
         
         
         • 
           

           i. Uncommon.

           
           
         • 
           

           ii. Associated with avulsion of central slip.

           
           
         • 
           

           iii. ORIF with disimpaction of articular fragments and replacement of central slip attachment.

      
      
   8. 
      

      Fractures of the distal phalanges:

      
      
      
      
      1. 
         

         Intra-articular fractures:

         
         
         
         
         • 
           

           i. Mallet’s fracture (▶ Fig. 29.6a ):

           

           
           
           
           
           • 
             

             Extensor digitorum avulsion with fracture of the dorsal lip.

             
             
           • 
             

             Commonly treated nonoperatively with dorsal splinting for 6 weeks.

             
             
           • 
             

             Surgery considered for subluxation.

             
             
           • 
             

             Not clear that surgery outperforms nonoperative treatment in the short or long term.

           
           
         • 
           

           ii. Jersey finger (▶ Fig. 29.6b ):

           
           
           
           
           • 
             

             Flexor digitorum profundus avulsion.

             
             
           • 
             

             Most commonly involves the ring finger.

             
             
           • 
             

             Bone injury is often an avulsion fragment at the tendinous insertion site.

             
             
           • 
             

             Treatment is generally operative via tendon repair and repair of bony fragment if large.

         
         
      2. 
         

         Extra-articular fractures:

         
         
         
         
         • 
           

           i. Stellate crush fractures are treated nonoperatively:

           
           
           
           
           • 
             

             Splinting of DIP for comfort (should leave PIP joint free so as to promote maximum motion).

           
           
         • 
           

           ii. Operative indications:

           
           
           
           
           • 
             

             Displaced shaft fracture (at risk for nonunion).

             
             
           • 
             

             Concomitant wound and some nail bed injuries that might benefit from surgery.

           
           
         • 
           

           iii. Severely comminuted fractures or open fractures with significant soft-tissue injury may warrant amputation of distal phalanx.

      
      
   9. 
      

      MCP joint dislocations:

      
      
      
      
      1. 
         

         Dorsal dislocations are more common.

         
         
      2. 
         

         They can be seen on radiographs as joint space widening. It often requires lateral radiograph to adequately assess them.

         
         
      3. 
         

         Simple dislocations:

         
         
         
         
         • 
           

           i. Closed reduction after infiltration of local.

           
           
         • 
           

           ii. Usually stable after reduction.

         
         
      4. 
         

         Complex dislocations:

         
         
         
         
         • 
           

           i. Volar plate interposition into the joint or other soft-tissue involvement.

           
           
         • 
           

           ii. Irreducible closed.

           
           
         • 
           

           iii. Open reduction: dorsal—split the volar plate to allow it to go around the metacarpal head.

         
         
      5. 
         

         Volar dislocations are often unstable.

         
         
      6. 
         

         Thumb MCP dislocation is usually stable after closed reduction. Ligaments usually heal without surgery.

      
      
   10. 
       

       PIP joint dislocations:

       
       
       
       
       1. 
          

          Dorsal dislocations are common.

          
          
       2. 
          

          Volar and rotational dislocations are uncommon and more difficult to reduce from interposition of ligament.

          
          
       3. 
          

          Closed reduction under digital block:

          
          
          
          
          • 
            

            i. Active motion.

            
            
          • 
            

            ii. Buddy taping for 3 weeks.

          
          
       4. 
          

          ORIF for rare collateral ligament interposition.

       
       
   11. 
       

       DIP joint dislocations:

       
       
       
       
       1. 
          

          Often associated with tendon rupture or wound.

          
          
       2. 
          

          Generally easy to reduce under digital block.

          
          
       3. 
          

          Surgery is not helpful if reduction is stable, wound is adequately treated, and tendons are intact.

   
   
3. 
   

   Surgical Approaches

   
   
   
   
   1. 
      

      Finger:

      
      
      
      
      1. 
         

         Dorsal approach—split extensor tendon in the midline or between the central slip and lateral band.

         
         
      2. 
         

         Volar approach:

         
         
         
         
         • 
           

           i. Brunner’s (zigzag) incisions. Cross-flexion creases obliquely.

           
           
         • 
           

           ii. A1, A3, and A5 are expendable.

           
           
         • 
           

           iii. Flexor tendons can be retracted.

         
         
      3. 
         

         Lateral approach:

         
         
         
         
         • 
           

           i. Midaxial incision: make points at the end of flexion creases in flexion. These indicate incision line.

           
           
         • 
           

           ii. Important structures:

           
           
           
           
           • 
             

             Digital nerve and artery are volar to incision.

             
             
           • 
             

             Lateral bands need to be retracted or excised when approaching the proximal phalanx.

      
      
   2. 
      

      Metacarpals:

      
      
      
      
      1. 
         

         Dorsal approach:

         
         
         
         
         • 
           

           i. A straight, longitudinal incision is made between the adjacent metacarpal bones.

           
           
         • 
           

           ii. Interosseous muscles are elevated to expose the metacarpal.

      
      
   3. 
      

      MCP joint:

      
      
      
      
      1. 
         

         Dorsal approach:

         
         
         
         
         • 
           

           i. Straight or curved incision over the MCP joint.

           
           
         • 
           

           ii. Extensor apparatus is incised longitudinally or sagittal band is detached.

           
           
         • 
           

           iii. Repair upon closure.

           
           
         • 
           

           iv. Longitudinal capsulotomy is performed to gain direct access to the joint.

   
   
4. 
   

   Fixation Techniques

   
   
   
   
   1. 
      

      Kirschner’s wire fixation:

      
      
      
      
      1. 
         

         Perpendicular to fracture line.

         
         
      2. 
         

         Intramedullary.

      
      
   2. 
      

      ORIF.

      
      
   3. 
      

      Screws or plate and screws, depending on fracture pattern, fragmentation, and bone quality.

   
   
5. 
   

   Complications

   
   
   
   
   1. 
      

      Infection:

      
      
      
      
      1. 
         

         Pin track infection caused often due to pin–skin motion.

         
         
      2. 
         

         Deep infection—purulence, abscess, or osteomyelitis.

      
      
   2. 
      

      Malunion/nonunion:

      
      
      
      
      1. 
         

         Malalignment combined with dysfunction can be considered for osteotomy.

         
         
      2. 
         

         Nonunion:

         
         
         
         
         • 
           

           i. Very uncommon.

           
           
         • 
           

           ii. Infection, technical deficiencies, devitalized bone.

      
      
   3. 
      

      Stiffness:

      
      
      
      
      1. 
         

         Joint contracture.

         
         
      2. 
         

         Tendon adhesion.

         
         
      3. 
         

         Most common with wounds, crush, or open treatment.

         
         
      4. 
         

         Stretching after injury can be counterintuitive.

      
      
   4. 
      

      Post-traumatic osteoarthritis—articular deformity, damage, or subluxation.