1  Epidemiology and Specific Challenges

1.1 Incidence of Hand and Carpal Fractures

The incidence of hand and wrist fractures has increased and continues to do so, mainly because of the competitive nature of sports at the high school and college levels and the increased participation in sports for all ages of the general population.1 In 2010, 15% of all emergency department visits for children aged 19 years or younger were fracture related and the three most common fracture locations were in the upper extremities (forearm, finger, and wrist).² Approximately 46% of high school students in the United States participated in a sport in the 2009 to 2010 academic year.³ Using the National High School Sports-Related Injury Surveillance System, it was found that the hand/finger was the most commonly fractured body site (32%). This was true for football, boys’ soccer, volleyball, boys’ and girls’ basketball, wrestling, baseball, and softball.⁴ Additionally, a large number of children and adolescents participate in non-school–related activities that result in hand injuries, such as skateboarding and scooter-riding.⁵ Although sports are the most common cause of hand fracture in school-aged children, a study of pediatric hand fractures found that children between the ages of 1 and 3 years are most affected by crush injuries.⁶ Thus, biphasic peaks in fracture incidence are seen in 1-to 3-year-olds and again in 10- to 12-year-olds.⁶

Knowing the epidemiology of hand fractures can aid in clinical care by recognizing the types of fractures that commonly affect each age group and the mechanisms of injury that cause different fractures.

1.1.1 Metacarpal Fractures

Metacarpal fractures comprise 33% of all hand fractures reported in a national injury database during a 5-year period7 and 18% of all hand and/or forearm fractures in U.S. emergency departments.⁸ The most common location for fracture was at home.⁷ Metacarpal fractures have been reported to have the highest incidence in 10- to 19-year-olds,⁷ 15- to 24-year-olds,⁸ and 16- to 20-year-olds⁹ ( Fig. 1.1). In a study of pediatric hand fractures, the metacarpals of the small digit had the second highest incidence of fractures and most fractures were concentrated around the metacarpophalangeal joint of the small finger.¹⁰ Similarly, a study in Norway consisting of patients of all ages presenting with fracture found that the two most common sites of fractures were around the small finger metacarpophalangeal joint and the small finger metacarpal as a whole.¹¹

Males are more likely to incur a metacarpal fracture compared to females.^7,8 An interaction between age and sex has been shown to be significant; younger men are at the greatest risk of having a metacarpal fracture.⁷ Males also show peaks of hand, wrist, and forearm fracture occurrence in May and September, which is thought to be associated with participation in sports.⁹

Metacarpal fractures can be divided into base, shaft, head, and neck fractures ( Fig. 1.2).¹² Metacarpal neck fractures are the most common metacarpal fractures due to the weakness of the bone in this region. The cause of injury is usually punching a firm object which results in fracture of the metacarpal neck of the small finger, and is inappropriately termed a “boxer’s fracture.” In a national database, the most common mechanism of non-sports–related injury for a metacarpal fracture was “contact with a wall.”⁷ One case-control study found that patients with a boxer’s fracture had significantly higher mean scores than controls for self-defeating, borderline, and antisocial personality disorders.¹³

1.1.2 Phalangeal Fractures

After radius and ulna fractures, phalangeal fractures have the highest incidence of upper extremity fractures followed by metacarpal fractures ( Table 1.1).^8,14 Chung and Spilson reported that 5- to 14-year-olds have the highest incidence of phalangeal fractures⁸ ( Fig. 1.3), and Immerman et al similarly reported that 11- to 15-year-olds had the highest rate of phalangeal fractures.⁹ A 23-year retrospective review of patients in the Netherlands found that men in the ages 10 to 29 years had the greatest proportion of phalangeal fractures.15 In this study, most phalangeal fractures in both men and women were caused by sports (22 and 30%, respectively). However, machinery was the leading cause of injury in men in the ages of 40 to 69. Another study found that the odds of incurring a phalangeal fracture were four times higher (odds ratio [OR] 4.04 [3.04, 5.36]) in college field hockey players (who do not wear gloves) compared to gloved athletes in stick-handling sports (women’s lacrosse, men’s ice hockey, and men’s lacrosse). Gloves are not currently required nor recommended in women’s field hockey. Young children, ages 0 to 5 years, are susceptible to phalangeal fractures due to crush injuries,¹⁶ such as getting fingers stuck in a door. Distal tuft fractures of the phalanges are most common in this age group.^17,18

Fig. 1.1 Incidence of metacarpal fractures by age treated in U.S. emergency departments.
* Age groups 0–4, 65–74, 75–84, and > 85 had unreliable estimates and thus are lacking data. (Data from Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg 2001;26A:908–915.)

Fig. 1.2 Metacarpal bones. (This illustration is a provided courtesy of Dr. Nasa Fujihara.)

Phalangeal fractures can be divided into base, shaft, and condylar fractures12 ( Fig. 1.4) and fractures more commonly occur at the base.¹⁰ In studies of pediatric hand fractures, the proximal phalanx of the small finger^6,16,19 or the thumb¹⁰ had the highest incidence of fractures. Fractures involving the physis (growth plate) are described by the Salter-Harris classification system, types I to V ( Fig. 1.5). Phalangeal and metacarpal epiphyseal plates in the hand remain open until approximately 14½ years in girls and 16½ years in boys.²⁰ One retrospective review over a 2-year period consisted of 354 metacarpal or phalangeal fractures in children aged 18 years or younger in a single emergency room and hand clinic.¹⁹ The authors found that 34% of all fractures involved an epiphyseal plate. Of these injuries, 7.4% were Salter I, 78.7% were Salter II, 13.1% were Salter III, and 1.8% were Salter IV. A similar distribution of Salter-Harris fractures in the phalanges was observed in another study of children aged 21 years or younger.21 The majority (37%) of Salter II fractures occurred in the small finger and 69% of Salter II fractures occurred in the proximal phalanx.¹⁹

Fig. 1.3 Incidence of phalangeal fractures by age treated in U.S. emergency departments.
* Age group 75–84 had unreliable estimate and thus is lacking data. (Data from Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg 2001;26A:908–915.)

Fig. 1.4 Phalangeal bones. (This illustration is a provided courtesy of Dr. Nasa Fujihara.)

In phalangeal fractures, for most age groups, the thumb is the second most commonly fractured digit after the small finger. However, in individuals older than 65 years of age, excluding metacarpal fractures, the thumb was the most commonly injured digit (33% of hand fractures in this age group).22 Fractures involving the metacarpal shaft of the thumb are uncommon because force directed to the shaft is often transferred to the base resulting in a fracture through the metacarpal base.²³ Salter-Harris type II fractures were found to be the most common fracture (72%) of the base of the proximal phalanx of the thumb in children aged 10 years or younger.²⁴ A review of 823 hand and carpal fractures from patients aged 16 years or younger found an incidence of 1.3% for Salter-Harris type III fractures. Four out of eleven of these fractures involved the thumb and 91% (10/11) were caused by an athletic injury.²⁵ A Bennett fracture is an intra-articular fracture separating the volar–ulnar aspect of the metacarpal base from the remaining thumb metacarpal²⁶ ( Fig. 1.6). It is classified into three types: type 1 is a fracture with a large single ulnar fragment and subluxation of the metacarpal base, type 2 is an impaction fracture without subluxation of the thumb metacarpal, and type 3 is an injury with a small ulnar avulsion fragment in association with metacarpal dislocation.²⁷ In a record review of 71 fractures at the base of the thumb, Bennett’s fracture represented 63% of fractures (45/71). The majority of these fractures (96%) were incurred by men. The remaining 37% of fractures in this study were oblique comminuted basal fractures that were also incurred mainly by men.²⁸ A Rolando fracture describes comminuted fractures of the base of the thumb but should, ideally, be reserved for Y- or T-pattern fractures that include the volar–ulnar Bennett’s fragment in addition to a dorsal radial fragment.23 In a retrospective review of 17 cases of Rolando fracture, the majority (71%) occurred in men and the cause of injury was a fall on the hand (53%), a blow to the thumb (35%), or the hand being jammed (12%).

Fig. 1.5 Salter-Harris classification. (This illustration is a provided courtesy of Dr. Nasa Fujihara.)

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