Finger Fractures


166 Finger Fractures


Claire Ryan MD and David Ring MD PhD


Department of Surgery and Perioperative Care, Dell Medical School – The University of Austin at Texas, Austin, TX, USA


Clinical scenario



  • A 31‐year‐old woman presents to the Emergency Department after being struck on the right small finger while playing field hockey.
  • Physical examination reveals a diffusely swollen and tender small finger but with no deformity.

Top three questions



  1. How long should patients with extra‐articular small finger metacarpal (aka boxer’s) fractures be immobilized to achieve optimal outcomes?
  2. Should open reduction and internal fixation (ORIF) or a dynamic external device be used for the management of patients with unstable proximal interphalangeal (PIP) joint fracture/dislocations to optimize outcomes?
  3. Which is a better treatment for achieving optimal outcomes in patients with extra‐articular metacarpal and phalanx fractures: pinning or ORIF?

Question 1: How long should patients with extra‐articular small finger metacarpal (aka boxer’s) fractures be immobilized to achieve optimal outcomes?


Rationale


Extra‐articular small finger metacarpal fractures are extremely common and treatment methods vary widely from no immobilization to casting for up to six weeks.


Clinical comment


These fractures are generally treated nonoperatively but often occur in patients who may be poorly compliant with removable splints and early motion regimens.


Available literature and quality of the evidence


There are several high‐quality studies which examine this question including multiple level I studies.15


Findings


Statius Muller et al. randomized 40 patients with boxer’s fractures to either cast immobilization for three weeks versus one week of soft bandaging followed by mobilization.1 Angulation up to 70° was accepted without reduction. At three months postinjury, there was no statistical differences with respect to range of motion (ROM), satisfaction, pain perception, return to work and hobby, and need for physiotherapy. Kuokkanen et al. randomized 29 patients to either closed reduction and rigid immobilization or immediate mobilization.3 Patients treated without immobilization regained grip strength and ROM slightly earlier, but by three months the two groups were equivalent. They concluded that reduction and immobilization were not necessary.


Braakman et al. prospectively randomized 50 patients to either ulnar gutter casting or functional taping for four weeks.4 The functional taping group showed significantly earlier return of ROM and strength, but by six months there was no difference between the groups. There was no difference in increased fracture angulation between the groups. Similarly, van Aaken et al. compared buddy taping with early mobilization to closed reduction and casting for the treatment of small finger metacarpal neck fractures.5 The authors found no significant difference in functional outcomes, patient satisfaction, or metacarpophalangeal (MCP) joint motion between the two groups at four months.


Two trials compared cast immobilization and a custom functional fracture brace (level II evidence).6,7 Konradsen et al. found significantly better wrist, MCP, and PIP motion after three and four weeks, respectively, in the brace group, but no differences after three months.6 Sørensen et al. noted that only 42% of the brace group completed treatment, pointing to the challenges with compliance in this patient group.7 However, in those who completed treatment, there was no difference in ROM.


Sletten et al. randomized 85 patients with small finger metacarpal neck fractures with >30° palmar angulation found that patients who were treated with a week of splint immobilization followed by buddy taping had similar functional outcomes and satisfaction scores as patients who underwent operative treatment with closed reduction and bouquet pinning (level I).8


In a systematic review of studies of the treatment of small finger metacarpal neck fractures, Dunn et al. found that reduction and cast immobilization did not provide superior ROM, grip strength, or healing compared to treatment with a soft wrap without any reduction attempt.9 In a Cochrane review, Poolman et al. criticized the lack of consistent, validated outcome tools in all studies but concluded: “No single non‐operative treatment regimen for fracture of the neck of the fifth metacarpal can be recommended as superior to another” (level V).10


Although multiple different treatments are utilized by hand surgeons, there is good evidence that cast immobilization is unnecessary in the treatment of small finger metacarpal neck fractures. Level I evidence suggests an earlier improvement in ROM and grip strength will occur in patients treated with functional bracing or even taping. However, at medium‐term follow‐up, there is no significant difference in outcomes such as pain and ROM.


Resolution of clinical scenario



  • Early mobilization with either functional bracing or taping does not affect the final outcome of closed metacarpal fractures and appears to be associated with an earlier return of finger motion and grip strength.
  • Immobilization is also effective with good long‐term outcomes and can be utilized at the discretion of patient and surgeon.

Question 2: Should open reduction and internal fixation (ORIF) or a dynamic external device be used for the management of patients with unstable proximal interphalangeal (PIP) joint fracture/dislocations to optimize outcomes?

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Finger Fractures
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