Hand Fractures
Peter M. Waters, MD, MSSc
The majority (˜75%) of hand fractures have acceptable alignment and are stable. This means most hand fractures are not at significant risk of loss of alignment and are treated successfully closed. The focus here will be on operative indications and techniques. Please do not interpret the emphasis on operative care herein that we are advocating for surgical treatment of most pediatric and adolescent hand fractures. We just want to be certain you know how to do it when you must.
Operative Indications
The fractures that require operative intervention for reduction and stabilization are:
Seymour’s distal phalangeal physeal displaced fracture and entrapped nail bed
Displaced proximal or middle phalangeal neck that is malrotated or blocks flexion
Malrotated phalangeal or metacarpal shaft fractures
Displaced intra-articular phalangeal fractures
PIP joint intercondylar and bicondylar fractures
Thumb MCP joint SH III fracture dislocation
Base of thumb metacarpal CMC joint fracture dislocation (Bennet’s fracture)
Base of small metacarpal CMC joint fracture dislocation (reverse Bennet’s)
Irreducible MCP joint dislocation often with comminuted fracture metacarpal head
Equipment
Most pediatric and adolescent hand fractures that require surgery can be treated successfully with closed reduction percutaneous pinning (CRPP). Displaced intra-articular fractures often require open reduction pinning or small screw fixation. If early postfracture fixation motion is required for a better outcome, then a low-profile stable screw fixation is appropriate.
Smooth C-wires (0.28, 0.35, 0.45, and 0.62 inches) depend on the age of patient and the size of fragments
Modular AO hand or equivalent set with screws (1.5, 2.0, and 2.4 mm)
Fluoroscopy (usually mini-C arm)
Radiolucent hand table
Tourniquet available if CRPP fails, ORIF required
Hand reconstruction set available, if ORIF required
Percutaneous bone reduction clamps
Power drill
Positioning
Involved hand is positioned on a radiolucent hand table when reduction and stabilization is performed.
Regular versus mini-C arm decision is dependent on the size of patient and ease of imaging while holding reduction and stabilizing fracture.
The goals are to
obtain reliable images that enable you to provide desired care to patient
lessen radiation exposure to patient and operating room professionals
using a lower-dose imaging system (mini-C arm) does NOT achieve the goal, if obtaining helpful images is hard and over-imaging occurs
When possible, fluoroscopy comes in intermittently from hand region while surgeon and assistant sit opposite one another.
When feasible, mini-C arm is used to lessen health risk to patient and operating room professionals (Figure 15-1)
Seymour Distal Phalangeal Physeal Fracture
Open Reduction
Technique
Anesthesia and location of care
Conscious sedation or digital local anesthesia block in the emergency department
General anesthesia in operating room
Tourniquet control
Digital wrap in emergency department (ED)
Attach large snap to prevent leaving in place after procedure
Arm tourniquet in OR
Parallel incisions extending eponychial folds proximally on either side nail plate
Hyperflexion of distal interphalangeal joint (DIP)
Careful skin hook elevation dorsal ridge of nail fold (Figure 15-3)
Extract entrapped germinal matrix and proximal nail bed gently
Irrigate fracture site
Gently reduce physeal fracture to align DIP
Check fluoroscopy
Repair nail bed disruption
Outside in mattress repair with bioabsorbable suture (usually 5-0 or 6-0 chromic) (Figure 15-4)
Two adjacent sutures central-radial and central-ulnar nail fold
Figure 15-1 ▪ Use of a mini-C arm for hand fracture reduction and pinning.
Figure 15-2 ▪ Lateral X-ray view of displaced distal phalanx physeal fracture with entrapped nail bed (Seymour’s fracture).
Start proximal to paronychial fold, penetrate under dorsal hood
With physeal fracture reduced,
suture grasp germinal matrix and proximal nail bed
turn suture 180° and re-enter nail bed adjacent and parallel to the original suture, pass now heading from distal to proximal and from superficial to deep through germinal matrix and proximal nail bed
exit from under dorsal hood adjacent and parallel to the entry site
before tying suture, pass second adjacent horizontal mattress suture with the same technique as first
while maintaining reduction, tie both sutures securely in sequence
assess stability of fracture reduction with gentle stress and recheck fluoroscopy alignment
Decide if additional pin stability is needed
In ED, 18 gauge needle passed just volar to distal phalanx in pulp (Figure 15-5)
In OR, percutaneous pin from distal phalanx across fracture and DIP joint
Cast immobilization
in children less than 5 years of age, long-arm hand mitten cast
in older children, short-arm mitten cast
 Figure 15-3 ▪ Open reduction of Seymour’s fracture by extracting germinal matrix from entrapment in physeal fracture. |
 Figure 15-4 ▪ Sequential steps of outside in repair of nail bed laceration associated with Seymour’s fracture. (Used with permission from © COSF, Boston.) |
Postoperative Care
Cast and if pins are used, protection for 4 weeks
Switch from cast to mallet finger dorsal splint for an additional 2 weeks
Start gentle active DIP flexion out of splint at home only
Restore DIP flexion with home exercises
Monitor growth of nail over next 3 to 6 months
 Figure 15-5 ▪ Pinning through pulp to maintain reduction during healing of physeal fractures as noted by (A) lateral X-ray and (B) photograph. |
 Figure 15-6 ▪ Long-term nail deformity of inadequately treated Seymour’s fracture. |
Complications
Nail deformity
can occur with late presentation or nonanatomic care (Figure 15-6).
Infection
Can occur in late presentation (Figure 15-7)
Growth arrest
Rare and usually not consequential
 Figure 15-7 ▪ Late presenting infection distal phalanx from missed Seymour’s fracture. |
Phalangeal Neck Fractures
Closed Reduction Percutaneous Pinning
Indications
Displaced phalangeal neck fractures (Figure 15-8)
With malrotation
With block to interphalangeal joint flexion (<90° PIP joint flexion)
Exceptions are children <2 years of age, middle phalanx fractures with mild block to flexion, no malrotation, whose parents will tolerate slow remodeling
Technique
Reduction
Interestingly, the reduction and pinning is analogous to closed reduction percutaneous pinning of a supracondylar distal humerus fracture (turn to finger image upside down and magnify and they are the same with juxta-articular extension deformity with malrotation) (Figure 15-9)
Distract the fracture in ˜30 degrees of flexion to pull out to length
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