Intra-articular Hand Fractures

Metacarpal and phalangeal fractures are the most common upper extremity fractures. A study in 1998 showed that of all hand and forearm fractures in the United States, 23% were phalangeal and 18% were metacarpal. Metacarpal and phalangeal fractures are often unnoticed or treated as insignificant injuries. ^, Adults and adolescents typically require some form of rehabilitation following a fracture in the hand. To enable the patient to safely and successfully achieve an optimal result, the therapist must understand fracture terminology, management, and healing. This information coupled with a thorough knowledge of soft tissue injury and healing is the cornerstone to treatment. Most fractures and soft tissues heal on a common timeline, and rehabilitation principles and goals coincide with this period of healing. However, the injury patterns of intra-articular fractures and their concomitant soft tissue injuries, as well as the operative techniques for reduction, are more varied. So, the specifics of each patient’s intra-articular fracture, associated soft tissue injuries, status of stability, degree of healing, and expectations for final outcome must be discussed with the physician to ensure that an appropriate rehabilitation program is developed.

Several terms are used to describe the initial state of a fracture. “The anatomic restoration of bone integrity, or reduction , is crucial to provide the normal anatomic base needed for motion.” A nondisplaced fracture indicates that the bones are well-aligned with no alteration in normal bone anatomy. The bones in a displaced fracture are not well aligned. A displaced fracture must be reduced to its normal anatomic alignment and may require fixation to maintain that normal anatomy. After the anatomy of the bone has been restored, the physician determines if the fracture will maintain its position naturally. A stable fracture maintains the reduction and does not displace either spontaneously or with motion. Fractures that displace spontaneously or with motion are unstable . Additional management by the physician is needed to resolve the instability and convert it to a stable fracture. Fractures are described as either intra-articular or extra-articular . Intra-articular fractures occur within the joint articulation at the base or head of the bone. Extra-articular fractures occur outside the joint articulation in the shaft or neck of the bone. Additional information on fracture terminology is provided in Chapter 29 .

When the physician is planning surgery, “the need for biomechanical stability must be balanced with the need to preserve biologic integrity and blood supply while minimizing the risk for scarring. The additional stability of the implant must offset the risks of operative dissection.” Restoration of anatomy without function does not provide a desired outcome. More recently developed implants for fracture fixation can potentially provide stability and optimize outcomes with minimal soft tissue dissection through the use of small joint arthroscopy and intraoperative imaging.

Choices for fracture stabilization are based on the type of fracture and soft tissue injuries. Fixation methods include (1) immobilization with a cast or orthosis either with or without a closed reduction; (2) closed reduction and external or internal fixation (external fixator, Kirschner wires [K-wires]); or (3) open reduction with coaptive (K-wires, intermedullary pin), stable (screw, tension band), or rigid (lag screw, plate, 90/90 wiring) fixation. A full description of fixation methods for specific injuries is provided in Chapters 30 and 32 .

There are excellent resources available that provide a thorough understanding of the fracture-healing process. The reader is referred to the Journal of Hand Therapy, 2003, volume 16, issue 2, special edition on hand fracture management for more detailed information.

Fractures heal with new bone, as opposed to scar tissue, which develops to repair soft tissue injuries. Regenerated new bone unites the fracture ends by either primary or secondary healing methods. The type of fracture healing that occurs depends on the method of fixation.

Stable and rigid fixation methods described earlier provide compression across the fracture and prevent any motion across the fracture, which and allows for primary healing. A fracture callus does not form when healing occurs primarily. The advantages of stable and rigid fixation are “precise anatomical reduction, avoidance of peripheral callus with potential tissue adherence, full access to the hand for wound or edema control, immediate initiation of motion to maintain length in capsular joint structures, immediate gliding of tissue interfaces and the allowance for rehabilitation of any concomitant soft tissue injuries.” These advantages are only realized if an early motion program begins soon after surgery. It is also important to understand that rigid fixation methods allow for earlier and less protected motion; however, the fracture repair process is not accelerated. So, time must pass before the fracture site can tolerate the stress of resisted activities.

When the fracture is treated with external immobilization, closed reduction and immobilization, closed reduction and external fixation (CREF), closed reduction and internal fixation (CRIF), or open reduction and semirigid internal fixation (ORIF), such as with K-wires, secondary healing occurs. In secondary healing, the bone heals through initially forming a callus followed by remodeling into bone. The new bone that begins to form with secondary healing is weak, non-stress-oriented bone, so integrity of the repair site depends initially on the strength of the implant. At 2 to 3 weeks after the injury a clinical union is present with the development of callus formation.

During the healing period, motion is minimized, but not eliminated across the fracture gap. Micromotion at the fracture site actually stimulates blood flow to enhance fracture healing. The benefits of early motion with fixation types that allow for secondary healing are the preservation of blood supply and soft tissue integrity around the fracture site.

Healing timetables for fractures and associated therapy intervention is listed in Figure 33-1 .

Fracture healing timeline and therapy intervention: When the fracture is stabilized, via a closed or open reduction, an external support or protective orthosis (or brace) is needed. The external supports after a closed reduction may include casts, braces, orthoses, or external fixators. Coupled with the external support or protective orthosis during the inflammatory stage is the need to control (i.e., reduce or prevent the formation of) edema. Protected mobilization in the form of gentle active or passive motion (during the external immobilization phase after closed reduction) to the nonimmobilized joints is needed to avoid joint contractures proximal or distal to the fracture site and to glide soft tissue structures. Active motion should be emphasized for controlled mobilization and for tendon gliding. Although positioning in a protective orthosis still is needed during the repair phase, treatments that address passive range of motion (PROM) deficits can be initiated after open reduction; PROM interventions after a closed reduction are delayed until the remodeling stage. Strengthening typically is initiated after closed and open reductions in the remodeling stages. The hierarchical splinting regimen and strengthening is not often continued past the first 6 months, but these interventions may be required (the stippled arrows) for 1 year.

(From LaStayo PC, Winters KM, Hardy M. Fracture healing: Bone healing, fracture management, and current concepts related to the hand. J Hand Ther. 2003;16:81–93.)

Joint Injuries of the Hand

The activities of daily living (ADL) demand that the joints of the hand be both stable and allow for mobility. The hand requires stability to intricately transmit power from the forearm musculature to the fingertips. At the same time, the hand requires mobility to position the digits for countless tasks. The articulations of the joints of the hand are exceptionally designed to provide both characteristics. However, despite this ingenious design, the joints are vulnerable to damaging forces that may injure the supporting joint capsules and ligament complexes. Similar to fracture management, knowledge of joint terminology related to injury, treatment, and healing timelines is critical to helping the patient achieve an optimal recovery.

The complexity of a joint injury ranges from stable dislocation to contracture. Dislocation indicates a temporary displacement of bone from its normal position in a joint. Joint injury includes disruption to various structures such as ligaments and supporting joint capsule. Additionally, the dislocation can occur with an associated intra-articular fracture (i.e., fracture–dislocation ). The direction of the dislocation (e.g., dorsal, volar, lateral) describes the position of the bone relative to the injured joint. For instance, a dorsal dislocation of the proximal interphalangeal (PIP) joint indicates that the middle phalanx lies dorsal to the proximal phalanx. An unstable dislocated joint indicates a joint that does not maintain stability following anatomic reduction. In a joint contracture , the soft tissue around the joint becomes tight in the shortened position, thus limiting range of motion (ROM).

The soft tissue structures affected in a joint injury progress through three phases of healing to produce and remodel scar. ^, The inflammation phase occurs from 0 to 5 days; followed by the prolific fibroplasia phase, lasting 5 days to 4 to 6 weeks; and the scar-remodeling phase, which begins approximately 6 weeks after the injury and continuing for years. ^, Tendon healing to bone without operative intervention requires 6 to 8 weeks before placing unrestricted tension on the tendon (e.g., soft tissue mallet and central tendon injuries).

Treatment Philosophy

Feehan has developed comprehensive guidelines regarding early controlled motion of potentially unstable extra-articular hand fractures (see Chapter 31 ). Concepts from this article can be applied to the management of potentially unstable intra-articular fractures. Although evidence-based literature is lacking, clinical studies recommend an early motion program even following potentially unstable injuries. ^, The benefits include the potential to improve the quality and rate of fracture healing through the use of intermittent and limited loads, improved connective tissue healing due to physiologic stress applied early on, and improved soft tissue mobility (tendon excursion) around the injury site. These benefits are negated if the motion contributes to fracture malunion or nonunion or joint instability. On the other hand, prolonged immobilization leads to pain, degenerative changes, arthrofibrosis, and joint stiffness. Immobilization beyond 4 weeks for fractures in the hand generally have long-term detrimental effects.

The timing for introduction of early motion depends on the “structural strength” of the tissue over time. In theory, fibrin gains enough strength by day 3 to 5 to allow for active motion. Edema control measures and rest or immobilization are appropriate for the preceding days. The hand assumes a position of wrist flexion, metacarpophalangeal joint hyperextension, and PIP flexion when edema is not controlled. These positions can quickly become firm contractures. Proper positioning is required to prevent early contracture development. The patient’s other medical conditions and factors affecting local blood flow also influence the decision about when to begin early motion.

Deciding on how early motion should be applied involves determining the number of joints moved at one time, the type (active or passive) of motion, the duration of motion, and the safe arc of motion.

The time for initiation of early motion is the final option to consider. One must determine if the motion is intermittent or constant.

The goal of an early motion program is to provide the minimum amount of stress to healing tissues while allowing for the right amount of excursion of soft tissues to prevent motion-limiting adhesions. “Minimum” and “right” amounts are different for each patient and injury. LaStayo defined early controlled motion as active motion of the involved joint or previously immobilized structures and early protected motion as active or passive motion of the nonimmobilized joints. These terms are used throughout the chapter.

Precautions for Early Motion

The previously discussed information is intended to be a general guideline. The benefit and detriments of these stresses must be fully understood before initiating treatment. In managing complex injuries, the planning for early motion programs must not overload the weakest or most vulnerable tissue even if other structures involved in the injury are very stable. The consequences of inappropriate early motion must be understood.

In some instances, the injured joint actually requires immobilization up to 4 weeks whether treated with closed or open reduction. That period allows for the prolific fibroblastic stage of soft tissue healing to be completed, thus leading to increased joint stability that can eventually withstand active motion.

General Rehabilitation Goals

After the therapist performs a standard and comprehensive examination, problems are identified and goals are established. Outcome measures such as the Patient-Rated Wrist and Hand Evaluation (PRWHE) are useful for understanding functional deficits and pain. The general goals for patients with joint injuries in the hand are listed in Box 33-1 . Treatment planning begins by fully understanding the anatomy, injury, and potential complications; the surgical or nonsurgical management chosen; tissue tolerance for stress application; other medical conditions the patient may have that may affect fracture or soft tissue healing; the patient’s ability to perform required therapeutic interventions; and the patient’s goals and expectations. Full recovery may take several months.

Immobilization and Controlled and Protected Motion Phases

General therapy principles are applicable to most hand joint injuries and intra-articular fractures. Early edema control is accomplished through elevation, cold, compression, and manual edema mobilization. ^, Early reduction of edema is desirable to facilitate joint motion and tendon excursion and prevent contractures. Constant vigilance is necessary to evaluate and adjust orthoses as edema fluctuates. Pin care is essential for preventing irritation and infection. Pin care generally involves cleaning the skin surrounding the pin and then maintaining a dry, clean environment with appropriate dressings. If the external hardware does not directly block joint ROM, then the surgeon is contacted regarding the stability of the involved joint in relation to the initiation of controlled motion. Patient education is extensive and involves ensuring the patient understands the necessary precautions, the purpose of and reasoning behind the therapy program, and their expected participation. Precautions associated with all diagnoses must be fully understood to guide the specifics and timing for each technique. Early controlled motion generally begins with performing active short arc motion for the involved joint as well as placing the proximal and distal joints in positions that enhance tendon glide and excursion. Template orthotics allow specific desired degrees of motion. Blocking exercises do not imply resistance to the fracture and in fact, in some cases, provide support to the fracture site. One exception is the mobilization of a mallet finger injury, which generally begins with composite motion to prevent attenuation of the healing terminal extensor tendon. The importance of avoiding the development of an extensor lag cannot be overstated.

Early protected motion begins with isolated active and passive motion to the nonimmobilized joints as long as the structural stability of the injury can withstand this degree of motion. Motion then progresses to full isolated joint motion while always monitoring for extensor lag. As isolated motion improves, composite (flexion–extension of all joints for the involved digit) and tenodesis exercises are initiated.

Advancements in motion are not made if the patient experiences acute pain or a marked increase in edema occurs following a treatment intervention. Prompt referral back to the physician may be needed to ensure the injury remains stable. The cause of stiffness must be understood, as attempts to mobilize a malunited, unstable, or arthritic joint is contraindicated.

Motor reeducation strategies are employed to improve active motion. Early use of mirror imagery may limit cortical degradation. ^, Neuromuscular electrical nerve stimulation (NMES) for muscle reeducation and specific motor control strategies facilitate the correct activation of desired and isolated musculature. At times this may require extensive one-to-one observation and demonstration time spent with the patient. Performance of graded activity is very helpful in motor reeducation as long as the activity is structured to facilitate desired movement patterns. It is nonproductive to have patients performing graded activities if the desired motion and muscles are not being activated. In fact, poorly selected activities may end up reinforcing compensatory movement patterns instead of desired movement patterns.

Adapted and compensatory ADL strategies are reviewed based on individual patient needs followed by gradual return to functional tasks with the involved extremity.

Orthotics can improve active motion through positioning that allows for isolated joint movement and resisted motion. Orthotics can improve passive motion through application of low-load, prolonged-duration stress to shortened tissues.

Scar management includes mobilization combined with motion to restore movement between tissue planes, scar massage, and scar pads or silicone gel.

Passive motion techniques include joint distraction, heat modalities combined with positioning at the end ROM, composite stretch to shortened muscle tendon unit, and joint mobilization.

Desensitization, review of sensory precautions and sensory reeducation are rarely required in the management of these injuries. Pain control includes thermal or electrical modalities, edema reduction, and the resolution of stiffness.

If motion limitations persist, a thorough examination is performed to determine which tissue structures are responsible for the limitation, and appropriate therapeutic intervention is provided.

Guidelines for each specific type of joint injury and intra-articular fracture regarding immobilization, controlled and protected motion, anticipated problems and key exercises, therapeutic techniques, and orthoses are described on Tables 33-1 and 33-2 . It is important to note that time frames vary for each case.

Table 33-1

Protective Stage of Management Following Intra-articular Hand Fractures and Joint Injuries

PIP Joint Injuries
Collateral Ligament Injury
Degree of Injury	Immobilization/Controlled Motion	Time Frame
1. Grade I (stable through AROM and PROM)	Buddy-taping to adjacent digit above and below the PIPJ; a LF RCL injury is taped to the IF and LF UCL injury is taped to the RF. A RF RCL injury is taped to LF, and RF UCL is taped to the SF. The SF may need a custom-sewn buddy-strap due to length difference of the P1 and P2 of the adjacent RF. Buddy-straps may be padded to provide for neutral alignment of PIPJ.	2–4 weeks
	Modifications : If there is significant pain and swelling, a finger gutter with PIP and DIP in extension is used or an HB resting orthosis including MP in 70 degrees of flexion and IPs in full extension for involved and adjacent digit. Straps are used to control neutral PIP alignment. After approximately 1 week, replace orthosis with buddy-straps ( Fig. 33-2 )	Use orthosis for 1 week then replace with buddy-straps
2. Grade II (stable through AROM)	Finger gutter with PIP and DIP in extension or an HB resting orthosis, including MP in 70 degrees of flexion and IPs in full extension for involved and adjacent digit for 2–4 weeks. After initial period of rest for 2 weeks, replace orthosis with buddy-straps.	2 weeks full-time orthosis wear f/b intermittent use or buddy-straps
3. Grade III (unstable through AROM and PROM) non-op	See grade II. Controlled motion: FiB or HB static extension block or figure-of-8 orthosis to block arc of motion (usually limiting full PIPJ extension) where instability is present ( Fig. 33-3 ). After orthosis is discontinued, use buddy-straps as described above for grade 1 injury.	2–3 weeks full time, f/b intermittent use
	Modifications : May require surgeon’s observation using fluoroscopy to determine effectiveness of extension block orthosis

 

Dorsal Dislocation (P2 Dorsal to P1): Volar Plate Injury: May Involve Fracture Fragment: Type I–III
Management	Immobilization/Controlled Motion	Time Frame
4. Closed reduction	Controlled motion : Typically requires two buddy-tapes to adjacent digit placed around P1 and P2	2–4 weeks
	Modification : If additional protection is desired and FiB and HB dorsal PIP extension block or a figure-of-8 orthosis is used. Full active flexion is allowed by removing straps on the FiB orthosis. Exact degree of extension block is determined by the physician. The surgeon may use fluoroscopy to determine the effectiveness of the extension block orthosis, which can be alone or in conjunction with using buddy-tapes for AROM exercises (see Fig. 33-3 ).	1–2 weeks f/b buddy-straps until week 4
5. Extension block pinning	Controlled motion : FiB or HB static dorsal protective orthosis covering pin. Remove straps to allow for active flexion.	4 weeks
	Controlled motion : After pin removal, wean to a figure-of-8/FiB static dorsal extension block orthosis limiting hyperextension and allowing flexion as required	PRN
6. Hinged external fixation (often with associated fx)	Controlled motion : If an extension block is required, an FiB or HB static dorsal block orthosis accommodating the hinged fixation and allowing active and assisted flexion is fabricated. A protective HB radioulnar gutter can be used to protect the external fixator. An FiB orthosis can be used to provide additional protection and block extension ( Fig. 33-4 )	4–6 weeks
	Controlled motion : After the fixator is removed, the use of an orthosis depends on joint stability. If the joint has some instability, the patient will need to use figure-of-8 or FiB static extension block orthosis.	PRN

 

Volar Dislocation (P2 Volar to P1): May Injure Central Slip of Extensor Tendon
Management	Immobilization/Controlled Motion	Time Frame
7. Closed reduction—central slip intact	Controlled motion : Finger gutter with PIPJ in extension. The orthosis should allow for full DIP motion. Orthosis may be fabricated by using a circumferential design with a small opening laterally to accommodate changes in edema. The orthosis is removed for AROM of PIPJ.	2–3 weeks
	Modifications : For extra protection an exercise template volar finger gutter is used, allowing progressive degrees of PIPJ flexion when out of the protective orthosis. When there is significant stiffness, buddy taping to the adjacent digit can help guide motion of the involved digit during the day.	Beginning when ROM is started
8. Closed reduction—central slip rupture	Immobilization : Finger gutter as above. The PIPJ must be supported in extension full time especially when the orthosis is removed for hygiene. The patient is slowly weaned from the orthosis to avoid the development of an extensor lag.	4–6 weeks
	Controlled motion : A Capener-type ( Fig. 33-5 ) or Fib/HB dynamic PIP extension orthosis is used during the day and a finger gutter is used at night if starting AROM of PIPJ at week 4 or if extensor lag is evident.	Beginning when ROM is started
9. ORIF/repair of central tendon	Immobilization : A finger gutter with PIP and DIP in extension; if no internal fixation, for controlled motion, two exercise template orthoses are used ( Fig. 33-6 ) (see Chapter 39 ) 1 PIP extension orthosis used to perform isolated DIP flexion exercises 2 Finger gutter allowing PIP flexion to 30 degrees, DIP flexion to 25 degrees. Advance at week 2 to 40 degrees PIP flexion Week 3 to 50 degrees of PIP flexion Week 4 to 80 degrees of PIP flexion. If extensor lag develops, advance more slowly. If active motion is not progressing, use a flexion orthosis intermittently at week 4. The avoidance of extensor lag greater than 30 degrees is critical.	6 weeks total

 

Intra-articular Fractures Condylar, Volar/Dorsal Lip of P2/Pilon
Management	Immobilization/Controlled Motion	Time Frame
10. Volar fx: less than 30% of joint surface: Nondisplaced and stable. Non-op	Controlled motion : FiB or HB static dorsal PIP extension block orthosis typically limits the last 30 degrees of extension. The orthosis allows for active flexion by removing straps. Frequent reexaminations by physician are necessary to ensure fracture remains stable in the orthosis with remolding/refitting as necessary.	0–4 weeks
11. Volar fx greater than 40% of joint surface/condylar fx that are unstable: ORIF (lag screw/K-wire)	Controlled motion/immobilization : HB resting or gutter orthosis for the involved and adjacent digit(s) with MPJs in 70 degrees of flexion, DIP extension and PIP in position determined by fixation method (generally in full extension). May allow for active flexion based on stability of fixation.	0–3 or 4 weeks
	Modification : If pinned, provide pin protection as needed with bivalved orthosis/padded dressing or padded straps and PIPJ positioned as pinned.	4 weeks
12. Volar fx: hemihamate reconstruction	Controlled motion : FB static dorsal PIP extension block orthosis at 20–30 degrees of flexion for the involved digit. The straps are removed to allow for active finger flexion and extension to the limits of the orthosis.	Week 0–2
	Controlled motion : Finger based dorsal block or figure-of-8 orthosis to block full extension and buddy-straps for flexion exercises.	Week 3–4 (6)
13. Volar fx/pilon fx/condylar fx that are unstable: Dynamic external fixation	Controlled motion : HB static dorsal extensor block orthosis to block full PIPJ extension when hinge is unlocked for exercises or with external fixator in place.	0–2 or 4 weeks
	Controlled motion : A HB radioulnar gutter can be fabricated as needed to protect the external fixator from unwanted stresses.	0–4 or 6 weeks
	Modification : A static mallet type orthosis with the DIPJ in extension if an extensor lag is present. The fixation may tether the lateral bands along P2	0–4 or 6 weeks
14. Dorsal lip fx. of P2 involving attachment of central tendon non-op and ORIF with K-wire	See item 8 above. Immobilization of PIPJ in extension. The orthosis protects pins as required.	6 weeks for non-op 4 weeks for post-op
15. Combined fracture–dislocation—Any management	Controlled motion/immobilization : FiB or HB static protective orthosis in a position depends on direction of dislocation (volar or dorsal), and the orthosis/exercise program may allow motion in the opposite direction (See items 4–9 above)	4 weeks
	Modification : In cases of persistent instability after fracture management, the PIPJ may be immobilized full time to prevent recurrent dislocation followed by several weeks of protective orthotic use, position dependent on the direction of the dislocation.	2 weeks
16. PIPJ arthroplasty	See Chapter 107

 

DIP Joints (Index-Small) and Thumb IP Joint
Dislocation (Rare)
Management	Immobilization/Controlled Motion	Time Frame
17. Closed reduction	Controlled motion : FiB IP/thumb IP static dorsal extension block orthosis in 20–30 degrees of DIPJ flexion allowing active flexion of DIPJ thumb IPJ. For all DIPJ injures, maintenance of PIPJ full ROM is important.	2–3 weeks
18. Open reduction	Immobilization : DIPJ/thumb IPJ static orthosis to protect DIPJ/thumb IPJ pinning.	4 weeks

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