Introduction

Depending on the assessment method, hand fractures account for one fifth to one fourth of all fractures. The frequencies of fracture locations within the hand are classified very differently and factors specific for various countries appear to play a part in this. Fractures of the fingers and metacarpals are the most common, while fractures of the carpal bones are much rarer. Within the carpus, over 75% of fractures involve the scaphoid, followed by the triquetrum at just over 10%. Fractures of the trapezium, hamate, pisiform, lunate, and trapezoid each account for 3% or less.

The percentage of fractures of the hand in childhood is reported as up to 30%, which is a considerable number. Fractures occurring between the ages of 17 and 40 years occur predominantly in males. Nearly 50% of these occur at work and about 20% occur during sporting and leisure activities. This means that a very high proportion of fractures of the hand involve patients of working age. In this era of economic efficiency, the choice of treatment should ensure that workers can be reintegrated in the workforce as early as possible.

Restoration of function Considering the importance of the hand for daily life, the need for optimal management of hand and finger trauma becomes apparent. The aim is to achieve complete restoration of function by definitive treatment as soon as possible. All functionally important soft tissue structures (nerves, tendons, vessels, synovium, ligaments) must undergo primary surgical treatment at the same time whenever possible.

To restore function following fractures, the method (conservative or operative) that ensures the safest and fastest fracture consolidation should be employed so that functional rehabilitation is achieved as soon as possible. Among the available options, the treatment with the lowest complication rate must be chosen. This in turn demands many years of experience in hand surgery.

Since different operation methods lead to very different results with identical fracture types in different anatomical sites (finger ray and/or phalanx), the treatment that is most likely to be successful must always be selected for each location.

Early Motion Stability When surgical therapy is desirable, special attention is given to early motion stability.

Stability signifies the harmonious balance of complex static and dynamic systems. In the hand, these ensure the interaction of sensory and motor innervation, motor function, perfusion and static constancy, that is, the framework provided by the stable skeleton. If structural changes occur due to alterations of these complex harmonious systems, instability is produced where the original condition cannot be restored (e.g., loss of stability due to fracture). External influences and also disorders of internal dynamics can produce these structural changes.

Early motion stability, for instance when the skeleton is restored by surgical measures, is a state that still ensures the harmonious interplay of these complex systems even when affected by small changes and stresses. Before any decision on surgical fracture fixation is made, it is necessary to consider very thoroughly whether the goal of early motion stability can be achieved with the fixation.

Many fractures are sufficiently or relatively stable per se, for example, due to impaction, especially in the metaphyseal area, so that they are suitable for early functional management after brief conservative immobilization. These fractures should then be treated nonoperatively provided there is no significant axial deviation and/or rotation.

In such cases, closed and even open reduction often may lead to instability.

1.2 Recommendations

The following recommendations are based on a summary of empirical experience and experimental results in vitro and in vivo to provide rough guidelines:

Conservative treatment The most secure healing of a fracture takes place by secondary fracture healing (see Chapter ▶ 2.1). Prerequisites are fracture hematoma and adequate relative immobilization in the early phase along with sufficient stabilization in the transitional period between the soft-callus and hard-callus phases (see Chapter ▶ 2.1). Conservative therapy, applied correctly, meets these conditions. This means that nonoperative treatment of fractures is the therapy of first choice.

Surgical measures Surgical treatment may be indicated (see Chapter ▶ 4.3). However, the possibility that secondary fracture healing will be disturbed by an operation must be considered.

Thus, all percutaneous surgical procedures that do not interfere with the fracture and fracture hematoma are the next option. Percutaneous adaptive fixation (see Chapter ▶ 10.6, Chapter ▶ 10.10.3, Chapter ▶ 10.11, Chapter ▶ 10.13) and the external fixator (see Chapter ▶ 10.12) meet these requirements. The disadvantages of percutaneous surgical techniques include the need for additional external immobilization and, in the case of an external fixator, the complex care needed to avoid complications and possible lack of acceptance by the patient

Open reduction and internal fixation If surgery with internal fixation is absolutely indicated (Chapter ▶ 4.3), the following applies:

Joint fractures with a step-off must be stabilized without a step, if possible with inter-fragmentary compression (see Chapter ▶ 10.4, Chapter ▶ 10.6, Chapter ▶ 10.7.1).

Unstable metaphyseal fractures must be stabilized by internal fixation. Because of the relatively high healing potential of cancellous bone in the metaphyseal region, adaptive fixation usually suffices, as micromovements appear to promote fracture healing. An excessively rigid construction can obstruct healing. Fixed-angle locking fixation is permitted in the shaft region, if necessary at all, but is not absolutely necessary and is sometimes counterproductive particularly in the metaphyseal region.

Shaft fractures of long bones must be examined closely to see whether the fracture (transverse or oblique fracture) can be fixed by interfragmentary compression (see Chapter ▶ 10.7.1) by an appropriate surgical technique so that primary fracture healing can be ensured (see Chapter ▶ 2.2).

Additional neutralization of external forces is often required when a lag screw is used. It is achieved with a neutralization plate (see Chapter ▶ 10.5), which does not need to be a fixed-angle locking plate but can also be a regular standard plate or hybrid plate.

If fixed-angle locking treatment is considered exclusively, initially, interfragmentary compression of transverse and oblique fractures should be obtained surgically.

Whether the dynamic locking screw (DLS) or far-cortical locking technique will become widespread cannot be predicted at this time, especially in the area of the hand.

Extensive zones of comminution, especially in the tubular part of the shaft, require bridging internal fixation, although an external fixator (see Chapter ▶ 10.12) also can be considered. Bridging can be achieved both with a standard plate and with a fixed-angle locking plate. The latter may offer some additional advantages (see Chapter ▶ 10.7, Chapter ▶ 10.8).

There is currently consensus that plate internal fixation should be used with discretion in the middle and proximal phalanges, while it is used more in the metacarpals, along with intramedullary techniques (see Chapter ▶ 10.11).

Despite an optimal operation technique, there is a risk of postoperative limitation of motion, especially in the middle and proximal phalanges, due to scarring of the sliding layers of tendons and joints and because of the formation of callus, which restricts the use of internal fixation even if early motion stability can be achieved.

For intra-articular dislocated comminuted fractures especially of the proximal interphalangeal joint, treatment with functional extension/traction has proved effective (see Chapter ▶ 10.15), although early functional treatment produces astonishingly good results in the remodeling of the joint surfaces even in the case of nondislocated intra-articular fractures.

Conclusion If early motion stability is not achieved by internal fixation, nonsurgical treatment and possibly adaptive fixation are options with fewer associated risks.

Note

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