Chapter 13 Phalangeal and Metacarpal Phalangeal Fractures
Surgical Overview
• The method of fracture management indicated depends on several variables, including fracture location, configuration, stability, whether the fracture is open or closed, and whether there are associated injuries.
• The primary goal of fracture management is proper bony alignment with adequate stability for safe, early motion, and restoration of hand function.
1 Many phalangeal and metacarpal fractures are stable and can be treated with protective splinting and early mobilization.
2 Unstable shaft fractures and many articular fractures require fixation to restore stability. Options for surgical fixation of unstable fractures include percutaneous pinning or open reduction with Kirschner’s pin fixation, circumferential wiring, intramedullary fixation, compression screws, plate fixation, and external fixation.
• Distal phalanx fractures are the most common fractures in the hand.
1 Tuft fractures and nondisplaced, stable fractures of the shaft are managed with extension splinting of the distal interphalangeal joint for 3 weeks.
3 Injury to the nail matrix often occurs with open, displaced, transverse shaft fractures and with tuft fractures associated with crush injury.
4 Intra-articular fractures of the distal phalanx usually include avulsion of the extensor tendon insertion at the dorsal base (mallet injury), or of the flexor digitorum profundus (FDP) insertion at the volar base.
• Metacarpal neck fractures most frequently occur in the ring and small fingers. This common fracture, known as a boxer’s fracture, occurs from striking a solid object with a closed fist.
1 Metacarpal shaft fractures result from direct impact or axial loading through the metacarpal head.
2 Metacarpal neck and shaft fractures that are stable are treated with closed reduction and immobilization.
• Phalangeal fractures of the thumb are treated similarly to those of the fingers.
1 Surgery to restore stability is indicated for avulsion fractures with disruption of the ulnar collateral ligament (UCL) at the base of the proximal phalanx.
2 Extra- and intra-articular fractures of the base of the thumb proximal phalanx are more common than metacarpal shaft fractures.
3 Extra-articular base fractures are treated with closed reduction, with the addition of percutaneous pinning, if required to maintain the reduction.
Rehabilitation Overview
• The primary goal of rehabilitation of metacarpal and phalangeal fractures is to restore motion, strength, and functional use of the hand.
• For therapy to be progressed in a safe and timely manner, ongoing communication between the surgeon and therapist regarding the degree of stability and fracture healing is essential.
• Awareness of common complications facilitates early recognition and intervention. Complications of phalangeal and metacarpal fractures include malunion, nonunion, tendon adhesions, capsular contracture, and infection.
• The treatment guidelines that follow specifically address the postoperative management of fractures of the proximal and middle phalangeal shaft, metacarpal neck and shaft, and thumb metacarpal base. These guidelines may be used for fractures managed nonoperatively, with the time frames extended to allow for adequate stability via bony healing.
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