AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Background

Hand fractures, a frequent emergency department complaint, are the most common fractures of the body. Proper management at initial evaluation of hand injuries can prevent a significant amount of morbidity and disability. Emergency physicians, often the first to assess these fractures, must have the skills to properly evaluate and manage these injuries.

This article focuses entirely on fractures of the hand. Please see other articles for information on wrist injuries, soft-tissue hand injuries, and dislocations. Also see Medscape's Fracture Resource Center.

Pathophysiology

Basic concepts about bony structures of the hand help to understand injury patterns and manage hand fractures. The hand is a group of gliding bones surrounded by soft tissue. A relatively immobile center consisting of the second and third metacarpal bones provides fixed support on which intrinsic movements of the hand depend. More mobile bones of the hand, such as the first, fourth, and fifth metacarpals, may tolerate a greater degree of angulation without disability, while the less mobile second and third metacarpal bones must have more precise reduction to ensure proper function.

Frequency

United States

More than 16 million people each year receive emergency care for hand injuries. Common emergencies include fractures, ligamentous injuries, and infections.

Mortality/Morbidity

• Disability from hand injuries may result in loss of sensation, strength, and flexibility, the chief functions of the hands. Preserving function relies on maintaining the structural relationships of the intrinsic hand structures as well as musculotendinous connections from the forearm.
• Prevention of disability from hand injuries is the primary goal of treatment. Maintenance of function, rather than cosmesis, is of paramount concern in the management of hand injuries.

Age

Hand fractures occur in all age groups, although fractures in young children should prompt suspicion of child abuse.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

History

Hand fractures usually are not difficult to diagnose. Most patients provide a history of preceding trauma. Physicians initially evaluating injuries should elicit details of the trauma, as this may benefit the hand surgeon. If an industrial injury is the cause, details may help prevent injury to others. Document the following important details in ED records:

• Hand dominance of patient
• Hand that is injured
• Occupation and hobbies requiring dexterity
• Mechanism of injury
• • Did injury occur in a clean or dirty environment?
  • Were crush injuries sustained?
  • What was the position of the hand at time of injury?
  • Was injury the result of high-pressure grease, water, air, or paint injection?
  • Did a thermal, electric, or chemical injury occur?
  • Was patient wearing any type of jewelry on fingers?
  • If so, has it been removed?
• Injury as the result of an assault
• • Was hand open or fist clenched?
  • Are lacerations present, particularly overlying the metacarpophalangeal (MCP) joint (may indicate significant tendon injury)?
  • Did the patient's fist contact mouth or teeth?
• Note subjective motor or sensory deficits.
• Note length of time since initial injury.
• Document number of years since last tetanus immunization if lacerations or abrasions were sustained.
• Obtain significant medical history. Include documentation of disorders that may compromise healing and record previous hand injury or disability.
• Record medication and allergy history.
• Note other risk factors that may preclude adequate healing, such as tobacco or cocaine use.

Physical

• Physical examination is of vital importance in evaluating the injured hand. Develop a comprehensive routine for examining all hand injuries regardless of mechanism of injury.
• Hand structure
• • Five metacarpal bones are joined to wrist, articulating with the distal carpal row.
  • Thumb articulates chiefly with trapezium, creating a freely movable joint.
  • Remaining metacarpals articulate with trapezoid, capitate, and hamate from radial to ulnar direction.
  • • Ring and little fingers have about 20-25° of mobility at articulation in the anteroposterior (AP) plane.
    • Index and middle fingers have no flexion or extension capability at articulation.
  • Thumb consists of proximal and distal phalanges.
  • Remaining fingers consist of proximal, middle, and distal phalanges.
  • Proximal interphalangeal (PIP) joints allow flexion and extension and minimal abduction and adduction.
• Terminology
• • Palm of hand is referred to as volar or palmar surface.
  • Back of hand is referred to as dorsal surface.
  • Borders of hand are referred to as radial or ulnar.
  • The anatomic position of the hand is with the palms facing forward.
  • Fingers often are counted by roman numerals, with thumb as number I, but most clinicians prefer to use common names (ie, thumb, index finger, middle finger, ring finger, little finger) to avoid potential confusion.
  • Fingers are divided into segments by distal and proximal interphalangeal creases and digital creases. These segments correspond to underlying phalanges. Volar creases may not overlie corresponding joints precisely.
• Description of function
• • Rotation of hand from neutral position to palm up position is termed supination. Rotation to palm down position is termed pronation.
  • Radial and ulnar deviation correspond to movement of hand to stated direction from anatomic position.
  • Extension of hand refers to dorsal movement and flexion refers to volar movement.
  • Flexion and extension of fingers correspond to dorsal and volar movements, as mentioned above.
  • Abduction of fingers refers to movement of fingers away from an imaginary line drawn through the middle of the third finger. Adduction refers to movement toward this midline.
  • Carpometacarpal joint of thumb is capable of palmar adduction or flexion (toward midline), palmar abduction (away from palmar surface), radial abduction, retroposition (extension) adduction, and opposition. Interphalangeal joint of thumb can flex and extend only.
• Hand examination
• • Start hand examination by comparing injured hand to uninjured hand.
  • Note skin and soft tissue changes such as edema, erythema, cyanosis, ecchymosis, lacerations, and abrasions.
  • Abnormal positioning, especially of the fingers, may indicate fracture or tendon injury. Identification of rotational malalignment is critical.
  • Categorize location of the injury as ulnar, radial, volar, or dorsal.
  • Check vascular status by noting capillary refill at nail ridge. If fracture is more proximal, radial and ulnar artery pulsation should be noted. If bleeding is present, do not to clamp or ligate a vessel blindly, as nerves closely follow blood vessels.
• Neurologic examination
• • Remember to assess nerve integrity prior to instillation of anesthetics.
  • The 3 major nerves of the hand are the radial, median, and ulnar nerves.
• Sensory examination
• • Loss of sweating is apparent if sensory nerves are injured. In an uncooperative patient, hand may be immersed in hot water for 10 minutes. Skin distal to nerve injury will not wrinkle.
  • Two-point discrimination testing using a bent paper clip is easy and reliable. Ability to discriminate at less than 5 mm on fingertip is normal. If patient has abnormal discrimination, always test in relation to uninjured hand, as sensitivity is variable.
  • Although anatomic variation is possible, generally, the sensory distribution is as follows:
  • • The ulnar nerve supplies the fifth finger and the medial aspect of the fourth finger.
    • The median nerve supplies the volar aspect of the first through third fingers as well as the lateral aspect of the volar surface of the fourth finger.
    • The radial nerve supplies the dorsal surface of the entire hand except for the fifth finger.
  • Motor examination
  • • The radial nerve extends the wrist and the fingers.
    • The ulnar nerve allows adduction of the fourth and fifth fingers and adduction of the thumb.
    • The median nerve adducts the second and third fingers and allows opposition of the thumb to the fifth finger.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Lab Studies

• Lab studies are not indicated in the workup of acute fractures. 

Imaging Studies

• In ED, plain radiography is diagnostic test of choice to evaluate potential hand fractures.
• Standard radiographs include AP, lateral, and oblique views.
• Special imaging studies, such as MRI, CT, and bone scans, seldom are needed in ED to evaluate hand injuries.

Procedures

• Patients in severe pain or those who require reduction may be anesthetized by metacarpal or wrist nerve blocks.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Prehospital Care

• Prehospital care of most orthopedic injuries consists of administering pain medication, splinting the hand in the position in which it was found, applying ice, and elevating the extremity, if possible.
• Obtain as much information about mechanism of injury and conditions at the scene as possible.

Emergency Department Care

• ED care of hand fractures involves recognition of fracture, pain management, reduction and or splinting as appropriate, and referral. Primary concern is preservation of function.
• Fractures of the phalanges are the most common hand fractures. Fortunately, most are simple fractures and may be treated with padded aluminum splints or buddy taping.
• Except for distal phalanx fractures, all patients should be referred to a hand surgeon.
• Distal phalanx fractures
• • The most common distal phalanx injury is comminuted tuft fracture. No angulation or displacement is usually present, because the septa hold fragments in place on the volar surface and the nail acts as a splint along the dorsal surface.
  • Subungual hematoma, a common complication, may be treated by trephination (if the patient is experiencing significant discomfort) or nail removal and repair of nail bed. Treatment is controversial. Some authors advocate nail removal if hematoma comprises more than 50% of the nail surface, while others recommend removal only if the nail is disrupted, as long-term outcome does not improve with removal and repair of the nail bed. Regardless of treatment, warn the patient of potential nail deformity secondary to nail bed injury.
  • Antibiotics commonly are prescribed if nail is removed; trephination of subungual hematoma does not require antibiotic prophylaxis.
  • Treatment: Open injuries require thorough irrigation. These fractures usually are splinted with a padded aluminum splint extending from the volar proximal phalanx and curving around the fingertip to the proximal dorsal phalanx. This provides optimal protection.
• Dorsal avulsion fracture (mallet finger)
• • This fracture occurs due to forced flexion of an extended DIP joint, resulting in avulsion of the attachment of the extensor tendon. The deep flexor tendon pulls on the phalanx, causing distraction of the phalanx from the fragment, leading to subluxation of the phalanx in the volar direction.
  • On examination, the patient will have loss of extension at the DIP joint and tenderness over the dorsal aspect of the joint. 
  • Treatment is controversial. Many hand surgeons advocate exploration and open fixation, while others advocate splinting alone.
  • In the ED, the best course of action is splinting the distal phalanx in extension and the PIP joint in flexion for 6-8 weeks. Orthopedic referral is required. 
• Transverse fracture of distal phalanx
• • Transverse fractures usually are stable.
  • Transverse fractures may be splinted as described above.
  • If angulation persists after closed reduction, fracture may require surgical fixation with Kirschner wire.
• Middle and proximal phalangeal fractures
• • Usual descriptive terms such as transverse or oblique apply.
  • Examine fingers for rotational deformity. Flexing fingers slightly and observing nail plates best assesses this alignment.
  • Axes of nail plates should point toward the scaphoid bone and be essentially parallel. Compare to opposite hand. As little as 10° of deviation may be disabling.
  • A true lateral radiograph may be required to demonstrate anterior angulation of the fragment, as an oblique view often fails to show the degree of angulation.
  • Tendons will be injured if angulation is significant.
• Fracture of middle phalanx
• • Middle phalanx fractures have unpredictable stability after reduction.
  • These fractures require splinting.
  • Some advocate buddy taping if the phalanx is stable. Buddy taping allows mobility, may prevent stiffness, and aids quicker return to baseline activity.
  • Buddy taping alone is not appropriate for any displaced or rotated fracture. Do not use in transverse fractures, as stability is unpredictable.
  • Perform follow-up radiography in 7 days to assess stability.
  • If a fracture can not be stabilized with buddy taping, apply a gutter splint for 10-14 days, then obtain follow-up radiography. 
• Transverse fracture of the proximal phalanx
• • Transverse fractures of the proximal phalanx are usually unstable fractures, as interosseous muscles pull proximal fragments in a volar direction and central slip pulls the distal fragments dorsally.
  • Proximal phalanx fractures require splinting and, frequently, open reduction.
• Oblique and spiral fractures
• • Oblique and spiral fractures frequently cause malrotation of the involved finger.
  • Oblique and spiral fractures usually are unstable after reduction.
  • As with middle phalanx fractures, these fractures require splinting with either ulnar or radial gutter splints extending out to involve the digit to the distal phalanx.
• Condylar fractures
• • Condylar fractures may be noted only on oblique radiograph.
  • These fractures usually require open fixation.
• Comminuted fractures of the head of the middle and proximal phalanges may be treated with closed reduction and immobilization.
• Intra-articular fractures require orthopedic referral and often open reduction and fixation (ORIF).
• • Splint in the safe position.
  • Wrist should be extended 15-20° and MCP flexed about 70°.
  • Interphalangeal (IP) joints should be flexed 10-20° or the least amount needed to maintain reduction.
  • Complications
  • • These fractures may results in malrotation, degenerative arthritis, adhesion of tendon to bone (more common in open or widely angulated fractures), and joint stiffness from immobilization.
    • Boutonniere deformity (from rupture of extensor hood apparatus at PIP joint) may result from improperly treated middle phalanx fracture.
    • Flexor tendon rupture is rare.
• Metacarpal fractures
• • Divided below by location (head, shaft, neck, base) for discussion purposes.
  • Applying extension, abduction, and adduction forces to joints tests their integrity.
  • MCP collateral ligaments are taut in flexion and lax in extension, thus stability must be tested in multiple degrees of angulation.
• Metacarpal head fractures
• • Metacarpal head fractures often are severely comminuted and complicated by poor healing, even with appropriate ED care.
  • ED management includes splinting.
  • Immediate orthopedic referral is mandatory.
  • Complications include malrotation of finger, extensor tendon injury, posttraumatic arthritis, and avascular necrosis.
• Metacarpal neck fractures
• • Metacarpal neck fractures usually occur as a result of a direct blow to the knuckles and are the most common type of metacarpal fracture.
  • Fracture at the neck of the fifth metacarpal is termed boxer's fracture.
  • Mechanism of injury results in angulation of distal segment toward palm.
  • ED physician must inspect for rotational deformity.
  • Attachments of metacarpals to carpals are different for each finger and require different approaches.
  • • Metacarpals of middle and index fingers are fixed at the distal carpal row and do not allow flexion or extension. Eliminate angulation at the fracture sites of these fingers. Patients cannot tolerate more than 10-15° angulation of these fractures. ED management includes closed reduction, gutter splint, and prompt orthopedic referral. Metacarpal neck fractures often require wire placement to ensure alignment.
    • The metacarpals of the ring and little fingers allow flexion and extension at carpal attachments. These patients can tolerate greater angulation at fracture without loss of function. Up to 30-40° of angulation is acceptable. In a satisfactory outcome, the fifth finger can extend to 180° without deformity.
  • Complications
  • • Failure to correct rotational component can result in loss of function.
    • Failure to correct excessive angulation results in flexion of PIP joint and hyperextension of MCP joint when extending finger.
    • Extensor tendon injury
    • Collateral ligament injury
• Metacarpal shaft fractures
• • Metacarpal shaft fractures produce dorsal angulation and malrotation. 
  • Rotational deformities can be detected in 3 ways: Convergence test (scissoring), comparing the plane of the nail plates to the uninjured hand, and examining the diameter of fracture fragments on radiography.
  • Correct index and middle finger angulation, more than 10º is not acceptable. 
  • Ring and little fingers may tolerate up to 20º of angulation.
  • Little or no shortening of bones usually takes place, as transverse metacarpal ligaments hold fragments in place. Patients can tolerate 3 mm of shortening if no rotation or angulation is present.
  • Treat by splinting for 4-6 weeks.
  • Multiple fractures and those with shortening, angulation, or rotation require reduction and, usually, fixation.
  • Complications
  • • Malrotation weakens grip and causes pain on grasping.
    • Tendon injury frequently occurs with these fractures, and MCP joint may become stiff if splinted improperly (ie, in extension).
• Metacarpal base fractures
• • Intraarticular fractures at base of index and middle fingers are rare and, if present, usually of little clinical significance.
  • They may be associated with other fractures.
  • Fracture at base of fifth metacarpal is common and often associated with subluxation of metacarpal-hamate joint. Splint this fracture in a gutter splint and immediately refer patient to a hand surgeon.
• Metacarpal fractures of the thumb: Fractures of the first metacarpal are fairly rare, as bone is quite mobile.
• • Bennett fracture
  • • Bennett fracture is an oblique, intraarticular fracture at the volar base of the ulnar aspect of the first metacarpal.
    • Displacement of the larger fragment occurs from pull of the abductor pollicis longus muscle.
    • Emergency department treatment consists of immobilization in a thumb spica splint and orthopedic referral, as this injury requires surgery. If satisfactory reduction cannot be achieved, percutaneous wiring by orthopedic specialist is recommended.
    • Complications include traumatic arthritis and malunion (may result in subluxation of metacarpal-trapezial joint).
  • Rolando fracture
  • • This rare fracture is similar to the Bennett fracture, except that in addition to a small palmar fragment a large dorsal fragment creates a T- or Y-shaped fracture at the base of the metacarpal.
    • More commonly, the base of the metacarpal is severely comminuted.
    • ED treatment is thumb spica splint.
    • This fracture requires immediate orthopedic follow-up care for ORIF.

Consultations

Hand surgeon

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Control pain with commonly prescribed medications. Acetaminophen with codeine or hydrocodone usually suffices.

Prescribe antibiotics for open fractures, usually a cephalosporin (ie, cefazolin sodium) with broad-spectrum coverage added for grossly contaminated wounds.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Drug Category: Antibiotics

Therapy must cover all likely pathogens in this clinical setting. Antibiotic combinations may be required for broad coverage in grossly contaminated wounds.

FOLLOW-UP

Section 8 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Further Inpatient Care

• Care for the vast majority of patients with hand fractures as outpatients.
• Reserve inpatient care for those who must go directly to the operating room for ORIF. This is not a common occurrence.

Further Outpatient Care

• Because most patients have splints applied in the ED, discharge instructions should include signs and symptoms of constrictive splints or casts. Instruct patients of date and time of their follow-up appointment with an orthopedic surgeon or the phone number to call for an appointment.
• Instruct patients to rest and elevate the injured hand to reduce swelling and pain. Cold packs may also be recommended to minimize swelling.

Transfer

• Transfer of the patient with a hand fracture seldom is required.
• An exception is the patient with an amputated digit or hand requiring transfer to a hospital capable of emergent reimplantation.

Complications

• Malrotation
• Degenerative arthritis
• Adhesion of tendon to bone (more likely in open or widely angulated fractures)
• Joint stiffness from immobilization
• Boutonniere deformity (may result from improperly treated middle phalanx fracture)
• Nonunion of fractures resulting in prolonged disability

Prognosis

• The prognosis is excellent with good ED management and appropriate, timely referral.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Hand.

ACKNOWLEDGMENTS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, William R Fraser, DO, to the development and writing of this article.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Media file 1:  Assessment of the hand for rotational deformities of the fingers or metacarpals is essential, as such deformities, if untreated, may result in significant functional compromise. With fingers flexed at the metacarpophalangeal and proximal interphalangeal joints and extended at the distal interphalangeal joints, fingers should all point toward the scaphoid bone (see image).
	View Full Size Image
Media type:  Illustration

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

• American Society for Surgery of the Hand, Idler RS, Mantktelow RT. The Hand Examination and Diagnosis. New York: Churchill Livingstone; 1990:13-73.
• Emergency Medicine: Concepts and Clinical Practice [book on CD-ROM]. Mosby-Year Book; 1998. Antosia R, Lyn E.
• Harwood-Nuss A, Wolfson A. Hand injuries. In: Clinical Practice of Emergency Medicine. 4^th ed. 2005:1062-1065.
• Rosen P, Doris P. Musculoskeletal trauma. In: Diagnostic Radiology in Emergency Medicine. 1992:178-182.
• Ruiz E, Cicero JJ. Hand injuries and infections. In: Emergency Management of Skeletal Injuries. St. Louis, MO: Mosby-Year Book; 1990:339-59.
• Stewart C, Winograd S. Hand injuries: a step by step approach for clinical evaluation and definitive management. Emerg Med Rep. 1997;18:223-234.
• Tintinalli JE, Ruiz E, Krome RL. Injuries to the hand and digits. In: Emergency Medicine: A Comprehensive Study Guide. 2004. 6^th ed. New York: McGraw Hill; 2004:1665-1674.
• Simon RR, Koenigsknecht SJ. Fractures of the hand. In: Emergency Orthopedics. 4^th ed. New York: McGraw-Hill; 2001:97-133.

Article Last Updated: Jul 29, 2008