Hand Fracture Management in the ED

Updated: Mar 18, 2020
Author: Erik D Schraga, MD; Chief Editor: Trevor John Mills, MD, MPH 


Practice Essentials

More than 16 million people each year receive emergency care for hand injuries. Common emergencies include fractures, ligamentous injuries, and infections. Hand fractures, a frequent emergency department complaint, are the most common fractures of the body and account for about 1.5% of all emergency room visits and 40% of upper extremity fractures. Hand fractures occur in all age groups, although fractures in young children should prompt suspicion of child abuse.[1, 2, 3, 4, 5, 6, 7]

Fractures of the phalanges are the most common hand fractures. Metacarpal and phalangeal fractures are common injuries in athletes who participate in contact and ball-handling sports. 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. Most of these injuries are managed nonoperatively with immobilization, but certain displaced and angulated fractures, unstable fractures, and open injuries require surgical intervention.[1, 2, 3, 4, 5, 6, 7]

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.

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.

In the ED, plain radiography is the diagnostic test of choice to evaluate potential hand fractures.[8]  Standard radiographs include AP, lateral, and oblique views (see the images below). CT is sometimes necessary to check for intra-articular displacement and determine need for surgery

Phalangeal fractures. Complex unstable fracture of Phalangeal fractures. Complex unstable fracture of the proximal phalanx. Image courtesy of Mark Baratz, MD.
Displaced fourth and fifth metacarpal fractures, a Displaced fourth and fifth metacarpal fractures, anteroposterior view.
Fourth and fifth metacarpal fractures, oblique vie Fourth and fifth metacarpal fractures, oblique view.

Care for the vast majority of patients with hand fractures is completed on an outpatient basis. Reserve inpatient care for those who must go directly to the operating room for open reduction and internal fixation (ORIF). This is not a common occurrence.

Complications include the following[9, 10, 11, 12] :

  • 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

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.

Both operative and nonoperative treatment of hand fractures can result in numerous complications, including stiffness, malunion, nonunion, arthritis, infection, and complex regional pain syndrome.[10]

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.




Hand fractures usually are not difficult to diagnose. Most patients provide a history of preceding trauma. Physicians who initially evaluate 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

Questions regarding the mechanism of injury include the following:

  • 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?

Questions regarding the injury as the result of an assault include the following:

  • 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 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 the wrist, articulating with the distal carpal row.

(Metacarpophalangeal anatomy is depicted in the illustrations below.)

Metacarpophalangeal musculoskeletal structure. Metacarpophalangeal musculoskeletal structure.
Metacarpophalangeal ligaments. Metacarpophalangeal ligaments.

The thumb articulates chiefly with the trapezium, creating a freely movable joint. Remaining metacarpals articulate with the trapezoid, capitate, and hamate, from radial to ulnar direction. The 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.

The thumb consists of proximal and distal phalanges. The remaining fingers consist of proximal, middle, and distal phalanges. The proximal interphalangeal (PIP) joints allow flexion and extension and minimal abduction and adduction.


The palm of the hand is referred to as the volar or palmar surface.

The back of the hand is referred to as the dorsal surface.

The borders of the 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 the thumb as 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 the 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 the hand to a 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.

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.

The carpometacarpal joint of the thumb is capable of palmar adduction or flexion (toward midline), palmar abduction (away from palmar surface), radial abduction, retroposition (extension) adduction, and opposition. The interphalangeal joint of the thumb can flex and extend only.

Hand examination

Start a hand examination by comparing the injured hand to the 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.

(Assessment of rotational deformity is described in the image below.)

Assessment of the hand for rotational deformities 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).

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 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, the 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 the fingertip is normal. If the 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.





Imaging Studies

In the ED, plain radiography is the diagnostic test of choice to evaluate potential hand fractures.[8]  Standard radiographs include AP, lateral, and oblique views. Special imaging studies, such as MRI, CT, and bone scans, are seldom needed in the ED to evaluate hand injuries. However, hook of hamate fractures are difficult to identify on plain radiographs because the base of the hamate is not well visualized. When such fractures are suspected, CT is the imaging modality of choice.  It shows the complete hamate bone and is also useful for excluding other bone injuries or congenital anomalies. MRI may provide information regarding injury to the surrounding soft tissue and vascularity of the hamulus.[13]

(See the radiographic images below.)

Phalangeal fractures. Complex unstable fracture of Phalangeal fractures. Complex unstable fracture of the proximal phalanx. Image courtesy of Mark Baratz, MD.
Displaced fourth and fifth metacarpal fractures, a Displaced fourth and fifth metacarpal fractures, anteroposterior view.
Fourth and fifth metacarpal fractures, oblique vie Fourth and fifth metacarpal fractures, oblique view.




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.[14]

In a study of 145 cases of open hand fractures and/or dislocations, 102 cases received definitive and final management in the emergency department; in the other 43 cases, additional management took place in the operating room. Antibiotics were administered within 4 hours after injury, and irrigation and debridement were performed within 6 hours.[15]

Distal phalanx fractures

The most common distal phalanx injury is a 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. 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)

Dorsal avulsion fracture, or mallet finger, 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 and 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 the 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.[16]

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 cannot be stabilized with buddy taping, apply a gutter splint for 10-14 days, and then obtain follow-up radiography.[17]

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.[18, 19]

Oblique and spiral fractures

Oblique and spiral fractures frequently cause malrotation of the involved finger. Oblique and spiral fractures usually are unstable after reduction.[18]  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 radiographs. 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. The 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. These fractures may result 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 the PIP joint) may result from improperly treated middle phalanx fracture. Flexor tendon rupture is rare.

Metacarpal fractures

Metacarpal fractures are extremely common, constituting 20% of fractures that present to the ED and between 18 and 44% of all hand fractures.[20, 9, 21] Metacarpal fractures can be organized by anatomic location (head, shaft, neck, base). 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 the 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 the distal segment toward the palm. The ED physician must do and inspection for rotational deformity. Attachments of metacarpals to carpals are different for each finger and require different approaches.

Metacarpals of the 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° of 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.[18]

The metacarpals of the ring and little fingers allow flexion and extension at carpal attachments. Patients with injury to this area 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 incude the following:

  • Loss of function from failure to correct rotational component  .

  • Flexion of the PIP joint and hyperextension of the MCP joint when extending the finger due to failure to correct excessive angulation.

  • 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 include the following:

  • Malrotation weakens grip and causes pain on grasping.
  • Tendon injury frequently occurs with these fractures, and the MCP joint may become stiff if splinted improperly (ie, in extension).

Metacarpal base fractures

Intra-articular fractures at the base of the index and middle fingers are rare and, if present, usually of little clinical significance. They may be associated with other fractures. Fracture at the base of the fifth metacarpal is common and is often associated with subluxation of the metacarpal-hamate joint. Splint this fracture in a gutter splint and immediately refer the patient to a hand surgeon. Fractures of the first metacarpal are fairly rare, as the bone is quite mobile.

Bennett fracture

Bennett fracture is an oblique, intra-articular 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. ED 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 an orthopedic specialist is recommended.[22]  Complications include traumatic arthritis and malunion (may result in subluxation of the metacarpal-trapezial joint).[23, 24]

Rolando fracture

Rolando fracture is similar to 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.[25]  More commonly, the base of the metacarpal is severely comminuted. ED treatment is a thumb spica splint. This fracture requires immediate orthopedic follow-up care for ORIF. Rolando fractures can be associated with a poor prognosis, particularly when they occur on the dominant. Timely imaging, placement in a thumb spica splint, and orthopedic surgical evaluation are necessary to help ensure the best outcome.[26]

Hook of hamate fractures 

Fractures of the hamate are relatively rare and constitute 2-4% of carpal fractures.[27] The most frequent cause of fractures of the hamate hook is participation in sports that requiring a strong grip, such as golf, baseball, and tennis.[13, 27]  Lower arm cast immobilization is the usual treatment for acute nondisplaced hook of hamate fractures. However, this treatment approach often fails in the case of delayed fractures, and surgical intervention is required. The most common surgical treatments are hook excision and ORIF.[13, 27, 28]



Medication Summary

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.


Class Summary

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.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.


Class Summary

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

Cefazolin (Ancef, Kefzol, Zolicef)

First-generation, semisynthetic cephalosporin that, by binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication. Primarily active against skin flora, including Staphylococcus aureus. Typically used alone for skin and skin-structure coverage.

Total daily dosages are same for IV/IM routes.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in treatment of septicemia and skin-structure infections.

Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients with open fractures.

May need to adjust dose in patients diagnosed with renal impairment.