Hand Fracture Management in the ED Treatment & Management

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

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]