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Fractures of the wrist and hand.

Introduction

The hand is one of the most important organs of human body serving multiple day to day functions and, as such, disability resulting from poorly managed fractures of the hand can have huge implications for patients. This not only includes incapacity to complete actions of daily living but also inability to satisfactorily undertake many forms of employment. This not only has implications for the individual but also socio-economic implications.

Fractures of the hand are a common injury and one which, if inappropriately managed, may leave severe functional deficit. Preceding trauma to the hand is a usual occurrence and, with careful history and examination, clinical suspicion can usually be confirmed by the presence of fractures on plain radiography. Hand fractures can be treated conservatively or operatively, dependent upon the severity of fracture and displacement. Conservative management often requires immobilisation with plaster cast or splints. There are of course a variety of casts/splints available dependent on the site and nature of fracture. Generally nonoperative treatment requires much closer monitoring than operative fixation to ensure that the fracture position does not change. Weekly visits to the fracture clinic for check radiographs are required. As is usual for many fractures, the cast is generally left in place for three to six weeks although a fine balance exists between leaving the cast on for a sufficient period to allow the fracture to heal and the risks of stiffness and decreased range of motion of the various hand joints if the cast is not removed at the earliest opportunity. The ability to use the hand and fingers should return fully (AAOS 2007).

Ultimately, the main aim of all forms of management is to ensure return to full function and early mobilisation to reduce the risk of stiffness. Although this article is not a comprehensive review of hand fractures which is a vast topic in itself, it has been written to give a general overview for theatre personnel to enable them to understand these common injuries.

Anatomical considerations

The hand has complex anatomy with the interaction of bones, muscles, ligaments, arteries, nerves and soft tissues. The forearm has two long bones, the radius and ulna. These articulate with each other at the proximal and distal radio-ulnar joints and also with the carpal bones consisting of eight small bones. These are the

* Scaphoid

* Lunate

* Triquetrum

* Pisiform

* Trapezium

* Trapezoid

* Capitate

* Hamate

[FIGURE 1 OMITTED]

These carpal bones in turn articulate with five metacarpal bones. Four of these five metacarpals form the support for the respective fingers with one supporting the thumb. The fingers in turn consist of three bones called phalanges with the thumb consisting of two phalanges. Predictably these are termed the proximal, middle and distal phalanges when referring to the four fingers and proximal and distal phalanges when describing the thumb.

The hand musculature consists of various muscles and tendons which are responsible for different movements. The tendons which cross the wrist on the palmar side are called flexors and they normally flex at the wrist and fingers. Conversely the muscles on the dorsum of the hand muscles are responsible for extension at the wrist and hand and are predictably called extensors. To keep these extensors and flexors in place two transverse bands exist: on the extensor side--the extensor retinaculum, and on the palmar aspect--the flexor retinaculum (Moore et al 2006).

Other muscles which are important are

* Abductor pollicis longus and brevis (responsible for abduction of the thumb)

* Opponens pollicis

* Opponens digiti minimi

* Four lumbricals

* Palmar and dorsal interossei (Ellis 2006).

Thenar muscles include the abductor pollicis, abductor pollicis brevis (abducts the thumb), flexor pollicis brevis (flexes the thumb) and opponens pollicis (produces opposition of the thumb). These three muscles are supplied by the recurrent branch of the median nerve.

Hypothenar muscles include the abductor digiti minimi (abducts the 5th finger), flexor digiti minimi (flexes the little finger) and oppenens digiti minimi (opposes the fifth digit). These three muscles are supplied by the deep branch of ulnar nerve. In addition there is also the palmaris brevis innervated by the superficial branch of the ulnar nerve. The four lumbricals (flex metacarpophalangeal (MCP) joint and extend interphalangeal (IP) joint of each finger) arise from the tendons of the flexor digitorum profundus and insert into the radial sides of each finger proximal phalanx. The first two lumbricals are supplied by the median nerve whilst the third and fourth are supplied by the ulnar nerve.

The palmar interossei and dorsal interossei arise from the metacarpals. The palmar interossei (adduct the fingers) insert into the proximal phalanx and into the expansion of the extensor digitorum. The dorsal interossei (abduct the fingers) also insert into the proximal phalanges and dorsal digital hood. All interossei are supplied by the deep branch of ulnar nerve (Bowen et al 2006).

All of the nerves that travel to the hand cross the wrist. The three main nerves are the median, ulnar and radial nerves. The radial nerve is the branch of the posterior cord of brachial plexus; it continues in the forearm, emerges on the extensor side of the wrist and ends by supplying the lateral three and a half fingers on the dorsal side. The median nerve starts from the medial and lateral cords of the brachial plexus and ends in the wrist by supplying the skin of the lateral three and half fingers on the flexor or palmer side. The ulnar nerve emerges from the medial cord of the brachial plexus. It supplies the medial one and half fingers on the flexor side of the hand (Ellis 2006).

Two arteries enter the hand and these are the radial and ulnar arteries. These arteries further divide to form superficial and deep palmar arches. The superficial arterial arch is formed mainly from the ulnar artery and is completed by the superficial branch of the radial artery. The deep arterial arch is formed mainly by the deep branch of the radial artery and ends by the deep branch of the ulnar artery (Ellis 2006).

Of particular importance when considering hand fractures is the blood supply to the carpal scaphoid bone. The scaphoid bone receives the majority of its blood supply from dorsal vessels just distal to an area in the middle of the bone often referred to as the waist of the scaphoid bone. The proximal two thirds to three quarters of the scaphoid bone is supplied by these vessels entering the dorsal surface--the branches of radial artery. Therefore when the scaphoid sustains a fracture distal to this insertion, its blood supply can be disrupted. This can lead to avascular necrosis or death of the bone. The result is permanent damage to the bone warranting arthrodesis (Wheeless 2008).

Colles fractures

Although originally described as an extra-articular distal radius fracture, this is now rather loosely used to describe any distal radius fracture with dorsal angulation (Figure 2). Typically it is a fracture of the distal 2.5cm of radius with dorsal angulation and displacement leading to a 'dinner fork deformity'. These fractures are more common in advancing age and even more so in osteoporotic women. The decision for operative management of these fractures needs careful patient history including age, fracture pattern (often graded using the Frykmann classification) and any shortening (Fritz et al 1999). Non-operative treatment is generally in the form of a Colles plaster cast following reduction if required.

Historically the principal method used to surgically manage these fractures was percutaneous pinning using Kirchner wires, or external fixation. Unstable fractures with comminution need an aggressive approach (Young et al 2003). In the last decade, there has been a trend to manage the more unstable distal radius fractures with the use of open reduction/internal fixation (ORIF) by means of volar radius plates (Figure 3). Many centres are advocating their use routinely over other methods but ultimately there is considerable variability in the management of these fractures (Jupiter et al 2009).

Smith's fracture

These fractures (Figure 4) generally occur in younger patients and unlike Colles fractures (typical after a fall on the extended wrist), these occur when landing on a flexed wrist. For these reasons it is often termed the 'reverse Colles fracture.' It is again a distal radial extra-articular fracture, however in this case the angulation is volar. If there is an articular component to the fracture, the fracture is referred to as a Barton's fracture. Again careful evaluation is required to formulate either a conservative or operative management plan. Undisplaced fractures may be managed conservatively however even minimal displacement can necessitate open reduction/internal fixation often with a volar plate. Metal removal is advised after 3 months to prevent any bone on-growth and allow easy removal (Bongers 1984). The treatment methods are similar to the management of a Colles fracture with the exception of manupilation performed in reverse to Colles fracture manipulation.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

Bennett's and Rolondo's fracture

These are described as a fracture dislocation of the base of the 1st metacarpal i.e. at the base of the thumb. Bennett's fracture (Figure 5) was first described by Edward Hallaran Bennett in 1882 and involves a partial articular fracture of the base of the 1st metacarpal. A complete articular fracture is termed a Rolondo's fracture with swelling and pain at the thumb base following injury with limited motion on examination. Carpo-metacarpal instability is frequently noted with gentle stress. Early treatment is essential given that thumb mobility is essential for hand function and if this joint develops arthritis, all movements will be severely affected. Closed reduction and thumb spica cast immobilization can be effective in the treatment of some Bennett fractures (Milogevic et al 2005).

Generally, patients with small avulsion fractures with minimal articular incongruity and instability can be managed in spica cast and immobilisation in a plaster for at least 5 weeks with subsequent physiotherapy required to help improve mobility. These patients must be carefully monitored with serial radiography as the strong pull of the abductor pollicis longus (APL) frequently leads to displacement. As a result, open or closed reduction combined with internal fixation is frequently required. More than 1 mm of articular displacement after closed reduction is an indication for operative intervention. A suggested method for the treatment of these fractures was open reduction and lag screw rigid fixation (Foster & Hastings 1987). There have been subsequent studies however suggesting that conservatively treated patients retained good function post injury (Milogevic et al 2005) and those treated with closed wire fixation had significantly better results compared with either plaster immobilisation or open wire fixation (Lemberger 1980).

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

Scaphoid fracture

The scaphoid is the most commonly fractured hand bone (Figure 6). It accounts for about 70% of all carpal bone fractures (Leslie & Dickson 1981). Scaphoid fractures often occur in young and middle-aged adults following a fall on an outstretched hand. Post injury pain occurs primarily on the lateral side of the wrist, especially during dorsiflexion and abduction of the hand. Tenderness can be elicited in anatomical snuff box and above the distal radius on the flexor side. Diagnosis is usually confirmed by obtaining specific scaphoid radiographs but often even on these, fractures are missed. If clinical suspicion of fracture is high then a conservative treatment plan should be initiated and the repeat radiographs repeated one to two weeks later. If access to an MRI scanner is available, this has also been shown to accurately diagnose scaphoid fractures (Gaebler et al 1996). Five to twelve percent of scaphoid fractures are associated with other fractures, and approximately 1% of scaphoid fractures are bilateral. Ninety percent of scaphoid fractures heal completely if diagnosis is made early and treatment initiated (Boles 2007). Often conservative treatment with fracture immobilisation in scaphoid type cast is initiated. This is performed by a cast including the proximal phalanx of thumb and wrist in 10 degree flexion with radial deviation to provide compression allowing closure the fracture gap (Wheeless 2008). Scaphoid fixation has gained popularity but remains technically demanding and is required for displaced fractures. A modified trans-trapezial approach can be used as compared to volar percutaneous screw fixation of undisplaced fractures (Meermans & Verstreken 2008). The fracture normally heals 8-12 weeks post fixation and a functional range of wrist movements including full grip strength can be achieved successfully with the help of physiotherapy. Significantly displaced fractures need fixation and common methods include the use of either Herbert, AO cannulated or Acutrak screws. Bone grafting can be used in addition to these different screws (Ikeda et al 2008). As discussed earlier, the scaphoid blood supply may be interrupted with fracture and therefore there is a risk of developing scaphoid avascular necrosis. For this reason the role of bone grafting in treating the scaphoid fractures has gained importance over time. Studies have shown earlier healing with operatively managed fractures as compared to those treated in the cast with a lower nonunion rate (McQueen et al 2008).

Perilunate fracture dislocation

Perilunate dislocations (Figure 7) are a common injury occurring mainly in the young male population following a fall onto an outstretched hand or due to high energy trauma. They can have devastating results if missed on initial evaluation. They occur due to damage to the capsular ligamentous structures surrounding the lunate together with association with other carpal fractures and damage to the median nerve (Murray 2008).

[FIGURE 6 OMITTED]

Perilunate fracture dislocation should be reduced as soon as possible ideally in the casualty department with sedation and analgaesia. Post-reduction patients are placed in a scaphoid cast with careful observation for further neurological symptoms or loss of reduction. Studies have shown that closed reduction and internal fixation decreases the risk of re-dislocation and further, allows a stable environment for ligament healing (Garcia-Elias 2004). If however closed reduction is not possible, open reduction and internal fixation should be performed (Green & O'Brian, 1978).

Metacarpal fractures

Metacarpal fractures (Figure 8) are often subdivided according to the location of the fracture. Fractures commonly occur at the base, shaft or head. Fracture pattern is a further important consideration in the assessment of these fractures with oblique or spiral injuries more commonly associated with either shortening or rotation of the distal metacarpal fracture fragment compared to transverse fractures which tend to angulate. Rotation is difficult to assess radiologically and therefore careful clinical assessment is mandatory. Generally 10[degrees] of rotation is considered acceptable (Royle 1990).

[FIGURE 7 OMITTED]

The goal of managing intra-articular metacarpal fractures is always to maintain the articular surface. Non operative treatment includes manipulation and immobilisation in a plaster cast. The cast may be one of two types, either a short arm volar slab or a short-arm cast extending to the proximal interphalangeal joints with a metacarpo-phalangeal extension (these slabs are initially applied on the palmar side and later completed when swelling goes down). Patients are reviewed weekly with serial radiographs and evidence suggests that good reduction, if it is maintained, leaves little stiffness and good hand movements after removal of the plaster (Hofmeister 2008). Surgical methods include closed reduction with the use of Kirschner (K) wires to hold the fracture fragments in correct alignment (often by stabilisation of the fractured metacarpal to a stable neighbouring metacarpal or use of the intra-medullary K-wire technique). Failing this, open reduction and internal fixation with screws and/or plates has also been shown to provide good results (Omokawa et al 2008). Bone union can be successfully achieved in these patients over an average period of 8-12 weeks.

[FIGURE 8 OMITTED]

Fifth metacarpal fractures are often treated surgically if angulatation is more than 40 degrees (Sandner& Menke 2008). The use of K wires to stabilise the fracture and later mobilisation with middle hand brace has shown excellent results.

Phalangeal fractures

The phalanges can sustain injury very easily, often as a result of sporting injuries, and need appropriate treatment to ensure that the range of movement remains within functional levels. Fractures can consist of either distal, middle or proximal phalanges (Figure 9).

Distal phalanx:

Fractures occur at either the tuft, shaft or base of the distal phalanx. Fractures of the distal phalanx are often associated with nail, nail bed and crush injuries and therefore this should formulate part of the initial assessment.

Generally basal fractures are considered to be unstable due to forces exerted by the tendinous attachment leading to displacement of the fracture fragments. Extra-articular fractures are more common than intra-articular fractures. Intra-articular fractures are often due to avulsion of the extensor tendon and this is termed a Mallet finger, which is often treated conservatively in a Mallet splint. If there is a large avulsion fragment, surgical fixation may also be initiated (AAOS 2007).

If the fracture is due to the avulsion of flexor digitorum profundus, this is termed a Jersey fracture (Shabat et al 2004). Dependent upon the stability, these injuries can be treated with buddy strapping, plaster support, K-wires or screws. This type of injury is common in footballers catching their finger pulling on an opponent's jersey.

Middle phalanx:

Angulation and rotation are the main contributors to instability at the fracture site and this is more common with basal fractures. Intra-articular fractures of the middle phalanx are a challenge to manage and often there is residual functional loss. Treatment consists of splinting, Kirchsner wire fixation or open reduction, and internal fixation with plates and screws.

Proximal phalanx:

Head and basal fractures usually consist of an articular component in proximal phalanx fractures. The tendon both of the flexor and extensor aspect create deforming forces resulting in displacement. Proximal phalangeal fractures can be treated conservatively with plaster immobilisation, with plasters either supported by Zimmer splints or extensions over the fingers (Maitra& Burdett-Smith 1992). If there is severe fracture comminution then either internal or external fixation is required (Bowen 2006).

For extensive hand injury with the presence of open fractures and severe comminution, external fixation is favourable. The advantage with this technique includes careful examination of the wounds with good results in terms of early healing (Windolf et al 2008). Early mobilization is required to achieve maximum strength and full range of movements.

[FIGURE 9 OMITTED]

Oblique and comminuted fractures of proximal phalangeal fractures are commonly treated with internal fixation. The intraosseous wire fixation of the complex unstable and unreduceable phalangeal fracture has shown good results (Gorosh & Page 1989). Phalangeal fractures have great diversity and there are various concepts for conservative and surgical management. However, treatment of phalangeal fractures must respect the complex anatomy of the hand and must strive to achieve the greatest possible protection of soft tissue structures. Whatever technique is used, an organised and efficient postoperative physiotherapy programme is critical for satisfactory results.

Conclusion

Fractures of the wrist and hand are often challenging injuries that require early recognition and prompt treatment to avoid long term functional loss and disability. As detailed, numerous management options exist and whichever management plan is initiated, early return to function with hand physiotherapy and rehabilitation is essential.

KEYWORDS Fractures / Wrist / Hand / Non-operative treatment / Operative treatment

Provenance and Peer review: Commissioned by the editor; Peer reviewed; Accepted for publication June 2009.

References

American Academy of Orthopaedic Surgeons 2007 Hand Fractures http://orthoinfo.aaos.org/topic.cfm?topic=A00010 [Accessed 2 Jan 2009]

Bongers KJ 1984 Operative treatment of Smith's fracture The Netherlands Journal of Surgery 36 (1) 10-2

Boles CA 2007 Wrist, Scaphoid Fractures and Complications http://emedicine.medscape.com/article/397230overview [Accessed 2 Jan 2009]

Bowen JE, Malanga GA, Napolitano E 2006 Phalangeal Fractures http://emedicine.medscape.com/article/98322overview [Accessed 2 Jan 2009]

Ellis H 2006 Clinical Anatomy: a revision and applied anatomy for clinical students 11th ed p170-190 Oxford, Blackwell Publishing Ltd

Fritz T, Wersching D, Klavora R, Krieglstein C, Friedl W 1999 Combined Kirschner wire fixation in the treatment of Colles fracture. A prospective, controlled trial. Archives of Orthopaedic and Trauma Surgery 119 (3-4) 171-8

Foster RJ, Hastings II H 1987 Treatment of Bennett, Rolando and vertical intra articular trapezial fractures Clinical Orthopaedic Related Research 214 121-9

Gaebler C, Kukla C, Breitenseher M, et al 1996 Magnetic resonance imaging of occult scaphoid fractures Journal of Trauma 41 73-76

Garcia-Elias M 2004 Perilunate injuries including fracture dislocations In: Berger RA, Weiss APC eds Hand Surgery Vol I p511-523 Philadelphia, London, Tokyo, Lippincott Williams & Wilkins

Gorosh J, Page BJ 1989 Treatment of phalangeal fractures of the hand with intraosseous wire fixation Orthopaedic Reviews 18 (7) 800-6

Green DP, O'Brian ET 1978 Open reduction of carpal dislocations: indications and operative techniques Journal of Hand Surgery 3A 250-265

Hofmeister EP, Kim J, Shin AY 2008 Comparison of two methods of immobilization of fifth metacarpal neck fractures: a prospective randomized study Journal of Hand Surgery [Am] 33 (8)1362-8

Ikeda K, Osamura N, Tomita K 2008 Percutaneous screw fixation without bone graft for cystic-type scaphoid fractures Journal of Trauma 65 (6) 1453-8

Jupiter JB, Marent-Huber M 2009 LCP Study Group. Operative management of distal radial fractures with 2.4-millimeter locking plates. A multicenter prospective case series Journal of Bone and Joint Surgery [Am] 91 (1) 55-65

Leslie IJ, Dickson RA 1981 The fractured carpal scaphoid. Natural history and factors influencing outcome Journal of Bone and Joint Surgery 63-B 225-230

Lemberger U 1980 [Long-term results of treatment of Bennett fractures] Handchirurgie 12/3-4 245-6

Milogevic I, Sudjic V, Bumbasirevic V, Lesic A, Damjanovic G, Bumbasirevic M 2005 Nonoperative treatment of fractures of the base of the first metacarpal bone--Bennett fracture Acta Chirurgica Iugoslavica 52 (2) 67-71

Meermans G, Verstreken F 2008 Percutaneous transtrapezial fixation of acute scaphoid fractures Journal of Hand Surgery Eur 33 (6) 791-6

McQueen MM, Gelbke MK, Wakefield A, Will EM, Gaebler C 2008 Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid: a prospective randomized study Journal of Bone and Joint Surgery Br 90 (1) 66-71

Maitra A, Burdett-Smith P 1992 The conservative management of proximal phalangeal fractures of the hand in an accident and emergency department Journal of Hand Surgery [Br] 17 (3) 332-6

Moore K, Dalley A 2006 Clinically Oriented Anatomy 5th edition Philadelphia, London, Tokyo, Lippincott Williams & Wilkins

Murray P 2008 Perilunate Fracture Dislocations http://emedicine.medscape.com/article/1240108overview, accessed Jan 2009

Omokawa S, Fujitani R, Dohi Y, Okawa T, Yajima H 2008 Prospective outcomes of comminuted periarticular metacarpal and phalangeal fractures treated using a titanium plate system Journal of Hand Surgery [Am] 33 (6) 857-63

Royle SG 1990 Rotational deformity following metacarpal fracture Journal of Hand Surgery 15B 124-125

Sandner AM, Menke H 2008 Results of antegrade intramedullar Kirschner-wire pinning of subcapital fracture of the fifth metacarpal bone using Foucher's technique Handchirurgie Mikrochirurgie Plastische Chirurgie 40 (5) 336-341

Shabat S, Sagiv P, Stern A, Nyska M 2004 Avulsion fracture of flexor digitorum profundus tendon (Jersey Finger) type 3 http://www.springerlink.com/content/9mad4eb2105y 4dcp [Accessed 2 Jan 2009]

Wheeless CR 2008 Wheeless Text Book of Orthopaedics http://www.wheelessonline.com [Accessed 2 Jan 2009]

Windolf J, Siebert H, Werber KD, Schadel-Hopfner M 2008 Treatment of phalangeal fractures: recommendations of the Hand Surgery Group of the German Trauma Society Der Unfallchirurg 111 (5) 331-8

Young CF, Manu AM, Checketts RG 2003 Seven-year outcome following Colles' type distal radial fracture. A comparison of two treatment methods Journal of Hand Surgery [Br] 28 (5) 422-6

Correspondence address: Mr W Khan, UCL Institute of Orthopaedics, Royal Orthopaedic Hospital, Stanmore, HA7 4LP. Email: wasimkhan@doctors.org.uk

Mr Atif A Malik MBChB, MRCS Ed

Specialist Registrar Trauma and Orthopaedics, Chase Farm Hospital, Enfield

Dr Naveed Yousaf MBBS, MRCS

SHO, Trauma and Orthopaedics, Rochdale Infirmary, Rochdale

Mr Wasim Khan MRCS, PhD

Academic Orthopaedic Registrar, Royal National Orthopaedic Hospital, Stanmore

Dr Khan M H Ihsan MBBS

House Officer, Ihsan Hospital of Surgery and Pulmonary Medicine Hospital, Lahore

Mr Matt Ravenscroft FRCS (Orth)

Consultant Orthopaedic Surgeon, Stepping Hill Hospital, Stockport

No competing interests declared
Table 1: Flexors and extensors of hand

Common flexors                 Common extensors

Flexor carpi radialis          Extensor digitorum longus
Flexor digitorum superficial   Extensor indicis
Flexor digitorum profundus     Extensor digiti minimi
Flexor carpi ulnaris           Extensor carpi radialis longus
                               Extensor carpi radialis brevis
                               Extensor pollicis longus (EPL)
                               Extensor pollicis brevis (EPB)
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Title Annotation:CLINICAL FEATURE
Author:Malik, Atif A.; Yousaf, Naveed; Khan, Wasim; Ihsan, Mohammed; Ravenscroft, Matt
Publication:Journal of Perioperative Practice
Article Type:Clinical report
Geographic Code:1USA
Date:Feb 1, 2010
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