A brief overview of various fractures and dislocations seen in hand.

1. Fractures And Dislocations of Hand
Dr Aftab Alam

2. Basic Anatomy
Bones

3. Lumbricals and
interossei

4. Blood supply

5. MR Angiogram of
hand

9. Principles of Management
-Mechanism of injury should be assessed regarding magitude ,
direction, point of application.
-Fracture reduction, reduction maneuvres should not cause
additional trauma and should be gentle.
-Complete neurovascular examination should be done.
-Injuries to tendons should be addressed.
-Splints should immobilize minimum no. of joints and allow
unrestricted motion at other joints.
-Total duration of immobilization should rarely exceed 4 weeks.
-Plain radiographs , atleast 2 projections centered at level of
interest, oblique views may show displacements not evident
on other views.

10. Injuries of the Thumb

11. • First CMC joint - Most important
• Injuries (# SL DL) cause limitation of motion pain & weakness
Bennett Fracture
• Bennett , Irish , 1882
• Intraarticular # through base of first MC
• Shaft dislocated laterally due to pull of Abductor Pollicis
Longus
• Medial fragment remains in place due to Volar Oblique Lig.
• Reduction easy but difficult to maintain.
• Closed Pinning
• Open fixation with K wires / 2- 2.7 mm screw

14. Wagner Tech for closed pinning

16. • Postoperative Care –
Cast for 4 wks
If screw fixation is used active ROM with intermittent
splinting at 2 wks.
• Complications –
Malunion with CMC arthritis (1-3mm tolerated)
Reduction not to be attempted after 6 wks
Corrective Osteotomy by Giachino
Arthritis –Arthrodesis /Arthroplasty

17. Rolando Fracture
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Comminuted First Metacarpal Base #
Presents as ‘Y’ or ‘T’ Pattern
Differs from Bennette that usually no diaphyseal displacement
Likely for Posttraumatic arthritis – accurate reduction
Fixed with small wires placed under the subchondral bone
supplemented with a larger transarticular / transmetacarpal
pinning.
• TBW with Ex Fix
• T plate

22. • If reduction and fixation achieved well results are excellent.

23. Thumb Carpometacarpal Joint
Dislocation
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Rare Injury
Reported cases mostly Dorsal dislocations
Dorsoradial & Volar Ob Lig most imp in preventing dislocation
Should be reduced and immobilized early for 4-6 wk.
If unstable OR and pinning with DR lig repair, immobilize for 46wk.
• Recurrent dislocation warrants ligament repair and
immobilization.

26. Thumb immobilizer

27. Thumb Metacarpophalangeal
Fractures
• Usually involve ulnar margin of proximal phalynx due to UCL
avulsion
• Small frag/ <2-3 mm disp – no surgery
• Large frag / Angulated /Displaced – require surgery

29. Thumb Metacarpophalangeal
Dislocations
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Most common -Dorsal dislocation
Mech- hyperextension injury
Most common among all MCP dislocations
Simple- reducible closed
Complex- Irreducible by closed methods due to interposition
of sesamoids , volar plate , flexor tendon – open reduction
• Immobilized in 20 deg flexion for 4 wks

31. Thumb MCP Joint UCL Rupture
• Originally described by Campbell in 1955 as Gamekeeper’s
thumb actually referred to attritional injury in baseball
players.
• Skiing accidents/falls with forceful radial and palmer
abduction- Skier’s thumb

35. Stener Lesion - adductor aponeurosis interposed between
the ruptured ulnar collateral ligament and its site of insertion
on the base of the proximal phalanx.
Prevents healing -> chronic instability -> arthroses
Associated injuries - avulsion # , dorsal capsular rupture ,
volar plate tears.

36. • Plane Xray – if <2mm disp signifies absence of Steiner lesion
and heals with casting only.
• Avoid stress at joint to prevent Steiner lesion
• Salter Harris I/II injuries stress films contraindicated
• USG, Arthrography,MRI 
Incomplete rupture – thumb spica 4-6 wk
Complete rupture – surgical repair

37. Thumb MCP Radial Collateral Ligament
Injury
• Less frequent than UCL injury
• No lesion like steiner exist.
• Incomplete tears/tears without volar , rotational subluxationtreated with cast for 4-6 wks
• Complete tear with subluxation – direct repair.
• Supplemental PL tendon graft , advancement of APB for
chronic instability.

38. Improper treatment leads to painful instability during ‘push off’

39. Carpometacarpal Fracture-Dislocations
• Often obscured due to swelling and metacarpal overlap on
xray lat.
• Most commonly involved 5th MC displaced dorsally with 4th
• Alternatively all 4 may be displaced volarly
• Loss of parallel joint surfaces at the CMC articulations in xray
• CT is helpful in determining the extent of injury
• Closed reduction and fixation with k wires.
• Delayed presentations may require resection of proximal end
of MC with fusion or interposition arthroplasty.

40. #dislocation of 5th mc , reduced and fixed with k wires

41. CMC dislocation 4th 5th MC

42. HamatoMC #dislocaton

43. Intraarticular Fracture of the Fifth
Metacarpal Base
• Disabling injury
• If unattended, malunion results in weakness of grip and
painful joint.
• Lesion somewhat similar to Bennett # due to ECU attachment
• Reduction and pinning
• Malunion may require corrective osteotomy and resection
arthroplasty.

45. Malunion , resection arthroplasty , ECU tendon should be
reattached

46. Finger Metacarpophalangeal
Dislocations
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•
•
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Less common than IP dislocations
Commonly seen in Index finger
Dislocation results in Kaplans lesion
Fibrocartilaginous plate avulses from volar aspect of the
second metacarpal neck(weakest attachment).
• The flexor tendons and the pretendinous band are displaced
ulnarly and the lumbrical radially to the metacarpal head .

49. Reduction of MCP dislocation

50. • Incomplete dislocation- easy reduction
• Complete dislocation - 50 % success by closed reduction
-50% require open reduction by volar or dorsal approach and
requires complete division of volar plate.
• Subsequently protect joint from hyperextension for 3 wks

51. Metacarpal Shaft or Neck Fractures
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Generally treated by closed methods
OR & fixation req if multiple/assoc with soft tissue injury
Most imp factor in reduction- Rotational alignment
Transverse shaft #s fixed with IM K wires
Oblique #s can be fixed with interfragmentary screws

52. Boxer’s Fracture
• Metacarpal neck # involving little finger
• Metacarpal head is freed from any proximal stabilizing
influence so metacarpal head tilts volarly causing joint to lie
in hyperextension & collateral ligaments become slack.
• If joint is allowed to remain in hyperextension, collateral
ligaments will shorten, leading to limited MCP flexion.
• An infrequent variant of Boxer’s # may involve MC head

54. Angulation (measured-15)

56. • Non Operative Treatment
• Clawing results from the palmar displacement of the
metacarpal head & resulting imbalance of extrinsic tendons
Pt may have cosmetic deformity, but good function
• Reduction method
Collateral ligs must be placed in a tightened position to
control distal fragment and achieve reduction.
MC joint flexed to 90 to tighten collateral, flexed metacarpal is
directed dorsally, which effects reduction of metacarpal head
by correction of volar angulation.

57. • Criteria for acceptable reduction
Lateral view -angulation > 30-40 deg- functional deficit (pc) may
result - consider percutaneous pin fixation.
30 deg of angulation results in loss of 22% of finger ROM
AP view -little or no angulation should be accepted -indicates
mal-rotation of the digit

58. • Casting
Buddy taping should always be done irrespective of method
of casting.
This prevents malrotation.

60. Bouquet Pinning of Metacarpal Neck Fracture
Care should be taken to protect wrist extensors tendons by
giving an incision and partially elevating them
Sharp tip is cut off , bent about 3mm from leading end.
Enter the canal at most acute angle possible
Put several k wires through the # site
Goal is to tension the wires off the intact proximal cortex and
enter the distal fragment in various locations, creating a
“bouquet” effect.

63. • Operative treatment
can be done with K wires

64. Indications for plating of MC shaft #s
• Multiple fractures with gross displacement or additional soft
tissue injury
• Displaced diaphyseal transverse, short oblique, or short spiral
fractures
• Comminuted intraarticular and periarticular fractures
• Comminuted fractures with shortening or malrotation or both
• Fractures with substance loss or segmental defects.

65. Metacarpal Head Fractures
• Intraarticular , often of 4th and 5th MC heads
• Occurs during fist fight,hitting opponents teeth

66. IM K wire fixation of 4th MC shaft

67. Tech for percutaneous pinning

68. Tech for ORIF of MC shaft #

69. Plating for MC shaft

70. Multiple #s treated with plating

71. Ex Fix for 5th
MC shaft

72. MC shaft # fixed with Interfragmantary screws

73. Fracture of the Middle or Proximal Phalanx
Direct blow over dorsum
Palmer angulation with clawing

75. Pratt’s method ORIF

77. Proximal Interphalangeal Joint FractureDislocation
Always an unstable dorsal displacement of the middle phalanx
caused by disruption of the attachment of the volar
fibrocartilaginous plate.
If – single VOLAR fragment with >50% jt space – ORIF
-- <50% of articular space – active motion of PIP jt while
maintaining finger in extension block splint.
Other modalities include
Hemi-hamate autograft

78. • Closed Reduction and Extension Block
Splinting

80. Excessive comminution of middle phalynx shaft is better treated
by traction than by open methods.
Various available devices allow early motion at PIP and DIP jt

81. Dynamic External Splint Reduction
This technique relies on coupling distraction and volarly directed
forces across the joint in # dislocation of PIP jt

83. Interphalangeal Dislocations
Mostly dorsal
Easily reduced
Collaterals usually intact
If ligaments are ruptured, repair is required ,especially radial
collateral lig.
With persistent dorsal subluxation, the joint may be pinned in 20
degrees of flexion for 2 to 3 weeks.

84. Undiagnosed Interphalangeal Dislocations
Rarely a dislocation may be obscured by swelling.
Joint cartilage may be eroded by pressure from articular edge in
a weeks time,open reduction is necessary

85. Distal Phalangeal Fractures
Usually crushed comminuted #s
Require only splinting
In cases of near amputations 22-gauge hypodermic needle can
be used for supporting the bone while the soft tissues heal.
Sometimes may be fixed with compression screws to prevent
nonunion

87. Mallet finger

88. Distal interphalangeal joint extension lag due to disruption of the
terminal extensor tendon.
Mechanism of injury

89. Full passive joint extension is present.
Proximal migration of extensor apparatus may result in swan
neck deformity

90. Type 1: Closed or blunt trauma with loss of tendon continuity
with or without a small avulsion fracture
Type 2: Laceration at or proximal to the distal interphalangeal
joint with loss of tendon continuity
Type 3: Deep abrasion with loss of skin, subcutaneous cover, and
tendon substance
Type 4: 4A—transphyseal fracture in children
4B—hyperflexion injury with fracture of articular surface
of 20% to 50%
4C—hyperextension injury with fracture of the articular
surface usually greater than 50% with early or late volar
subluxation of the distal phalanx.

91. Treatment for type 1(most common)
Contineous extension of DIP jt with splint

92. Type 2 can be treated by tendon suture repair and Kirschner wire
fixation of the distal interphalangeal joint in full extension.
Type 3 mallet fingers require soft tissue coverage and pinning of
the distal interphalangeal joint and possible primary
arthrodesis.
Type 4 Open reduction and K wire fixation of the epiphyseal
fragment is indicated if closed reduction cannot be obtained

94. Type 4 mallet finger treated with pinning and pullout wire

97. Complications
Increased association of complications seen with
- rigid internal fixation (attributed to necessity)
- intra/periarticular injuries
Complications can be
- malunion/nonunion
- hardware associated
- extensor lag
- infection
- contractures
- instability

98. Infections
Seen despite excellent vascularity.
Often seen in injuries associated with crushing component
Preoperative wound culture proves to be of no help
Most commonly associated organism S.Aureus
Open wound , non contaminated with intact vascularity role of
antibiotics in reducing infection rate has not been supported

99. Stiffness
Most common and most feared complication
Resultant Stiffness is contributed by
magnitude of original trauma
age and genetic composition of the patient
duration of immobilisation
position of immobilisation
invasiveness of intervention
Position of immobilisation should follow the principles of
splinting ligaments at full length and balancing tendon forces
that act across a joint.

100. First webspace contractures are common , can be prevented by
splinting the first metacarpal in max abduction
Once a fixed contracture has developed , tenocapsulolysis can be
done if patient desires to improve motion

101. Hypersensitivity
• Small size of hand with complex distribution of fine nerves
provide very few areas to have clear incision or percutaneous
pins maintaining a distance of 1 cm
• Crush injuries- invariably assoc. with hypersensitivity
• Neuroma formation should be guarded especially while
operating on
-ulnar side of thumb MP(high conc. Of dorsal digital N
branches.
-radial side of wrist (near superficial radial N)
Treatment – gabapentin , amytriptyline , pregabalin , contact
desensitisation therapy

102. Malunion and Deformity
Frequently encountered due to lack of understanding hand biomechanics
belief that all hand # do well with non op treatment
due to a non compliant patient
Malunions should be managed with corrective osteotomy
at deformity site/ compensatory
Rotational corrections best done at MC base(cancellous)(25-30)
Rotational deformity is result of improper choice of non op Rx
Corrective osteotomies are more successfulful at MC level than
phalyngeal level

103. • Tenolysis alone improves extensor lag
• Intraarticular osteotomy can be done for selected cases of
intraarticular malunion at MC head.
• IA malunion may cause OA ,decreased grip and pain
• Exact pattern of osteotomy should be assessed for chosing
the type of osteotomy (opening wedge closing wedge , pivot
osteotomy oblique osteotomy)
• Shortening should be considered if closed osteotomy planned
• Extensor lag of 7 degrees predictable for every 2 mm
shortening

104. Nonunion
Rare in hand fractures with exception of distal phalynx.
Seen where - CRIF has caused distraction or
- ORIF with excessive stripping of periosteum
Hypertrophic nonunion addressed by DCP alone
Variable pitch compression screws for distal phalynx #
Osteonecrosis of MC head in IA # as it lacks independent blood
supply

105. Residual Instability
More common proximally (cmc) following dislocation.
Pure dislocations tend to be more unstable as all ligaments are
torn and require Lig-Lig or Lig-Bone healing
Fracture dislocations,one or more of key stabilizing ligaments
remain intact.
CMC #dislocations can be assesed by injecting local anaesthetic,
if it relieves pain, Arthrodesis (5th in 20-30deg)

106. Posttraumatic arthritis
IA # and residual joint instability may cause accelarated hyaline
cartilage wear.
There is poor corelation between radiographic appearance and
clinical loss of function and pain.
Fusion can be done for CMC of index and middle finger.
Fusion of MP and PIP jt results in loss of function

107. Tendon ruptures
Missed tendon ruptures associated with dislocations may lead to
deformity posture
mallet finger it DIP
boutonniere deformity at PIP
Treatment involves arthrodesis in flexion at DIP whereas effort
should be made at PIP jt to restore extension as arthrodesis is
not well tolerated here.