Hand Trauma

Hand Fractures and Dislocations

What are hand fractures and dislocations? The hand is made up of the phalanges, the small bones of the thumb and fingers, and the long bones of the hand called the metacarpals, which attach the hand to the wrist or carpal bones. There are five metacarpals, one for each digit. There are 14 phalanges; two for the thumb and three for each finger. Fractures of the hand involve fractures or breaks of the above-mentioned bones. They usually result from trauma, which may include a fall, hitting an object, or twisting or crushing-type injuries. Fractures may be non-displaced, in other words, the bones are still in good alignment. They may be displaced or have loss of normal alignment. They may be comminuted, meaning many fragments. They may be open fractures, meaning they are associated with a laceration and the bone may have protruded through the skin, which means it may be contaminated with dirt or other material. They may be intra-articular fractures, meaning the fracture extends into the joint. Dislocations of the hand include the joints of the fingers and the joints between the metacarpals and wrist or carpal bones. Finger dislocations occur commonly. They are often associated with sporting injuries or falls. Some dislocations are stable once they are reduced. Other dislocations are inherently unstable and require fixation, immobilization or repair of the ligaments. Dislocations can also be associated with fractures, and some of which may extend into the joint. These can be closed or open injuries. The thumb carpometacarpal joint is prone to dislocation or fracture dislocation.

What does the hand do?

The hand does just about everything. We use our hands for fine motor activities such as plucking an eyebrow or removing a splinter. We use them for repetitious activities like writing, typing and a variety of work situations. Our hands are used for eating and daily hygiene. They are also used for strenuous activities such as lifting weights, swinging a sledgehammer and if you’re a gymnast, you may walk on your hands, though usually that is reserved for the lower extremities. The hand is a very complicated organ and the ability to oppose the thumb sets us apart from most of the animal kingdom.

Diagnosis and Examination

The history and mechanism of injury are very important when dealing with hand injuries. Also important are the activities of the individual and what their expectations from treatment may be. The hand is a complicated organ so multiple organ systems must be evaluated, including the skin. Are there burns, lacerations or crush injuries? It is important to assess the function of the nerves and tendons. Vascular assessment is very important, as is the function of the small muscles of the hand. X-rays of the hand are very important for evaluating fractures and dislocations. Sometimes special views are necessary, in addition to the standard views obtained in the emergency room. In certain situations, diagnosis cannot be made from x-rays alone, which can result in other studies such as a CAT scan or MRI.

Nonsurgical Treatment of Fractures and Dislocations

Many non-displaced fractures with minimal soft tissue damage can be adequately treated with rest, splinting or buddy taping. It is imperative that the physician’s instruction for the appropriate amount of immobilization be carefully followed as ending splinting too soon may lead to displacement of the fractures, which could require operative intervention. Additionally, many dislocations are stable once they are reduced. These can often be treated with a short period of immobilization followed by motion, therapy and gradual return to normal activities. In both non-displaced fractures and stable dislocations, failure to follow the appropriate treatment program may result in stiffness, loss of reduction, nonunion and later surgery.

Surgical Treatment of Fractures and Dislocations

Open fractures and dislocations, i.e. injuries that are contaminated, and lacerations with bone or joints protruding generally require debridement, wound closure and fixation of the fracture, or dislocation. Displaced fractures may be rotationally mal-aligned or angular and often require reduction and internal fixation to control the alignment. Some dislocations of the joints, particularly those associated with fractures, require operative intervention. Almost all fractures extending into the joints where the joint and articular surfaces displace require operative intervention. Surgical treatment of fractures and dislocations is generally carried out in the operating room under anesthesia using sterile technique with x-ray control and the intent of obtaining the best possible reduction of the fracture, the articular surface or dislocation. This will be accomplished using pins, screws, plates and a variety of fixation devices that are available. After surgery, the hand is generally immobilized in a compressive dressing. It is imperative with both operative and non-operative treatment that the arm be elevated to control swelling and the activity level must closely follow the instructions of the surgeon. As much as possible we try to control swelling with elevation and early motion. One of our greatest concerns in treating hand fractures and dislocations is minimizing the stiffness, which can generally be accomplished by a good reduction, good therapy, a good exercise program and a cooperative patient. Other complications include infections (which are uncommon), skin complications, and circulatory complications. Injuries that are associated with lacerations or crush injuries to the nerves, arteries and tendons have a much higher incident of complications than simple closed fractures.

Outcomes

Outcomes are largely dependent on the severity of the injury. Simple non-displaced fractures in a cooperative patient who follows the treatment program will generally have a high level of satisfaction and maximize return to normal function. On the other hand, some severe injuries which result in not only fractures or dislocations but also associated soft tissue injury including nerve and tendon damage, skin loss, and comminuted intra-articular fractures may never have normal function. It is important to talk to your physician about your needs and goals and make sure you have a clear understanding of reasonable expectations from your surgeon. Not infrequently with hand surgery is it necessary to later remove pins, screws and metal plates. Sometimes additional surgery must be carried out to free up scar tissue around nerves and tendons, and assist in resuming motion. Nevertheless most common fractures and most common dislocations of the hand end up with generally very good outcomes and quite useful (though not necessarily normal) function.