Hand is anatomically divided in palm, thumb and four fingers. Palm is often referred as hand. Severe hand trauma causes fracture, dislocation or soft tissue injury. Fracture of the metacarpal bone is observed in palm and fracture of the phalanges is located in fingers or thumb. Fracture of the metacarpal bone results in symptoms over palm. Similarly fracture of phalanges causes symptoms over thumb and fingers. Soft tissue injuries result in tear of ligaments and tendon. Fracture of the bones in palm and fingers are caused by direct impact, forceful twist or high-energy muscle contraction in opposing directions.
Bones of the Hand, Thumb and Fingers
Total number of bones in Palm and Fingers are 19.
- Palm- 5 Metacarpal Bones
- Thumb- 2 Phalanges
- Four Fingers- 12 Phalanges
Joints of the Hand, Thumb and Fingers
Total number of joints in Palm and Fingers are 19.
- Joints between Wrist and Palm- 5 Metacarpo-carpal Joint
- Joint between Palm and Thumb- 1 Metacarpo- Phalangeal Joint
- Joint between Palm and 4 Fingers- 4 Metacarpo- Phalangeal Joint.
- Joint in Thumb- 1 Inter-Phalangeal Joint
- Joints in Fingers- 8 inter-Phalangeal Joints
Risk Factors Causing Fracture of Hand and Fingers
Chronic Smoking Causing Fracture of Hand and Fingers
- Chronic smoking results in decreased oxygen carrying capacity of the blood resulting in relative tissue hypoxia.1
- Hypoxia increases proteolytic activities, which delays healing of minor bruising and laceration.2 Superficial injury of the periosteum and bone often results in inadequate healing followed by micro-necrosis of the bone.
- Repeated injury of the same area often leads to hairline fracture.
Obesity Causing Fracture of Hand and Fingers
- Domestic fall causing twist of the extremity frequently results in fracture.
- Weight transmission during slip and fall in obese patient generates an additional acceleration and force, which is transmitted through extremity or pelvic bone resulting in fracture.
Osteoporosis Resulting in Fracture of Hand and Fingers
Osteoporosis causes weak bone. Fall or impact often results in fracture.
Direct Impact Causing Fracture of Hand and Fingers
- Metacarpal (bones in hand) and phalanges (bones in fingers) are superficial and linked by thin but strong ligaments and tendons. Direct impact over hand and fingers causes fracture of metatarsal bone and phalanges because of lack of soft tissue cushion of subcutaneous tissue and muscles.
- A blow by a heavy object causes severe accelerated force against the bone. Severe blow thus causes fracture of thin and weak metacarpal bone and phalanges.
- Similarly direct forceful impact is observed in sports injury. Sports injury induces high-energy impact, which often results in fracture of bones in palm and fingers.
- Moderate direct impact also causes fracture in patients suffering with osteoporosis.
Falling On an Outstretched Hand Leading to Fracture of Hand and Fingers
- Falling on an outstretched hand causes severe transmission of accelerated force resulting in mostly fracture of the metacarpal (palm) bone and phalanges (finger).
- Fall often results in fracture if patient has a history of osteoporosis.
Twisting the Hand Resulting in Fracture of Hand and Fingers
Unaware twist of the hand causes distribution of force in opposite direction resulting in fracture. Most of the injuries are observed in sports injuries.
Causes Of Fracture of Hand and Fingers
- Auto Accident
- Work Accident-
- Example- Injury caused by Lawn Mower and Snow blower.3
- Domestic Fall
- Sports Injury
- Inflicted Injury
Types of Fracture of Hand and Fingers
a. Hairline Fracture-
- Hairline fracture is also known as "Stress Fracture".
- Stress or hairline fracture of the hand is mostly seen in metacarpal bone.
- Hairline fracture is relatively superficial and does not cross entire thickness of the bone.
b. Non-Displaced Fracture of Hand (Metacarpal Bone) and Fingers (Phalanges)
- Non-displaced fracture is observed in metacarpal bone and phalanges.
- Fracture causes full thickness crack in the bone without any separation of the proximal or distal segment.
- Adjacent bone maintains anatomical position without separation.
c. Displaced Fracture of Hand (Metacarpal Bone) and Fingers (Phalanges)
- The upper or lower fragments are displaced from anatomical position and often overlapped.
- Separation is often complete.
- Blood supply to adjacent fractured bone is interrupted and may result in avascular necrosis if not treated within 6 to 8 hours following injury.
d. Comminuted Fracture of Hand (Metacarpal Bone) and Fingers (Phalanges)
- Comminuted fracture is often associated with multiple fragments of bones in palm and hand.
- Comminuted fracture is often seen following severe direct impact.
- Fragments of the bone completely separated and do not maintain any contact.
- Blood supply to adjacent fractured bones is interrupted resulting in avascular necrosis.
e. Compound Fracture of Hand (Metacarpal Bone) and Fingers (Phalanges)
- Compound fracture is a complete displaced fracture with open wound seen with metatarsal fracture as well as fracture of phalanges.
- The fragment of the bone is exposed to atmosphere through an open skin wound.
- Infection and avascular necrosis is common complication.
f. Extra-Articular and Intra-Articular Fracture
- Fracture is either extra articular or intra-articular.
- Extra-articular fracture is outside the joint mostly located over the shaft of the bone.4
- Intra-articular fracture is within the joint or extra-articular fracture extends in joint.
- Intra-articular fracture involves head (epiphysis) of the metacarpal bone or phalanges.
Symptoms for Fracture of Hand and Fingers
Severe Pain of Hand and Fingers-
Pain is described as acute or chronic pain depending on onset and duration of pain.
Acute Pain Symptoms for Fracture of Hand and Fingers
- Acute Severe Pain- Pain immediately following injury is severe and intractable in intensity known as acute pain.
- Acute pain- Lasts for 3 to 6 months.
Chronic Pain Symptoms for Fracture of Hand and Fingers
- Chronic Pain- Pain continuing for more than 3 months is known as chronic pain. Chronic pain last more than 3 to 6 months.
- Severe Pain- Intensity of pain continues to be severe if not treated with surgery.
- Moderate Pain- Intensity of chronic pain following close reduction and surgery is often moderate in intensity.
Swelling of the Hand and Fingers
- Swelling over Fractured Site- Patient complains of joint swelling. Swelling is caused by hematoma (blood clot), tissue edema and protrusion of bony fragments protruding out of the skin and soft tissue.
- Mild Swelling- Hairline and non-displaced fracture may not show obvious swelling but patient often complaints of swelling in hand and fingers.
Unable to Bend Finger
- Patient often complaints of difficulties in bending finger or thumb.
- Bending is difficult following displaced, comminuted or compound fracture.
Signs for Fracture of Hand and Fingers
Bruising Of the Skin Covering Fracture
Bruising- Examination of the palm and hand indicates bruising of the skin. Bruising is caused by subcutaneous blood and tissue trauma.
Difficulties In Moving Hand And Fingers
- Movements- Patient is unable to move fingers or thumb following fracture of phalanges.
- Soft Tissue Injury- Tendon injury such as tear or dislocation of tendon causes difficulties in finger movement.
- Joints of the Hand- Metacarpo-Phalangeal Joint or Inter-Phalangeal Joint is often stiff following fracture.
- Stiffness- Stiffness is observed because of prolonged joint immobility, which is secondary to pain and fracture.
Deformity or Crooked Fingers
- Mal-alignment of fracture End-Proximal and distal phalanges may align and heal in angle resulting in crooked finger when fracture is healed.
- Angle of deformity-X-Ray will show the angle between the proximal and distal fragment.
- Short Finger- Finger is often short in length when compared to opposite finger.
Restricted Joint Movements
- Restricted Joint- Patient is often unable to move fingers at Metacarpo-Phalangeal joint or Inter-Phalangeal joint.
- Cause of Joint Movement Restriction- Joint stiffness is caused by prolonged immobilized joint with cast or braces.
- Tenderness- Tenderness is a pain provoked by examination such as touch and pressure.
- Tender Area- Examination of the fractured site of the palm and finger indicates tender and painful area.
- Mild to Moderate Tenderness- Observed following touch.
- Severe Tenderness of Pain- Observed following pressure or deep tissue examination.
Inability to Grab
- Fracture of Metacarpal Bone (Palm)- Patient is unable to grab the object in hand with fractured metatarsal bone.
- Fracture of phalanges (Hand)- Patient will be able to hold the object in palm when fracture involves one or two fingers.
Finger Crosses Over to Adjacent Finger
- Fracture of Metacarpal Bone- Finger does not cross and lies over adjacent bone
- Fracture of phalanges- Finger in few cases may cross over and lie on top of adjacent finger.
Fracture of metacarpal bone- Fracture of 4th or 5th metacarpal bone causes depressed knuckles over head of 4th and 5th metacarpal bone. Also known as a depressed knuckle or boxer's fracture.
Investigations to Evaluate Fracture of Hand and Fingers
X-rays of Hand (Metacarpal Bone) and Fingers (Phalanges)-
- Initial X-ray is performed to diagnose cause of the pain.
- Fracture of metacarpal bone and phalanges are observed as a proximal and distal fragment in plain X-Ray.
- X-ray picture will indicate type of fracture such as oblique, horizontal, vertical or comminuted.
- X-Ray may not show hairline fracture.
MRI of Hand (Metacarpal Bone) and Fingers (Phalanges)-
- MRI is often not necessary to diagnose fracture of hand and fingers if X-Ray shows the clear picture of fracture.
- MRI is indicated for hairline fracture and comminuted fracture.
Ultrasound Examination of Hand (Metacarpal Bone) and Fingers (Phalanges)-
- Ultrasound is a high frequency sound wave. The high frequency sound wave is transmitted through the body to create an image.
- Ultrasound is used to evaluate the bleeding and hematoma (blood clot).
White blood cell count (WBC) - WBC is increased if infection is associated with fracture of metacarpal bone and phalanges.
Treatment Options for Fracture of Hand and Fingers
Choice of Treatment for Fracture of Hand and Fingers
- Conservative Treatment
- Physical Therapy
- Interventional Pain Therapy
- Close Reduction Of Dislocation And Fracture
- Surgical Treatment
1. Conservative Treatment for Fracture of Hand and Fingers
a. Restriction of Hand and Finger Movement-
Ace Bandage for Fractured Fingers
- Ace bandage immobilizes finger movements.
- Prescribed for hairline fracture.
Finger and Hand Braces to Immobilize Fractured Hand and Fingers
- Braces prevent movement of wrist joint and finger.
- Mostly prescribed for metatarsal fracture near wrist joint.
Splints to Immobilize Finger5-
- Splint is made of light metal covered by soft materials. Splint can be bent to accommodate finger and wrist curves.
- Splints are prescribed for fracture of thumb and fingers.
Immobilize Finger and Hand by Cast
- Prescribed for hand (metacarpal bone) and finger (phalanges) fracture.
- Cast is also used following surgery for 2 to 4 weeks.
b. Heat and Infra Red Therapy for Fracture of Hand and Fingers
- Infra red light is applied over fracture site using infra red light generating equipment.
- Infra red light reduces stiffness in hand and finger.
- Infra red therapy also helps to reduce pain over fractured bone.
c. Daily Exercises for Fracture of Hand and Fingers
- Finger and forearm muscle exercise is advised during treatment.
- Patient is advised to continue with exercise following surgery as well as following removal of cast and braces.
- Muscle exercise will prevent muscle stiffness, atrophy and weakness.
d. Support Hand and Arm in Sling
Treatment prevents swelling of the soft tissue and stiffness of the palm and finger joints.
e. Ice the Finger and Palm
Reduces hematoma and swelling of the tissue over fractured metacarpal (palm) bone and phalanges (finger).
2. Medications for Fracture of Hand and Finger
- Anti-depressant Analgesics
- Anti-epileptic Analgesics
- Muscle Relaxants
A. NSAIDS (Non-Steroidal Anti-inflammatory Medications) for Fracture of Hand and Fingers
NSAIDs are prescribed for inflammation and pain. Most common NSAIDs prescribed are Motrin, Naproxen and Celebrex.
Tablets are available as 200 mg, 600 mg and 800 mg, Daily dosage is 1600 to 2400 mg per day.
Tablets are available as 275 mg, 350 mg and 500 mg. Daily dosage- 750 to 1500 mg per day.
Tablet available as 600 mg. Daily Dosage- 600 to 1200 mg per day.
Tablets available as 100 mg and 200 mg. Daily dosage- 200 to 400 mg per day
B. Opioids Therapy for Fracture of Hand and Fingers
Opioids are prescribed for acute and chronic pain, when NSAIDs are not effective or NSAIDs are contraindicated because of side effects.
Opioids are prescribed for short-term pain relief or prolonged pain relief and are categorized as:
- Short Acting Opioids and
- Long Acting Opioids
Short Acting Opioid Medications for Fracture of Hand and Fingers
Hydrocodone: Vicodin, Lortab and Norco.
Vicodin- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 650 mg of Tylenol.
Daily Dosage- 15 to 60 mg of hydrocodone
Lortab- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 500 mg of Tylenol.
Daily Dosage- 15 to 60 mg of hydrocodone and
Norco- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 350 mg of Tylenol.
Daily Dosage- 15 to 60 mg of hydrocodone and
Norco is preferred if higher dosage like 30 to 60 mg of hydrocodone is prescribed for pain treatment so tylenol dosage is kept below 2 gram.
Oxycodone- Oxy IR and Percocet.
Oxy-IR- Strength of pills- 5 mg, 7.5 mg and 10 mg
Daily dosage- 15 to 60 mg
Percocet- Pills contain Oxycodone and Tylenol.
- Strength of Oxycondon- 5 mg, 7.5 mg and 10 mg.
- Strength of Tylenol- 325 mg, 500 mg and 650 mg.
- Maximum allowed dosage of Tylenol is 4 gm.
MS IR (Morphine Sulphate Immediate Release)
- Available as liquid and pills.
- Liquid strength- 20 mg/mL
- Pill strength- 15 and 30 mg
- Daily dosage 60 mg to 120 mg.
Long Acting Opioid Medications for Fracture of Hand and Fingers
- Pills available as 10 mg, 20 mg, 40 mg and 80 mg.
- Suggested safe dosage per day- 40 mg to 160 mg.
Morphine- MS Contin
- Pills available as 15 mg, 30 mg, 60 mg, 100 mg and 200 mg.
- Suggested safe dosage per day- 90 mg to 200 mg.
- Pills available as 10 mg
- Suggested safe dosage per day- 40 to 80 mg
C. Muscle Relaxants for Fracture of Hand and Fingers
Muscle relaxants are prescribed for muscle spasm and joint stiffness
- Pills available as 5 mg, 10 mg, 15 mg and 20 mg
- Suggested safe dosage per day- 30 to 60 mg
- Pills available as 5 mg and 10 mg
- Suggested safe dosage per day- 20 to 30 mg
- Pills available as 800 mg
- Suggested safe dosage per day- 2400 to 3200 mg
- Pills available as 500 mg and 750 mg
- Suggested safe dosage per day- 1500 to 2150 mg
3. Physical Therapy (PT) For Fracture Of Hand And Finger
Goal of Physical Therapy (PT)
- Improve joint movements and muscle strengthening.
- Maintain normal muscle tone and improve coordination.
Physical Therapy (PT) Techniques-
- Ultrasound Therapy
- Infrared or Heat Therapy
- Cold Therapy
- Massage Therapy
4. Interventional Pain Therapy for Fracture of Hand and Fingers
Interventional pain therapy is an invasive treatment. Choice of Interventional Pain Therapy is as follows
Cortisone Injection for Fracture of Hand and Fingers
- Cortisone injection is performed to reduce inflammation.
- Severe pain if not responding to NSAIDs and opioids, then the chronic pain is treated with frequent cortisone injections.
- Injections are repeated between 3 to 6 months.
Local Anesthetic Injection for Fracture of Hand and Fingers
- Therapeutic value of just local anesthetic injection is very limited.
- Procedure is also performed prior to physical therapy so as to relieve the pain to achieve aggressive physical therapy.
- Median Nerve block is often performed prior to physical therapy every 2 weeks for 6 to 8 weeks.7
Avoid Injection for Fracture of Hand and Fingers when:
- Compound fracture
- Osteomyelitis of fracture bones (infected bone)
- Skin infection
- Allergies to local anesthetics
5. Close Reduction for Fracture of Hand and Fingers5
Indications for Close Reduction to Treat Fracture of Hand and Fingers
- Non-displaced Fracture
- Oblique or transverse displaced fracture
Close Reduction of Fracture of Phalanges-
- Close reduction is performed under local anesthesia, deep sedations or general anesthesia.
- Close reduction is performed by pulling wrist and finger in opposite directions under x-ray guidance.
- Finger joint movement is restricted with splint or cast for 6 to 8 weeks.
Close Reduction of Fracture Metacarpal Bone-
- Close reduction is performed under local anesthesia, deep sedations or general anesthesia.
- Close reduction is performed by pulling forearm and hand in opposite directions under x-ray guidance.
- Hand (palm) movements are restricted with cast for 6 to 8 weeks.
Advantages of Close Reduction-
- Procedure is performed under mild to moderate sedation
- Skin incision and tissue trauma is avoided.
- Recovery is faster.
- Infection is rare.
Disadvantage of Close Reduction Procedure-
- Recurrence of fracture or separation of proximal and distal fragment may follow in few cases
- Failure of close reduction follows surgical treatment and overall delay in healing of fracture.
- Casting following close reduction may not prevent recurrence of fracture.
- Healing may be slow resulting in prolonged placement of cast.
- Prolonged casting may result in muscle wasting, muscle atrophy and severe joint stiffness.
6. Surgery for Fracture of Hand and Fingers
External Fixation8 for Fracture of Hand and Fingers
Indication for External Fixation-
- Unstable and non-displaced metacarpal (hand) and phalangeal fracture.
- Displaced metacarpal and phalangeal fracture.
- Procedure is performed under local anesthesia or sedation like close reduction.
- Fracture is reduced so fragments of fractured bones are aligned as near normal link.
- Fracture of Phalanges- Proximal pin is inserted in metacarpal bone and distal pin is inserted in distal fragment of the fracture bone.
- Fracture of Metacarpals- Proximal pin is inserted in radius or ulna and distal pin is inserted in distal fragment of fracture metacarpal bone.
- External Fixator is connected to proximal and distal pin.
- External fixator is used to pull two fracture segments until the end lies together in normal anatomical position.
- In few cases cast is applied over hand, wrist and forearm to prevent wrist joint and finger movements.
Advantages of Percutaneous External Fixation
- Open surgery is avoided
- Better joint stability is achieved than close reduction.
- Cast placement is not necessary.
- Permanent placement of hardware is avoided
- Minimum soft tissue injury
- Less painful procedure than open fixation
- Scarring and surgical trauma is avoided
Disadvantage Of Percutaneous External Fixation -
- Bulky instruments and frame around hand and fingers.
- Unable to use injured hand and arm
- Fail to reduce or maintain dislocated or fracture wrist joint
- Infection caused by internal pins
- Nerve injury while placing pins
- Bleeding and hematoma resulting from laceration of blood vessels while placing pins in fractured segments.
- Laceration or tear of ligaments and tendon by pin
Internal Fixation (Plates, Screws, Pins) for Fracture of Hand and Fingers
- Unstable metacarpal and phalangeal fracture
- Displaced fracture of metacarpal bone and phalanges.
- Comminuted fracture of metacarpal bone and phalanges.
- Compound fracture of metacarpal bone and phalanges.
- Fracture associated with symptoms of pinch nerve like tingling, numbness and muscle weakness are treated with open reduction and internal fixation.
- Failed close reduction
- Failed external fixation treatment
Advantage Of Open Reduction And Internal Fixation Procedure-
- Internal fixation prevents nerve and vascular injury.
- Cast can be removed in 2 to 3 weeks
- Early physical therapy prevents long-term muscle atrophy and joint stiffness.
- Increase joint stability
Disadvantage Of Open Reduction And Internal Fixation Procedure-
- Procedure is performed under anesthetics.
- Incision may cause soft tissue, tendon, ligament or muscle damage.
- Surgery may cause infection of surgical wound and fracture site.
- Infection follows prolonged recovery and wound healing.
- Infection may need long-term antibiotic treatment.
- Plates, wire or screw may have to be removed if surgery is followed by wound infection.
Complications of Surgery
- Plate and screws may be misplaced or broken.
- Joint infection may force to remove hardware.
- Surgical soft tissue injury may cause nerve damage, vascular tear or tendon rupture.
Surgical Techniques Used for Fracture of Hand and Fingers:
"K" Wires Insertion-
- "K" wire is inserted and passed through proximal and distal fragment.
- Tightening the stainless steel "K" wire brings proximal and distal fragments together. Wire holds the fragments of fracture together.
- Surgery is useful in fracture of phalanges and metacarpal bone.
Plate and Screws9-
- Proximal and distal end of the fracture metatarsal bone are manually aligned with each other.
- Steel plate is placed against the fractured segment to prevent separation of the fragments. Steel plate is anchored to proximal and distal fragments of the fracture bone. Plates are shaped to maintain anatomical curves of finger (phalanges) and hand (metacarpal) bones.
Prognosis Following Treatment for Fracture of Hand and Fingers
Healing of intra-capsular fracture of metacarpal bone and phalanges results in arthritis of the joint in few cases.
Osteoma or Fractured Callus-
Healing of fracture may result in bony lump over the fracture site. Bony lump is also known as Fractured Callus.
Facture may be associated with infection of bones of proximal and distal fragments. Osteomyelitis is an infection of bone.
Prolonged Time to Heal the Fracture-
Osseous union of the proximal and distal bone is often delayed for prolonged time in patients who are chronic smoker and continue smoking during healing.
Healing of fracture may be associated with visible and palpable deformity.
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