Residency · Residency · Plastic Surgery

Fractures and Dislocations of the Hand and Wrist

Overview

Hand and wrist fractures are among the most common injuries treated by plastic and hand surgeons. Understanding fracture patterns, stability criteria, and fixation principles is essential. Malunion, malrotation, and stiffness are the primary complications to avoid. ---

General Principles

Goals of Treatment

Anatomic reduction (especially articular surfaces). Stable fixation allowing early motion. Preservation of tendon and neurovascular function. Prevention of rotational malalignment.

Indications for Operative Fixation

Intra-articular fractures with >1-2 mm step-off. Unstable fracture patterns (oblique, spiral with shortening, comminuted). Rotational malalignment that cannot be corrected with closed reduction. Open fractures. Multiple fractures. Failed closed management.

Assessing Rotation

Each finger should point toward the scaphoid tubercle when flexed. Scissoring of fingers indicates rotational malalignment. Even 5 degrees of malrotation causes 1.5 cm of digital overlap at the fingertip. ---

Distal Phalanx Fractures

Types

Tuft fractures: crush injuries; treat with protective splinting, nail bed repair if needed. Shaft fractures: usually stable; splint in extension. Dorsal base avulsion: mallet fracture (see Topic 16). Volar base avulsion: FDP avulsion (Jersey finger).

Jersey Finger (FDP Avulsion)

Leddy and Packer Classification:

Most common in ring finger (75%). Mechanism: forceful extension against an actively flexed DIP (tackling in football). ---

Phalangeal Fractures

Proximal Phalanx Fractures

Apex volar angulation: interossei flex the proximal fragment, central slip extends the distal fragment. Acceptable alignment: <10 degrees angulation (sagittal), <2 mm shortening, no rotational malalignment. Fixation options: buddy taping (stable), K-wires, lag screws, plate fixation (dorsal or lateral). Dorsal plating may lead to extensor tendon adhesions -- lateral plating gaining favor.

Middle Phalanx Fractures

Angulation depends on fracture location relative to FDS insertion: Fractures proximal to FDS insertion: apex dorsal angulation. Fractures distal to FDS insertion: apex volar angulation. Condylar fractures: unicondylar fractures are unstable and require ORIF with lag screws.

Pilon Fractures of the Base of the Middle Phalanx

Comminuted intra-articular fractures from axial load. Involve >50% of the articular surface. Treatment options: hemi-hamate autograft reconstruction, volar plate arthroplasty, dynamic external fixation, ORIF. ---

Metacarpal Fractures

Metacarpal Head Fractures

Intra-articular; require anatomic reduction. Often comminuted from fight-bite mechanism. ORIF with mini screws or K-wires.

Metacarpal Neck Fractures (Boxer's Fracture)

Most common: 5th metacarpal neck. Apex dorsal angulation due to interosseous pull.

Treatment: ulnar gutter splint in intrinsic plus position; ORIF if exceeds acceptable angulation.

Metacarpal Shaft Fractures

Transverse: apex dorsal angulation. Oblique/spiral: prone to shortening and rotation. >5 mm shortening or any rotational malalignment requires fixation. Fixation options: K-wires, lag screws (oblique fractures), plate and screws.

Metacarpal Base Fractures

Index and middle: relatively stable due to rigid CMC joints. Ring and small: more mobile CMC joints; higher energy injuries.

Bennett Fracture (Thumb)

Intra-articular fracture-dislocation at the base of the first metacarpal. Small volar-ulnar fragment remains attached to the trapezium by the anterior oblique ligament. Metacarpal shaft displaces radially and proximally by APL pull. Treatment: CRPP or ORIF (requires anatomic articular reduction).

Rolando Fracture

Comminuted intra-articular fracture at the base of the first metacarpal (T or Y pattern). Worse prognosis than Bennett fracture. Treatment: ORIF if reducible fragments; external fixation or K-wires if severely comminuted.

<image>Four-panel medical illustration showing common metacarpal and phalangeal fracture patterns. Panel 1: Boxer's fracture of the 5th metacarpal neck with apex dorsal angulation and acceptable angulation limits labeled for each digit. Panel 2: Bennett fracture-dislocation at the thumb CMC joint showing the volar-ulnar fragment attached to the trapezium and the displaced metacarpal shaft. Panel 3: Proximal phalanx fracture with apex volar angulation and the deforming muscle forces (interossei and central slip) illustrated with arrows. Panel 4: Assessment of rotational alignment showing the normal finger cascade pointing to the scaphoid tubercle versus scissoring deformity from malrotation.</image>

PIP Joint Injuries

Dorsal Dislocation (Most Common)

Middle phalanx displaces dorsally on the proximal phalanx. Volar plate ruptures from its distal insertion. Usually stable after reduction -- buddy tape and early motion. Test stability: assess for redislocation with progressive extension after reduction.

Volar Dislocation

Less common but more problematic. Central slip disruption required for volar dislocation to occur. Must splint PIP in extension for 6 weeks to protect central slip repair (treat as boutonniere).

Fracture-Dislocations

Dorsal fracture-dislocation with volar base fracture of the middle phalanx. Stability depends on the percentage of articular surface involved: <30%: usually stable after reduction; extension block splinting. 30-50%: borderline; extension block pinning or dynamic external fixation. >50%: unstable; volar plate arthroplasty, hemi-hamate arthroplasty, or ORIF.

Volar Plate Arthroplasty

The volar plate is advanced into the articular defect and secured to bone. Provides a smooth gliding surface and volar buttress. Progressive extension allowed from the block position. ---

MCP Joint Dislocations

Simple (Reducible)

Hyperextension injury. Volar plate ruptures from proximal attachment. Reduce with flexion of the wrist and MCP (do NOT hyperextend further during reduction).

Complex (Irreducible)

Volar plate interposes in the joint (Kaplan lesion). Pathognomonic radiographic sign: sesamoid bone within the widened joint space. Dimpling of the palmar skin. Closed reduction fails -- open reduction required (volar approach preferred). Index finger most commonly affected.

Thumb MCP Ulnar Collateral Ligament Injury (Gamekeeper's / Skier's Thumb)

UCL tear with or without avulsion fracture. Stener lesion: torn UCL displaces superficial to the adductor aponeurosis, preventing healing. Physical exam: >30 degrees laxity (or >15 degrees more than contralateral) indicates complete tear. Stress radiographs or MRI to confirm. Complete tear / Stener lesion: surgical repair or reconstruction. Partial tear: thumb spica cast for 4-6 weeks. ---

Scaphoid Fractures

Anatomy

Most commonly fractured carpal bone (70% of all carpal fractures). Blood supply: retrograde from the dorsal branch of the radial artery entering distally. Proximal pole has the most tenuous blood supply (highest risk of AVN).

Fracture Location

Waist (70%): most common. Proximal pole (20%): highest AVN risk. Distal pole/tuberosity (10%): best prognosis.

Diagnosis

Anatomical snuffbox tenderness, scaphoid tubercle tenderness, pain with axial compression of the thumb. Initial radiographs may be negative -- scaphoid series (PA, lateral, oblique, ulnar deviation PA). If high clinical suspicion with negative x-rays: MRI (gold standard) or CT, or empiric thumb spica immobilization and repeat films at 2 weeks.

Treatment

Non-displaced waist fractures: thumb spica cast for 8-12 weeks (long arm for first 6 weeks, then short arm). Displaced fractures (>1 mm displacement), proximal pole fractures, nonunions: ORIF with headless compression screw (Herbert screw, Acutrak). Nonunion: vascularized bone graft (1,2 intercompartmental supraretinacular artery graft -- 1,2 ICSRA) or non-vascularized iliac crest bone graft with screw fixation.

Avascular Necrosis

13-50% of proximal pole fractures. Presents with persistent pain, sclerotic proximal pole on imaging. Treatment: vascularized bone graft (1,2 ICSRA pedicled graft or free medial femoral condyle graft). ---

Perilunate Injuries

Spectrum (Mayfield Classification)

Stage I: scapholunate ligament disruption (scapholunate dissociation). Stage II: perilunate dislocation (capitate dislocates dorsally from the lunate). Stage III: lunotriquetral ligament disruption. Stage IV: lunate dislocation (lunate tilts volarly into the carpal tunnel -- may compress the median nerve).

Transscaphoid Perilunate Fracture-Dislocation

Greater arc injury: fracture through the scaphoid waist with perilunate dislocation. High-energy mechanism.

Diagnosis

Lateral radiograph is key: disruption of Gilula arcs, "spilled teacup" sign (lunate dislocation). Often missed on initial ED evaluation (25% initially misdiagnosed).

Treatment

Closed reduction followed by ORIF. Combined dorsal and volar approach: dorsal for scapholunate ligament repair and scaphoid fixation; volar for carpal tunnel release and lunate reduction. Scapholunate ligament repair with K-wire fixation and dorsal capsulodesis. ---

DRUJ Instability

Anatomy

Distal radioulnar joint stabilized by the triangular fibrocartilage complex (TFCC). TFCC includes the dorsal and volar radioulnar ligaments, articular disc, meniscus homologue, and ECU subsheath.

Assessment

Piano key test: dorsovolar translation of the ulna relative to the radius. Compare to contralateral side. Assess in pronation (dorsal radioulnar ligament tested) and supination (volar radioulnar ligament tested).

Treatment

Acute TFCC tears: above-elbow cast in supination for 4-6 weeks; arthroscopic repair if failed conservative management. Chronic instability: TFCC reconstruction, ulnar shortening osteotomy (if positive ulnar variance). Darrach procedure (distal ulna excision): for low-demand patients; risk of radioulnar convergence in young/active patients. Sauve-Kapandji procedure: DRUJ arthrodesis with proximal ulna pseudarthrosis; maintains ulnar head buttress. ---

Clinical Pearls

Rotational malalignment is the most common reason for operative fixation of hand fractures -- 5 degrees of malrotation at the proximal phalanx causes 1.5 cm of finger overlap. The safe position of immobilization (MCP 70-90 degrees flexion, IP extension) prevents collateral ligament contracture at the MCP joints -- never splint the MCP joints in extension. Boxer's fractures (5th metacarpal neck) tolerate up to 40 degrees of angulation without functional deficit; index and middle metacarpal neck fractures tolerate much less (10-15 degrees).

A complex MCP dislocation (irreducible) is recognized by a widened joint space with a sesamoid in the joint on radiograph -- do not attempt repeated forceful closed reduction. Scaphoid fractures with negative initial radiographs should be immobilized in a thumb spica and reimaged at 2 weeks, or MRI should be obtained if early diagnosis is needed. Perilunate dislocations are a commonly missed diagnosis -- always evaluate the lateral wrist radiograph for disruption of the normal colinear relationship of the radius, lunate, and capitate. Bennett fractures require anatomic articular reduction -- even 1-2 mm of step-off leads to early arthritis of the thumb CMC joint. ---.

References

• Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat Res. 2006;445:133-145.
• Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg. 2000;8(2):111-121.
• Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78(3):357-365.
• Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5(3):226-241.
• Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984;66(1):114-123.
• Rettig AC. Athletic injuries of the wrist and hand. Am J Sports Med. 2003;31(6):1038-1048.

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