Principles of Metacarpal and Phalangeal Fracture Management: A Review of Rehabilitation Concepts

Principles of Metacarpal and PhalangealFracture Management: A Review ofRehabilitation ConceptsMaureen A. Hardy, PT, MS, CHT1

Patients with common hand fractures are likely to present in a wide variety of outpatientorthopedic practices. Successful rehabilitation of hand fractures addresses the need to (1) maintainfracture stability for bone healing, (2) introduce soft tissue mobilization for soft tissue integrity, and(3) remodel any restrictive scar from injury or surgery. It is important to recognize the intimaterelationship of these 3 tissues (bone, soft tissue, and scar) when treating hand fractures. Fractureterminology precisely defines fracture type, location, and management strategy for hand fractures.These terms are reviewed, with emphasis on their operational definitions, as they relate to thecourse of therapy. The progression of motion protocols is dependent on the type of fracturehealing, either primary or secondary, which in turn is determined by the method of fracturefixation. Current closed- and open-fixation methods for metacarpal and phalangeal fractures areaddressed for each fracture location. The potential soft tissue problems that are often associatedwith each type of fracture are explained, with preventative methods of splinting and treatment. Acomprehensive literature review is provided to compare evidence for practice in managing thevariety of fracture patterns associated with metacarpal and phalangeal fractures, following closed-and open-fixation techniques. Emphasis is placed on initial hand positioning to protect the fracturereduction, exercise to maintain or regain joint range of motion, and specific tendon-glidingexercises to prevent restrictive adhesions, all of which are necessary to assure return of functionpost fracture. J Orthop Sports Phys Ther 2004;34:781-799.

Key Words: bone healing, hand, fingers

Injury to the densely compacted structures of the hand ofteninvolves damage to multiple tissues. In this confined area, allneighboring tissues share trauma and its consequence. It is amistake to consider fracture healing apart from soft tissuehealing, because successful outcomes require the return of

functional integrity to both tissues. Soft tissues commonly involved withfractures include cartilage (with intra-articular fractures), joint capsule,ligaments, fascia, and the enveloping dorsal hood fibers. Occasionally, insevere polytrauma cases, tendons and nerves adjacent to the fracture arealso injured. Following open fractures or open reduction procedures, awound is created that must heal with scar tissue—another tissue to beremodeled and considered during rehabilitation. It is well recognizedthat soft tissue scarring affects hand function more than fracturehealing, and joint stiffness is the most frequent complication offractures.50

1 Director, Hand Management Center, St Dominic Jackson Memorial Hospital, Jackson, MS; ClinicalAssistant Professor, School of Health Related Professions, University of Mississippi Medical Center,Jackson, MS.Address correspondence to Maureen A. Hardy, Hand Management Center, St Dominic Jackson MemorialHospital, 969 Lakeland Dr, Jackson, MS 39216. E-mail: [email protected]

The optimal therapy program ad-dresses these 3 components (bone,soft tissue, and scar healing) incombination.

In the 1970s, therapy for handfractures was delayed 6 to 8 weekswhile the hand was immobilized.Stiff joints, adherent tendons,muscle atrophy, scar, and painwere the focus of our interven-tions. Results of corrective surgicalprocedures, such as capsulectomiesfor joint release and tenolysis torestore tendon gliding, were poorfor patients with frac-tures.16,43,101,113 Joints with stiff-ness and abnormal articularsurfaces, due to limited reductiontechniques in small bones, facedthe choice of fusion (arthrodesis)or joint replacement(arthroplasty). Recent studies onfractures requiring combinedcapsulectomy and tenolysis showthat outcomes are still poor, espe-cially for return of active tendonfunction.25,64,74,86 Add to this di-lemma that 24% of digits thatrequire these release proceduresare noninjured, border digits thatwere included in the immobiliza-tion, and we lament along withLanz,64 who states that ‘‘Damageof the gliding ability of tissues(around a fractured digit) is al-most irreparable.’’ Enhanced un-derstanding of the biology offracture healing, better decisionmaking in initial fracture manage-ment, technical advances in im-plant design, improved surgical

Journal of Orthopaedic & Sports Physical Therapy 781

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skills with respect for gliding structures, and earlycontrolled mobilization have contributed to reducingthe incidence of complications that we once faced.

The purpose of this manuscript is to review currentconcepts of management for metacarpal andphalangeal fractures, with special emphasis on poten-tial problems that need to be addressed in the courseof rehabilitation. The challenge for the health careteam is to design intervention protocols that recog-nize the need to maintain fracture stability formaximal bone healing, while also introducing early,controlled-motion protocols to preserve soft tissueintegrity and facilitate scar remodeling. This paper isbased on a thorough review of the literature andcurrent practice principles. The information is pre-sented within the context of an overview of fracturehealing, followed by guidelines for managing specifictypes of fractures common in the hand.

PRINCIPLES FOR FRACTURE MANAGEMENT

Is the Fracture Stable?

The quest in fracture management is to achievefracture stability. Fractures that are stable will heal;fractures that are not stable can result in malunions,infections, pseudoarthrosis, or nonunion. Stability ofa fracture is achieved when the fracture maintains itsreduction and does not displace either spontaneouslyor with motion.39 If the fracture has not distorted thebone’s normal contour and the fracture ends areapproximated, it is termed nondisplaced. A bone thathas lost its normal anatomical contour due to separa-tion of the fracture ends is called displaced. Thedisplaced fracture ends must be reunited for healingto occur and to prevent deformities. The methodsused to bring anatomic order and realignment backto the fractured bone is called reduction. Reductioncan be achieved by either closed manual techniques,by percutaneous fixation, or by open surgical meth-ods.

Stable fractures will maintain their position at restand will not lose the proper approximation of frac-ture ends with inherent muscle tension or whencontrolled-motion protocols are initiated. Some frac-ture types are known to have intrinsic stability, suchas nondisplaced transverse, and short oblique con-figurations. These fractures require no further inter-vention other than protective immobilization to allowhealing to commence. Intrinsically stable fracturesare usually treated with conservative, closed methodsof support for 2 to 3 weeks, then supported withremovable splints for initiation of controlled motion.

Fractures that are aligned but subject to misalign-ment with certain postures or tensions are termedpotentially unstable. Potentially unstable fracturesinclude oblique, avulsion, and comminuted fractures.These fractures can often be managed with protective

immobilization that maintains the reduction or re-stricts motion in the direction of instability. Asfracture coalescence occurs, the immobilization canbe modified to allow incremental increases in rangeof motion (ROM). Alternately, potentially unstablefractures can be supported with the introduction ofcoaptive hardware such as K-wires, pins, or wiringtechniques that protect against displacement. Thesedevices can be inserted either percutaneously (closedreduction) or via surgical exposure (open reduction).Coaptive forms of hardware bring about alignment,but they do not control for rotation stresses, nor dothey impart any internal strength to the fracture.Coaptive devices therefore require further externalsupport to eliminate unwanted deforming stresses asthe fracture heals.

Unstable fractures will not maintain reduction, asdisplacement reoccurs despite immobilization. Ex-amples of unstable fractures include long oblique,spiral, condylar and any irreducible fractures, andfractures with articular fragments greater than 30%or incongruity greater than 2 mm.39 Stability of thesefractures can only be assured with the supportprovided by fixation devices. All fixation implantspromote reduction, but some provide added internalstrength across the fracture line. The more rigidimplants, such as screws, plates, dorsal band, and90-90 wiring techniques, permit immediate motionand only require modest external support for woundcare. The coaptive implants, however, such as pins,K-wires, intramedullary rods, staples, and interosseouswiring, do require more rigid external support aspreviously noted.4,65

Is the Fracture Healing?Primary Bone Healing Implant choice drives the

course of fracture healing. Implants introduced viaopen reduction internal fixation (ORIF) that provideabsolute stability and compression of the fracturepermit primary bone healing to occur. Primary bonehealing is direct bone-to-bone healing without anyexternal callus. Compression across the fracture lineeliminates the space-occupying hematoma, thus re-ducing the fracture gap. Compression combined withrigid fixation, that eliminates all but micromotion,provides an environment suitable for osteoclast cut-ting cones to form and cross the fracture line. Thesecutting cones have osteoclasts that forage forward, byosteoblastic action, leaving an empty trail behind(haversian canal) that is filled with osteons (a singlebasic unit of bone).75 For an in-depth review offracture healing see LaStayo et al.64

One advantage of primary healing via rigid internalfixation is precise anatomic reduction. This is espe-cially important in articular fractures where jointincongruities can lead to degenerative joint prob-lems. As the need for peripheral callus to support thebone ends is avoided (the metallic implant substitutes

782 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

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for the callus), so also is avoided the potentialproblem of tissue adherence to the callus duringimmobilization. Once the surgical dressing is re-moved, usually in 3 to 5 days, there is full access tothe hand for wound or edema control measures.Early initiation of motion is permitted as theseimplants provide sufficient internal support to allowmotion without endangering the fracture align-ment.65 In polytrauma cases, soft tissue mobilizationprograms for repaired tendons can begin immedi-ately without fear of displacing the fracture.

A disadvantage of primary healing is that it canonly occur with mechanical stabilization provided viasurgery; consequently, there are 2 wounds to heal:the fracture and the soft tissue incision. Without theinitiation of early motion post-ORIF, there is a greaterpotential for soft tissue adherence. Although newbone is formed more quickly in primary healing, it isnot strong bone.75 This newly formed woven bone(weak) will gain tensile strength as it is remodeledbased on its environmental stresses and strains tobecome lamellar bone (strong). Bones healing byclosed conservative management and those treated byopen reduction methods achieve the same level oftensile strength by 12 weeks. This implies that pri-mary healing is not faster healing, so strengtheningprograms must be delayed until the remodelingphase has begun at 6 to 8 weeks.

Secondary Bone Healing Fractures treated by externalsupport or coaptive implants, that reduce the fracturebut do not provide compression, must rely on callusformation to bridge the fracture gap. Because boneformation will not occur in an environment ofmotion, callus is a temporary, biological fixation thatforms in an area with motion and functions to reducethis motion as it matures and hardens (soft callus tohard callus).7 Callus then resembles a natural gluethat holds the fracture ends together. As the callusgains stiffness, the fracture fragments are renderedmore stable.42 Excessive, unrestricted motion canoverwhelm the fragile support offered by early softcallus, leading to loss of reduction and possiblynonunion.104 With secondary healing, ROM exercisesare delayed or limited during the first 3 weeks, oruntil the callus has achieved enough tensile strengthto tolerate controlled movement. Callus that is suffi-ciently ‘‘clinically stiff’’ at 3 weeks to permit motion isnot strong enough yet to bear functional loads.53

After 3 weeks, soft callus transitions into a harderfibrocartilage callus, then through a process of miner-alization true bone is formed. Goodship42 summa-rized this cascade of connective tissue differentiationas one in which, ‘‘The entire spectrum of connectivetissue is seen from blood to bone through hematoma,granulation tissue, fibrous tissue, fibrocartilage,hyaline cartilage, woven and ultimately lamellarybone.’’

The primary advantage of secondary bone healingis that there is minimal soft tissue disruption. Thisequates to less scar remodeling. The periosteal sleeve,when intact, envelops the bone adding another inter-nal layer of fracture support and is an importantblood supply source for the bone. Noninvasive frac-ture management does not violate this tissue, as doopen fixation methods that may require periostealstripping for implant application.

One disadvantage of secondary healing is therelatively long period of protected immobilizationthat is required, during which soft tissues can becomecontracted or adherent to the callus. Often, initiationof motion at 3 to 4 weeks is still limited to a saferange dictated by the fracture’s potential instability.Prolonged immobilization results in atrophy of softtissues, osteoporosis, thinning of articular cartilage,severe joint stiffness, and at times pain.52

Is Closed or Open Reduction Required?The vast majority of metacarpal and phalangeal

fractures can be treated without surgery, using closedmethods that emphasize alignment and early pro-tected motion (Figure 1).69 Fracture immobilizationshould provide for adequate healing, relief of pain,protection from displacement or reinjury, and resto-ration of hand function.45 All splinting programsrecognize the need to position the metacarpo-phalangeal (MP) joints in flexion to avoid extensioncontracture. The thumb MP joint is not exempt fromthis rule and many stiff thumbs result fromhyperextended thumb spica immobilization. Theinterphalangeal (IP) joints are routinely rested in fullextension, with the exception of volar plate fractures.Unpublished data by Greer45 states that the followingprinciples (REDUCE) for effective plaster cast orthermoplastic splinting should be incorporated in alldesigns: (1) reduction of the fracture is maintained,(2) eliminate contractures through positioning, (3)don’t immobilize fractures more than 3 weeks, (4)uninvolved joints should not be splinted in stablefractures, (5) creases of the skin should not beobstructed by the splint, and (6) early active tendongliding is encouraged.

Fractures that cannot be reduced with closedmanipulation (or those that fail to maintain theirreduction), open fractures, and displaced articularfractures are candidates for operative fixation proce-dures. Insertion of the fixation device does not alwaysrequire a surgical incision. Closed reduction withexternal fixation or closed reduction with internalfixation includes percutaneous application of pins,K-wires, and external fixators under radiologic C-armguidance. Limited open reduction and internal fixa-tion uses small incisions to insert screws orintermedullary fixation. Open methods of internalfixation (ORIF) do require surgical exposure of thefracture for insertion of K-wires, plates, screws, and

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 783

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FIGURE 1. Fracture stability achieved with closed reduction meth-ods (cast, splint, brace, external fixator) or with coaptive forms offixation (pins, K-wires, intramedullary rods) require a form ofexternal support to promote callus formation during the inflamma-tory and repair stages of healing. As healing progresses, therapyintervention proceeds from edema prevention, to protected mobili-zation with tendon gliding of nonimmobilized joints, and toacceleration of controlled soft tissue mobilization for full activetendon gliding. Passive range of motion to regain full joint mobility,and strengthening programs, are delayed to the early and lateremodeling phase, respectively, when the hard callus is convertingto bone. Fracture stability achieved with open reduction methods(screws, wiring, plates) still require protective, postoperative splintsupport initially; however, full active motion can and should beemphasized early. Because the implant serves as a substitute forhard callus, passive motion can be initiated during the repair phase.Strengthening programs are delayed until the remodeling phase toassure fracture union, under the implant, has occurred. Reprintedfrom LaStayo64 with permission from Elsevier.

osseous wiring. The hardware used in fracture fixa-tion falls into 2 categories: (1) coaptive devices thathold the fracture ends together without compression(secondary callus healing); and (2) rigid forms offixation that immobilize and compress the fracture(primary healing). Freeland39 stated that, ‘‘. . . thechoice of the implant is less important than achievinga threshold of stabilization that will allow fracturehealing in concert with early rehabilitation.’’

Coaptive Fixation: External Fixators, IntramedullaryRods, K-wires, Pins, Interosseous Wiring Jabaley57 statedthat fixation must be good enough to permit move-ment, but need not be excessive, given that the smallbones in the hand do not bear weight. It is cautioned

that well-placed coaptive implants that allow ROMexercises without load may be insufficient to protectthe fracture against resistance (motion with load).One week after surgery a removable splint is appliedin a functional, ‘‘rehabilitation ready’’ position, whichthe patient removes for suture/pin site cleaning, andto perform protected active ROM (AROM) exer-cises.39 Full motion may not be possible at all jointsdue to constraints from the hardware. Controversydoes exist regarding the initiation of motion withcoaptive fixation. Incidence of infection, fracturedisplacement, nonunion, and pain have been cited asreasons to delay motion until the fixators are re-moved.9,54 Advances in osteosynthesis materials isbelieved to provide sufficient stability to permit con-trolled, protected ROM exercises with this type offixation in place.8,32,44,78 Weiss109 investigated initia-tion of motion at 1, 2, 3, and 4 weeks for individualswith proximal phalanx (P1) fractures with K-wirefixation. Results showed no difference in ROM whenmotion was initiated between 1 to 21 days. However,when motion was delayed more than 21 days, therewas a significant loss of mobility.

At 4 to 6 weeks, the K-wires and pins are removed,the splint is adjusted for proper fit and worn forcontinued fracture protection for another 2 weeks.AROM exercises (out of the splint) are performedhourly to regain full mobility. The callus is consid-ered ‘‘clinically stiff’’ enough for free active motionbut is not stable enough to bear a functional load,which occurs after 6 to 8 weeks.53 Dynamic or serialstatic splints may be initiated after 6 to 8 weeks’ timeto overcome any soft tissue contractures. Earlystrengthening exercises with light resistance can beinitiated at 8 weeks, but unrestricted return to sportsand heavy work is delayed until after 10 weeks, ascallus remodeling to lamellar bone with increasedfracture strength does not occur until this later stageof bone healing.21

Rigid Fixation: Plates, Screws, Tension Band Wiring,90-90 Wiring Open reduction with rigid forms offixation provide definitive fixation, assure compres-sion for stability, and permit early motion for goodrestoration of function.69 Full AROM is the early goalas edema diminishes. Dynamic splints may be used at2 weeks for soft tissue stretching, because of thestability provided by the rigid fixation. An exceptionis forced extension with tension band wiring tech-niques, because the dorsal surface wiring on themetacarpal compresses the fracture with flexion butwill cause gapping of the fracture with forced exten-sion. Early strengthening exercises with light resis-tance can be initiated at 6 weeks, but unrestrictedreturn to sports and heavy work is delayed until after10 weeks, similar to secondary healing, to assureadequate fracture strength has occurred.

It is important that therapists managing handfractures understand the role and intent of the


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various forms of fixation of fractures as they dictatethe course of rehabilitation. Ideally the therapistwould have access to both the radiographs and anoperative/emergency department report on the med-ical management of the fracture. In the absence ofthis ideal environment, a minimum of 2 facts must beprovided with the therapy referral: date of fractureand method of fixation. The fracture date starts thebone-healing timetable, and the method of fixation(dictating the type of healing) influences the rate atwhich motion can be reintroduced. The goals ofhand therapy then are to reintroduce safe earlymobilization while maintaining fracture stability.91

Is the Edema Under Control?

Edema after injury is common to all fractures.Patient education for edema control is an essentialcomponent of the initial therapy visit. Rest, ice,compression, and elevation (‘‘RICE’’) are emphasizedfor edema control. Edema is poorly tolerated in thedigits due to the confining space. Distended jointspredictably move into positions that permit the great-est expansion of the joint capsule and collateralligaments.35 Edema postures the hand into wristflexion, MP joint extension, IP joint flexion, andthumb adduction: a dropped ‘‘claw hand.’’ Func-tional splinting seeks to place the hand in a restingposition that will avoid this deformed posturing. Icecan be easily performed with the use of large bags offrozen peas (1 bag applied volarly and 1 dorsally) andis effective even over a splint or cast. Coban (sized 1inch [2.5 cm] for fingers and 2 inches [5 cm] for thehand) is an elastic self-adhering bandage that pro-vides effective compression. Eccles33 showed that thegreatest reduction in swelling was obtained with thehand supported in elevation overnight.

Early mobilization to promote venous return viamuscle contraction is advocated in stable fractures.Having the patient adduct the fingers tightly andmaintain this tension while flexing at the MP jointcan enhance both intrinsic muscle pumping andachieve the desired joint positions of full MP flexionand IP extension. Double buddy straps, appliedproximal and distal to the proximal IP joint (PIP),serve to protect fracture alignment and encouragemobility of the injured digit. Patients are also in-structed in shoulder and elbow ROM exercise inelevation to facilitate proximal muscle pumping.

Are the Tendons Gliding?

AROM is initiated as soon as possible, based on themethod of fixation, to prevent osseous adhesions totendons, ligaments, capsules, or skin.82 The mostimportant tendon-gliding exercises to initiate earlyare those for the flexor digitorum profundus (FDP),flexor digitorum superficialis (FDS), extensor

digitorum communis and central slip to preventtendon adherence to fracture callus.15

To assure the extensor tendon glide over fracturedmetacarpal bones, MP extension is performed in the‘‘hook fist’’ posture (Figure 2A). To gain extensorhood glide over proximal phalanx (P1) fractures, theintrinsic plus position is performed, facilitated bymanually blocking the MP joint into flexion (Figure2B). Micks71 showed that the central slip is respon-sible for initiating extension from a fully flexed PIPjoint position, while the lateral bands (interossei andlumbricals) achieve full terminal PIP extension. If fullPIP extension is lacking, flexing the wrist may assistby the addition of passive tenodesis action (stretch ofthe extensor mechanism).

Selective gliding of flexor tendons is achieved bychoosing positions that differentiate movement be-tween the FDP and FDS to achieve maximal glide ofeach. Wehbe106,107 used metal tags on the tendons todemonstrate that the FDP must glide 60 mm, com-pared to 49 mm of FDS glide, to achieve full fisting.This research suggests that for P1 and middle pha-lanx (P2) fractures, flexor tendons need to achievemaximal differential glide to prevent restrictive adhe-sions with loss of motion. FDP tendon gliding isperformed by manually blocking the PIP joint toallow full flexor power to be directed to the distaljoint (Figure 2C). To promote selective FDP flexortendon glide past the superficialis tendon, the ‘‘clawfist’’ posture of MP extension with PIP and distalinterphalangeal joint (DIP) maximal flexion isachieved (Figure 2D). FDS tendon blocking exerciserequires inhibition of the FDP tendon of the samefinger, which also contributes to PIP joint flexion.This inhibition of the profundus is achieved bymanually restricting DIP motion in the unaffecteddigits with attempted PIP flexion in the involved digit(Figure 2E). Because the FDP tendons blend into 1multistrand tendon inserting into the muscle belly,blocking 1 tendon’s excursion effectively blocks allothers.14 The only motor that is now free to glide andflex the PIP joint is the FDS tendon. The ‘‘sublimisfist’’ (Figure 2F) maximally glides the FDS tendonpast the FDP tendon with full MP and PIP flexionand an extended DIP joint. Full fisting, flexion of all3 joints simultaneously, promotes full gliding of allflexor tendons with the FDP tendon gliding past theFDS tendon.105

PRINCIPLES FOR MANAGING METACARPALFRACTURES

The metacarpal bones have intrinsic stability pro-vided proximally by strong interosseous ligamentsbinding them to the carpal bones, and distally by thetransverse metacarpal ligament linking all metacarpalheads. These ligaments serve to tether and anchorboth ends of the metacarpal, preventing excessive


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FIGURE 2. Tendon glide exercises: (A) claw posture to achieve extensor digitorum communis (EDC) tendon glide over metacarpal bone; (B)intrinsic plus posture to achieve central slip/lateral bands glide over proximal phalanx (P1); (C) flexor digitorum profundus (FDP) blockingexercises to glide FDP tendon over P1; (D) hook fist posture to promote selective FDP tendon glide; (E) flexor digitorum sublimis (FDS)blocking exercise to glide FDS tendon over middle phalanx; (F) sublimis fist posture to promote selective FDS tendon glide.

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displacement with injury. This is especially true formiddle and ring metacarpal fractures as they have theadditional support of intact adjacent metacarpals.Fractures in the border digits, index and small, tendto be more unstable due to loss of surrounding intactmetacarpal pillars. The thumb metacarpal, sitting at47° rotation away from the other digits, is the mostmobile and most unstable if fractured.100

Metacarpal fractures represent 35% of hand frac-tures. Due to their good blood supply, these fracturesheal rapidly with osseous restoration in 6 weeks.Fractures of this bone are described at 4 distinctlocations: base, shaft, neck, and head. The mostimportant soft tissue concerns with metacarpal frac-tures are preserving MP joint flexion and maintainingEDC glide. Table 1 lists the potential problems thatcan occur and strategies for therapeutic intervention.

Metacarpal Base Fracture

Base fractures are an intra-articular fracture result-ing from high force that disrupts the rigid carpalligaments (index and middle), or overwhelms thenormal flexibility of the ulnar metacarpals (ring andsmall).41 The insertions of the wrist flexors andextensors on the metacarpal base can be a deformingforce. These are uncommon injuries associated withviolent accidents resulting in a fracture-dislocationpattern. The most common occurrence is at the fifthmetacarpal-hamate articulation, which is often un-stable due to the pull of the extensor carpi ulnaris,flexor carpi ulnaris, and abductor digiti minimi thatinsert on the metacarpal base.12 Fractures at thislocation limit the normal descent of the ulnarmetacarpals, causing weakness of grip. The deepmotor branch of the ulnar nerve, passing beneaththe hook of the hamate, is also vulnerable to injuryin this fracture.76 The index and middle metacarpalbase fractures are also unstable due to the insertionof the extensor carpi radialis longus and flexor carpiradialis on the second metacarpal and extensor carpiradialis brevis on the third.

Closed reduction with casting of the wrist for 4 to 6weeks is indicated for nondisplaced or minimallydisplaced fractures. Bora12 reported ‘‘satisfactory’’return of grip strength and activities in 18 patientstreated with this method. Displaced fractures repre-sent an associated carpometacarpal joint dislocationthat can lead to joint incongruity, degenerative jointdisease and ultimately further carpal collapse.41 ORIFis necessary to restore joint approximation, preventpain, and assure return of grip strength. Postopera-tively, a cast is worn for 4 to 6 weeks to protect thisinjury at the wrist. This prolonged immobilization isnecessary to protect the healing fracture from thedeforming forces of the wrist tendon insertions.70

During this time the fingers are free and encouragedto move. Once clinical signs of healing are present, aprotective wrist splint is used for 3 to 4 weeks whilewrist rehabilitation is initiated.

TABLE 1. Potential problems with metacarpal fractures andstrategies for therapeutic intervention.

Potential Problems Prevention and Treatment

Dorsal hand edema Coban wrap compression, ice,elevation, high-voltage stimu-lation

Dorsal skin scar contracturethat prevents full fist

Silicone TopiGel, simultaneousheat and stretch with handwrapped in a fisted position;friction massage

MP joint contracted in exten-sion

Initially: position MP joint at70° flexion in protectivesplint

Late: dynamic or static progres-sive MP joint flexion splint

Adherence of EDC tendon tofracture with limited MP jointflexion

Initially: teach EDC glide exer-cises to prevent adherence;splint IP joint in extensionduring exercise to concen-trate flexion power at MPjoint

Late: dynamic MP flexionsplint; NMES of EDC withon ! off cycle

Intrinsic muscle contracturesecondary to swelling andimmobilization

Initially: teach instrinsic stretch(instrinsic minus position)

Late: static progressive splint inintrinsic minus position

Dorsal sensory radial/ulnarnerve irritation

Desensitization program;iontophoresis with lidocaine

Attrition and potential ruptureof extensor tendon overprominent dorsal boss orlarge plate

Rest involved tendon; contactphysician if painful symptomswith AROM persist

Scissoring/overlapping of digitswith flexion

Slight: buddy tape to adjacentdigit

Severe: malrotation deformityrequiring ORIF

Absence of MP head Shortening of metacarpal; maynot be functional problem

Absence of MP head and MPjoint extension lag

Shortening of metacarpal withredundancy in extensorlength; splint in extension atnight; strengthen intrinsicsabduction/adduction; NMESof intrinsics with off ! oncycle

Absence of MP head withvolar prominence and painwith grip

Neck fracture angulatedvolarly; minor: padded workglove; major: reduction ofangulation required

Abbreviations: AROM, active range of motion; EDC, extensordigitorum communis; MP, metacarpophalangeal; IP, interphalangeal;NMES, neuromuscular electrical stimulation.


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Metacarpal Shaft Fracture

Shaft fractures are extra-articular fractures causedby fall, blow, or crushing force that usually angulatedorsally and may have components of shorteningand/or rotation. They are described by the fractureconfiguration as transverse, oblique, or spiral. Intrin-sic muscle tension, arising from its origin on the volarproximal metacarpal through its bony insertion onthe proximal phalanx, will cause both ends of themetacarpal bone to flex towards each other, pushingthe fracture ends dorsally (known as apex dorsalpresentation). Resting tension of the long extrinsicfinger flexors contributes to the deformity.Metacarpal fractures with apex dorsal angulationcause the metacarpal bone to be shortened, causing adeleterious effect on the extensor mechanism byaltering the muscle’s normal length-tension relation-ship. For each 2-mm increment of bone shorteningthere is a corresponding 7° extensor lag at the MPjoint.97 The natural ability to hyperextend the MPjoint will overcome this extensor loss for minimalbone shortening; but this deformity leaves a promi-nent dorsal boss that has been implicated in attritionrupture of extensor tendons.96

Stable, nondisplaced transverse metacarpal shaftfractures with apex dorsal angulation can be treatedclosed with glove support,68 buddy taping,112 shorthand casts,29 long ulnar/radial gutter splints, orhand-based fabricated splints that incorporate 3points of reduction pressure (1 dorsal point over thefracture site and 2 volar points, proximal and distal tothe fracture, that provide counterpressure).70,102,103

C-arm visualization of the fracture with the splint onwill assure improvement in the angulation after 1week.58 Sorenson92 found poor compliance and skinbreakdown with prefabricated splints as compared toulnar gutter casts. Konradsen,61 using fiberglass cast-ing, and Jones,58 using thermoplastic material, fabri-cated custom-made, hand-based fracture braces withthe 3-point reduction technique. Both studies com-pared this functional brace, which allowed wrist anddigital motion, with plaster ulnar gutter casting.Together, these 2 studies support the advantages ofthe functional brace with improved motion, de-creased pain, ability to deliver corrective reductionforce, less extensor lag, and decreased need forpostfracture therapy. Current best-practice fracturesupport for managing nondisplaced, angulatedmetacarpal shaft fractures is provided by custom-made casts or splints that incorporate the 3-pointpressure fixation built within the splint and allowsfree active joint motion (Figure 3).

Fractures that are potentially unstable require addi-tional support. Ulnar or radial gutter splints thatimmobilize both the injured metacarpal and its adja-cent stable metacarpal, including wrist, MP, and PIPjoints have been the norm (Figure 4A-B). Feehan36

FIGURE 3. (A) metacarpal shaft fracture treated with 3-point pres-sure fixation built inside splint; (B) straps secured to apply correctivepressure to dorsal apex angulation of fracture.

proposed the concept of ‘‘serial splint reduction,’’ inwhich the splint is gradually cut down as fracturehealing proceeds, permiting controlled-motion exer-cises (Figure 4C-D).

Multiple metacarpal fractures may require that allfingers be included in the cast (Figure 5A).Ashkenaze6 described a splint that includes the wristand metacarpal shafts with dorsal support extendingout to the PIP joint, with the volar support ending atthe distal palmar crease to allow free MP and IP jointmotion. Seventy degrees of MP joint flexion reducesthe intrinsic and extrinsic flexors influence on dorsalangulation.90 The IP joints are free to move duringthe day but strapped into extension at night toprevent flexion contractures (Figure 5B). Buddystrapping of the injured digit to a noninjured adja-cent finger, especially in oblique fractures, is protec-tive against malrotation and facilitates early motion.Hall47 reported using this type of clam digger immo-bilization in over 1000 fractures, modified to plasterin noncompliant patients. This best-practice manage-ment technique assures protection of fracture stabil-ity, maintains proper hand posture, and respects the

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FIGURE 4. (A) Radial gutter splint for fractures of index or middle metacarpals; (B) ulnar gutter splint for fractures of ring or smallmetacarpals; (C) serial reduction of splint to permit motion as fracture healing occurs; (D) passive range of motion in splint.

importance of motion in the early rehabilitation offracture.

Oblique and spiral metacarpal fractures canshorten and rotate. The ill effects of this telescopingand malrotation will be evident when the patientattempts to make a fist. The rotated position of themetacarpal will cause digital overlapping and thetelescoping will cause loss of the normal metacarpal

head prominence of the involved bone. FollowingORIF, a circumferential, hand-based splint is worn toprotect the metacarpal area from direct trauma; nojoint motion is restricted with this splint. Kuntscher63

reported that 105 fractures postoperatively providedwith this type of functional fracture brace resulted indecreasing the number of hand therapy visits withearly, pain-free return of hand function.

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FIGURE 5. (A) Cast for multiple metacarpal fractures permittingearly active finger flexion; (B) resting volar component added tomaintain interphalangeal joints in full extension.

Metacarpal Neck FractureNeck fractures are the most common metacarpal

fracture, also known as fighter’s or boxer’s fracture.The impact of a closed fist hitting an object canfracture the metacarpal at its weakest point, theextra-articular neck. With fight/bite injury, the fistcontact with the mouth of another can result in toothpenetration into the MP joint. Any skin laceration atthe MP joint level with fight/bite fractures should besuspect for infection.

Trauma causes the fractured metacarpal head todisplace with volar angulation. Debate continues overthe necessity to reduce and immobilize these frac-tures.3,14,56 However, angulated neck fractures thatheal with volar displacement over 30° place theintrinsic muscle in a shortened position, which re-duces the muscle’s excursion capacity. This loss of fullmuscle length results in limited ability to initiateflexion at the MP joint.3 Other complications ofpoorly reduced neck fractures include a metacarpalhead prominence in the palm that is painful withgrip, and compensatory hyperextension of the proxi-mal phalanx at the MP joint to clear the fingers forgrasp. Acceptable angulation is less than 15° in theindex and middle metacarpals, while the ring andsmall metacarpals can function with less than 30° due

to their compensatory mobility. If these acceptablereduction angles cannot be maintained with externalsupport alone, then operative treatment is recom-mended.93

Once the volarly flexed metacarpal head is reducedback in proper alignment with the shaft, it is impor-tant to hold the MP joint in over 70° flexion, as thetaught collateral ligaments will aid in securing themetacarpal head in place. A traditional ‘‘clam dig-ger’’ or intrinsic plus splint can be used that includes:(1) keeping the wrist in slight extension; (2) holdingthe MP joint in flexion by a dorsal block componentthat extends out to the PIP joint; (3) stopping thevolar side of the splint at the MP web area, permit-ting limited MP and full PIP flexion.5,24 Neck frac-tures have also been treated with a hand-based splintthat incorporates the 3 points of pressure and mustextend volarly over the palmar aspect of themetacarpal head to apply the correct dorsal force.48,61

Jones58 instructed patients to gradually tighten thestraps as edema subsided, and found that this gradualapplication of stress reduced the fracture as effec-tively as manipulation with anesthesia. It is recom-mended that reduced fractures use the hand-basedsplint that maintains the MP flexed with a dorsalblock.24 If reduction is inadequate or potentiallyunstable, the 3-point splint should be used.

Closed reduction percutaneous pinning withK-wires is recommended to maintain reduction inunstable neck fractures.88 One week postoperatively,the surgical dressing is removed and an immobiliza-tion splint is applied to protect this coaptive fixationat that time. The patient is instructed in protectedROM exercises out of the splint. At 4 to 6 weeks theK-wires are removed and the patient should thenregain full AROM.

Metacarpal Head Fracture

Head fractures are intra-articular fractures causedby high axial loads that can involve avulsion of thecollateral ligaments, including a fracture fragment,fracture of 1 or both condyles, or shattering of thejoint surface into many small-comminuted pieces.

Collateral ligament avulsion fractures if undetectedcan lead to chronic pain and joint instability. If thefracture fragment is nondisplaced, the injury can betreated with protective splints that hold the MP jointflexed at 50° to 70° for 4 to 6 weeks.38 Displacedfractures require ORIF with fixation that allows earlyprotected motion.93

Fracture displacement of 1 to 2 mm at the articularsurface is more easily tolerated in the upper extrem-ity than in the lower extremity weight-bearing joints;however, ORIF is indicated for fractures that involvemore than 20% of the articular surface to preventerosive joint changes and to allow AROM by the thirdweek postfracture.6,50

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Comminuted fractures that do not lend themselveswell to operative fixation, due to the many smallfragments involved, can be treated with closed immo-bilization in a radial/ulnar gutter splint with the MPjoints flexed to 70°. However, comminuted fractureswith substantial loss of bone length are better treatedwith external fixators or bridging plates that maintainbone length.23 Immobilization is shortened to 2 to 3weeks, because early motion benefits articular carti-lage repair. Salter80 cautions that excellent reductionof the fracture may still lead to a poor result due tothe concomitant cartilage injury with its limitedregenerative capacity. His definitive work on intra-articular fractures showed that continuous passivemotion begun in the first postoperative week stimu-lates both bone and cartilage healing.81

PRINCIPLES FOR MANAGING PHALANGEALFRACTURES

Phalangeal fractures are more unstable thanmetacarpal fractures as they lack intrinsic musclesupport and are adversely affected by tension in thelong finger tendons.112 Phalangeal fractures respondmore unfavorably to immobilization than metacarpalfractures, with a predicted 84% return of motion,compared to 96% return in metacarpal fractures.88 Ifimmobilization is continued longer than 4 weeks, themotion return drops to 66%.98 In 19% of digitalfractures, nonfractured neighboring fingers also losemotion.55 Functional outcome in these fractures isnot so dependent on fracture site; rather, unsatisfac-tory results are more related to open fractures,comminuted fractures, and associated soft tissue inju-ries.78 Table 2 lists potential problems that can occurwith phalangeal fractures and strategies for therapeu-tic intervention.

Proximal Phalanx (P1) Base FractureIntra-articular base fractures are due to an abduc-

tion force from sports injuries or a fall on anoutstretched hand. These articular fractures requireaccurate reduction to restore normal joint kinemat-ics. After reduction, stability of the fracture positioncan be maintained with conservative treatment due totension in the surrounding intact joint capsule, collat-eral ligament complex, interossei tendons, and volarplate for fractures in the proximal 6- to 9-mm rangefrom the joint.111 Positioning the MP joint in 70°flexion results in balanced tension of these capsularstructures. The PIP and DIP joints, buddy taped to anadjacent digit, are allowed early active motion. Theintrinsic plus position of the splint design also causesthe extensor aponeurosis to be tightened and drawndistally over the base of P1, providing compression ofthe fracture. After 2 to 3 weeks,79 or 3 to 4 weeks,32

depending on callus formation, the splint can beremoved for protected ROM at the MP joint.

TABLE 2. Potential problems with phalangeal fractures andstrategies for therapeutic intervention.

Potential Problems Prevention and Treatment

Loss of MP flexion Circumferential PIP and DIPextension splint to concen-trate flexor power at MPjoint; NMES to interossei

Loss of PIP extension Central slip blocking exercises;during the day MP extensionblock splint to concentrateextensor power at PIP joint;at night PIP extension guttersplint; NMES to EDC andinterossei with dual channelsetup

Loss of PIP flexion Isolated FDP tendon glide exer-cises; during the day MPflexion blocking splint toconcentrate flexor power atPIP joint; at night flexionglove; NMES to FDS

Loss of DIP extension Resume night extension splint-ing; NMES to interossei

Loss of DIP flexion Isolated FDP tendon glide exer-cises; PIP flexion blockingsplint to concentrate flexorpower at DIP joint; stretchORL tightness; NMES to FDP

Lateral instability any joint Buddy strap or finger hingedsplint that prevents lateralstress

Impending Boutonniere defor-mity

Early DIP active flexion tomaintain length of lateralbands

Impending swan neck defor-mity

FDS tendon glide at PIP jointand terminal extensor tendonglide at the DIP joint

Pseudo claw deformity Splint to hold MP joint in flex-ion with PIP joint full exten-sor glide

Pain Resume protective splintinguntil healing is ascertained;address edema, desensitiza-tion program

Abbreviations: DIP, distal interphalangeal; EDC, extensor digitorumcommunis; FDP, flexor digitorum profundus; FDS, flexor digitorumsuperficialis; MP, metacarpophalangeal; NMES, neuromuscular elec-trical stimulation; ORL, oblique retinacular ligament; PIP, proximalinterphalangeal.

Displaced base fractures can not be reduced withMP joint positioning alone as often the collateralligament, attached to the fracture fragment, isavulsed. Shewring’s review89 of 33 displaced basefractures found a high rate of nonunion with conser-vative management due to displacement of the frac-ture as the collateral ligament tightens with flexion ofthe MP joint. These avulsion fractures occur mostoften at the ulnar collateral ligament of the thumb or


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FIGURE 6. (A) Wrist and distal joint immobilizer splint used duringexercise sessions to promote flexion at the metacarpophalangealjoint (MP); (B) MP joint flexion isolated during exercise with use ofdual blocking splints.

index and radial collateral ligament of the ring andsmall fingers.8,79 Techniques used for fixation ofdisplaced fractures include tension band wiring usinga figure-of-eight weave,62 intraosseous wiring withadditional K-wire support,110 or screw fixation.2,50 AsMP joint stiffness with loss of flexion is the mostcommon postoperative soft tissue complication of P1base fractures, protective splinting must rest the MPjoint in flexion. When active exercises are initiated toregain full MP flexion, the use of splints holding thewrist, PIP, and DIP joints immobilized during exer-cise, will facilitate all flexor strength directed towardsthe MP joint (Figure 6A-B). Continuous passivemotion (CPM) following ORIF with rigid fixation isindicated to maintain joint mobility, decrease edema,and stimulate the healing of articular cartilage.81

P1 Shaft Fracture

Fractures occurring in digital flexor zone II, called‘‘no man’s fractures,’’17 are renown for the worstprognosis in regaining full mobility.31 Ninety percentof the bone’s surface is covered by gliding struc-tures—the central tendon dorsally, lateral bands bilat-erally, and the FDP tendon volarly—that can easilybecome adherent to fracture callus. Fractures of theshaft require accurate reduction to allow these softtissues to glide normally.110

Nondisplaced fractures require protection, but nottotal immobilization. Inclusion of a neighboringnoninjured digit in the splint and buddy strappingpermit early AROM. Oxford73 recommends a single-digit circumferential splint for stable fractures, whichprovides extended lateral support at the PIP joint fordistal shaft fractures or volar and dorsal immobiliza-tion of the MP joint for proximal shaft fractures. Thisdesign allows for free active PIP joint motion.

Displaced P1 fractures present with apex palmarangulation. This angulation is due to a volar force atthe base of P1 by the interossei insertion, while theextensor expansion pulls the distal fragment dor-sally.11 Freeland39 recommends that the ‘‘least intru-sive technique be used to provide a threshold ofstrength that reliably holds the fracturesecurely . . . and would allow simultaneous early reha-bilitation.’’ Methods of fixation for displaced, un-stable fractures include closed transcutaneousinsertion of K-wires or intramedullary rods,percutaneous miniscrews, open internal fixation withminiscrews, miniplates, and mini external fixators.40

The most common problem at this level beginswith an extensor lag at the PIP joint, which developsinto a fixed joint flexion contracture.74 The worstcase scenario results when minimal motion at the PIPjoint results in a fixed flexed position of the joint,which is compensated at the MP joint withhyperextension to remove the flexed finger from thepalm. A pseudo-claw hand posture is created. Preven-tion of this deformity relies on emphasizing PIP jointextension at rest and early tendon glide along allbone surfaces. Initially, a splint is made that main-tains flexion at the MP joint, with a dorsal hoodexpansion to securely strap the PIP joint into fullextension at rest (Figure 5).24 The volar part of thesplint stops at the distal palmar crease. Hourly thedistal straps are removed to permit early tendongliding, emphasizing central slip, lateral bands, FDS,and FDP tendons, respectively. Full PIP joint flexionis not promoted until the patient is able to activelyextend the PIP joint to 0°.34 Burkhalter17 reminds usthat it is far easier to gain flexion than extension atthis joint.

Later, a functional blocking splint can be used tocounter the pseudo-boutonniere posturing that oc-curs with less than optimal tendon gliding (Figure7A-B). The splint immobilizes the MP joint in flexion,protecting against MP hyperextension, while alsodirecting all flexor and extensor tendon power to thePIP joint. Light-resistance exercises for PIP jointflexion and PIP joint extension are facilitated whenperformed in the splint.

P1 Condylar FractureThe 2 condyles at the head of the proximal

phalanx, with their intimate convex-concave fit on themiddle phalanx base, provide stability to a joint

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FIGURE 7. (A) Pseudo-boutonniere deformity of ring digit followingproximal phalanx fracture; (B) the blocking splint facilitates flexorand extensor tendon gliding at the proximal interphalangeal joint(PIP).

deprived of much soft tissue support. The type oftissue injury caused with a lateral deviation force isdependent on the rate of loading: stress applied withlow loading rate causes collateral ligament injury,while a high loading rate can result in a collateralavulsion fracture, or a unicondylar (1 side) orbicondylar (2 sides) fracture configuration at thehead of P1.60 A ball forcing the digit away from thecenter line of the hand most often fractures thecondyle towards the middle of the hand.109 This is acommon sports injury that is often misdiagnosed as a‘‘jammed finger’’ as the athlete can move the fingerwell.82 Continued unsupported use of the hand canchange a simple nondisplaced fracture into anangulated fracture with painful joint incongruity.93

These potentially unstable fractures are best treatedwith ORIF to assure good joint alignment is achieved.

The problem with ORIF at this level is access to theP1 head directly under the central extensor slip.Authors have advocated various incision locations:splitting the extensor tendon longitudinally,77 incisingbetween the lateral band and the central tendon,72

excising the insertion of the central tendon creatinga flap,20 or a lateral midaxial incision.54 As the mostsignificant complication following P1 fracture is lossof full PIP joint extension, the lateral approaches thatspare direct trauma to the central tendon are moreappealing. However, Horton48 found that despite the

lateral incision used for screw placement, the ORIFgroup in his study had 3 times greater PIP jointextension lag (27°), as compared to the group thatreceived closed reduction treatment (8°). This maybe partly explained by the mutually dependent roleplayed by the central slip and lateral bands inachieving full PIP joint extension. It may be thatadhesions in either system will affect PIP joint exten-sion.

Pain and swelling at the PIP joint postoperativelyare a great barrier to rehabilitation. Swelling willdraw the joint into a flexed posture that over timewill become a contracture. Splinting must rest thePIP joint in full extension, with hourly short-arcAROM performed. It is crucial that the patient workto achieve proximal gliding of the extensor mecha-nism, and thus 0° extension to prevent an extensorlag. The use of continuous passive motion (CPM)following rigid internal fixation of these fracturesresults in regeneration of hyaline articular cartilage,reduction of edema, prevention of adhesions andjoint stiffness, and is painless.80 Incised and repairedcentral slip tendons can also be treated with theshort-arc-motion protocol, as there is continuity ofthe extensor tendon longitudinally. Full PIP jointflexion is limited for 3 weeks to prevent splitting thesutured tendon approximation.

Middle Phalanx (P2) Base FractureThis intra-articular fracture is caused by a

hyperextension, hyperflexion, or lateral deviationforce on an outstretched finger, as occurs in basket-ball and volleyball injuries, or from a fall onto theoutstretched hand.87 Hyperextension or hyperflexioninjuries are often severe enough to cause the PIPjoint to dislocate with associated soft tissue damage tothe volar plate or central slip respectively, commonlycalled avulsion fractures. With severe compressivetrauma, comminuted fractures of the articular surfaceoccur, causing depression of the fragments into thebone shaft, called a pilon fracture. Pilon is derivedfrom the Latin word ‘‘pounder,’’ indicating the forcerequired to create this deformity.95

Palmar Plate Avulsion Fracture Also known as dorsalfracture dislocation, this fracture results from ahyperextension injury in which the distal attachmentof the volar plate, at the base of P2, is ruptured alongwith a variable portion of the articular surface of thevolar middle phalanx. Without the normal restrainsprovided by an intact volar plate, tension from thefinger extensors on their distal attachment causes thebase fracture to dislocate dorsally. The percent ofarticular surface involved and the percent of jointdislocation determine severity of this fracture.83

Buddy taping and immediate active motion are usedto manage less severe fractures. Fractures of moder-ate severity (20% to 40% of the articular surfaceinvolved) are treated with extension block splinting

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for greater than 6 weeks. This fracture is at risk fordisplacement with full extension. A dorsal blocksplint prevents the joint from extending by 30° to40°, yet allows full joint flexion (Figure 8). Thisprotocol allows fracture compression with flexion,while avoiding fracture separation with extension. Asfracture healing ensues, the splint angle is subse-quently remolded at less extension block weekly,permitting gain in extension range. Usually there is aslight flexion contracture at the end of the 6- to8-week splinting regime, which can be treated withdynamic extension splinting.30 Fractures with greaterthan 40% of joint surface involvement usually do notremain congruent in any limited arc of motion andare therefore managed with ORIF.

Central Slip Avulsion Fracture This fracture, alsoknown as ‘‘dorsal fracture dislocation’’ or ‘‘bouton-niere fracture,’’ includes a fracture fragment fromthe dorsal base of P2 that is attached to the centralextensor tendon. Fortunately it is a rare injury andtreatment depends on the ability to restore the volarsubluxed P2 back to approximate the avulsed frag-ment. Reduced fractures are immobilized in full PIPjoint extension for 4 to 6 weeks, and the patient isinstructed in active DIP joint flexion exercises tomaintain gliding and length of the lateral bands andoblique retinacular ligament (Figure 9). Flexion atthe DIP joint will prevent the appearance of aboutonniere deformity post immobilization.22 Closedreduction, however, is often difficult due to soft tissueconstraints, necessitating ORIF with pin, screw, ortension band wiring.8 A removable protective finger-based splint is worn that maintains the PIP joint in

FIGURE 8. Volar plate avulsion fracture treated with extensionblock splint that limits full extension at the proximal interphalangealjoint (PIP); the degree of blocking is determined by fracturedisplacement with extension. The distal strap (not shown) isremoved to allow active PIP and distal interphalangeal joint (DIP)flexion and extension.

FIGURE 9. Cast for central slip avulsion fracture that maintains fullproximal interphalangeal joint extension while allowing active distalinterphalangeal joint flexion to maintain the length of oblique lateralligaments and lateral bands.

FIGURE 10. Dynamic traction splint for comminuted pilon frac-tures. The finger is moved passively along the arc several times perday to stimulate regeneration of articular cartilage and remodel thejoint surface. Rubber band tension is measured to assure 300 g ofligamentotaxis distractive force throughout the range.

full extension and is removed for passive ROMexercises. Pins are removed at 2 to 3 weeks, at whichtime, active ROM can begin to further glide softtissues. With screw fixation, active motion can beginimmediately with the use of the same splint toprevent flexed posturing at the PIP joint.

Pilon Fracture Severe compressive trauma can causethe head of the proximal phalanx to impact into thebase of P2, creating many small, crushed fracturefragments. The distal articular surface of the PIPjoint is essentially destroyed. ORIF seeks to elevatethe central depressed articular fragments and main-tain their length with bone grafts or externalfixators.51 Another option is to use a combination oftraction and motion to model a new joint throughthe use of dynamic traction splinting (Figure 10).This latter method uses a radial or ulnar gutter splintthat blocks the MP joint in flexion. Rubber band


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traction from a circular outrigger is attached toexposed K-wires passed through the middle phalanxdistal to the fracture. Tension is measured with aHalston gauge to assure that adequate distractiveforce of 300 gm is exerted. The distractive force usesa concept called ‘‘ligamentotaxis,’’ in which the softtissue envelope that encircles the fracture (intactperiosteum, collateral ligaments, joint capsule) isplaced under longitudinal tension, causing these softtissues to narrow and compress the fracture.58 Duringthe day the dynamic-traction component is movedalong the circular outrigger hoop to achieve passivePIP joint motion, which is beneficial to articularcartilage healing. The splint is worn continuously for6 to 8 weeks (removed briefly for dressing purposes)to prevent displacement of the fracture.46 Kearney59

reported on a 9-year follow-up of patients treatedwith dynamic traction and found that all joints werepain-free and asymptomatic, they maintained their87° arc of PIP joint motion, and the joint space hadbeen maintained, indicating good cartilage thickness.The use of dynamic traction for pilon fractures wascompared with ORIF and found to produce the sameresults with fewer complications.95

P2 Shaft Fracture

Fractures at this location are rare, due in part tothe short, broad shaft that is stronger here than inproximal bones. The path of the lateral bands,spiraling from their lateral position at the PIP joint tobecome conjoined dorsally over the distal part of thisphalanx, place them in jeopardy of adhering tofracture callus with closed methods, or of becomingimpaled with pins and screws with open methods.Longitudinally placed pins down the medullary canaltry to avoid this soft tissue problem.8 Limitation oflateral band gliding will result in loss of DIP jointterminal extension. Midshaft fractures can angulateeither dorsally or volarly, resulting in shortening ofthe middle phalanx shaft. This skeletal shorteningwill cause an imbalance in extensor tendon-bonelength ratio, resulting in loss of terminal DIP jointextension. Loss of full DIP joint extension, due toeither lateral band adherence or redundance, leadsto the classic swan neck deformity of DIP flexion withexcessive extensor force directed at hyperextendingthe PIP joint.1 Cannon19 recommended 3 weeksimmobilization with closed methods or K-wire fixa-tion, as FDS tendon action can displace this fracturedue to its insertion on the P2 shaft. The digit issplinted in the functional position of MP joint flexionwith PIP and DIP joints in full extension. For longoblique or spiral fractures, ORIF or percutaneous useof screws provides enough stability to allow AROMwithin 1 week. Emphasis is placed on FDS tendonglide at the PIP joint and terminal extension glide atthe DIP joint, countering the swan neck deformity.

P2 Neck FractureNeck or subcapital fractures are more common in

young children whose fingers have been trapped inclosed doors or electric windows. These fractures areusually markedly displaced and unstable, requiringORIF. Stern’s review93 of complications suggests thatK-wires should remain in for a longer duration of 4to 6 weeks. Postoperative therapy is based on thestability of the fixation. DIP joint stiffness, with loss ofactive flexion, and an extensor lag are the chiefcomplications. Protective splinting of the DIP joint infull extension, with frequent removal for FDP tendongliding is recommended.

Distal Phalanx (P3) FracturesThe distal exposed portion of the finger is most

vulnerable to injury, with fractures at the P3 levelaccounting for 50% of hand fractures.18 Causes offracture include crush to the distal tuft, as whenfingers are caught in closed doors or machines, blowsto an extended finger, and sports-related volar anddorsal articular avulsion fractures.84

P3 Base Fracture

Articular avulsion fractures are closed injuries thatresult when an actively contracting tendon is force-fully pushed into the opposite direction. Tendonrupture alone can occur, or an articular fragment ofvariable size can be avulsed along with the tendon.Two common types of avulsion fractures at this levelare ‘‘jersey’’ fracture and ‘‘baseball’’ fracture.

Volar Jersey Avulsion Fracture This fracture is namedafter the football injury in which one player grabs theshirt of an opponent who pulls away forcefully,causing the FDP tendon, with a bone chip, to beavulsed from the volar base of P3. Loss of terminaljoint active flexion requires early and judicious care,as FDP tendon muscle shortening can occur ifundetected. With small fragments, the tendon (withthe fracture fragment attached) is surgically reat-tached through P3 using wire pull-out sutures over adorsal button. A dorsal blocking splint is fabricatedand the postoperative Durand tendon motion proto-col is followed.19 Large fracture fragments requirethe additional support of K-wires to assure good jointsurface congruence is achieved.84 A modified Durandprogram is performed, omitting DIP joint flexionuntil the wire is removed.

Dorsal Avulsion Fracture This fracture, known as‘‘mallet fracture’’ or ‘‘baseball fracture,’’ is commonto all sports and hobbies in which an extended fingeris forced into either flexion or hyperextension.65 Theextensor terminal tendon is avulsed off the dorsalbase of P3, with a chip of variable-sized bone at-tached. If the fracture piece represents less that onethird of the articular surface, it may be managed with


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FIGURE 11. Tip protector splint bivalved to maintain distalinterphalangeal joint (DIP) extension and accommodate swelling formallet fractures.

closed splinting of the DIP joint in extension for 6weeks (Figure 11). Bivalving the splint, which issecured with coban wrap, allows accommodation forany swelling. Splinting is continued at night andduring vigorous activities for another 2 to 4 weeks. Ifextensor lag at the DIP joint is noted, then splintingis resumed during the day also.

Fracture fragments that are greater than one thirdof the articular surface can be surgically reattachedusing various wiring techniques.10,27,28,99,108

Damron’s27 analysis of these common fixation meth-ods noted that none of the fixation methods provideenough stability to permit early motion. All jointsmust be immobilized for a minimum of 6 weeks, aswith conservative methods. Surgical treatment formallet fractures have been reported to have a 53%complication rate due to infection, joint incongruity,nail deformity, and extensor lag; as opposed to a 45%complication rate for closed treatment.94 Wehbe106

suggests that due to these findings most malletfractures should be treated with conservative closedmethods.

Following the 6 weeks of continuous immobiliza-tion in extension, composite flexion and extension ofthe PIP and DIP joints is taught. Blocked DIP jointflexion exercises are not performed, as this wouldstretch out the oblique retinacular ligament (ORL).Because the greatest complication of mallet fracturesis a DIP joint extensor lag, an intact ORL will serveto passively assist DIP joint extension as PIP jointactive extension occurs.19

P3 Shaft Fracture

Trauma at this level, proximal to the nail bed,usually causes an open wound that needs to besupported with external splinting or K-wire andsplinting for 3 weeks. Wound care, edema measures,

and motion at the MP and PIP joints is encouragedafter the first week. Active ROM at the DIP joint canbe initiated after 3 weeks if callus consolidationpermits. Loss of full DIP joint flexion is usually dueto soft tissue contracture of joint structures anddorsal skin scar. Wrapping the digit with coban intoan intrinsic minus position and then dipping intoparaffin provides simultaneous heat and stretch,which has been shown to have the best effect on softtissue lengthening.49 This is followed by blockingexercises for FDP tendon glide.

P3 Tuft Fracture

Treatment of the tuft fracture, even when commi-nuted, is relatively simple. Compression around thetip facilitates fragment approximation and diminishesthe very painful effect of bleeding and swelling at thislevel. A thin, protective splint extending to, but notincluding, the PIP joint is worn for 2 to 3 weeks.Fibrous union is slow to ossify at this level, requiringseveral months26; however, motion can and should bereintroduced at the DIP level by reducing the lengthof the protective splint and encouraging joint mo-tion. The more difficult aspect of managing thesefractures is the extent of nail bed injury that may bepresent and require suturing. Dressing changes thatdo not disturb the repaired nail bed are performedafter soaking the tip of the finger in a sterilecontainer filled with saline and part hydrogen perox-ide.19

The finger pulp region is densely innervated withsensory end organs that painfully respond to theinitial crush, nail bed damage, and swelling with thedevelopment of hypersensitivity to touch. Use of aTopiGel sleeve, once nail bed healing is complete,assists in scar management as well as dampeningpainful sensory input. Desensitization programs thatinclude vibration, putty press, and texture toleranceare beneficial to accommodate to normal fingertipuse.

Occasionally, the fracture pattern shows significantdisplacement of the 2 fracture fragments, requiringORIF with K-wire fixation for 3 weeks.2 Protective,supportive splinting, including DIP and PIP joints,initially allows the inflammatory period to resolve.Care must be taken that the splint does not rubagainst the exposed pin, as excessive irritation canresult in a pin tract infection.

CONCLUSION

Unique to hand anatomy, soft tissues glide inmultidirections mere millimeters away from skeletalstructures. It is impossible, then, to consider skeletalinjury as isolated trauma to bone tissue only. Traumaand fracture displacement can harm surrounding softtissue structures as well as encase both together in


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the healing processes of callus and scar. Successfulrehabilitation of hand fractures addresses the need tomaintain fracture stability, introduce soft tissue mobi-lization, and remodel restrictive scar.

A review of the literature found a paucity of studieson fracture rehabilitation. Until recently, therapistsdid not treat fractures; rather, they treated the softtissue complications secondary to prolonged immobi-lization. These complications have been the impetusfor development of early controlled-motion programsduring the appropriate phase of fracture healing.With few prospective or controlled studies to guideus, evidence for best-practice strategies in fracturerehabilitation is often gleaned from failure experi-ences.

The anatomy and biology of bone healing assists indirecting the position and duration of immobiliza-tion, the initiation of motion protocols, and strength-ening exercises to meet functional demands. Thecourse and progression of bone healing is directlyrelated to the chosen fracture fixation mode. Bothoperative and nonoperative methods of fracture man-agement share the common goal of assuring thatfractures heal in correct alignment, while permittingearly mobility protocols. Lee66 summarized this con-cept: ‘‘The outcome of any fracture is influenced bythe choice of treatment as well as the type andduration of immobilization.’’ This article describesfracture management choices, immobilization posi-tions, early motion protocols, and intervention strate-gies for potential problems unique to eachmetacarpal and phalangeal fracture location in thehand.

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Principles of Metacarpal and Phalangeal Fracture Management: A Review of Rehabilitation Concepts

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