fractures of the carpus and hand

ORTHOPAEDICS III: UPPER LIMB

Fractures of the carpusand handStephen Bostock

AbstractFractures of the carpus and hand are common. Diagnosis and treatment is

often simple and straightforward. At other times diagnosis can be difficult

and, even with the best possible treatment, the outcome may be disap-

pointing. This article describes a variety of carpal injuries with particular

reference to the scaphoid fracture and perilunate fracture dislocation. This

is followed by a description of bony injuries that can affect the hand:

including fractures of the metacarpals and phalanges, crush injuries, avul-

sions, gamekeeper’s thumb, and Bennett’s fracture.

Keywords Avulsion; Bennett; carpus; crush; gamekeeper; hand;

metacarpal; perilunate; phalanx; scaphoid

General principles

History and physical examination

All carpal and hand injuries require careful assessment. In

addition to recording the mechanism of injury, it is important to

document handedness, occupation and other functional

requirements that the patient may have (for example at work,

sports, hobbies).

Swelling and tenderness should be noted during the physical

examination and it is important that a careful assessment for

deformity is made when a fracture is suspected. In metacarpal

and phalangeal fractures, particular attention should be paid to

rotation of the digit. Significant malrotation is often not apparent

on plain radiographs.

Radiography

Carpal injuries: Anteroposterior (AP) and lateral views of the

wrist are obtained. A series of four ‘scaphoid views’ should be

obtained if there is scaphoid tenderness. Further specialized

views, together with other imaging modalities (computed

tomography (CT), magnetic resonance imaging (MRI)) are often

necessary following specialist referral if a carpal injury is

confirmed, or where clinical suspicion is high.

Suspected metacarpal fracture: the standard views of an injured

hand are an AP and an oblique view. These are adequate to

diagnose a metacarpal fracture. If a fracture is confirmed a ‘true

lateral’ view should be obtained to allow a more accurate

assessment of the degree of angulation, which may otherwise be

underestimated.

Stephen Bostock MB ChB BMedSci FRCS (Orth) is a Consultant Orthopaedic

Surgeon at the Northern General Hospital in Sheffield, UK. Conflicts of

interest: none declared.

SURGERY 28:2 70

Suspected phalangeal fracture: AP and lateral radiographs of

the affected digit should be obtained. Standard views of the hand

may also be helpful if there is pain at the base of the proximal

phalanx.

Management

Open fractures: in the presence of a wound, a phalangeal frac-

ture should be treated as an open injury. Early management

includes recording the location and extent of the wound together

with clinical testing of the appropriate nerves, tendons and

vessels. The wound is then dressed with a sterile dressing and

antibiotic and tetanus prophylaxis given. A temporary splint may

be necessary. These cases almost invariably require formal

surgical exploration.

Massive hand trauma: management of these difficult cases

usually requires referral to a specialist centre. Treatment is

complex and often requires multiple operations.

Pathological fractures: pathological fractures occur when

a bone has been weakened by an underlying disease process.

They are often the result of a relatively trivial injury. Treatment

should take into consideration the underlying pathology.

Fractures of the carpus

The eight carpal bones may be fractured in isolation, in combi-

nation with each other, or in combination with ligamentous

injuries.

Scaphoid

The scaphoid is the most commonly fractured carpal bone.

Anatomically, these fractures can be divided into those affecting

the waist (70%), the proximal pole (20%) or the distal third

(10%). Clinical suspicion should be aroused by tenderness over

the scaphoid, for example in the interval between the extensor

pollicis longus and extensor pollicis brevis distal to the radial

styloid (the anatomical snuffbox). If suspicion is high, and even

if the first series of plain radiographs appear normal, the patient

should be treated as if there is a fracture with plaster immobili-

zation. A scaphoid cast that incorporates the thumb is tradi-

tionally used, although a Colles’ plaster appears to be just as

effective. Patients are usually reassessed at 2 weeks and, where

doubt exists, further scaphoid views are obtained. If a fracture is

present it is usually visible at this stage.

The majority of scaphoid fractures can be managed non-

operatively in plaster with a period of 6 weeks of immobilization

in the first instance. If at 6 weeks the scaphoid area remains

tender and the fracture line continues to be visible on X-rays, an

extended period of immobilization may be recommended. With

this type of regimen, a small proportion of fractures fail to unite.

The prognosis for union is poorer with a small proximal frag-

ment, largely owing to the bone’s retrograde blood supply.

There is a vogue towards early internal fixation with the

advantage that the wrist can be mobilized early. There is also

some evidence to suggest that internal fixation of an acute frac-

ture reduces (although does not eliminate) the risk of non-union.

The Herbert screw was designed specifically for scaphoid fixation

(Figure 1).

� 2009 Elsevier Ltd. All rights reserved.

Screw fixation of the scaphoid

1. The trailing thread is buried in the bone. 2. Screw design gives compression across the fracture site.

1

2

Figure 1


Isolated fractures of the other carpal bones

Dorsal avulsion fractures of the triquetrum are relatively

common and are managed conservatively. Most lunate ‘frac-

tures’ are secondary to Keinbock’s disease and are not the result

of an acute injury. Fractures of the body of the hamate usually

heal with conservative treatment. A fracture of the hook of the

hamate carries the risk of non-union and fixation of the hook

may be indicated. Trapezium and trapezoid fractures seldom

occur and usually settle with conservative treatment, as will

a fracture of the pisiform. Isolated fractures of the capitate are

also rare, being more commonly seen as part of a perilunate

dislocation. Whether in isolation or not, most capitate fractures

require fixation.

Perilunate fracture dislocations

These are a group of injuries in which there is disassociation of

the carpus about the lunate. A lesser (ligamentous) and a greater

(bony) arc of injury have been described by Mayfield and are

often combined to produce a mixture of bone and ligamentous

damage. Radiographs can be difficult to interpret. The lateral

radiograph usually reveals the nature of the injury, with the

capitate no longer sitting centrally on the lunate (Figure 2).

Finger fractures

Distal phalanx

Crush injuries: crush injuries to the distal phalanges are

common. Treatment of these fractures is usually conservative. A

subungual haematoma implies damage to the nail bed and, if

present, consideration should be given to exploration and nail

bed repair.

Mallet finger: mallet finger is caused by avulsion of the

extensor tendon from the base of the distal phalanx. The tendon

may have an attached bony fragment of variable size (Figure 3).

SURGERY 28:2 71

Most of these injuries can be managed with a ‘mallet splint’ for

6e8 weeks. Operative intervention is usually indicated,

however, if there is volar subluxation of the distal phalanx joint.

Avulsion of the flexor digitorum profundus: avulsion of the

flexor digitorum profundus may involve a bony fragment and, if

so, the fragment may be seen on X-ray at a variable distance from

its origin. The displacement reflects retraction of the tendon.

Treatment is operative.

Proximal and middle phalanges

Fractures of the shaft: rotation must be assessed clinically and

even undisplaced fractures are potentially unstable. In many

patients, however, early active mobilization is acceptable,

provided the progress of the patient is monitored carefully with

regular radiographs. Immobilization of any sort carries the risk of

joint stiffness. To limit this risk, the splinted fingers should be in

the ‘intrinsic plus’ position (Figure 4).

Displaced fractures usually require reduction and stabilisation

with some form of operative fixation. Adequate splintage is often

difficult to maintain. Percutaneous fixation with K-wires is

a popular method of fixation, though early mobilization may not

be possible (Figure 5).

Open reduction and internal fixation is becoming increasingly

popular with the development of hand-specific screw and plate

systems (Figure 5). This allows for immediate active mobiliza-

tion, though the soft tissue dissection is associated with its own

set of potential problems (for example adhesions, delays in

union, infection).

Condylar fractures: condylar fractures may affect one or both

of the condyles. Most condylar fractures are displaced and

require reduction and fixation. Open reduction may be neces-

sary, but increases the risk of avascular necrosis of the distal

fragment(s).


Carpal disclocation

Is this a simple displaced fracture of the scaphoid? Look carefully at the lateral X-ray, the lunate and capitate are disconnected. This is a trans-scaphoid perilunate dislocation of the carpus.

L

C

Figure 2


Fractures of the base of the middle phalanx

� Avulsion of the central slip may take with it a small bony

fragment. If untreated this will lead to a ‘boutonniere’

deformity. Treatment is by reattachment.

Injury to the volar plate is common and is caused by hyper-

extension. A small ‘pull-off’ fragment of bone may be visible

adjacent to the base of the middle phalanx on the volar side.

Most can be treated by early active mobilization, though some

advocate a splint to block the last 15e20� of extension.

� Marginal fractures e ‘neighbour strapping’ may be used to

achieve early mobilization of marginal fractures if they are

undisplaced and small.

� Fracture subluxations are a subgroup of proximal interpha-

langeal (PIP) joint injuries. There is a fracture of the base of

the middle phalanx, which is often comminuted and associ-

ated with subluxation of the joint on the lateral view

(Figure 3). They present a difficult group, because the

comminuted fragments are usually too small to fix. The use of

an external fixator to distract the PIP joint is becoming

increasingly popular. Traction reduces the subluxation and

improves the position of the fragments by the process of

‘ligamentotaxis’.

SURGERY 28:2 72

Metacarpals

Fractures of the metacarpals occur predominantly on the ulnar

side of the hand. The fifth metacarpal is most commonly affected,

often as a result of punching injury.

Metacarpal head

If displaced, fractures of the metacarpal head usually require

open reduction. A tooth-induced injury should be suspected if

the fracture is associated with an overlying wound. These

injuries carry a risk of serious metacarpophalangeal (MCP) joint

infection and require appropriate surgical washout and antibiotic

treatment.

Neck

Significant angulation may be well tolerated in the ring and little

fingers (up to 40�). Only 10e15� of angulation should be

accepted in the index and middle fingers.

Shaft

A true lateral radiograph is essential to assess angulation. Up to

10� of angulation may be acceptable in the index and middle

fingers, and 20� in the ring and little fingers. Displaced fractures

may be treated by closed manipulation and percutaneous


The ‘intrinsic plus’ position

The ‘intrinsic plus’ position minimizes the risk of metacarpophalangeal and interphalangeal joint contracture

Figure 4

Clockwise from top left: mallet finger, spiral fracture of proximal phalanx, comminuted fracture shaft fifth metacarpal, proximal interphalangeal

joint fracture subluxation.

Figure 3


SURGERY 28:2 73

fixation. Some fractures require open reduction with internal

fixation.

Base

Fractures of the metacarpal base are often intra-articular. True

lateral radiographs are required to exclude joint subluxation. If

subluxed, the joint requires reduction and stabilization (usually

with wires).

Thumb

Gamekeeper’s thumb

Gamekeeper’s thumb is caused by rupture of the ulnar collateral

ligament of the MCP joint. This may be associated with an

avulsed fragment of bone from the base of the proximal phalanx.

Clinically, there is pain and tenderness at the level of the MCP

joint. Increased laxity can be difficult to appreciate and this

injury can be missed. Treatment is usually by operative repair.

Bony fragments can often be reattached.

Bennett’s fracture

Bennett’s fracture is an intra-articular fracture of the base of the

thumb metacarpal in which the MCP joint is subluxed. Extra-

articular fractures of the thumb metacarpal are not true Bennett’s

fractures, while comminuted intra-articular fractures are more


Methods of fixation for a displaced fracture of the shaft of a phalanx

a K wires b Screws c Screw and plate

Figure 5


accurately termed Rolando’s fractures. Manipulation with percu-

taneous fixation or formal internal fixation is usually required.

Summary

Fractures of the carpus and hand are common. Diagnosis and

treatment depend on the bone involved, the site within the

bone, and the fracture’s displacement and stability. The

outcome of hand fractures depends both on the site and severity

of the initial injury, and the method of treatment. A

SURGERY 28:2 74

FURTHER READING

Clay NR, Dias JJ, Costigan PS, et al. Need the thumb be immobilised in

scaphoid fractures? A randomised prospective trial. J Bone Joint Surg

1991 Sep; 73: 828e32.

Green D, Hotchkiss R, Pederson W, Wolfe S. Green’s operative hand

surgery. 5th edn. Churchill Livingstone, 2005.

Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new

screw. J Bone Joint Surg 1984 Jan; 66: 114e23.

Jupiter J, Ring D. AO manual of fracture management: hand and wrist.

Thieme, 2004.


fractures of the carpus and hand

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