Fracture management
Fracture	Period of full immobilisation	Position of immobilisation	Criteria for referral	Important notes
Proximal phalanx	Up to 3 weeks	Safe position	Intra-articular surface involvement >30%Unstable fractures – rotation – excessive angulation – Multiple fingers	Review X-ray in 1 week Begin active exercise early
Middle phalanx	Up to 3 weeks	Interphalangeal joints in extension	Intra-articular surface involvement >30%Unstable fractures – rotation – excessive angulation – Multiple fingers	Review X-ray in 1 week Begin active exercise early
Volar plate avulsion fracture	1 week	Slight flexion or use an extension blocking splint	Large avulsion fragment Fragment within joint space (passive range of motion reduced)	Flexion exercises commence at 1 week with intermittent splint Extension exercises commence at 3 weeks
Distal phalanx	2–3 weeks	L-shaped splint to protect soft tissue	Large loss of soft tissue Intra-articular surface involvement >30%	Usually stable fractures Often crush injury mechanism Treat associated nail injury#
Mallet fracture	6–8 weeks	DIP joint in slight hyperextension	Avulsion fragment >30% of articular surface	Patient education regarding the wearing of a splint
Metacarpals 2–5	3–4 weeks	Safe position MCP at 90 degrees	Rotation Angulation >10 degrees for metacarpals 2 and 3 Angulation >20–30 degrees for metacarpals 4 and 5 Open fracture Multiple metacarpals involved	Repeat X-ray at 1 and 2 weeks After 3–4 weeks active exercise and intermittent splinting/supportive bandage Resume contact sport in 6–8 weeks

Metacarpals 2–5 fractures

• Metacarpal fractures account for 18–44% of all hand fractures.
• Non-thumb metacarpals, especially the fifth finger, constitute about 88% of these fractures.
• The majority are isolated, simple, closed, and stable.
• There is often a lack of comprehensive literature and consensus on the optimal treatment approach.
• Anatomy of the Metacarpals:
  • The four finger metacarpals form a transverse arch with a concave palmar aspect.
  • The index and middle finger metacarpals are relatively fixed, whereas the ring and small finger metacarpals have a 15–25° range of motion.
• Pathoanatomy and Diagnostic Criteria:
  • Fractures can be open/closed, intra-/extra-articular, and exhibit various fracture line patterns.
  • Diagnoses involve examining shortening, angulation, rotational deformity, and radiographic views.
• Nonoperative Treatment Overview:
  • Most metacarpal fractures, particularly the 5th metacarpal, can be effectively treated without surgery.
  • Treatment modalities vary based on the type of fracture and may include buddy taping, splinting, or casting.
• Detailed Nonoperative Treatment Approaches:
  • For 5th metacarpal neck fractures, methods like traction reduction and cast immobilization have shown 81% improvement in angulation.
  • Different immobilization methods (buddy taping, splint, or cast) are used, with the length of immobilization depending on clinical examination rather than X-ray evidence.
• Outcomes and Effectiveness of Nonoperative Treatments:
  • Nonoperative treatments often result in satisfactory functional and aesthetic outcomes.
  • Studies indicate that various types of metacarpal fractures respond well to nonoperative treatments, with near-normal function and aesthetics achievable even with significant angulation.
• Specifics on Fracture Types and Recommended Treatments:
  • 5th Metacarpal neck or shaft fractures may not need reduction; options include buddy taping or splint/cast immobilization.
  • Index, middle, and ring finger metacarpal shaft fractures may be treated with a palmar wrist splint and immediate mobilization.
• Clinical Studies and Findings:
  • A study comparing nonoperative and surgical treatments for small finger metacarpal fractures found generally favorable outcomes for nonoperative treatments.
  • Another study indicated that splinting without reduction attempt for small finger metacarpal neck fractures yielded satisfactory results.
• Immobilization Method Efficacy:
  • No particular immobilization method for conservative management has proven superior.
  • A trial comparing ulnar gutter casting in different MCP joint positions showed no significant difference in outcomes.
• Conservative Treatment of Other Metacarpal Fractures:
  • Non-thumb metacarpal oblique fractures treated with palmar wrist splints and immediate mobilization showed a 100% union rate, with excellent recovery of grip strength

Metacarpal neck fracture (sometimes labelled a “Boxer’s Fracture” when found in little finger metacarpal) For metacarpal neck fractures (i.e. the 5th metacarpal neck “Boxer’s Fracture”), greater degrees of apex-dorsal angulation may be accepted, so long as the clinical examination doesn’t reveal findings of malrotation, extensor lag (‘pseudoclawing’), or ‘MC head in the palm’ (palpable MC head because of angulation, felt palmarly) .	Left: neck fracture little finger metacarpal Right: neck fracture middle metacarpal
Metacarpal shaft fracture – Degree of acceptable angulation for fractures of metacarpal shaft and neck
Metacarpal Head Fracture   – Fractures of the metacarpal heads are relatively rare and usually result from a direct blow, crush, or missile injury -Most metacarpal head fractures require referral because they are intraarticular and typically comminuted
Metacarpal Base Fracture To better appreciate any dorsal subluxation in these injuries, a lateral or oblique view should be examined

Usual ED management of this fracture

Closed metacarpal injuries not needing reduction should be splinted in the safe hand position (Wrist in 20 degrees of extension, MCP joints in 70    degrees of flexion, IP joints in full extension)
b

• Where required, reduction can take place under procedural sedation and/or regional anaesthesia.
• After applying some longitudinal traction to the digit, the MCP is flexed to 90 degrees and then axial loading applied to the proximal phalanx to correct any flexion angulation.
• The hand is then splinted in the safe hand position as above

advice to parents

• Elevation of the limb, typically in a sling.
• Avoid activities involving the possibility of heavy impacts on the hand or cast, such as sports.
• Plaster care advice.

Thumb Fractures

classification

• By location (distal or proximal phalanx, or metacarpal),
• By presence or absence of growth plate involvement (Salter Harris classification),
• By particular fracture pattern (UCL injury/Skier’s thumb, Bennett’s fracture)
• Or as closed vs open fractures

Mechanism of Injury:

• Crush injuries, often in doorways, are common in children, leading to tuft fractures or Seymour fractures, possibly with nailbed injuries.
• Hyperabduction of the thumb, typically from falls or sports (like catching a ball awkwardly), can cause ‘Skier’s thumb’ (UCL injury with or without bony avulsion from the base of P1).
• Axial loading of the thumb in adolescents may result in intra-articular metacarpal base fractures (Bennett or Rolando fractures).

Clinical Presentation:

• Thumb fractures are characterized by local bruising, swelling, pain, loss of function, and sometimes deformity.
• Rotational deformity is assessed by comparing with the uninjured thumb, though this can be challenging to discern.
• Subungual hematoma or displacement of the nail plate may indicate an underlying fracture.

Fractures at the base of thumb:

	Bennett Fracture: usually from axial loading of the thumb in patients with closed physes. X-ray shows a small fragment of the metacarpal base articulating with the trapezium; muscles attaching elsewhere on the main part of the metacarpal  tend to pull it into subluxation. Examination will show bruising and tenderness at the thumb MCP joint ED management involves immobilisation in a thumb-spica (see below) and arranging an appointment within a week with the hand surgery team Definitive management by the hand surgery team requires reduction, usually involving K-wire insertion  Rolando fracture is similar to a Bennett fracture, except that instead of a clean break, the bone is shattered into several pieces.
	Fracture through an open physis  involving the same mechanism and deformation patterns as in a Bennett fracture. X-ray: This example shows a Salter-Harris II fracture of the metacarpal. Management is as with a Bennett Fracture above.
	Fracture proximal shaft of metacarpal usually from axial loading. Management is as with a Bennett fracture, as it is usually subjected to the same deforming forces from the muscle insertions.

Fractures of proximal phalanx

	Ulnar Collateral Ligament Injury/Avulsion (a.k.a. Gamekeeper’s or Skier’s Thumb) typically results from hyperabduction of the thumb. Clinical Examination: – Presents with bruising, swelling at the MCP joint, and focal tenderness on the ulnar side. – Pain is noticeable during pinch grip. – Ligament stability is tested by applying valgus stress to the MCP joint in slight flexion and full extension. – Laxity greater than 35 degrees, or more than 15 degrees compared to the uninjured thumb, suggests UCL injury, regardless of X-ray results. Radiological Assessment: – X-rays may reveal an avulsion at the UCL insertion or might appear normal Emergency Department Management: – Initial management includes applying a thumb spica and arranging early follow-up with the Hand Surgery Team, irrespective of avulsion presence. Definitive Management: – Most cases are managed non-operatively with hand therapy. – Some instances may require surgical repair.
	Radial Collateral Ligament Injuries Examination reveals ligamentous laxity on the radial aspect of the MCP joint, and local tenderness X-Ray findings are usually normal; avulsion is uncommon.
	Proximal Phalanx shaft fracture Examination reveals local swelling and tenderness +/- deformity ED Management involves closed reduction if angulated or displaced, then immobilisation in a thumb spica. Follow-up will be via hand surgery clinic
	Fracture through physeal plate of proximal phalanx (Salter-Harris) Examination will reveal local swelling and tenderness ED Management involves immobilisation in a thumb spica (with closed reduction if significantly angulated or displaced) Follow-up will be via hand surgery clinic within a week.
	Proximal Phalanx Neck fracture Examination will reveal local swelling and tenderness.Definitive Management requires early expert reduction by specialist hand surgery team, often with K-wire fixation. This should take place within a few days.ED Management involves immobilisation in a thumb spica and appropriate communication with the hand surgery team.

Fractures of distal phalanx

	Distal Phalanx Tuft Fracture Examination reveals local swelling and tenderness +/- deformity +/- nailbed injury Management consists mainly of treating any associated soft tissue or nailbed injury or tip avulsion.   Start appropriate oral antibiotics for any open fractures.F ollow up is with GP for most injuries, but Hand Surgery team if nailbed repair required or significant tissue disruption
	Seymour Fracture These are open fractures through the growth plate with associated nailbed injury and displacement of proximal nail plate from the nail fold.  They are significantly less common in the thumb than in the other fingers.   Management requires admission for washout, debridement, reduction, nailbed repair and antibiotics.

Reduction in ED:

• Some fractures may require reduction in the ED as previously described.

Immobilization:

• Almost all closed thumb fractures are immobilized in a thumb spica cast, made of plaster or fibreglass.
• In fractures of the thumb metacarpal (UCL/Skiers, Bennett’s, shaft fractures), the spica should allow mobility at the IP joint of the thumb.

Follow-Up:

• Patients with closed thumb fractures generally need a follow-up in a hand surgery clinic about a week later.
• This interval allows swelling to reduce for a more accurate assessment of the need for surgical management.
• The clinic may include multidisciplinary assessment, including hand therapy, to optimize recovery.

Advice to Parents:

• Provide plaster care instructions for the thumb spica.
• Elevate the injured limb initially to reduce swelling.
• Avoid activities that risk impact to the injured thumb, like sports.

Potential Complications:

• Arthritis, especially with intra-articular fractures or delayed diagnosis.
• Malunion.
• Stenar Lesion of UCL, causing MCP joint instability.
• Delayed diagnosis of base of thumb fractures, leading to long-term reduction in joint function.

References:

• Kozin’s “Fractures and Dislocations along the Pediatric Thumb Ray” in Hand Clinics, 2006.