Académique Documents
Professionnel Documents
Culture Documents
COMMENTARY
Patients with common hand fractures are likely to present in a wide variety of outpatient
orthopedic practices. Successful rehabilitation of hand fractures addresses the need to (1) maintain
fracture 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 intimate
relationship of these 3 tissues (bone, soft tissue, and scar) when treating hand fractures. Fracture
terminology 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 the
course of therapy. The progression of motion protocols is dependent on the type of fracture
healing, either primary or secondary, which in turn is determined by the method of fracture
fixation. Current closed- and open-fixation methods for metacarpal and phalangeal fractures are
addressed for each fracture location. The potential soft tissue problems that are often associated
with each type of fracture are explained, with preventative methods of splinting and treatment. A
comprehensive literature review is provided to compare evidence for practice in managing the
variety of fracture patterns associated with metacarpal and phalangeal fractures, following closedand open-fixation techniques. Emphasis is placed on initial hand positioning to protect the fracture
reduction, exercise to maintain or regain joint range of motion, and specific tendon-gliding
exercises to prevent restrictive adhesions, all of which are necessary to assure return of function
post fracture. J Orthop Sports Phys Ther 2004;34:781-799.
CLINICAL
immobilization that maintains the reduction or restricts motion in the direction of instability. As
fracture coalescence occurs, the immobilization can
be modified to allow incremental increases in range
of motion (ROM). Alternately, potentially unstable
fractures can be supported with the introduction of
coaptive hardware such as K-wires, pins, or wiring
techniques that protect against displacement. These
devices can be inserted either percutaneously (closed
reduction) or via surgical exposure (open reduction).
Coaptive forms of hardware bring about alignment,
but they do not control for rotation stresses, nor do
they impart any internal strength to the fracture.
Coaptive devices therefore require further external
support to eliminate unwanted deforming stresses as
the fracture heals.
Unstable fractures will not maintain reduction, as
displacement reoccurs despite immobilization. Examples of unstable fractures include long oblique,
spiral, condylar and any irreducible fractures, and
fractures with articular fragments greater than 30%
or incongruity greater than 2 mm.39 Stability of these
fractures can only be assured with the support
provided by fixation devices. All fixation implants
promote reduction, but some provide added internal
strength across the fracture line. The more rigid
implants, such as screws, plates, dorsal band, and
90-90 wiring techniques, permit immediate motion
and only require modest external support for wound
care. The coaptive implants, however, such as pins,
K-wires, intramedullary rods, staples, and interosseous
wiring, do require more rigid external support as
previously noted.4,65
783
COMMENTARY
CLINICAL
FIGURE 1. Fracture stability achieved with closed reduction methods (cast, splint, brace, external fixator) or with coaptive forms of
fixation (pins, K-wires, intramedullary rods) require a form of
external support to promote callus formation during the inflammatory and repair stages of healing. As healing progresses, therapy
intervention proceeds from edema prevention, to protected mobilization with tendon gliding of nonimmobilized joints, and to
acceleration of controlled soft tissue mobilization for full active
tendon gliding. Passive range of motion to regain full joint mobility,
and strengthening programs, are delayed to the early and late
remodeling phase, respectively, when the hard callus is converting
to bone. Fracture stability achieved with open reduction methods
(screws, wiring, plates) still require protective, postoperative splint
support initially; however, full active motion can and should be
emphasized early. Because the implant serves as a substitute for
hard callus, passive motion can be initiated during the repair phase.
Strengthening programs are delayed until the remodeling phase to
assure fracture union, under the implant, has occurred. Reprinted
from LaStayo64 with permission from Elsevier.
osseous wiring. The hardware used in fracture fixation falls into 2 categories: (1) coaptive devices that
hold the fracture ends together without compression
(secondary callus healing); and (2) rigid forms of
fixation that immobilize and compress the fracture
(primary healing). Freeland39 stated that, . . . the
choice of the implant is less important than achieving
a threshold of stabilization that will allow fracture
healing in concert with early rehabilitation.
Coaptive Fixation: External Fixators, Intramedullary
Rods, K-wires, Pins, Interosseous Wiring Jabaley57 stated
that fixation must be good enough to permit movement, but need not be excessive, given that the small
bones in the hand do not bear weight. It is cautioned
784
The metacarpal bones have intrinsic stability provided proximally by strong interosseous ligaments
binding them to the carpal bones, and distally by the
transverse metacarpal ligament linking all metacarpal
heads. These ligaments serve to tether and anchor
both ends of the metacarpal, preventing excessive
785
COMMENTARY
CLINICAL
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) blocking
exercises 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.
786
Desensitization program;
iontophoresis with lidocaine
787
COMMENTARY
CLINICAL
FIGURE 3. (A) metacarpal shaft fracture treated with 3-point pressure fixation built inside splint; (B) straps secured to apply corrective
pressure to dorsal apex angulation of fracture.
COMMENTARY
CLINICAL
FIGURE 4. (A) Radial gutter splint for fractures of index or middle metacarpals; (B) ulnar gutter splint for fractures of ring or small
metacarpals; (C) serial reduction of splint to permit motion as fracture healing occurs; (D) passive range of motion in splint.
789
Splint to hold MP joint in flexion with PIP joint full extensor glide
Pain
791
COMMENTARY
CLINICAL
Loss of MP flexion
FIGURE 6. (A) Wrist and distal joint immobilizer splint used during
exercise sessions to promote flexion at the metacarpophalangeal
joint (MP); (B) MP joint flexion isolated during exercise with use of
dual blocking splints.
P1 Shaft Fracture
Fractures occurring in digital flexor zone II, called
no mans fractures,17 are renown for the worst
prognosis in regaining full mobility.31 Ninety percent
of the bones surface is covered by gliding structuresthe central tendon dorsally, lateral bands bilaterally, and the FDP tendon volarlythat can easily
become adherent to fracture callus. Fractures of the
shaft require accurate reduction to allow these soft
tissues to glide normally.110
792
P1 Condylar Fracture
The 2 condyles at the head of the proximal
phalanx, with their intimate convex-concave fit on the
middle phalanx base, provide stability to a joint
793
COMMENTARY
CLINICAL
FIGURE 9. Cast for central slip avulsion fracture that maintains full
proximal interphalangeal joint extension while allowing active distal
interphalangeal joint flexion to maintain the length of oblique lateral
ligaments and lateral bands.
FIGURE 10. Dynamic traction splint for comminuted pilon fractures. The finger is moved passively along the arc several times per
day to stimulate regeneration of articular cartilage and remodel the
joint surface. Rubber band tension is measured to assure 300 g of
ligamentotaxis distractive force throughout the range.
P3 Base Fracture
Articular avulsion fractures are closed injuries that
result when an actively contracting tendon is forcefully pushed into the opposite direction. Tendon
rupture alone can occur, or an articular fragment of
variable size can be avulsed along with the tendon.
Two common types of avulsion fractures at this level
are jersey fracture and baseball fracture.
Volar Jersey Avulsion Fracture This fracture is named
after the football injury in which one player grabs the
shirt of an opponent who pulls away forcefully,
causing the FDP tendon, with a bone chip, to be
avulsed from the volar base of P3. Loss of terminal
joint active flexion requires early and judicious care,
as FDP tendon muscle shortening can occur if
undetected. With small fragments, the tendon (with
the fracture fragment attached) is surgically reattached through P3 using wire pull-out sutures over a
dorsal button. A dorsal blocking splint is fabricated
and the postoperative Durand tendon motion protocol is followed.19 Large fracture fragments require
the additional support of K-wires to assure good joint
surface congruence is achieved.84 A modified Durand
program is performed, omitting DIP joint flexion
until the wire is removed.
Dorsal Avulsion Fracture This fracture, known as
mallet fracture or baseball fracture, is common
to all sports and hobbies in which an extended finger
is forced into either flexion or hyperextension.65 The
extensor terminal tendon is avulsed off the dorsal
base of P3, with a chip of variable-sized bone attached. If the fracture piece represents less that one
third of the articular surface, it may be managed with
795
COMMENTARY
P2 Shaft Fracture
P2 Neck Fracture
CLINICAL
P3 Tuft Fracture
P3 Shaft Fracture
Trauma at this level, proximal to the nail bed,
usually causes an open wound that needs to be
supported with external splinting or K-wire and
splinting for 3 weeks. Wound care, edema measures,
796
Treatment of the tuft fracture, even when comminuted, is relatively simple. Compression around the
tip facilitates fragment approximation and diminishes
the very painful effect of bleeding and swelling at this
level. A thin, protective splint extending to, but not
including, the PIP joint is worn for 2 to 3 weeks.
Fibrous union is slow to ossify at this level, requiring
several months26; however, motion can and should be
reintroduced at the DIP level by reducing the length
of the protective splint and encouraging joint motion. The more difficult aspect of managing these
fractures is the extent of nail bed injury that may be
present and require suturing. Dressing changes that
do not disturb the repaired nail bed are performed
after soaking the tip of the finger in a sterile
container filled with saline and part hydrogen peroxide.19
The finger pulp region is densely innervated with
sensory end organs that painfully respond to the
initial crush, nail bed damage, and swelling with the
development of hypersensitivity to touch. Use of a
TopiGel sleeve, once nail bed healing is complete,
assists in scar management as well as dampening
painful sensory input. Desensitization programs that
include vibration, putty press, and texture tolerance
are beneficial to accommodate to normal fingertip
use.
Occasionally, the fracture pattern shows significant
displacement of the 2 fracture fragments, requiring
ORIF 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 rub
against the exposed pin, as excessive irritation can
result in a pin tract infection.
CONCLUSION
Unique to hand anatomy, soft tissues glide in
multidirections mere millimeters away from skeletal
structures. It is impossible, then, to consider skeletal
injury as isolated trauma to bone tissue only. Trauma
and fracture displacement can harm surrounding soft
tissue structures as well as encase both together in
797
COMMENTARY
REFERENCES
CLINICAL
54. Horton TC, Hatton M, Davis TR. A prospective randomized controlled study of fixation of long oblique and
spiral shaft fractures of the proximal phalanx: closed
reduction and percutaneous Kirschner wiring versus
open reduction and lag screw fixation. J Hand Surg
[Br]. 2003;28:5-9.
55. Huffaker WH, Wray RC, Jr., Weeks PM. Factors influencing final range of motion in the fingers after
fractures of the hand. Plast Reconstr Surg. 1979;63:8287.
56. Hunter JM, Cowen NJ. Fifth metacarpal fractures in a
compensation clinic population. A report on one hundred and thirty-three cases. J Bone Joint Surg Am.
1970;52:1159-1165.
57. Jabaley ME, Wegener EE. Principles of internal fixation
as applied to the hand and wrist. J Hand Ther.
2003;16:95-104.
58. Jones AR. Reduction of angulated metacarpal fractures
with a custom fracture-brace. J South Orthop Assoc.
1995;4:269-276.
59. Kearney LM, Brown KK. The therapists management of
intra-articular fractures. Hand Clin. 1994;10:199-209.
60. Kiefhaber TR, Stern PJ, Grood ES. Lateral stability of the
proximal interphalangeal joint. J Hand Surg [Am].
1986;11:661-669.
61. Konradsen L, Nielsen PT, Albrecht-Beste E. Functional
treatment of metacarpal fractures 100 randomized cases
with or without fixation. Acta Orthop Scand.
1990;61:531-534.
62. Kozin SH, Bishop AT. Tension wire fixation of avulsion
fractures at the thumb metacarpophalangeal joint.
J Hand Surg [Am]. 1994;19:1027-1031.
63. Kuntscher M, Blazek J, Bruner S, Wittemann M,
Germann G. [Functional bracing after operative treatment of metacarpal fractures]. Unfallchirurg.
2002;105:1109-1114.
64. Lanz U, Hahn P. Tendon adhesions. In: Bruser P, Gilbert
A, eds. Finger Bone and Joint Injuries. London, UK:
Martin Dunitz; 1999.
65. LaStayo PC, Winters KM, Hardy M. Fracture healing:
bone healing, fracture management, and current concepts related to the hand. J Hand Ther. 2003;16:81-93.
66. Lee SG, Jupiter JB. Phalangeal and metacarpal fractures
of the hand. Hand Clin. 2000;16:323-332, vii.
67. McCue FC, 3rd, Meister K. Common sports hand
injuries. An overview of aetiology, management and
prevention. Sports Med. 1993;15:281-289.
68. McMahon PJ, Woods DA, Burge PD. Initial treatment of
closed metacarpal fractures. A controlled comparison of
compression glove and splintage. J Hand Surg [Br].
1994;19:597-600.
69. McMurtry RY, Paley D. Open treatment. In: Neviaser RJ,
ed. Controversies in Hand Surgery. New York, NY:
Churchill Livingstone; 1990.
70. McNemar TB, Howell JW, Chang E. Management of
metacarpal fractures. J Hand Ther. 2003;16:143-151.
71. Micks JE, Reswick JB. Confirmation of differential loading of lateral and central fibers of the extensor tendon.
J Hand Surg [Am]. 1981;6:462-467.
72. OBrien ET. Fractures of the metacarpals and phalanges.
In: Green DP, ed. Hand Surgery. New York, NY:
Churchill Livingstone; 1988:709-775.
73. Oxford KL, Hildreth DH. Fracture bracing for proximal
phalanx fractures. J Hand Ther. 1996;9:404-405.
74. Page SM, Stern PJ. Complications and range of motion
following plate fixation of metacarpal and phalangeal
fractures. J Hand Surg [Am]. 1998;23:827-832.
75. Perren SM. Physical and biological aspects of fracture
healing with special reference to internal fixation. Clin
Orthop. 1979;175-196.
799
COMMENTARY
CLINICAL