Fractures of The Fingers

Fractures of the hand and fingers are the most common fracture leading to an emergency room visit. These are often caused by crush injuries, finger-twisting injuries, or axial loading (such as from punching an object). Many of these injuries do not require surgical treatment. These fractures are further divided into:

  • Metacarpal Fractures
  • Proximal and Middle Phalanx Fractures
  • Distal Phalanx Fractures

Metacarpal Fractures

Fractures of the metacarpal often occur from an impact to a closed fist (such as punching an object) or a twisting injury to the fingers. They may also occur from a crushing injury to the hand. When nondisplaced, these fractures heal reliably with 3-4 weeks in a cast. Occasionally, a closed reduction (“straightening” of the bone under anesthesia) may be required prior to placing the cast. If the fracture is more severe and unstable, it is best treated surgically. This may be accomplished with any combination of pins, plates, or screws followed by hand therapy. When pins are used, these are usually temporary and are removed in the office 3-4 weeks after surgery (this is fairly painless and hurts no more than having stitches removed). Often, pins can be inserted without even making an incision. When screws and plates are used, an incision is necessary and the implants are usually permanent, but this allows the patient to begin moving the hand and fingers within a few days after surgery. A few examples of these treatment options are shown below.

Example: 60-year-old woman who struck the hand on the ground after tripping on a tree root. X-rays show a comminuted and displaced 5th metacarpal fracture, which was treated by plate and screws. She began hand therapy 3 days after surgery.

Proximal and Middle Phalanx Fractures

Like metacarpal fractures, proximal phalanx fractures are also extremely common. Many of these are also treated with splinting or casting, when the deformity is not great. However, when there is significant deformity or the fracture is unstable, internal fixation (surgery to realign and stabilize the fracture) is necessary. Whether or not surgery is chosen, stiffness of the fingers are a major problem with fractures of this type, and hand therapy is usually necessary to help the patient recover motion. Examples of treatment of these fractures are pictured below.

Example 1: Fracture of small finger proximal phalanx in a 65-year-old woman with Dupuytren’s contracture affecting the same finger. Notice the obvious rotational deformity with the small finger pointing completely away from the ring finger. This was treated by closed reduction under local anesthetic followed by application of a specialized cast for 3 weeks. The healed fracture is seen at the right.

Example 2: Fracture of small finger proximal phalanx, rugby injury. This is an unstable fracture pattern with malrotation of the finger and was treated by plates and screws. The patient began hand therapy within 5 days of the surgery and did very well. Photos of the patient’s hand 4 months postop are seen at right.

Example 3: Example of a severe index finger middle phalanx fracture caused by crushing injury in a teenage girl, treated by closed reduction and pinning. From left to right: X-ray taken at time of injury; X-ray taken in the operating room after pin stabilization (no incision was made for this surgery – the large metal instrument coming in from the right is a tool holding the finger in position just for the X-ray); X-ray taken 4 months later after pin removal (pins were removed 3 weeks postop, in the office) and complete healing.

Distal Phalanx Fractures

These fractures usually occur from a crushing injury (see fingertip injuries) and often also have a major soft tissue injury or nail injury associated with them. Treatment is often more dictated by the soft tissue injury than by the fracture itself and may include simple splinting or pinning of the fracture. A special subtype of this injury is a “mallet fracture,” in which a small piece of bone is pulled up with the extensor tendon. Mallet fractures are usually treated with 4-6 weeks in a special splint to keep the fingertip straight, or in rare cases surgery if the fracture is large enough to cause joint dislocation.

Mallet Finger

Mallet finger, sometimes called baseball finger, is caused by injury to the tip of the finger in which the tendon that straightens the fingertip is damaged. If the fingertip will not straighten, medical treatment is needed to restore movement.

Distal Phalanx Fractures

These fractures usually occur from a crushing injury (see fingertip injuries) and often also have a major soft tissue injury or nail injury associated with them. Treatment is often more dictated by the soft tissue injury than by the fracture itself and may include simple splinting or pinning of the fracture. A special subtype of this injury is a “mallet fracture,” in which a small piece of bone is pulled up with the extensor tendon. Mallet fractures are usually treated with 4-6 weeks in a special splint to keep the fingertip straight, or in rare cases surgery if the fracture is large enough to cause joint dislocation.

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