Current concepts in managing fractures of metacarpal and phalangess

Abstract

Fractures of the metacarpal and phalanges constitute 10% of all fractures. No where in the body, the form and function are so closely related to each other than in hand. Too often these fractures are treated as minor injuries resulting in major disabilities. Diagnosis of skeletal injuries of the hand usually does not pose major problems if proper clinical examination is supplemented with appropriate radiological investigations. Proper preoperative planning, surgical intervention wherever needed at a centre with backing of equipment and implants, selection of appropriate anaesthesia and application of the principle of biological fixation, rigid enough to allow early mobilisation are all very important for a good functional outcome. This article reviews the current concepts in management of metacarpal and phalangeal fractures incorporating tips and indications for fixation of these fractures. The advantages and disadvantages of various approaches, anaesthesia, technique and mode of fixation have been discussed. The take-home message is that hand fractures are equally or more worthy of expertise as major extremity trauma are, and the final outcome depends upon the fracture personality, appropriate and timely intervention followed by proper rehabilitation. Hand being the third eye of the body, when injured it needs a multidisciplinary approach from the beginning. Though the surgeon's work appears to be of paramount importance in the early phase, the contribution from anaesthetist, physiotherapist, occupational therapist, orthotist and above all a highly motivated patient cannot be overemphasised.

Keywords: Skeletal hand trauma; metacarpal fractures; phalangeal fractures.

Figure 1

X-ray showing multiple fractures involving the shaft of the 4th metacarpal, basal intra articular fracture of the 5th metacarpal and open comminuted fracture of the proximal phalanx of the right little finger. ORIF is indicated in multiple fractures involving the hand. Note that the comminuted fracture of the shaft of the 4th metacarpal has been fixed with a bone tie and a neutralisation plate

Figure 2

Multiple closed fractures of the phalangeal bones treated with CRIF using K wires

Figure 3

Short oblique fracture of the proximal phalanx of the index finger with six possible ways for centripetal placement of K wires

Figure 4

One of the methods of centrifugal placement of K wires wherein the K wire is first passed through the fracture site into the proximal fragment (a and b). After achieving reduction, the same K wire is driven back into the distal fragment (c and d).This placement is termed as centrifugal, proximo-distal, radio-ulnar.

Figure 5

Spiral fracture of the shaft of the 4^th metacarpal fixed with ORIF using two screws

Figure 6

Open fracture of the neck of the proximal phalnx of right thumb fixed with bone tie and external fixator following repair of EPL tendon

Figure 7

Open two part fracture of the 4th metacarpal head and fracture proximal phalanx of the middle finger fixed with SS wire and criss cross K wires respectively

Figure 8

Closed Bennet's fracture fixed with CRIF using two K wires across the fracture site

Figure 9

Closed unstable unicondylar fractures of the head of the middle phalanx fixed with a closed transverse K wire following acceptable reduction