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Principles of Metacarpal and Phalangeal

Fracture Management: A Review of


Rehabilitation Concepts

Key Words: bone healing, hand, fingers

njury to the densely compacted structures of the hand often


involves damage to multiple tissues. In this confined area, all
neighboring tissues share trauma and its consequence. It is a
mistake to consider fracture healing apart from soft tissue
healing, because successful outcomes require the return of
functional integrity to both tissues. Soft tissues commonly involved with
fractures include cartilage (with intra-articular fractures), joint capsule,
ligaments, fascia, and the enveloping dorsal hood fibers. Occasionally, in
severe polytrauma cases, tendons and nerves adjacent to the fracture are
also injured. Following open fractures or open reduction procedures, a
wound is created that must heal with scar tissueanother tissue to be
remodeled and considered during rehabilitation. It is well recognized
that soft tissue scarring affects hand function more than fracture
healing, and joint stiffness is the most frequent complication of
fractures.50
1
Director, Hand Management Center, St Dominic Jackson Memorial Hospital, Jackson, MS; Clinical
Assistant Professor, School of Health Related Professions, University of Mississippi Medical Center,
Jackson, MS.
Address correspondence to Maureen A. Hardy, Hand Management Center, St Dominic Jackson Memorial
Hospital, 969 Lakeland Dr, Jackson, MS 39216. E-mail: mhardy@stdom.com

Journal of Orthopaedic & Sports Physical Therapy

The optimal therapy program addresses these 3 components (bone,


soft tissue, and scar healing) in
combination.
In the 1970s, therapy for hand
fractures was delayed 6 to 8 weeks
while the hand was immobilized.
Stiff joints, adherent tendons,
muscle atrophy, scar, and pain
were the focus of our interventions. Results of corrective surgical
procedures, such as capsulectomies
for joint release and tenolysis to
restore tendon gliding, were poor
for
patients
with
fractures.16,43,101,113 Joints with stiffness and abnormal articular
surfaces, due to limited reduction
techniques in small bones, faced
the choice of fusion (arthrodesis)
or
joint
replacement
(arthroplasty). Recent studies on
fractures requiring combined
capsulectomy and tenolysis show
that outcomes are still poor, especially for return of active tendon
function.25,64,74,86 Add to this dilemma that 24% of digits that
require these release procedures
are noninjured, border digits that
were included in the immobilization, and we lament along with
Lanz,64 who states that Damage
of the gliding ability of tissues
(around a fractured digit) is almost irreparable. Enhanced understanding of the biology of
fracture healing, better decision
making in initial fracture management, technical advances in implant design, improved surgical
781

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

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Maureen A. Hardy, PT, MS, CHT 1

skills with respect for gliding structures, and early


controlled mobilization have contributed to reducing
the incidence of complications that we once faced.
The purpose of this manuscript is to review current
concepts of management for metacarpal and
phalangeal fractures, with special emphasis on potential problems that need to be addressed in the course
of rehabilitation. The challenge for the health care
team is to design intervention protocols that recognize the need to maintain fracture stability for
maximal bone healing, while also introducing early,
controlled-motion protocols to preserve soft tissue
integrity and facilitate scar remodeling. This paper is
based on a thorough review of the literature and
current practice principles. The information is presented within the context of an overview of fracture
healing, followed by guidelines for managing specific
types of fractures common in the hand.

PRINCIPLES FOR FRACTURE MANAGEMENT

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Is the Fracture Stable?


The quest in fracture management is to achieve
fracture stability. Fractures that are stable will heal;
fractures that are not stable can result in malunions,
infections, pseudoarthrosis, or nonunion. Stability of
a fracture is achieved when the fracture maintains its
reduction and does not displace either spontaneously
or with motion.39 If the fracture has not distorted the
bones normal contour and the fracture ends are
approximated, it is termed nondisplaced. A bone that
has lost its normal anatomical contour due to separation of the fracture ends is called displaced. The
displaced fracture ends must be reunited for healing
to occur and to prevent deformities. The methods
used to bring anatomic order and realignment back
to the fractured bone is called reduction. Reduction
can be achieved by either closed manual techniques,
by percutaneous fixation, or by open surgical methods.
Stable fractures will maintain their position at rest
and will not lose the proper approximation of fracture ends with inherent muscle tension or when
controlled-motion protocols are initiated. Some fracture types are known to have intrinsic stability, such
as nondisplaced transverse, and short oblique configurations. These fractures require no further intervention other than protective immobilization to allow
healing to commence. Intrinsically stable fractures
are usually treated with conservative, closed methods
of support for 2 to 3 weeks, then supported with
removable splints for initiation of controlled motion.
Fractures that are aligned but subject to misalignment with certain postures or tensions are termed
potentially unstable. Potentially unstable fractures
include oblique, avulsion, and comminuted fractures.
These fractures can often be managed with protective
782

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

Is the Fracture Healing?


Primary Bone Healing Implant choice drives the
course of fracture healing. Implants introduced via
open reduction internal fixation (ORIF) that provide
absolute stability and compression of the fracture
permit primary bone healing to occur. Primary bone
healing is direct bone-to-bone healing without any
external callus. Compression across the fracture line
eliminates the space-occupying hematoma, thus reducing the fracture gap. Compression combined with
rigid fixation, that eliminates all but micromotion,
provides an environment suitable for osteoclast cutting cones to form and cross the fracture line. These
cutting cones have osteoclasts that forage forward, by
osteoblastic action, leaving an empty trail behind
(haversian canal) that is filled with osteons (a single
basic unit of bone).75 For an in-depth review of
fracture healing see LaStayo et al.64
One advantage of primary healing via rigid internal
fixation is precise anatomic reduction. This is especially important in articular fractures where joint
incongruities can lead to degenerative joint problems. As the need for peripheral callus to support the
bone ends is avoided (the metallic implant substitutes

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

Is Closed or Open Reduction Required?


The vast majority of metacarpal and phalangeal
fractures can be treated without surgery, using closed
methods that emphasize alignment and early protected motion (Figure 1).69 Fracture immobilization
should provide for adequate healing, relief of pain,
protection from displacement or reinjury, and restoration of hand function.45 All splinting programs
recognize the need to position the metacarpophalangeal (MP) joints in flexion to avoid extension
contracture. The thumb MP joint is not exempt from
this rule and many stiff thumbs result from
hyperextended thumb spica immobilization. The
interphalangeal (IP) joints are routinely rested in full
extension, with the exception of volar plate fractures.
Unpublished data by Greer45 states that the following
principles (REDUCE) for effective plaster cast or
thermoplastic splinting should be incorporated in all
designs: (1) reduction of the fracture is maintained,
(2) eliminate contractures through positioning, (3)
dont immobilize fractures more than 3 weeks, (4)
uninvolved joints should not be splinted in stable
fractures, (5) creases of the skin should not be
obstructed by the splint, and (6) early active tendon
gliding is encouraged.
Fractures that cannot be reduced with closed
manipulation (or those that fail to maintain their
reduction), open fractures, and displaced articular
fractures are candidates for operative fixation procedures. Insertion of the fixation device does not always
require a surgical incision. Closed reduction with
external fixation or closed reduction with internal
fixation includes percutaneous application of pins,
K-wires, and external fixators under radiologic C-arm
guidance. Limited open reduction and internal fixation uses small incisions to insert screws or
intermedullary fixation. Open methods of internal
fixation (ORIF) do require surgical exposure of the
fracture for insertion of K-wires, plates, screws, and

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

783

COMMENTARY

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The primary advantage of secondary bone healing


is that there is minimal soft tissue disruption. This
equates to less scar remodeling. The periosteal sleeve,
when intact, envelops the bone adding another internal layer of fracture support and is an important
blood supply source for the bone. Noninvasive fracture management does not violate this tissue, as do
open fixation methods that may require periosteal
stripping for implant application.
One disadvantage of secondary healing is the
relatively long period of protected immobilization
that is required, during which soft tissues can become
contracted or adherent to the callus. Often, initiation
of motion at 3 to 4 weeks is still limited to a safe
range dictated by the fractures potential instability.
Prolonged immobilization results in atrophy of soft
tissues, osteoporosis, thinning of articular cartilage,
severe joint stiffness, and at times pain.52

CLINICAL

for the callus), so also is avoided the potential


problem of tissue adherence to the callus during
immobilization. Once the surgical dressing is removed, usually in 3 to 5 days, there is full access to
the hand for wound or edema control measures.
Early initiation of motion is permitted as these
implants provide sufficient internal support to allow
motion without endangering the fracture alignment.65 In polytrauma cases, soft tissue mobilization
programs for repaired tendons can begin immediately without fear of displacing the fracture.
A disadvantage of primary healing is that it can
only occur with mechanical stabilization provided via
surgery; consequently, there are 2 wounds to heal:
the fracture and the soft tissue incision. Without the
initiation of early motion post-ORIF, there is a greater
potential for soft tissue adherence. Although new
bone is formed more quickly in primary healing, it is
not strong bone.75 This newly formed woven bone
(weak) will gain tensile strength as it is remodeled
based on its environmental stresses and strains to
become lamellar bone (strong). Bones healing by
closed conservative management and those treated by
open reduction methods achieve the same level of
tensile strength by 12 weeks. This implies that primary healing is not faster healing, so strengthening
programs must be delayed until the remodeling
phase has begun at 6 to 8 weeks.
Secondary Bone Healing Fractures treated by external
support or coaptive implants, that reduce the fracture
but do not provide compression, must rely on callus
formation to bridge the fracture gap. Because bone
formation will not occur in an environment of
motion, callus is a temporary, biological fixation that
forms in an area with motion and functions to reduce
this motion as it matures and hardens (soft callus to
hard callus).7 Callus then resembles a natural glue
that holds the fracture ends together. As the callus
gains stiffness, the fracture fragments are rendered
more stable.42 Excessive, unrestricted motion can
overwhelm the fragile support offered by early soft
callus, leading to loss of reduction and possibly
nonunion.104 With secondary healing, ROM exercises
are delayed or limited during the first 3 weeks, or
until the callus has achieved enough tensile strength
to tolerate controlled movement. Callus that is sufficiently clinically stiff at 3 weeks to permit motion is
not strong enough yet to bear functional loads.53
After 3 weeks, soft callus transitions into a harder
fibrocartilage callus, then through a process of mineralization true bone is formed. Goodship42 summarized this cascade of connective tissue differentiation
as one in which, The entire spectrum of connective
tissue is seen from blood to bone through hematoma,
granulation tissue, fibrous tissue, fibrocartilage,
hyaline cartilage, woven and ultimately lamellary
bone.

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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

that well-placed coaptive implants that allow ROM


exercises without load may be insufficient to protect
the fracture against resistance (motion with load).
One week after surgery a removable splint is applied
in a functional, rehabilitation ready position, which
the patient removes for suture/pin site cleaning, and
to perform protected active ROM (AROM) exercises.39 Full motion may not be possible at all joints
due to constraints from the hardware. Controversy
does exist regarding the initiation of motion with
coaptive fixation. Incidence of infection, fracture
displacement, nonunion, and pain have been cited as
reasons to delay motion until the fixators are removed.9,54 Advances in osteosynthesis materials is
believed to provide sufficient stability to permit controlled, protected ROM exercises with this type of
fixation in place.8,32,44,78 Weiss109 investigated initiation of motion at 1, 2, 3, and 4 weeks for individuals
with proximal phalanx (P1) fractures with K-wire
fixation. Results showed no difference in ROM when
motion was initiated between 1 to 21 days. However,
when motion was delayed more than 21 days, there
was a significant loss of mobility.
At 4 to 6 weeks, the K-wires and pins are removed,
the splint is adjusted for proper fit and worn for
continued fracture protection for another 2 weeks.
AROM exercises (out of the splint) are performed
hourly to regain full mobility. The callus is considered clinically stiff enough for free active motion
but is not stable enough to bear a functional load,
which occurs after 6 to 8 weeks.53 Dynamic or serial
static splints may be initiated after 6 to 8 weeks time
to overcome any soft tissue contractures. Early
strengthening exercises with light resistance can be
initiated at 8 weeks, but unrestricted return to sports
and heavy work is delayed until after 10 weeks, as
callus remodeling to lamellar bone with increased
fracture strength does not occur until this later stage
of bone healing.21
Rigid Fixation: Plates, Screws, Tension Band Wiring,
90-90 Wiring Open reduction with rigid forms of
fixation provide definitive fixation, assure compression for stability, and permit early motion for good
restoration of function.69 Full AROM is the early goal
as edema diminishes. Dynamic splints may be used at
2 weeks for soft tissue stretching, because of the
stability provided by the rigid fixation. An exception
is forced extension with tension band wiring techniques, because the dorsal surface wiring on the
metacarpal compresses the fracture with flexion but
will cause gapping of the fracture with forced extension. Early strengthening exercises with light resistance can be initiated at 6 weeks, but unrestricted
return to sports and heavy work is delayed until after
10 weeks, similar to secondary healing, to assure
adequate fracture strength has occurred.
It is important that therapists managing hand
fractures understand the role and intent of the

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

various forms of fixation of fractures as they dictate


the course of rehabilitation. Ideally the therapist
would have access to both the radiographs and an
operative/emergency department report on the medical management of the fracture. In the absence of
this ideal environment, a minimum of 2 facts must be
provided with the therapy referral: date of fracture
and method of fixation. The fracture date starts the
bone-healing timetable, and the method of fixation
(dictating the type of healing) influences the rate at
which motion can be reintroduced. The goals of
hand therapy then are to reintroduce safe early
mobilization while maintaining fracture stability.91

Are the Tendons Gliding?

PRINCIPLES FOR MANAGING METACARPAL


FRACTURES

AROM is initiated as soon as possible, based on the


method of fixation, to prevent osseous adhesions to
tendons, ligaments, capsules, or skin.82 The most
important tendon-gliding exercises to initiate early
are those for the flexor digitorum profundus (FDP),
flexor digitorum superficialis (FDS), extensor

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

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

785

COMMENTARY

Edema after injury is common to all fractures.


Patient education for edema control is an essential
component of the initial therapy visit. Rest, ice,
compression, and elevation (RICE) are emphasized
for edema control. Edema is poorly tolerated in the
digits due to the confining space. Distended joints
predictably move into positions that permit the greatest expansion of the joint capsule and collateral
ligaments.35 Edema postures the hand into wrist
flexion, MP joint extension, IP joint flexion, and
thumb adduction: a dropped claw hand. Functional splinting seeks to place the hand in a resting
position that will avoid this deformed posturing. Ice
can be easily performed with the use of large bags of
frozen peas (1 bag applied volarly and 1 dorsally) and
is effective even over a splint or cast. Coban (sized 1
inch [2.5 cm] for fingers and 2 inches [5 cm] for the
hand) is an elastic self-adhering bandage that provides effective compression. Eccles33 showed that the
greatest reduction in swelling was obtained with the
hand supported in elevation overnight.
Early mobilization to promote venous return via
muscle contraction is advocated in stable fractures.
Having the patient adduct the fingers tightly and
maintain this tension while flexing at the MP joint
can enhance both intrinsic muscle pumping and
achieve the desired joint positions of full MP flexion
and IP extension. Double buddy straps, applied
proximal and distal to the proximal IP joint (PIP),
serve to protect fracture alignment and encourage
mobility of the injured digit. Patients are also instructed in shoulder and elbow ROM exercise in
elevation to facilitate proximal muscle pumping.

CLINICAL

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Is the Edema Under Control?

digitorum communis and central slip to prevent


tendon adherence to fracture callus.15
To assure the extensor tendon glide over fractured
metacarpal bones, MP extension is performed in the
hook fist posture (Figure 2A). To gain extensor
hood glide over proximal phalanx (P1) fractures, the
intrinsic plus position is performed, facilitated by
manually blocking the MP joint into flexion (Figure
2B). Micks71 showed that the central slip is responsible for initiating extension from a fully flexed PIP
joint position, while the lateral bands (interossei and
lumbricals) achieve full terminal PIP extension. If full
PIP extension is lacking, flexing the wrist may assist
by the addition of passive tenodesis action (stretch of
the extensor mechanism).
Selective gliding of flexor tendons is achieved by
choosing positions that differentiate movement between the FDP and FDS to achieve maximal glide of
each. Wehbe106,107 used metal tags on the tendons to
demonstrate that the FDP must glide 60 mm, compared to 49 mm of FDS glide, to achieve full fisting.
This research suggests that for P1 and middle phalanx (P2) fractures, flexor tendons need to achieve
maximal differential glide to prevent restrictive adhesions with loss of motion. FDP tendon gliding is
performed by manually blocking the PIP joint to
allow full flexor power to be directed to the distal
joint (Figure 2C). To promote selective FDP flexor
tendon glide past the superficialis tendon, the claw
fist posture of MP extension with PIP and distal
interphalangeal joint (DIP) maximal flexion is
achieved (Figure 2D). FDS tendon blocking exercise
requires inhibition of the FDP tendon of the same
finger, which also contributes to PIP joint flexion.
This inhibition of the profundus is achieved by
manually restricting DIP motion in the unaffected
digits with attempted PIP flexion in the involved digit
(Figure 2E). Because the FDP tendons blend into 1
multistrand tendon inserting into the muscle belly,
blocking 1 tendons excursion effectively blocks all
others.14 The only motor that is now free to glide and
flex the PIP joint is the FDS tendon. The sublimis
fist (Figure 2F) maximally glides the FDS tendon
past the FDP tendon with full MP and PIP flexion
and an extended DIP joint. Full fisting, flexion of all
3 joints simultaneously, promotes full gliding of all
flexor tendons with the FDP tendon gliding past the
FDS tendon.105

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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

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

displacement with injury. This is especially true for


middle and ring metacarpal fractures as they have the
additional support of intact adjacent metacarpals.
Fractures in the border digits, index and small, tend
to be more unstable due to loss of surrounding intact
metacarpal pillars. The thumb metacarpal, sitting at
47 rotation away from the other digits, is the most
mobile and most unstable if fractured.100
Metacarpal fractures represent 35% of hand fractures. Due to their good blood supply, these fractures
heal rapidly with osseous restoration in 6 weeks.
Fractures of this bone are described at 4 distinct
locations: base, shaft, neck, and head. The most
important soft tissue concerns with metacarpal fractures are preserving MP joint flexion and maintaining
EDC glide. Table 1 lists the potential problems that
can occur and strategies for therapeutic intervention.

During this time the fingers are free and encouraged


to move. Once clinical signs of healing are present, a
protective wrist splint is used for 3 to 4 weeks while
wrist rehabilitation is initiated.
TABLE 1. Potential problems with metacarpal fractures and
strategies for therapeutic intervention.
Potential Problems

Coban wrap compression, ice,


elevation, high-voltage stimulation

Dorsal skin scar contracture


that prevents full fist

Silicone TopiGel, simultaneous


heat and stretch with hand
wrapped in a fisted position;
friction massage

MP joint contracted in extension

Initially: position MP joint at


70 flexion in protective
splint
Late: dynamic or static progressive MP joint flexion splint

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Intrinsic muscle contracture


secondary to swelling and
immobilization

Initially: teach instrinsic stretch


(instrinsic minus position)
Late: static progressive splint in
intrinsic minus position

Dorsal sensory radial/ulnar


nerve irritation

Desensitization program;
iontophoresis with lidocaine

Attrition and potential rupture


of extensor tendon over
prominent dorsal boss or
large plate

Rest involved tendon; contact


physician if painful symptoms
with AROM persist

Scissoring/overlapping of digits Slight: buddy tape to adjacent


with flexion
digit
Severe: malrotation deformity
requiring ORIF
Absence of MP head

Shortening of metacarpal; may


not be functional problem

Absence of MP head and MP


joint extension lag

Shortening of metacarpal with


redundancy in extensor
length; splint in extension at
night; strengthen intrinsics
abduction/adduction; NMES
of intrinsics with off on
cycle

Absence of MP head with


volar prominence and pain
with grip

Neck fracture angulated


volarly; minor: padded work
glove; major: reduction of
angulation required

Abbreviations: AROM, active range of motion; EDC, extensor


digitorum communis; MP, metacarpophalangeal; IP, interphalangeal;
NMES, neuromuscular electrical stimulation.

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

787

COMMENTARY

Adherence of EDC tendon to


Initially: teach EDC glide exerfracture with limited MP joint
cises to prevent adherence;
flexion
splint IP joint in extension
during exercise to concentrate flexion power at MP
joint
Late: dynamic MP flexion
splint; NMES of EDC with
on off cycle

CLINICAL

Dorsal hand edema

Metacarpal Base Fracture


Base fractures are an intra-articular fracture resulting from high force that disrupts the rigid carpal
ligaments (index and middle), or overwhelms the
normal flexibility of the ulnar metacarpals (ring and
small).41 The insertions of the wrist flexors and
extensors on the metacarpal base can be a deforming
force. These are uncommon injuries associated with
violent accidents resulting in a fracture-dislocation
pattern. The most common occurrence is at the fifth
metacarpal-hamate articulation, which is often unstable due to the pull of the extensor carpi ulnaris,
flexor carpi ulnaris, and abductor digiti minimi that
insert on the metacarpal base.12 Fractures at this
location limit the normal descent of the ulnar
metacarpals, causing weakness of grip. The deep
motor branch of the ulnar nerve, passing beneath
the hook of the hamate, is also vulnerable to injury
in this fracture.76 The index and middle metacarpal
base fractures are also unstable due to the insertion
of the extensor carpi radialis longus and flexor carpi
radialis on the second metacarpal and extensor carpi
radialis brevis on the third.
Closed reduction with casting of the wrist for 4 to 6
weeks is indicated for nondisplaced or minimally
displaced fractures. Bora12 reported satisfactory
return of grip strength and activities in 18 patients
treated with this method. Displaced fractures represent an associated carpometacarpal joint dislocation
that can lead to joint incongruity, degenerative joint
disease and ultimately further carpal collapse.41 ORIF
is necessary to restore joint approximation, prevent
pain, and assure return of grip strength. Postoperatively, a cast is worn for 4 to 6 weeks to protect this
injury at the wrist. This prolonged immobilization is
necessary to protect the healing fracture from the
deforming forces of the wrist tendon insertions.70

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Metacarpal Shaft Fracture

Shaft fractures are extra-articular fractures caused


by fall, blow, or crushing force that usually angulate
dorsally and may have components of shortening
and/or rotation. They are described by the fracture
configuration as transverse, oblique, or spiral. Intrinsic muscle tension, arising from its origin on the volar
proximal metacarpal through its bony insertion on
the proximal phalanx, will cause both ends of the
metacarpal bone to flex towards each other, pushing
the fracture ends dorsally (known as apex dorsal
presentation). Resting tension of the long extrinsic
finger flexors contributes to the deformity.
Metacarpal fractures with apex dorsal angulation
cause the metacarpal bone to be shortened, causing a
deleterious effect on the extensor mechanism by
altering the muscles normal length-tension relationship. For each 2-mm increment of bone shortening
there is a corresponding 7 extensor lag at the MP
joint.97 The natural ability to hyperextend the MP
joint will overcome this extensor loss for minimal
bone shortening; but this deformity leaves a prominent dorsal boss that has been implicated in attrition
rupture of extensor tendons.96
Stable, nondisplaced transverse metacarpal shaft
fractures with apex dorsal angulation can be treated
closed with glove support,68 buddy taping,112 short
hand casts,29 long ulnar/radial gutter splints, or
hand-based fabricated splints that incorporate 3
points of reduction pressure (1 dorsal point over the
fracture site and 2 volar points, proximal and distal to
the fracture, that provide counterpressure).70,102,103
C-arm visualization of the fracture with the splint on
will assure improvement in the angulation after 1
week.58 Sorenson92 found poor compliance and skin
breakdown with prefabricated splints as compared to
ulnar gutter casts. Konradsen,61 using fiberglass casting, and Jones,58 using thermoplastic material, fabricated custom-made, hand-based fracture braces with
the 3-point reduction technique. Both studies compared this functional brace, which allowed wrist and
digital motion, with plaster ulnar gutter casting.
Together, these 2 studies support the advantages of
the functional brace with improved motion, decreased pain, ability to deliver corrective reduction
force, less extensor lag, and decreased need for
postfracture therapy. Current best-practice fracture
support for managing nondisplaced, angulated
metacarpal shaft fractures is provided by custommade casts or splints that incorporate the 3-point
pressure fixation built within the splint and allows
free active joint motion (Figure 3).
Fractures that are potentially unstable require additional support. Ulnar or radial gutter splints that
immobilize both the injured metacarpal and its adjacent stable metacarpal, including wrist, MP, and PIP
joints have been the norm (Figure 4A-B). Feehan36
788

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.

proposed the concept of serial splint reduction, in


which the splint is gradually cut down as fracture
healing proceeds, permiting controlled-motion exercises (Figure 4C-D).
Multiple metacarpal fractures may require that all
fingers be included in the cast (Figure 5A).
Ashkenaze6 described a splint that includes the wrist
and metacarpal shafts with dorsal support extending
out to the PIP joint, with the volar support ending at
the distal palmar crease to allow free MP and IP joint
motion. Seventy degrees of MP joint flexion reduces
the intrinsic and extrinsic flexors influence on dorsal
angulation.90 The IP joints are free to move during
the day but strapped into extension at night to
prevent flexion contractures (Figure 5B). Buddy
strapping of the injured digit to a noninjured adjacent finger, especially in oblique fractures, is protective against malrotation and facilitates early motion.
Hall47 reported using this type of clam digger immobilization in over 1000 fractures, modified to plaster
in noncompliant patients. This best-practice management technique assures protection of fracture stability, maintains proper hand posture, and respects the

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COMMENTARY

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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.

importance of motion in the early rehabilitation of


fracture.
Oblique and spiral metacarpal fractures can
shorten and rotate. The ill effects of this telescoping
and malrotation will be evident when the patient
attempts to make a fist. The rotated position of the
metacarpal will cause digital overlapping and the
telescoping will cause loss of the normal metacarpal

head prominence of the involved bone. Following


ORIF, a circumferential, hand-based splint is worn to
protect the metacarpal area from direct trauma; no
joint motion is restricted with this splint. Kuntscher63
reported that 105 fractures postoperatively provided
with this type of functional fracture brace resulted in
decreasing the number of hand therapy visits with
early, pain-free return of hand function.

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

789

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FIGURE 5. (A) Cast for multiple metacarpal fractures permitting


early active finger flexion; (B) resting volar component added to
maintain interphalangeal joints in full extension.

Metacarpal Neck Fracture


Neck fractures are the most common metacarpal
fracture, also known as fighters or boxers fracture.
The impact of a closed fist hitting an object can
fracture the metacarpal at its weakest point, the
extra-articular neck. With fight/bite injury, the fist
contact with the mouth of another can result in tooth
penetration into the MP joint. Any skin laceration at
the MP joint level with fight/bite fractures should be
suspect for infection.
Trauma causes the fractured metacarpal head to
displace with volar angulation. Debate continues over
the necessity to reduce and immobilize these fractures.3,14,56 However, angulated neck fractures that
heal with volar displacement over 30 place the
intrinsic muscle in a shortened position, which reduces the muscles excursion capacity. This loss of full
muscle length results in limited ability to initiate
flexion at the MP joint.3 Other complications of
poorly reduced neck fractures include a metacarpal
head prominence in the palm that is painful with
grip, and compensatory hyperextension of the proximal phalanx at the MP joint to clear the fingers for
grasp. Acceptable angulation is less than 15 in the
index and middle metacarpals, while the ring and
small metacarpals can function with less than 30 due
790

to their compensatory mobility. If these acceptable


reduction angles cannot be maintained with external
support alone, then operative treatment is recommended.93
Once the volarly flexed metacarpal head is reduced
back in proper alignment with the shaft, it is important to hold the MP joint in over 70 flexion, as the
taught collateral ligaments will aid in securing the
metacarpal head in place. A traditional clam digger or intrinsic plus splint can be used that includes:
(1) keeping the wrist in slight extension; (2) holding
the MP joint in flexion by a dorsal block component
that extends out to the PIP joint; (3) stopping the
volar side of the splint at the MP web area, permitting limited MP and full PIP flexion.5,24 Neck fractures have also been treated with a hand-based splint
that incorporates the 3 points of pressure and must
extend volarly over the palmar aspect of the
metacarpal head to apply the correct dorsal force.48,61
Jones58 instructed patients to gradually tighten the
straps as edema subsided, and found that this gradual
application of stress reduced the fracture as effectively as manipulation with anesthesia. It is recommended that reduced fractures use the hand-based
splint that maintains the MP flexed with a dorsal
block.24 If reduction is inadequate or potentially
unstable, the 3-point splint should be used.
Closed reduction percutaneous pinning with
K-wires is recommended to maintain reduction in
unstable neck fractures.88 One week postoperatively,
the surgical dressing is removed and an immobilization splint is applied to protect this coaptive fixation
at that time. The patient is instructed in protected
ROM exercises out of the splint. At 4 to 6 weeks the
K-wires are removed and the patient should then
regain full AROM.

Metacarpal Head Fracture


Head fractures are intra-articular fractures caused
by high axial loads that can involve avulsion of the
collateral ligaments, including a fracture fragment,
fracture of 1 or both condyles, or shattering of the
joint surface into many small-comminuted pieces.
Collateral ligament avulsion fractures if undetected
can lead to chronic pain and joint instability. If the
fracture fragment is nondisplaced, the injury can be
treated with protective splints that hold the MP joint
flexed at 50 to 70 for 4 to 6 weeks.38 Displaced
fractures require ORIF with fixation that allows early
protected motion.93
Fracture displacement of 1 to 2 mm at the articular
surface is more easily tolerated in the upper extremity than in the lower extremity weight-bearing joints;
however, ORIF is indicated for fractures that involve
more than 20% of the articular surface to prevent
erosive joint changes and to allow AROM by the third
week postfracture.6,50

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

Comminuted fractures that do not lend themselves


well to operative fixation, due to the many small
fragments involved, can be treated with closed immobilization in a radial/ulnar gutter splint with the MP
joints flexed to 70. However, comminuted fractures
with substantial loss of bone length are better treated
with external fixators or bridging plates that maintain
bone length.23 Immobilization is shortened to 2 to 3
weeks, because early motion benefits articular cartilage repair. Salter80 cautions that excellent reduction
of the fracture may still lead to a poor result due to
the concomitant cartilage injury with its limited
regenerative capacity. His definitive work on intraarticular fractures showed that continuous passive
motion begun in the first postoperative week stimulates both bone and cartilage healing.81

TABLE 2. Potential problems with phalangeal fractures and


strategies for therapeutic intervention.
Potential Problems

Loss of PIP extension

Central slip blocking exercises;


during the day MP extension
block splint to concentrate
extensor power at PIP joint;
at night PIP extension gutter
splint; NMES to EDC and
interossei with dual channel
setup

Loss of PIP flexion

Isolated FDP tendon glide exercises; during the day MP


flexion blocking splint to
concentrate flexor power at
PIP joint; at night flexion
glove; NMES to FDS

Loss of DIP extension

Resume night extension splinting; NMES to interossei

Loss of DIP flexion

Isolated FDP tendon glide exercises; PIP flexion blocking


splint to concentrate flexor
power at DIP joint; stretch
ORL tightness; NMES to FDP

Lateral instability any joint

Buddy strap or finger hinged


splint that prevents lateral
stress

Impending Boutonniere deformity

Early DIP active flexion to


maintain length of lateral
bands

Impending swan neck deformity

FDS tendon glide at PIP joint


and terminal extensor tendon
glide at the DIP joint

Pseudo claw deformity

Splint to hold MP joint in flexion with PIP joint full extensor glide

Pain

Resume protective splinting


until healing is ascertained;
address edema, desensitization program

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Proximal Phalanx (P1) Base Fracture


Intra-articular base fractures are due to an abduction force from sports injuries or a fall on an
outstretched hand. These articular fractures require
accurate reduction to restore normal joint kinematics. After reduction, stability of the fracture position
can be maintained with conservative treatment due to
tension in the surrounding intact joint capsule, collateral ligament complex, interossei tendons, and volar
plate for fractures in the proximal 6- to 9-mm range
from the joint.111 Positioning the MP joint in 70
flexion results in balanced tension of these capsular
structures. The PIP and DIP joints, buddy taped to an
adjacent digit, are allowed early active motion. The
intrinsic plus position of the splint design also causes
the extensor aponeurosis to be tightened and drawn
distally over the base of P1, providing compression of
the fracture. After 2 to 3 weeks,79 or 3 to 4 weeks,32
depending on callus formation, the splint can be
removed for protected ROM at the MP joint.

Abbreviations: DIP, distal interphalangeal; EDC, extensor digitorum


communis; FDP, flexor digitorum profundus; FDS, flexor digitorum
superficialis; MP, metacarpophalangeal; NMES, neuromuscular electrical stimulation; ORL, oblique retinacular ligament; PIP, proximal
interphalangeal.

Displaced base fractures can not be reduced with


MP joint positioning alone as often the collateral
ligament, attached to the fracture fragment, is
avulsed. Shewrings review89 of 33 displaced base
fractures found a high rate of nonunion with conservative management due to displacement of the fracture as the collateral ligament tightens with flexion of
the MP joint. These avulsion fractures occur most
often at the ulnar collateral ligament of the thumb or

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

791

COMMENTARY

Circumferential PIP and DIP


extension splint to concentrate flexor power at MP
joint; NMES to interossei

CLINICAL

Loss of MP flexion

PRINCIPLES FOR MANAGING PHALANGEAL


FRACTURES
Phalangeal fractures are more unstable than
metacarpal fractures as they lack intrinsic muscle
support and are adversely affected by tension in the
long finger tendons.112 Phalangeal fractures respond
more unfavorably to immobilization than metacarpal
fractures, with a predicted 84% return of motion,
compared to 96% return in metacarpal fractures.88 If
immobilization is continued longer than 4 weeks, the
motion return drops to 66%.98 In 19% of digital
fractures, nonfractured neighboring fingers also lose
motion.55 Functional outcome in these fractures is
not so dependent on fracture site; rather, unsatisfactory results are more related to open fractures,
comminuted fractures, and associated soft tissue injuries.78 Table 2 lists potential problems that can occur
with phalangeal fractures and strategies for therapeutic intervention.

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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.

index and radial collateral ligament of the ring and


small fingers.8,79 Techniques used for fixation of
displaced fractures include tension band wiring using
a figure-of-eight weave,62 intraosseous wiring with
additional K-wire support,110 or screw fixation.2,50 As
MP joint stiffness with loss of flexion is the most
common postoperative soft tissue complication of P1
base fractures, protective splinting must rest the MP
joint in flexion. When active exercises are initiated to
regain full MP flexion, the use of splints holding the
wrist, PIP, and DIP joints immobilized during exercise, will facilitate all flexor strength directed towards
the MP joint (Figure 6A-B). Continuous passive
motion (CPM) following ORIF with rigid fixation is
indicated to maintain joint mobility, decrease edema,
and stimulate the healing of articular cartilage.81

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

Nondisplaced fractures require protection, but not


total immobilization. Inclusion of a neighboring
noninjured digit in the splint and buddy strapping
permit early AROM. Oxford73 recommends a singledigit circumferential splint for stable fractures, which
provides extended lateral support at the PIP joint for
distal shaft fractures or volar and dorsal immobilization of the MP joint for proximal shaft fractures. This
design allows for free active PIP joint motion.
Displaced P1 fractures present with apex palmar
angulation. This angulation is due to a volar force at
the base of P1 by the interossei insertion, while the
extensor expansion pulls the distal fragment dorsally.11 Freeland39 recommends that the least intrusive technique be used to provide a threshold of
strength that reliably holds the fracture
securely . . . and would allow simultaneous early rehabilitation. Methods of fixation for displaced, unstable fractures include closed transcutaneous
insertion of K-wires or intramedullar y rods,
percutaneous miniscrews, open internal fixation with
miniscrews, miniplates, and mini external fixators.40
The most common problem at this level begins
with an extensor lag at the PIP joint, which develops
into a fixed joint flexion contracture.74 The worst
case scenario results when minimal motion at the PIP
joint results in a fixed flexed position of the joint,
which is compensated at the MP joint with
hyperextension to remove the flexed finger from the
palm. A pseudo-claw hand posture is created. Prevention of this deformity relies on emphasizing PIP joint
extension at rest and early tendon glide along all
bone surfaces. Initially, a splint is made that maintains flexion at the MP joint, with a dorsal hood
expansion to securely strap the PIP joint into full
extension at rest (Figure 5).24 The volar part of the
splint stops at the distal palmar crease. Hourly the
distal straps are removed to permit early tendon
gliding, emphasizing central slip, lateral bands, FDS,
and FDP tendons, respectively. Full PIP joint flexion
is not promoted until the patient is able to actively
extend the PIP joint to 0.34 Burkhalter17 reminds us
that it is far easier to gain flexion than extension at
this joint.
Later, a functional blocking splint can be used to
counter the pseudo-boutonniere posturing that occurs with less than optimal tendon gliding (Figure
7A-B). The splint immobilizes the MP joint in flexion,
protecting against MP hyperextension, while also
directing all flexor and extensor tendon power to the
PIP joint. Light-resistance exercises for PIP joint
flexion and PIP joint extension are facilitated when
performed in the splint.

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

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

deprived of much soft tissue support. The type of


tissue injury caused with a lateral deviation force is
dependent on the rate of loading: stress applied with
low loading rate causes collateral ligament injury,
while a high loading rate can result in a collateral
avulsion fracture, or a unicondylar (1 side) or
bicondylar (2 sides) fracture configuration at the
head of P1.60 A ball forcing the digit away from the
center line of the hand most often fractures the
condyle towards the middle of the hand.109 This is a
common sports injury that is often misdiagnosed as a
jammed finger as the athlete can move the finger
well.82 Continued unsupported use of the hand can
change a simple nondisplaced fracture into an
angulated fracture with painful joint incongruity.93
These potentially unstable fractures are best treated
with ORIF to assure good joint alignment is achieved.
The problem with ORIF at this level is access to the
P1 head directly under the central extensor slip.
Authors have advocated various incision locations:
splitting the extensor tendon longitudinally,77 incising
between the lateral band and the central tendon,72
excising the insertion of the central tendon creating
a flap,20 or a lateral midaxial incision.54 As the most
significant complication following P1 fracture is loss
of full PIP joint extension, the lateral approaches that
spare direct trauma to the central tendon are more
appealing. However, Horton48 found that despite the

Middle Phalanx (P2) Base Fracture


This intra-articular fracture is caused by a
hyperextension, hyperflexion, or lateral deviation
force on an outstretched finger, as occurs in basketball and volleyball injuries, or from a fall onto the
outstretched hand.87 Hyperextension or hyperflexion
injuries are often severe enough to cause the PIP
joint to dislocate with associated soft tissue damage to
the volar plate or central slip respectively, commonly
called avulsion fractures. With severe compressive
trauma, comminuted fractures of the articular surface
occur, causing depression of the fragments into the
bone shaft, called a pilon fracture. Pilon is derived
from the Latin word pounder, indicating the force
required to create this deformity.95
Palmar Plate Avulsion Fracture Also known as dorsal
fracture dislocation, this fracture results from a
hyperextension injury in which the distal attachment
of the volar plate, at the base of P2, is ruptured along
with a variable portion of the articular surface of the
volar middle phalanx. Without the normal restrains
provided by an intact volar plate, tension from the
finger extensors on their distal attachment causes the
base fracture to dislocate dorsally. The percent of
articular surface involved and the percent of joint
dislocation determine severity of this fracture.83
Buddy taping and immediate active motion are used
to manage less severe fractures. Fractures of moderate severity (20% to 40% of the articular surface
involved) are treated with extension block splinting

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

793

COMMENTARY

FIGURE 7. (A) Pseudo-boutonniere deformity of ring digit following


proximal phalanx fracture; (B) the blocking splint facilitates flexor
and extensor tendon gliding at the proximal interphalangeal joint
(PIP).

CLINICAL

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lateral incision used for screw placement, the ORIF


group in his study had 3 times greater PIP joint
extension lag (27), as compared to the group that
received closed reduction treatment (8). This may
be partly explained by the mutually dependent role
played by the central slip and lateral bands in
achieving full PIP joint extension. It may be that
adhesions in either system will affect PIP joint extension.
Pain and swelling at the PIP joint postoperatively
are a great barrier to rehabilitation. Swelling will
draw the joint into a flexed posture that over time
will become a contracture. Splinting must rest the
PIP joint in full extension, with hourly short-arc
AROM performed. It is crucial that the patient work
to achieve proximal gliding of the extensor mechanism, and thus 0 extension to prevent an extensor
lag. The use of continuous passive motion (CPM)
following rigid internal fixation of these fractures
results in regeneration of hyaline articular cartilage,
reduction of edema, prevention of adhesions and
joint stiffness, and is painless.80 Incised and repaired
central slip tendons can also be treated with the
short-arc-motion protocol, as there is continuity of
the extensor tendon longitudinally. Full PIP joint
flexion is limited for 3 weeks to prevent splitting the
sutured tendon approximation.

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for greater than 6 weeks. This fracture is at risk for


displacement with full extension. A dorsal block
splint prevents the joint from extending by 30 to
40, yet allows full joint flexion (Figure 8). This
protocol allows fracture compression with flexion,
while avoiding fracture separation with extension. As
fracture healing ensues, the splint angle is subsequently remolded at less extension block weekly,
permitting gain in extension range. Usually there is a
slight flexion contracture at the end of the 6 - to
8-week splinting regime, which can be treated with
dynamic extension splinting.30 Fractures with greater
than 40% of joint surface involvement usually do not
remain congruent in any limited arc of motion and
are therefore managed with ORIF.
Central Slip Avulsion Fracture This fracture, also
known as dorsal fracture dislocation or boutonniere fracture, includes a fracture fragment from
the dorsal base of P2 that is attached to the central
extensor tendon. Fortunately it is a rare injury and
treatment depends on the ability to restore the volar
subluxed P2 back to approximate the avulsed fragment. Reduced fractures are immobilized in full PIP
joint extension for 4 to 6 weeks, and the patient is
instructed in active DIP joint flexion exercises to
maintain gliding and length of the lateral bands and
oblique retinacular ligament (Figure 9). Flexion at
the DIP joint will prevent the appearance of a
boutonniere deformity post immobilization.22 Closed
reduction, however, is often difficult due to soft tissue
constraints, necessitating ORIF with pin, screw, or
tension band wiring.8 A removable protective fingerbased splint is worn that maintains the PIP joint in

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.

FIGURE 8. Volar plate avulsion fracture treated with extension


block splint that limits full extension at the proximal interphalangeal
joint (PIP); the degree of blocking is determined by fracture
displacement with extension. The distal strap (not shown) is
removed to allow active PIP and distal interphalangeal joint (DIP)
flexion and extension.
794

full extension and is removed for passive ROM


exercises. Pins are removed at 2 to 3 weeks, at which
time, active ROM can begin to further glide soft
tissues. With screw fixation, active motion can begin
immediately with the use of the same splint to
prevent flexed posturing at the PIP joint.
Pilon Fracture Severe compressive trauma can cause
the head of the proximal phalanx to impact into the
base of P2, creating many small, crushed fracture
fragments. The distal articular surface of the PIP
joint is essentially destroyed. ORIF seeks to elevate
the central depressed articular fragments and maintain their length with bone grafts or external
fixators.51 Another option is to use a combination of
traction and motion to model a new joint through
the use of dynamic traction splinting (Figure 10).
This latter method uses a radial or ulnar gutter splint
that blocks the MP joint in flexion. Rubber band

J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

Fractures at this location are rare, due in part to


the short, broad shaft that is stronger here than in
proximal bones. The path of the lateral bands,
spiraling from their lateral position at the PIP joint to
become conjoined dorsally over the distal part of this
phalanx, place them in jeopardy of adhering to
fracture callus with closed methods, or of becoming
impaled with pins and screws with open methods.
Longitudinally placed pins down the medullary canal
try to avoid this soft tissue problem.8 Limitation of
lateral band gliding will result in loss of DIP joint
terminal extension. Midshaft fractures can angulate
either dorsally or volarly, resulting in shortening of
the middle phalanx shaft. This skeletal shortening
will cause an imbalance in extensor tendon-bone
length ratio, resulting in loss of terminal DIP joint
extension. Loss of full DIP joint extension, due to
either lateral band adherence or redundance, leads
to the classic swan neck deformity of DIP flexion with
excessive extensor force directed at hyperextending
the PIP joint.1 Cannon19 recommended 3 weeks
immobilization with closed methods or K-wire fixation, as FDS tendon action can displace this fracture
due to its insertion on the P2 shaft. The digit is
splinted in the functional position of MP joint flexion
with PIP and DIP joints in full extension. For long
oblique or spiral fractures, ORIF or percutaneous use
of screws provides enough stability to allow AROM
within 1 week. Emphasis is placed on FDS tendon
glide at the PIP joint and terminal extension glide at
the DIP joint, countering the swan neck deformity.

Neck or subcapital fractures are more common in


young children whose fingers have been trapped in
closed doors or electric windows. These fractures are
usually markedly displaced and unstable, requiring
ORIF. Sterns review93 of complications suggests that
K-wires should remain in for a longer duration of 4
to 6 weeks. Postoperative therapy is based on the
stability of the fixation. DIP joint stiffness, with loss of
active flexion, and an extensor lag are the chief
complications. Protective splinting of the DIP joint in
full extension, with frequent removal for FDP tendon
gliding is recommended.

Distal Phalanx (P3) Fractures


The distal exposed portion of the finger is most
vulnerable to injury, with fractures at the P3 level
accounting for 50% of hand fractures.18 Causes of
fracture include crush to the distal tuft, as when
fingers are caught in closed doors or machines, blows
to an extended finger, and sports-related volar and
dorsal articular avulsion fractures.84

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

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P2 Shaft Fracture

P2 Neck Fracture

CLINICAL

traction from a circular outrigger is attached to


exposed K-wires passed through the middle phalanx
distal to the fracture. Tension is measured with a
Halston gauge to assure that adequate distractive
force of 300 gm is exerted. The distractive force uses
a concept called ligamentotaxis, in which the soft
tissue envelope that encircles the fracture (intact
periosteum, collateral ligaments, joint capsule) is
placed under longitudinal tension, causing these soft
tissues to narrow and compress the fracture.58 During
the day the dynamic-traction component is moved
along the circular outrigger hoop to achieve passive
PIP joint motion, which is beneficial to articular
cartilage healing. The splint is worn continuously for
6 to 8 weeks (removed briefly for dressing purposes)
to prevent displacement of the fracture.46 Kearney59
reported on a 9-year follow-up of patients treated
with dynamic traction and found that all joints were
pain-free and asymptomatic, they maintained their
87 arc of PIP joint motion, and the joint space had
been maintained, indicating good cartilage thickness.
The use of dynamic traction for pilon fractures was
compared with ORIF and found to produce the same
results with fewer complications.95

and motion at the MP and PIP joints is encouraged


after the first week. Active ROM at the DIP joint can
be initiated after 3 weeks if callus consolidation
permits. Loss of full DIP joint flexion is usually due
to soft tissue contracture of joint structures and
dorsal skin scar. Wrapping the digit with coban into
an intrinsic minus position and then dipping into
paraffin provides simultaneous heat and stretch,
which has been shown to have the best effect on soft
tissue lengthening.49 This is followed by blocking
exercises for FDP tendon glide.

P3 Tuft Fracture

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FIGURE 11. Tip protector splint bivalved to maintain distal


interphalangeal joint (DIP) extension and accommodate swelling for
mallet fractures.

closed splinting of the DIP joint in extension for 6


weeks (Figure 11). Bivalving the splint, which is
secured with coban wrap, allows accommodation for
any swelling. Splinting is continued at night and
during vigorous activities for another 2 to 4 weeks. If
extensor lag at the DIP joint is noted, then splinting
is resumed during the day also.
Fracture fragments that are greater than one third
of the articular surface can be surgically reattached
using various wiring techniques. 10,27,28,99,108
Damrons27 analysis of these common fixation methods noted that none of the fixation methods provide
enough stability to permit early motion. All joints
must be immobilized for a minimum of 6 weeks, as
with conservative methods. Surgical treatment for
mallet fractures have been reported to have a 53%
complication rate due to infection, joint incongruity,
nail deformity, and extensor lag; as opposed to a 45%
complication rate for closed treatment.94 Wehbe106
suggests that due to these findings most mallet
fractures should be treated with conservative closed
methods.
Following the 6 weeks of continuous immobilization in extension, composite flexion and extension of
the PIP and DIP joints is taught. Blocked DIP joint
flexion exercises are not performed, as this would
stretch out the oblique retinacular ligament (ORL).
Because the greatest complication of mallet fractures
is a DIP joint extensor lag, an intact ORL will serve
to passively assist DIP joint extension as PIP joint
active extension occurs.19

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

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1. Agee J. Treatment principles for proximal and middle


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1992;23:35-40.
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Zimmer TJ. The use of power-driven staples in fracture
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2001;15:54-60.
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Hand Clin. 1997;13:541-555.

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CLINICAL

the healing processes of callus and scar. Successful


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A review of the literature found a paucity of studies
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The anatomy and biology of bone healing assists in
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metacarpal and phalangeal fracture location in the
hand.

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