Hand Fracture – Finger / metacarpal fractures
What is hand fracture?
There are 14 bones in five fingers that connect to 5 metacarpal bones in the palm of the hand. Any discontinuation or break in these bones is called finger fracture or broken hand or broken knuckle. Fracture in hand seems to be a minor injury but it is not, as it influences many specialized activities like power gripping, pinch grip, tripod grip, hook grip etc. Fractures in the hand can occur due to direct injury due to a fall, twisting injury, crush injury, while catching a ball, slamming door on fingers accidently or working with drills, saw or other tools, punching, motor vehicle accidents, industrial accidents etc.
Broken finger accounts for 10 % of all fractures in the skeletal system and metacarpal fractures constitute 40% of all hand fractures. The most common hand fracture is a fracture of 5th metacarpal, also known as boxer’s fracture. This is caused by punching or striking a hard surface with a closed fist. Distal finger is more commonly affected by injury and are usually associated with injuries to the nail bed.
What are the symptoms of hand fracture?
Pain, swelling, tenderness and bruising at the affected site are the common symptoms of broken finger. You may feel difficulty in moving the injured finger and some are associated with deformity, shortening and scissors over its neighbour when making a fist.
How is it diagnosed?
It is diagnosed by your medical history, history of injury, physical examination and an X-ray. X-ray helps to determine the exact position of the fracture. CT scan is performed in selected patients to assess the magnitude of injury and plan for surgery.
What happens if nothing is done?
If it is left untreated, broken finger can become stiff, deformed, painful with non-union or mal-union of bone fragments.
How is it treated?
Management of hand fracture depends on the location of fracture, displacement, deformity and its stability. Majority of the fractures could be treated conservatively by closed reduction, immobilization by splint, application of ice packs, painkillers and hand therapy.
Surgery is indicated in
- Multiple fractures
- Open fracture
- Unstable or irreducible fracture
- Rotational deformity
- Unacceptable angulation
- Associated neurovascular or tendon injury
- Nail bed injury
- Displaced Intra-articular fracture
- Fracture gap with interposition of soft tissues
What are the non-operative treatments?
The non-operative treatment involves the following-
- Closed reduction- your surgeon will realign your bones by pulling down your hand/finger and immobilizing in a splint/cast. This process is also called reduction maneuver or closed reduction. This mechanical pulling is performed gently and slowly but still, it is painful. You might need local anaesthesia and painkillers like codeine or paracetamol before this procedure so that you don’t feel pain.
- Immobilization- after closed reduction, your fractured hand is immobilized in a splint/cast for 3-4 weeks to allow proper healing and prevent new injury to the affected area.
- Ice packs (frozen peas bag)– you can also apply ice on the joint for 20 -30 minutes in every 2 to 3 hours in first few days of the injury as it can relieve pain and swelling.
- Medications– anti-inflammatory medicines like ibuprofen or aspirin may be given to regulate pain and swelling for few days, as long-term consumption of these medicines can delay fracture healing and may cause damage to your kidneys and stomach.
- You have to keep your hand and wrist elevated (above the level of your heart) and keep moving your other fingers, wrist, elbow and shoulder to maintain the flexibility and prevent stiffness of its joints.
- The fracture union is confirmed by x-rays at regular intervals – 2,4,6 and12 weeks, however in selected patients weekly x-rays are needed to assess displacement in the first 3 weeks
- Hand therapy- early motion exercises are started after 3-4 weeks of immobilization to prevent stiffness and maintain the good mobility in your hand. Your hand is prone for getting stiff and hand therapy under the supervision of your surgeon is paramount for optimal outcome.
What does the operation involve?
Surgery is necessary in cases where bone fragments are displaced or unstable. The main aim of the surgery is stabilization and proper alignment of the bone fragments.
- You are admitted to the hospital and the operation is usually performed as a day case.
- The operation is performed under general anaesthesia or local anaesthesia (Block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation, but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
- A tourniquet is tied around your upper arm or the base of finger to reduce blood loss during surgery.
- Procedure– once anaesthesia is given to the patient, antibiotics are also given to him to prevent any infection during and after the operation. In open fractures, the soft tissues and bone that are exposed are cleaned thoroughly. A cut or incision is made in the affected site and the bone fragments are repositioned to their normal position. This procedure is called open reduction. Then, the bone fragments are fixed with the help of plates, pins or screws so that they remain in the proper position while healing process. This process is called internal fixation. In some cases, the fracture is reduced and held with pins or pins connected to a rod (external fixator). In cases of multiple fractures, bone substitutes are used to have faster healing and to fill the gap. The skin is closed with the help of absorbable sutures.
- The operation takes 1-2 hours to end. Most patients are discharged on the same day.
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery; patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- Your hand is rested in a half cast for 2 weeks to protect it from injury and allow proper healing.
- You should keep your arm elevated (above the level of your heart) most of the times as it prevents swelling. Besides keep moving your fingers, elbow and shoulder.
- Before discharge, your physiotherapist will teach you gentle exercises of the hand, wrist, elbow and shoulder that you can start soon after the operation from the first day.
- The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
- Following ORIF with plates and screw, usually the plaster is changed to splint and hand therapy commenced
- If the fracture is fixed with pins, that has to stay for 4 weeks and removed in the clinic after check x-rays
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- You will be guided by your surgeon and hand therapists based on radiographic (X-ray) and clinical union of the fracture. In majority of the cases, you could start a gentle range of movement (ROM) exercises at 2 weeks and progress to more strenuous activities (swimming, driving, lightweights in gym etc) around six weeks. It is advisable to avoid contact sports or any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of fracture, quality of bone and method of fixation.
Are there any risks?
- Stiffness in the finger
- Post-traumatic arthritis
- Hardware complications- screw penetration into the joint, tendon irritation
- Injury to digital nerve and blood vessels
- Tendon injury
- Complex regional pain syndrome
What are the results of the operation?
Most patients regain full function and strength of the injured hand with fewer major complications (<1%). It is more predictable under the experiences of the author.
When can I return to driving and work?
You can get back to work in 2-4 weeks if you have a desk job, however might take 2- 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3 months and you should be able to resume driving in 4-6 weeks. The above time line could vary based on the severity of injury and the treatment modality. Your physician will be able to advise you.
- Dog lead traction injury – fracture of little finger with rotational deformity
- Fixed with screws and patient regained full function back in 3 months.
- Multiple metacarpal fractures following skiing injury fixed with plates and screws
- Pathological fracture of finger treated with curettage, bone grafting and ORIF