Thumb fracture

What is Thumb fracture?

Thumb is composed of two phalanges (that extends from the top of thumb to the knuckle) and 1st metacarpal (that extends from the knuckle to the base of the thumb). Any discontinuation or break in any of these bones of the thumb is known as thumb fracture or broken thumb. Fracture in thumb seems to be a minor injury but it is not, as it influences many specialized activities like power gripping, pinch grip, tripod 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. Thumb constitutes almost 40% of your hand function, any injury to thumb affects the function of the hand significantly. Broken thumb accounts for10 percent of all fractures. 12% of hand fractures occur in thumb whose incidences rises up to 20 % in people above the age of 65 years. 80 % of thumb fractures occur at the base of thumb towards the metacarpals. The most common type of this fracture is Bennet fracture.

 

What are the symptoms of Thumb fracture?

Pain, swelling, tenderness and bruising at the affected site are the common symptoms of broken thumb. You may feel difficulty in moving the injured thumb and some fractures are associated with deformity, shortening and rotates out of its position when making a fist. Numbness and coldness in the thumb is also common.

 

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 thumb can become stiff, deformed, painful with reduced hand span, non-union or mal-union of bone fragments.

 

How is it treated?

Management of thumb fracture depends on the location of fracture, displacement, deformity and its stability. Majority of the fractures could be treated conservatively by closed reduction, immobilisation by splint, application of ice packs, painkillers and hand therapy.

Surgery is indicated in

  • Multiple fractures
  • Open fracture
  • Polytrauma
  • Unstable or irreducible fracture
  • Rotational deformity
  • Unacceptable angulation
  • Associated neurovascular or tendon injury
  • Nail bed injury
  • Malunion
  • Non-union
  • 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 thumb and immobilizing in a splint/cast. This process is also called reduction manoeuvre 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 thumb 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 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 thumb. 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 purpose of surgery is to restore range of motion and full function of the thumb by proper alignment and stabilization 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 thumb to reduce blood loss during surgery.
  • Procedure– once anaesthesia is given to the patient, antibiotics are also given 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 pain.
  • Your thumb 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?

  • Malunion
  • Non-union
  • Infection
  • Stiffness
  • Instability
  • 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.

Thumb fracture 

  1. Base of thumb fracture with joint subluxation
  2. Open reduction internal fixation with plates and screws

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