METACARPAL AND

PHALANGES
FRACTURES IN ADULT
Presenter: Dr. Sakar Raj Pandey
Moderator: Assit. Prof Dr Sushil Paudel
CONTENTS:
• Metacarpal Fracture Introduction
• Metacarpal Head fracture
• Metacarpal neck fracture
• Metacarpal shaft fracture
• Metacarpal base fracture
• Proximal phalynx fracture
• Middle phalynx fracture
• Distal phalynx fracture
INTRODUCTION
• Metacarpal and phallanges fractures constitutes of 10% of all
fractures

• More than half work related

• Male> Female
Clinical Evaluation
• History: Age, Occupation, Dominance of hand and Systemic Injury
• Mechanism of Injury: Crush/Direct Trauma/ Twist/ Tear/ Laceration etc
• Time of injury (for open fractures)
• Exposure to contamination
• Physical Examination:
-Digit viability (CRT<2secs)
- Neurologic status
-Rotational and angulatory deformity
-ROM
INDICATIONS FOR FIXATION OF METACARPAL
AND PHALANGEAL FRACTURES
• Irreducible fractures
• Malrotation (spiral and short oblique)
• Intra-articular fractures
• Subcapital fractures (phalangeal)
• Open fractures
• Segmental bone loss
• Polytrauma with hand fractures
• Multiple hand or wrist fractures
• Fractures with soft tissue injury (vessel, tendon, nerve, skin)
• Reconstruction (i.e., osteotomy)
 METACARPAL FRACTURES
• Typically occur in patients aged 10-40 years.

• Men > women.

• Young men - secondary to a punching mechanism or a direct blow to

the hand.

• Geriatric - secondary to a low energy fall.

• Bennett fracture is the most common fracture involving the base of

the thumb.
Pathoanatomy and Applied
Anatomy Relating to Metacarpal
Fractures
• Participates in formation of the three arches of the hand.
• Two transverse arches at the CMC and MP joint levels.
• Metacarpals themselves are longitudinally arched with a fairly broad
convex dorsal surface.
• Held tightly bound to each other by strong interosseous ligaments at
their bases and by the deep transverse intermetacarpal ligaments
distally.
• Shortening of individual metacarpal fractures is limited by these same
ligaments.
• In the sagittal plane, the primary deforming forces are the intrinsic
muscles, which can be counteracted through MP joint flexion, an
important component of the reduction maneuver for metacarpal
fractures.

• Correction of apex dorsal angulation and rotational control is

achieved indirectly by grasping the finger to exert control over the
distal metacarpal fragment
Metacarpal Head Fracutre
• Rare and usually intraarticular.

• Index metacarpal most commonly involved.

• Comminuted fractures occurs most commonly.

Types of Metacarpal Head Fracutre
• Epiphyseal (all nondisplaced Salter-Harris type III)
• Ligamentous avulsions
• Osteochondral slices
• Three-part fractures occurring in different planes (sagittal, coronal,
axial)
• Comminuted fractures
• Boxer’s fractures with extension into joint
• Fractures with substance loss
• Occult compression fractures with subsequent avascular necrosis
Radiographic view
• AP
• Oblique
• Lateral- difficult to interpret because of the adjacent
overlying metacarpal heads

Brewerton view: - appreciate the articular contour

better.
Treatment
• Displaced ligament avulsion # and Osteochondral # - ORIF

• Two-part coronal, sagittal, and oblique intra-articular fractures- ORIF

with K wires or interfragmentory screws.

• A comminuted intra-articular fracture is the most difficult fracture to

treat.

• ORIF may be frustrating, if not impossible. Alternative forms of

treatment include skeletal traction or silicone arthroplasty.
Metacarpal Neck Fracture
• Most common one is Boxer’s fracture
involving 4th and 5th MC

• Invariably occur when a clenched MP joint

strikes a solid object and angulates with its
apex dorsal.

• Nonunion is uncommon; however, malunion

occasionally can be a problem.
Indications for operative
intervention
• Angulation greater than 70 degrees in lateral view

• Rotatory malalignment

• Associated fractures in fifth ray of hand

• Open fractures with associated soft tissue injury

(excluding human bites)

• Presence of pseudoclawing
 Closed Reduction of Metacarpal
Neck Fractures
• By Jahss Maneuver

• Maintenance of closed
reduction by percutaneous
longitudinal or crossed K
wires.

• Disadvantage-does not provide rigid fixation and

requires external immobilization for 2 to 3 weeks.
“Bouquet” osteosynthesis
• Reduced in closed fashion
• A hole is made in the proximal ulnar metaphysis of the metacarpal
• Three blunt pre-bent K wires are passed antegrade down the
medullary canal, across the fracture, and into the subchondral bone
of the metacarpal head
• Advantage of avoiding the fracture site, but it can be technically
difficult, and pins can migrate either proximally or distally.
Open Reduction of Metacarpal Neck
Fractures
• Indicated when manipulation fails to restore acceptable angulatory or
rotational alignment

• Mini-condylar blade plate for rigid stabilization.

• Considerably higher rates of complications have been reported,

however, in cases involving open fractures or soft tissue injury or both
Metacarpal Shaft Fractures
• Broadly classified into three types: transverse, oblique (and spiral),
and comminuted.

• Transverse fractures are usually produced by axial loading and

angulate with the apex dorsal.

• Reduction generally is required for angulation greater than 30 degrees

in the small finger, angulation greater than 20 degrees in ring finger,
and any angulation in the middle and index fingers
• Oblique and spiral fractures- torsional forces and can cause rotational
malalignment.
• Malrotation is poorly tolerated.
• Difficult to assess radiographically.
• Best judged clinically by asking the patient to flex all the fingers
simultaneously

• Comminuted fractures - direct impact

• Associated with soft tissue injury, and shortening
Closed Reduction and Plaster
Immobilization
• Works well for most metacarpal fractures.
• Many are inherently stable and may be
treated with minimal or no immobilization.
• When the PIP joints are extended in this
splint, the hand assumes the intrinsic-plus
or clam-digger position.
• Immobilization in Short arm Cast
Closed Reduction and Percutaneous
Pinning
• Antegrade or retrograde percutaneous pinning with K wires

• May interfere with extensor tendon function unless the pin is buried
within the medullary canal.

• Using an awl, a cortical window is made at the ulnar base of the fifth
metacarpal 1 cm distal to the CMC joint.

• Three or four pre-bent (approximately 30 degrees) 0.9-mm pins are

inserted and buried within the medullary canal.
Open Reduction
• Indications for open reduction:
-Open Fractures: bone loss, contamination, or soft tissue injury.

-Multiple Fractures: Stabilising effect of metacarpal lost

-Unstable Fractures

-Malalignment: Rotational
Techniques of Open Reduction
• Kirschner Pins
- Either single or multiple pins
- In Crossed, Transverse, Longitudinal (Intramedullary)
or combined.
- For longitudinal fixation- drilled in antegrade fashion
from the fractured end out the dorsal radial aspect of
the metacarpal head.
-After reduction, the pin can be drilled in a retrograde
fashion back down the shaft through the reduced
fracture
Other techniques:
• Cerclage and Interosseous Wiring
• Composite (Tension Band) Wiring
• Intramedullary Fixation
• Interfragmentary Compression Screws
• Plate and Screw fixation
• Bioabsorbable Fixation
Segmental Metacarpal Loss
• Restoration of metacarpal stability and function after segmental bone
loss is a challenge.
• Occurs after an open injury and is nearly always associated with
varying degrees of soft tissue injury or loss.
• Restoration of hand function is usually staged and begins with
thorough debridement of devitalized tissue
Two philosophies
• Traditional viewpoint: maintain metacarpal length with transverse
intermetacarpal K wires or external fixation devices, with soft tissue
coverage performed as a primary or delayed procedure
• Bone grafting is performed only after joint motion is regained and
healed wounds have matured.

• Freeland and Jabaley believed that the best time to restore osseous
stability with a bone graft and internal fixation is within the first 10
days of injury (“the golden period of wound repair”).
Metacarpal Base Fractures
• Avulsion Fractures of the Second and Third Metacarpal Bases

- Isolated intra-articular fractures of the base of the second and

third metacarpals are rare.

-Usually the result of a fall on a flexed wrist.

- Justification for surgical reattachment includes restoration of the

integrity of the extensor carpi radialis longus or brevis,

reconstitution of the articular surface of the CMC joint, and

elimination of a potentially irritating fragment of dorsal bone.

Fracture-Dislocations of the Ring
Finger Carpometacarpal Joint
• Ring finger CMC joint dislocations are uncommon, may be associated
with a metacarpal fracture

• Isolated ring finger metacarpal fractures should raise the possibility of

an associated CMC joint injury
Fracture-Dislocations of the Small
Finger Carpometacarpal Joint
• Intra-articular fractures of the hamate–fifth metacarpal joint are
common
• Usually associated with proximal and dorsal subluxation of the
metacarpal.
• The base of the fifth metacarpal consists of a concave-convex facet
that articulates with the hamate and a flat radial facet that articulates
with the fourth metacarpal base.
• The injury results from a longitudinally directed force along the fifth
metacarpal resulting in proximal and dorsal subluxation of the
metacarpal base.
Fractures of the Thumb Metacarpal
Metacarpal Head Fractures
• Unusual.

• Displaced articular fractures require anatomic reduction.

• Fixation can be obtained with percutaneous

K wires or by open reduction.

• Approached by splitting the dorsal apparatus

between the EPL and EPB
 Shaft and Base Fractures of the Thumb
• Fractures of the thumb metacarpal occur in three locations:
shaft, base, and articular fractures.

• Extraarticular fractures through the base are

common and are usually transverse or oblique.

• The fracture is angulated with its apex dorsal

such that the distal fragment is adducted and flexed.

• True lateral radiograph is necessary to evaluate the

degree of angulation.
• Closed reduction of epibasal thumb fractures - longitudinal
traction, downward pressure on the apex of the fracture, mild
pronation of the distal fragment, and thumb extension.

• The reduction is often unstable because of the

deforming force of the abductor pollicis.

• Angulation of > 30 °-compensatory hyperextension

of the MP joint .
• In fracture >30 °, closed reduction and
percutaneous pinning.
• Open shaft fractures may require an external fixator to prevent
metacarpal shortening and to allow soft tissue healing
Articular Fractures of the Thumb Metacarpal
Base
Bennett Fracture

• An articular fracture of the base of the thumb metacarpal consisting of a

single, variable-sized, volar-ulnar fracture fragment.
• MOI: metacarpal is axially loaded and partially flexed.
• A pyramidal shaped fragment consists of the volar-ulnar aspect
of the metacarpal base.
• Anterior oblique ligament which runs from the fractured fragment
to the trapezium holds the fragment.
• The remaining metacarpal base subluxates radially, proximally, and
dorsally
• Articular incongruity of 1 to 3 mm is well
tolerated, provided that union and joint stability
are achieved.

• When the Bennett fragment is less than

15% to 20% of the articular surface,
we prefer CRPP of the CMC joint

• The technique of closed pinning described

by Wagner is preferred.
• If the metacarpal is reduced to the Bennett fragment and there is
less than 2 mm of articular step-off, we accept the reduction and
immobilize the digit in a thumb spica cast.
• Possibilities for internal fixation

1. Transfixion of the base of the first

metacarpal to the trapezium

2. Transfixion of the thumb base to the

second metacarpal

3. Combination of both
ORIF

Indications

• Irreducible fractures
• High-demand patients and those who need
immediate restoration of a full range of
motion.

• However, ORIF is possible only if the anterior

marginal fragment is large enough for
internal fixation (>20% of the articular
surface).
 Rolando Fractures of the Thumb
• Any comminuted articular fracture of the base of
the thumb metacarpal.

• MOI: significant axial load that splits and crushes

the metacarpal articular surface.

• Worse prognosis than Bennett's fracture.

• Swollen, tender, visibly deformed thumb base

• AP and lateral X-rays may not show the full extent

of comminution and so a Robert view or CT
• The choice of treatment depends primarily on the degree of
comminution.

• Successful CRPP is usually difficult to accomplish in this fracture because

of the difficulty of reducing all the articular fragments

• Because of the likelihood of posttraumatic arthritis after these fractures

accurate reduction is important.

• Techniques of open reduction include:

-Multiple Kirschner wires
-Plate fixation
-External fixators
• The combination of TBW and an external
fixator can result in an acceptable reduction.

• The external fixator is used to align the

comminuted fragments and to restore length
and TBW provides stability

• If the fracture is stable, the external fixator may

be removed

• If not stable the fixator should remain in place

for 8 weeks.
Complications of Metacarpal
Fractures
• Malunion
• Dorsal Angulation
• Malrotation
• Osteomyelitis
• Nonunion (Uncommon)
 PHALANGEAL FRACTURES

Fractures of the Distal Phalanx

• Most commonly encountered fractures in hand.

• Can be classified into:

-Tuft
-Shaft
-Intraaricular Fractures.
 Tuft Fractures
• Usually secondary to a crushing injury and often associated with
laceration of the nail matrix or pulp or both.

• Closed tuft fractures frequently associated with a painful subungual

hematoma.

• Decompression provides dramatic pain relief

• Short period of immobilization (10 to 14 days) is indicated for

symptomatic relief.

• Comminuted tuft fractures rarely require internal fixation

Shaft Fractures
• Two Types: Transverse and Longitudinal

• Nondisplaced transverse #- sufficiently stabilized by the surrounding soft

tissue and do not require internal fixation

• Displaced transverse #
-May be open and are often associated with a transverse
laceration of the overlying nail matrix.
-Longitudinal Kirschner pin fixation and nail matrix repair should be
considered.
Dorsal Base Fractures
• Closed reduction and pin fixation is the treatment of choice for
shearing dorsal base fractures comprising over 25% of the articular
surface.
• May rarely require ORIF

Volar Base Fractures

• ORIF is the treatment of choice for highly displaced volar base
fractures that have a large intra-articular fragment and loss of FDP
functional integrity.
• Lag Screw and rarely extension block pinning
Fractures Middle Phalanx
• Most fracture patterns are similar to proximal phalanx

• Fractures of the middle phalanx can be grouped by the anatomic

regions of head, neck, shaft, and base

• Intra-articular fractures that occur at the base of the middle most

functionally devastating of all fractures and dislocations of the hand

• Difficulty in treating
Pathoanatomy and Applied Anatomy
Relating to Middle Phalanx Fractures
TREATMENT OPTIONS:

• # involving proximal aspect of DIPJ can occur as isolated

middle phalanx articular #, involving one or both
condyles & may extend proximally into shaft (diaphysis).

• Stable #: protective splinting & followed closely with

radiographs.

• If alignment is maintained: Buddy taping & ROM

exercises (begin at 3 wks & continue for additional 3 wks
or until radiographic healing is present)

• Unstable or displaced #: Reduction + stabilized either with K-wires or screws.

• Unicondylar # of middle phalanx:
• Transverse, oblique (short or long), or
comminuted.
• Cause: Axial load combined with lateral
angulation of finger.
• It is unstable & needs operatively treatment.
• If conservative treatment is attempted,
secondary displacement, leading to
angulation of finger, often occurs
Bicondylar # of head of middle phalanx :

• T-shaped with long or short” T”.

• Reversed lambda #: combination of long oblique #
separating one condyle with short oblique/ transverse
# separating other condyle.
• Cause: axial load combined with lateral angulation of
finger.
• Tend to be very unstable & should be treated
operatively (Anatomical reduction recommended). If
conservative treatment is attempted, secondary
displacement is likely, leading to angulation of finger.
• Lag screw fixation is indicated both for
short T-shaped & reversed lambda
fractures.

• Consequences of malunion (pain,

deformity, or degenerative joint
disease, at DIPJ) can be dealt with by
arthrodesis, which is usually
procedure with acceptable outcome.
• Vertical # plane & Oblique # plane:
• Screw should be placed perpendicular to intercondylar # plane
Rehabilitation

• removable splint may be applied at the end of the operation, with the
hand in an intrinsic plus position (“safe” or “Edinburgh” position).
Immobilize the hand in a safe position for 2 weeks.
Middle phalanx shaft #:
• Treatment depends on stability & fracture pattern (Transverse Vs
oblique/spiral).
• Stable, non-displaced #:
-Immobilization (2–3 weeks) followed by protected motion
with buddy taping.
-F/u for any displacement & clinical signs of malrotation.
-If malrotation: reduction & stabilization.
• Oblique #: are unstable even following closed reduction & often
result in shortening, which is poorly tolerated by extensor
mechanism.
• Spiral #: Shorten & rotates. Needs stabilization.
• P & S fixation: Good stability & allow early ROM, but
Disadvantage: hardware tends to irritate extensor tendons, resulting in
adhesions, necessitating removal & tenolysis to improve tendon gliding.

• Lag screws: better tolerated than P & S, but still requires soft tissue
dissection, resulting adhesions & limit postoperative motion.

• K-wire fixation: Minimal soft-tissue stripping & Easier removal, healing

• Disadvantage: fixation not rigid, so rehabilitation program cannot be as
aggressive.
Fractures involving the base of
the middle phalanx includes:
• The volar base fractures, resulting dorsal subluxation of the middle phalanx,

• Dorsal base fractures (involving the insertion of the central slip of the
extensor mechanism),

• Avulsion of collateral ligaments, or pilon type of fracture involving the

dorsal and volar margins, with a depressed central articular fragment.

• Fractures involving proximal phalanx head can involve one or both condyles
and can occur with or without proximal extension.
Middle phalanx base articular
fractures
• Fracture dislocations of PIP joint- axial load in a dorsal direction or longitudinal
direction when the finger is slightly flexed.
• Classified according to amount of articular surface involved:
- <30% of articular surface of base of middle phalanx: stable & managed non-
operatively.
- 30–50% of articular surface are tenuous & are usually unstable.
- >50% are unstable & result in dorsal subluxation of phalanx.
• Lateral radiographs should be carefully evaluated
for the “V sign”, indicative of dorsal subluxation

• If there is convergence of joint space creating

dorsal “V”, patient may be able to flex digit at PIPJ,
but this occurs through hinge process rather than
rotation & joint surface will degenerate.
Treatment:
• Directed at recreating a congruent joint surface & restoring motion.

• Stable fractures and those which are classified as tenuous but

maintain stable reduction & congruent joint with no more than 30° of
flexion managed non-operatively with dorsal extension block splint.

• Active flexion is initiated and extension is allowed short of the point

of subluxation. These patients should be followed closely to ensure
that subluxation of the joint does not develop.
• Unstable fractures, or those which a congruent joint cannot be
established with <30° of flexion, require operative treatment.

• A variety of techniques have been described, including

-Extension block pinning
-Open reduction and internal fixation
-Volar plate arthroplasty
-Replacement arthroplasty
-External fixation
Proximal phalanx head fractures
• Intra-articular and anatomic reduction and early motion of these injuries is
goal.

• Can involve one or both condyles

• Often unstable & require treatment.

• Stable, non-displaced fractures - short period of immobilization with frequent

radiographic evaluation.

• Motion is typically started at 3 weeks and the finger is protected with buddy
taping to an adjacent digit.
• Fixation is dependent- size of the fragment and ability to reduce the joint with
closed manipulation.
• If anatomic alignment can be obtained with closed reduction and the fragment
can be stabilized with K-wires, these can be treated as a stable non-displaced
fracture. Often, anatomic reduction requires open exposure.
• The fragments are often large enough to hold at least one small (1.0 mm) screw
and K-wire or two screws. This provides enough stability to begin early motion
and minimizes adhesions to extensor tendons.
• When both condyles are involved, initial alignment and stabilization of
the articular surface is preferred.

• Then, the articular surface can be secured to the shaft either with K-
wires or plates & screws.

• Although P & S provide good stability, they require more dissection,

and adhesions to extensor tendons are likely to occur, often requiring
secondary procedure to remove the hardware and perform tenolysis.
Proximal phalanx shaft & base
fractures
• Fracture of shaft of proximal phalanx can be transverse or oblique.

• Transverse fractures typically have apex volar angulation & are unstable.

• Fractures of the base are typically transverse.

• If not reduced & stabilized, the extensor mechanism will shorten, creating an
extensor lag at PIPJ.
• Percutaneous fixation has advantage of
stabilizining fracture and allowing early
motion while minimizing soft-tissue injury.

• 2 crossed K-wires typically provide enough

stability to allow early motion.

• The wires can be inserted proximally via base

with one on each side of MC head or distally,
with one entering along head or neck.

• Alternatively, K-wires can be placed via MCPJ

in flexion.
• The disadvantage is K-wire is passed through the articular surface, but in
cases with substantial soft-tissue edema, this may help prevent MCPJ
extension contractures.

• By 3–4 weeks, # is usually stable enough for removal of K-wires.

• Protected motion should occur until complete fracture healing.

• Radiographic healing lags behind clinical healing, which typically occurs

around 6 weeks.

• ORIF with plates and screws can allow immediate motion, but adherence of
the tendon to the hardware can be problematic, often resulting in stiffness
& need for secondary procedures.
• Oblique or spiral fractures should be evaluated in flexion as well as
extension

• Often shorten obliquely, resulting in a rotational deformity.

• Fixation can be accomplished with either K-wires or interfragmentary

screws if the length of fracture is 2 times length of diameter of
bone.

• ORIF with interfragmentary screws allows enough stability to proceed

with early active motion & when anatomically reduced, primary bone
healing.

• Adhesions between screws & tendons are less when plates are not
used, & although removal is sometimes necessary, often screws can
 References
• Green’s Operative Hand Surgery , 8th edition
• Rockwood and Green’s Fractures in Adults , 9th edition
• Campbell’s operative orthopaedics , 14th edition
• Apley’s System of Orthopaedics and Fractures, 10th edition
 THANK YOU

• Next presentation: Adult Pelvis Acetabulum Fracture by Dr. Milan

Pudasaini