The hand is made up of 27 bones that form its supporting framework. A fracture occurs when enough force is applied to a bone to break it. This is an all too common injury in hands. However, there are many different types of hand fractures and a number of variable that a hand surgeon must consider to determine what is the optimal treatment option for any given patient.
Figure 1 – Various types of hand fractures.
A fracture may cause pain, stiffness, and loss of movement.
Some fractures will cause an obvious deformity, such as a crooked finger with its obvious associated functional compromise.
Because of the close relationship of bones to ligaments and tendons, the hand may be stiff and weak after the fracture and associated traumatic inflammation heals.
Additionally, the forces that caused the fracture may also injure the associated ligaments and tendons.
Fractures that involve joint surfaces may lead to early arthritis in those involved joints.
A splint or cast may be used to treat a fracture that is not displaced, or to protect a fracture that has been set.
Many fractures require a formal “reduction”. This refers to the act of pulling the bones back into anatomical alignment.
“Closed reduction” – no surgical incision is required. Occasionally such operations require the use of “internal fixation” with the use of pins or wires – closed reduction and internal fixation.
“Open reduction” – refers to an incision being required to access the bone fragments to perform the reduction. These are always associated with internal fixation where the fragment are held in position by pins, plates or screws – open reduction and internal fixation (ORIF).
Occasionally, bone may be missing or be so severely crushed that it cannot be repaired. In such cases, a bone graft may be necessary. This involves harvesting bone from another part of the body to help provide more stability.
Fractures that have been set may be held in place by an “external fixator,” a set of metal bars outside the body attached to pins which are placed in the bone above and below the fracture site, in effect keeping it in traction until the bone heals.
Once the fracture has enough stability, motion exercises are started to try to avoid stiffness.
Figure 2. – Use of K-wires, plates and screws to treat the various fractures. Note that no internal fixation was used for the Boxer’s fracture.
Perfect alignment of the bone on x-ray is not always necessary to get good function. A bony lump may appear at the fracture site as the bone heals and is known as a “fracture callus.” This is a normal healing process and the lump usually gets smaller over time.
The forces required to fracture a bone also act on the surrounding soft tissues. Therefore, significant soft tissue trauma also occurs with its resultant swelling. This swelling is magnified by the bleeding that occurs the bone ends at the site of the fracture. Overall, swelling occurs at the site of the fracture and often affects the whole hand. This swelling can cause stiffness to the hand and fingers.
Other problems with hand fractures include a shift in position (malunion), infection, slow healing, or complete failure to heal (non-union).
Ache – the hand often aches for up to 12 months after the fracture even though it has healed.
In general it takes 6 weeks for a hand fracture to heal and a further 6 weeks to reach near normal strength. Very heavy lifting and contact sport should be avoided until the fracture has solidly healed (8-12 weeks).
X-rays can take 3-5 months to show signs of healing. Therefore, progress x-rays should only be taken if clinically indicated.
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