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Principles of Metacarpal and Phalangeal Fracture Management: A Review of Rehabilitation Concepts

Maureen A. Hardy, PT, MS, CHT 1
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.

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 tissue—another 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

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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
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CLINICAL COMMENTARY

Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Journal of Orthopaedic & Sports Physical Therapy

condylar and any irreducible fractures. nor do they impart any internal strength to the fracture. 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 . Intrinsically stable fractures are usually treated with conservative. This is especially important in articular fractures where joint incongruities can lead to degenerative joint problems. infections. Unstable fractures will not maintain reduction. The more rigid implants. provides an environment suitable for osteoclast cutting cones to form and cross the fracture line. immobilization that maintains the reduction or restricts motion in the direction of instability. followed by guidelines for managing specific types of fractures common in the hand. or nonunion. Fractures that are aligned but subject to misalignment with certain postures or tensions are termed potentially unstable. intramedullary rods. The methods used to bring anatomic order and realignment back to the fractured bone is called reduction. Primary bone healing is direct bone-to-bone healing without any external callus. and 90-90 wiring techniques.4. Compression across the fracture line eliminates the space-occupying hematoma. pseudoarthrosis. All fixation implants promote reduction. These cutting cones have osteoclasts that forage forward. A bone that has lost its normal anatomical contour due to separation of the fracture ends is called displaced. All rights reserved. but they do not control for rotation stresses. but some provide added internal strength across the fracture line. Alternately. These fractures require no further intervention other than protective immobilization to allow healing to commence.39 If the fracture has not distorted the bone’s normal contour and the fracture ends are approximated. These fractures can often be managed with protective 782 Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. The information is presented within the context of an overview of fracture healing. These devices can be inserted either percutaneously (closed reduction) or via surgical exposure (open reduction).39 Stability of these fractures can only be assured with the support provided by fixation devices. do require more rigid external support as previously noted.75 For an in-depth review of fracture healing see LaStayo et al. or by open surgical methods. while also introducing early. however. potentially unstable fractures can be supported with the introduction of coaptive hardware such as K-wires. closed methods of support for 2 to 3 weeks. K-wires.64 One advantage of primary healing via rigid internal fixation is precise anatomic reduction. such as pins. by percutaneous fixation.65 Is the Fracture Healing? Primary Bone Healing Implant choice drives the course of fracture healing. by osteoblastic action. This paper is based on a thorough review of the literature and current practice principles. Reduction can be achieved by either closed manual techniques. thus reducing the fracture gap. such as nondisplaced transverse. avulsion. spiral. and fractures with articular fragments greater than 30% or incongruity greater than 2 mm. PRINCIPLES FOR FRACTURE MANAGEMENT Is the Fracture Stable? The quest in fracture management is to achieve fracture stability. and comminuted fractures. pins. then supported with removable splints for initiation of controlled motion. Some fracture types are known to have intrinsic stability. staples. with special emphasis on potential problems that need to be addressed in the course of rehabilitation. or wiring techniques that protect against displacement. it is termed nondisplaced.skills with respect for gliding structures. and short oblique configurations. as displacement reoccurs despite immobilization. Implants introduced via open reduction internal fixation (ORIF) that provide absolute stability and compression of the fracture permit primary bone healing to occur. Stability of a fracture is achieved when the fracture maintains its reduction and does not displace either spontaneously or with motion. The coaptive implants. Coaptive forms of hardware bring about alignment. the immobilization can be modified to allow incremental increases in range of motion (ROM). The displaced fracture ends must be reunited for healing to occur and to prevent deformities. Coaptive devices therefore require further external support to eliminate unwanted deforming stresses as the fracture heals. and early controlled mobilization have contributed to reducing the incidence of complications that we once faced. Fractures that are stable will heal. As fracture coalescence occurs. permit immediate motion and only require modest external support for wound care. The purpose of this manuscript is to review current concepts of management for metacarpal and phalangeal fractures. Examples of unstable fractures include long oblique. Potentially unstable fractures include oblique. controlled-motion protocols to preserve soft tissue integrity and facilitate scar remodeling. The challenge for the health care team is to design intervention protocols that recognize the need to maintain fracture stability for maximal bone healing. plates. fractures that are not stable can result in malunions. 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. leaving an empty trail behind (haversian canal) that is filled with osteons (a single basic unit of bone). and interosseous wiring. that eliminates all but micromotion. dorsal band. Compression combined with rigid fixation. such as screws.

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). (5) creases of the skin should not be obstructed by the splint. protection from displacement or reinjury. The interphalangeal (IP) joints are routinely rested in full extension. with the exception of volar plate fractures.104 With secondary healing. hyaline cartilage. One disadvantage of secondary healing is the relatively long period of protected immobilization that is required. screws. relief of pain. Without the initiation of early motion post-ORIF. using closed methods that emphasize alignment and early protected motion (Figure 1). so also is avoided the potential problem of tissue adherence to the callus during immobilization. fibrocartilage. and (6) early active tendon gliding is encouraged. there is full access to the hand for wound or edema control measures. Prolonged immobilization results in atrophy of soft tissues. must rely on callus formation to bridge the fracture gap. Closed reduction with external fixation or closed reduction with internal fixation includes percutaneous application of pins. Fractures that cannot be reduced with closed manipulation (or those that fail to maintain their reduction). The periosteal sleeve. plates. Goodship42 summarized this cascade of connective tissue differentiation as one in which. and restoration of hand function.53 After 3 weeks. when intact. so strengthening programs must be delayed until the remodeling phase has begun at 6 to 8 weeks. A disadvantage of primary healing is that it can only occur with mechanical stabilization provided via surgery. fibrous tissue. Once the surgical dressing is removed. This implies that primary healing is not faster healing. severe joint stiffness.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). Callus that is sufficiently ‘‘clinically stiff’’ at 3 weeks to permit motion is not strong enough yet to bear functional loads. or until the callus has achieved enough tensile strength to tolerate controlled movement. (2) eliminate contractures through positioning. unrestricted motion can overwhelm the fragile support offered by early soft callus.52 Is Closed or Open Reduction Required? CLINICAL The vast majority of metacarpal and phalangeal fractures can be treated without surgery. (3) don’t immobilize fractures more than 3 weeks. open fractures. that reduce the fracture but do not provide compression. Although new bone is formed more quickly in primary healing. osteoporosis. and 783 COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®.45 All splinting programs recognize the need to position the metacarpophalangeal (MP) joints in flexion to avoid extension contracture. thinning of articular cartilage.for the callus). Often.65 In polytrauma cases. it is not strong bone. This equates to less scar remodeling. there are 2 wounds to heal: the fracture and the soft tissue incision. granulation tissue. initiation of motion at 3 to 4 weeks is still limited to a safe range dictated by the fracture’s potential instability. consequently.42 Excessive. K-wires. Because bone formation will not occur in an environment of motion.69 Fracture immobilization should provide for adequate healing. the fracture fragments are rendered more stable.’’ The primary advantage of secondary bone healing is that there is minimal soft tissue disruption. there is a greater potential for soft tissue adherence. Bones healing by closed conservative management and those treated by open reduction methods achieve the same level of tensile strength by 12 weeks. Early initiation of motion is permitted as these implants provide sufficient internal support to allow motion without endangering the fracture alignment. Limited open reduction and internal fixation uses small incisions to insert screws or intermedullary fixation. as do open fixation methods that may require periosteal stripping for implant application. then through a process of mineralization true bone is formed. (4) uninvolved joints should not be splinted in stable 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. during which soft tissues can become contracted or adherent to the callus. leading to loss of reduction and possibly nonunion. Insertion of the fixation device does not always require a surgical incision. envelops the bone adding another internal layer of fracture support and is an important blood supply source for the bone. J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . Open methods of internal fixation (ORIF) do require surgical exposure of the fracture for insertion of K-wires. Noninvasive fracture management does not violate this tissue. woven and ultimately lamellary bone. usually in 3 to 5 days. and displaced articular fractures are candidates for operative fixation procedures. and at times pain. ROM exercises are delayed or limited during the first 3 weeks. Secondary Bone Healing Fractures treated by external support or coaptive implants. and external fixators under radiologic C-arm guidance. As the callus gains stiffness. All rights reserved. ‘‘The entire spectrum of connective tissue is seen from blood to bone through hematoma.7 Callus then resembles a natural glue that holds the fracture ends together. soft tissue mobilization programs for repaired tendons can begin immediately without fear of displacing the fracture. callus is a temporary. soft callus transitions into a harder fibrocartilage callus. The thumb MP joint is not exempt from this rule and many stiff thumbs result from hyperextended thumb spica immobilization.

Interosseous Wiring Jabaley57 stated that fixation must be good enough to permit movement. nonunion.69 Full AROM is the early goal as edema diminishes. full active motion can and should be emphasized early. but unrestricted return to sports and heavy work is delayed until after 10 weeks. At 4 to 6 weeks. and permit early motion for good restoration of function. and to perform protected active ROM (AROM) exercises. Early strengthening exercises with light resistance can be initiated at 8 weeks. because the dorsal surface wiring on the metacarpal compresses the fracture with flexion but will cause gapping of the fracture with forced extension.53 Dynamic or serial static splints may be initiated after 6 to 8 weeks’ time to overcome any soft tissue contractures. However. plates) still require protective. K-wires.21 Rigid Fixation: Plates. which the patient removes for suture/pin site cleaning. 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). respectively. however.’’ Coaptive Fixation: External Fixators.9. Strengthening programs are delayed until the remodeling phase to assure fracture union. AROM exercises (out of the splint) are performed hourly to regain full mobility. Intramedullary Rods. because of the stability provided by the rigid fixation. Passive range of motion to regain full joint mobility. and 4 weeks for individuals with proximal phalanx (P1) fractures with K-wire fixation.39 Full motion may not be possible at all joints due to constraints from the hardware. external fixator) or with coaptive forms of fixation (pins. Pins. and (2) rigid forms of fixation that immobilize and compress the fracture (primary healing). Controversy does exist regarding the initiation of motion with coaptive fixation. Because the implant serves as a substitute for hard callus. One week after surgery a removable splint is applied in a functional. Tension Band Wiring. and to acceleration of controlled soft tissue mobilization for full active tendon gliding.Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. passive motion can be initiated during the repair phase. 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 . An exception is forced extension with tension band wiring techniques. given that the small bones in the hand do not bear weight.44. under the implant. . Incidence of infection. as callus remodeling to lamellar bone with increased fracture strength does not occur until this later stage of bone healing. intramedullary rods) require a form of external support to promote callus formation during the inflammatory and repair stages of healing. similar to secondary healing. but unrestricted return to sports and heavy work is delayed until after 10 weeks. and pain have been cited as reasons to delay motion until the fixators are removed. there was a significant loss of mobility. to assure adequate fracture strength has occurred. and strengthening programs. therapy intervention proceeds from edema prevention. the K-wires and pins are removed. which occurs after 6 to 8 weeks. postoperative splint support initially. 3.78 Weiss109 investigated initiation of motion at 1. . 2. when motion was delayed more than 21 days. Early strengthening exercises with light resistance can be initiated at 6 weeks. The callus is considered ‘‘clinically stiff’’ enough for free active motion but is not stable enough to bear a functional load.32. but need not be excessive. assure compression for stability. Results showed no difference in ROM when motion was initiated between 1 to 21 days. ‘‘. ‘‘rehabilitation ready’’ position. brace. wiring. All rights reserved. the splint is adjusted for proper fit and worn for continued fracture protection for another 2 weeks. K-wires. Freeland39 stated that. 90-90 Wiring Open reduction with rigid forms of fixation provide definitive fixation. the choice of the implant is less important than achieving a threshold of stabilization that will allow fracture healing in concert with early rehabilitation.54 Advances in osteosynthesis materials is believed to provide sufficient stability to permit controlled. Dynamic splints may be used at 2 weeks for soft tissue stretching. Fracture stability achieved with open reduction methods (screws. splint. has occurred. when the hard callus is converting to bone. to protected mobilization with tendon gliding of nonimmobilized joints. Fracture stability achieved with closed reduction methods (cast.8. As healing progresses. fracture displacement. protected ROM exercises with this type of fixation in place. 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). FIGURE 1. Screws. Reprinted from LaStayo64 with permission from Elsevier. are delayed to the early and late remodeling phase.

extensor PRINCIPLES FOR MANAGING METACARPAL FRACTURES The metacarpal bones have intrinsic stability provided proximally by strong interosseous ligaments binding them to the carpal bones. Early mobilization to promote venous return via muscle contraction is advocated in stable fractures. capsules. 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. the ‘‘claw fist’’ posture of MP extension with PIP and distal interphalangeal joint (DIP) maximal flexion is achieved (Figure 2D). 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).’’ Functional splinting seeks to place the hand in a resting position that will avoid this deformed posturing. the intrinsic plus position is performed. flexor tendons need to achieve maximal differential glide to prevent restrictive adhesions with loss of motion. Eccles33 showed that the greatest reduction in swelling was obtained with the hand supported in elevation overnight. Micks71 showed that the central slip is responsible for initiating extension from a fully flexed PIP joint position. Patient education for edema control is an essential component of the initial therapy visit. Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®.35 Edema postures the hand into wrist flexion. Rest. 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. which also contributes to PIP joint flexion. serve to protect fracture alignment and encourage mobility of the injured digit.91 Is the Edema Under Control? Edema after injury is common to all fractures. 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. Because the FDP tendons blend into 1 multistrand tendon inserting into the muscle belly. promotes full gliding of all flexor tendons with the FDP tendon gliding past the FDS tendon. IP joint flexion.107 used metal tags on the tendons to demonstrate that the FDP must glide 60 mm. applied proximal and distal to the proximal IP joint (PIP). Selective gliding of flexor tendons is achieved by choosing positions that differentiate movement between the FDP and FDS to achieve maximal glide of each. Patients are also instructed in shoulder and elbow ROM exercise in elevation to facilitate proximal muscle pumping.105 CLINICAL COMMENTARY Are the Tendons Gliding? AROM is initiated as soon as possible. and thumb adduction: a dropped ‘‘claw hand. and elevation (‘‘RICE’’) are emphasized for edema control. If full PIP extension is lacking. flexing the wrist may assist by the addition of passive tenodesis action (stretch of the extensor mechanism). MP joint extension. Coban (sized 1 inch [2. The goals of hand therapy then are to reintroduce safe early mobilization while maintaining fracture stability. to achieve full fisting. Edema is poorly tolerated in the digits due to the confining space. compression. Wehbe106. All rights reserved. This research suggests that for P1 and middle phalanx (P2) fractures. 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.various forms of fixation of fractures as they dictate the course of rehabilitation. ice. to prevent osseous adhesions to tendons. blocking 1 tendon’s excursion effectively blocks all others. Ideally the therapist would have access to both the radiographs and an operative/emergency department report on the medical management of the fracture. ligaments. or skin. Double buddy straps. To gain extensor hood glide over proximal phalanx (P1) fractures. 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).15 To assure the extensor tendon glide over fractured metacarpal bones. compared to 49 mm of FDS glide. facilitated by manually blocking the MP joint into flexion (Figure 2B). The fracture date starts the bone-healing timetable. FDS tendon blocking exercise requires inhibition of the FDP tendon of the same finger. while the lateral bands (interossei and lumbricals) achieve full terminal PIP extension. and distally by the transverse metacarpal ligament linking all metacarpal heads. flexion of all 3 joints simultaneously. MP extension is performed in the ‘‘hook fist’’ posture (Figure 2A). These ligaments serve to tether and anchor both ends of the metacarpal. digitorum communis and central slip to prevent tendon adherence to fracture callus. Full fisting. based on the method of fixation.14 The only motor that is now free to glide and flex the PIP joint is the FDS tendon. and the method of fixation (dictating the type of healing) influences the rate at which motion can be reintroduced. flexor digitorum superficialis (FDS). To promote selective FDP flexor tendon glide past the superficialis tendon. Distended joints predictably move into positions that permit the greatest expansion of the joint capsule and collateral ligaments. preventing excessive 785 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 .5 cm] for fingers and 2 inches [5 cm] for the hand) is an elastic self-adhering bandage that provides effective compression.82 The most important tendon-gliding exercises to initiate early are those for the flexor digitorum profundus (FDP).

E F FIGURE 2. (F) sublimis fist posture to promote selective FDS tendon glide. (D) hook fist posture to promote selective FDP tendon glide. (B) intrinsic plus posture to achieve central slip/lateral bands glide over proximal phalanx (P1). 786 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 .A B C D Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. Tendon glide exercises: (A) claw posture to achieve extensor digitorum communis (EDC) tendon glide over metacarpal bone. (E) flexor digitorum sublimis (FDS) blocking exercise to glide FDS tendon over middle phalanx. (C) flexor digitorum profundus (FDP) blocking exercises to glide FDP tendon over P1.

TABLE 1. or overwhelms the normal flexibility of the ulnar metacarpals (ring and small). iontophoresis with lidocaine Rest involved tendon. neck. Table 1 lists the potential problems that can occur and strategies for therapeutic intervention. The deep motor branch of the ulnar nerve. MP. is also vulnerable to injury in this fracture. Closed reduction with casting of the wrist for 4 to 6 weeks is indicated for nondisplaced or minimally displaced fractures. a protective wrist splint is used for 3 to 4 weeks while wrist rehabilitation is initiated. and head. splint in extension at night. simultaneous heat and stretch with hand wrapped in a fisted position.100 Metacarpal fractures represent 35% of hand fractures. Postoperatively. active range of motion. prevent pain. causing weakness of grip. extensor digitorum communis. ice. Potential Problems Dorsal hand edema Prevention and Treatment Coban wrap compression. contact physician if painful symptoms with AROM persist COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. Fractures of this bone are described at 4 distinct locations: base. Once clinical signs of healing are present.displacement with injury. metacarpophalangeal. minor: padded work glove. may not be functional problem Shortening of metacarpal with redundancy in extensor length. degenerative joint disease and ultimately further carpal collapse. flexor carpi ulnaris. During this time the fingers are free and encouraged to move. All rights reserved. NMES. IP. J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 787 . strengthen intrinsics abduction/adduction. a cast is worn for 4 to 6 weeks to protect this injury at the wrist. tend to be more unstable due to loss of surrounding intact metacarpal pillars. The most common occurrence is at the fifth metacarpal-hamate articulation.41 ORIF is necessary to restore joint approximation. This prolonged immobilization is necessary to protect the healing fracture from the deforming forces of the wrist tendon insertions. NMES of EDC with on Ͼ off cycle Intrinsic muscle contracture secondary to swelling and immobilization Dorsal sensory radial/ulnar nerve irritation Attrition and potential rupture of extensor tendon over prominent dorsal boss or large plate Initially: teach instrinsic stretch (instrinsic minus position) Late: static progressive splint in intrinsic minus position Desensitization program. which is often unstable due to the pull of the extensor carpi ulnaris.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. Due to their good blood supply.70 CLINICAL Adherence of EDC tendon to Initially: teach EDC glide exerfracture with limited MP joint cises to prevent adherence.41 The insertions of the wrist flexors and extensors on the metacarpal base can be a deforming force. interphalangeal. is the most mobile and most unstable if fractured. The most important soft tissue concerns with metacarpal fractures are preserving MP joint flexion and maintaining EDC glide. friction massage Initially: position MP joint at 70° flexion in protective splint Late: dynamic or static progressive MP joint flexion splint Dorsal skin scar contracture that prevents full fist MP joint contracted in extension Metacarpal Base Fracture Base fractures are an intra-articular fracture resulting from high force that disrupts the rigid carpal ligaments (index and middle). Fractures in the border digits. passing beneath the hook of the hamate. neuromuscular electrical stimulation. EDC. Potential problems with metacarpal fractures and strategies for therapeutic intervention. and abductor digiti minimi that insert on the metacarpal base. The thumb metacarpal. Displaced fractures represent an associated carpometacarpal joint dislocation that can lead to joint incongruity. Scissoring/overlapping of digits Slight: buddy tape to adjacent with flexion digit Severe: malrotation deformity requiring ORIF Absence of MP head Absence of MP head and MP joint extension lag Shortening of metacarpal. high-voltage stimulation Silicone TopiGel. sitting at 47° rotation away from the other digits. and assure return of grip strength.12 Fractures at this location limit the normal descent of the ulnar metacarpals. NMES of intrinsics with off Ͼ on cycle Neck fracture angulated volarly. This is especially true for middle and ring metacarpal fractures as they have the additional support of intact adjacent metacarpals. major: reduction of angulation required Absence of MP head with volar prominence and pain with grip Abbreviations: AROM. these fractures heal rapidly with osseous restoration in 6 weeks. These are uncommon injuries associated with violent accidents resulting in a fracture-dislocation pattern. index and small. Bora12 reported ‘‘satisfactory’’ return of grip strength and activities in 18 patients treated with this method. elevation. flexion splint IP joint in extension during exercise to concentrate flexion power at MP joint Late: dynamic MP flexion splint. shaft.

and PIP joints have been the norm (Figure 4A-B). Both studies compared this functional brace. nondisplaced transverse metacarpal shaft fractures with apex dorsal angulation can be treated closed with glove support. including wrist. will cause both ends of the metacarpal bone to flex towards each other. modified to plaster in noncompliant patients. Ashkenaze6 described a splint that includes the wrist and metacarpal shafts with dorsal support extending out to the PIP joint. blow. maintains proper hand posture. less extensor lag. Multiple metacarpal fractures may require that all fingers be included in the cast (Figure 5A). Buddy strapping of the injured digit to a noninjured adjacent finger. For each 2-mm increment of bone shortening there is a corresponding 7° extensor lag at the MP joint.103 C-arm visualization of the fracture with the splint on will assure improvement in the angulation after 1 week. especially in oblique fractures.112 short hand casts. proximal and distal to the fracture. Current best-practice fracture support for managing nondisplaced. arising from its origin on the volar proximal metacarpal through its bony insertion on the proximal phalanx. oblique. (B) straps secured to apply corrective pressure to dorsal apex angulation of fracture. pushing the fracture ends dorsally (known as apex dorsal presentation). Ulnar or radial gutter splints that immobilize both the injured metacarpal and its adjacent stable metacarpal. (A) metacarpal shaft fracture treated with 3-point pressure fixation built inside splint. Konradsen. 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). permiting controlled-motion exercises (Figure 4C-D). Seventy degrees of MP joint flexion reduces the intrinsic and extrinsic flexors influence on dorsal angulation. 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. and decreased need for postfracture therapy. but this deformity leaves a prominent dorsal boss that has been implicated in attrition rupture of extensor tendons. decreased pain. and respects the J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . FIGURE 3.58 using thermoplastic material. or hand-based fabricated splints that incorporate 3 points of reduction pressure (1 dorsal point over the fracture site and 2 volar points. is protective against malrotation and facilitates early motion. fabricated custom-made. Hall47 reported using this type of clam digger immobilization in over 1000 fractures. ability to deliver corrective reduction force. causing a deleterious effect on the extensor mechanism by altering the muscle’s normal length-tension relationship. This best-practice management technique assures protection of fracture stability.97 The natural ability to hyperextend the MP joint will overcome this extensor loss for minimal bone shortening. All rights reserved. Fractures that are potentially unstable require additional support. these 2 studies support the advantages of the functional brace with improved motion. hand-based fracture braces with the 3-point reduction technique. or crushing force that usually angulate dorsally and may have components of shortening and/or rotation. and Jones. with plaster ulnar gutter casting.102. Feehan36 788 A B Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®.29 long ulnar/radial gutter splints. with the volar support ending at the distal palmar crease to allow free MP and IP joint motion.96 Stable. that provide counterpressure).68 buddy taping.90 The IP joints are free to move during the day but strapped into extension at night to prevent flexion contractures (Figure 5B). Intrinsic muscle tension. They are described by the fracture configuration as transverse.70.’’ in which the splint is gradually cut down as fracture healing proceeds. MP.58 Sorenson92 found poor compliance and skin breakdown with prefabricated splints as compared to ulnar gutter casts.61 using fiberglass casting.Metacarpal Shaft Fracture Shaft fractures are extra-articular fractures caused by fall. proposed the concept of ‘‘serial splint reduction. Together. or spiral. which allowed wrist and digital motion.

A B CLINICAL C D COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. a circumferential. (C) serial reduction of splint to permit motion as fracture healing occurs. 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. All rights reserved. Following ORIF. hand-based splint is worn to protect the metacarpal area from direct trauma. 789 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . no joint motion is restricted with this splint. (A) Radial gutter splint for fractures of index or middle metacarpals. The ill effects of this telescoping and malrotation will be evident when the patient attempts to make a fist. importance of motion in the early rehabilitation of fracture. (D) passive range of motion in splint. Oblique and spiral metacarpal fractures can shorten and rotate. pain-free return of hand function. FIGURE 4. (B) ulnar gutter splint for fractures of ring or small metacarpals. 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.

All rights reserved. Trauma causes the fractured metacarpal head to displace with volar angulation. The patient is instructed in protected ROM exercises out of the splint.56 However. Debate continues over the necessity to reduce and immobilize these fractures. It is recommended that reduced fractures use the hand-based splint that maintains the MP flexed with a dorsal block. or shattering of the joint surface into many small-comminuted pieces. fracture of 1 or both condyles. Metacarpal Neck Fracture Neck fractures are the most common metacarpal fracture. including a fracture fragment. With fight/bite injury. and found that this gradual application of stress reduced the fracture as effectively as manipulation with anesthesia. the surgical dressing is removed and an immobilization splint is applied to protect this coaptive fixation at that time. Metacarpal Head Fracture Head fractures are intra-articular fractures caused by high axial loads that can involve avulsion of the collateral ligaments. This loss of full muscle length results in limited ability to initiate flexion at the MP joint. At 4 to 6 weeks the K-wires are removed and the patient should then regain full AROM. 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. then operative treatment is recommended. FIGURE 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. as the taught collateral ligaments will aid in securing the metacarpal head in place.A B Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. the 3-point splint should be used.5. Closed reduction percutaneous pinning with K-wires is recommended to maintain reduction in unstable neck fractures.6.61 Jones58 instructed patients to gradually tighten the straps as edema subsided. If these acceptable reduction angles cannot be maintained with external support alone. (2) holding the MP joint in flexion by a dorsal block component that extends out to the PIP joint.38 Displaced fractures require ORIF with fixation that allows early protected motion.93 Once the volarly flexed metacarpal head is reduced back in proper alignment with the shaft. If the fracture fragment is nondisplaced.48. while the ring and small metacarpals can function with less than 30° due 790 to their compensatory mobility. however. Any skin laceration at the MP joint level with fight/bite fractures should be suspect for infection. also known as fighter’s or boxer’s fracture.88 One week postoperatively. the fist contact with the mouth of another can result in tooth penetration into the MP joint.3. it is important to hold the MP joint in over 70° flexion. the injury can be treated with protective splints that hold the MP joint flexed at 50° to 70° for 4 to 6 weeks. (B) resting volar component added to maintain interphalangeal joints in full extension. Collateral ligament avulsion fractures if undetected can lead to chronic pain and joint instability. and compensatory hyperextension of the proximal phalanx at the MP joint to clear the fingers for grasp.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. The impact of a closed fist hitting an object can fracture the metacarpal at its weakest point.14. (A) Cast for multiple metacarpal fractures permitting early active finger flexion.3 Other complications of poorly reduced neck fractures include a metacarpal head prominence in the palm that is painful with grip. which reduces the muscle’s excursion capacity. Acceptable angulation is less than 15° in the index and middle metacarpals. (3) stopping the volar side of the splint at the MP web area. permitting limited MP and full PIP flexion. A traditional ‘‘clam digger’’ or intrinsic plus splint can be used that includes: (1) keeping the wrist in slight extension. angulated neck fractures that heal with volar displacement over 30° place the intrinsic muscle in a shortened position. the extra-articular neck.50 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 .24 If reduction is inadequate or potentially unstable.

FDS. NMES. during the day MP flexion blocking splint to concentrate flexor power at PIP joint. nonfractured neighboring fingers also lose motion. MP. Displaced base fractures can not be reduced with MP joint positioning alone as often the collateral ligament.112 Phalangeal fractures respond more unfavorably to immobilization than metacarpal fractures. Potential Problems Loss of MP flexion Prevention and Treatment Circumferential PIP and DIP extension splint to concentrate flexor power at MP joint. comminuted fractures with substantial loss of bone length are better treated with external fixators or bridging plates that maintain bone length. compared to 96% return in metacarpal fractures. stability of the fracture position can be maintained with conservative treatment due to tension in the surrounding intact joint capsule.23 Immobilization is shortened to 2 to 3 weeks. collateral ligament complex. These articular fractures require accurate reduction to restore normal joint kinematics. metacarpophalangeal.98 In 19% of digital fractures. address edema. NMES to EDC and interossei with dual channel setup Isolated FDP tendon glide exercises. All rights reserved. PIP flexion blocking splint to concentrate flexor power at DIP joint. The intrinsic plus position of the splint design also causes the extensor aponeurosis to be tightened and drawn distally over the base of P1.55 Functional outcome in these fractures is not so dependent on fracture site. NMES to interossei Central slip blocking exercises.88 If immobilization is continued longer than 4 weeks. because early motion benefits articular cartilage repair. and volar plate for fractures in the proximal 6. comminuted fractures. attached to the fracture fragment. NMES to FDP Buddy strap or finger hinged splint that prevents lateral stress Early DIP active flexion to maintain length of lateral bands FDS tendon glide at PIP joint and terminal extensor tendon glide at the DIP joint Splint to hold MP joint in flexion with PIP joint full extensor glide Resume protective splinting until healing is ascertained. desensitization program Loss of PIP extension Loss of PIP 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.to 9-mm range from the joint. at night flexion glove. are allowed early active motion. After reduction. neuromuscular electrical stimulation. Shewring’s 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.Comminuted fractures that do not lend themselves well to operative fixation.111 Positioning the MP joint in 70° flexion results in balanced tension of these capsular structures. Potential problems with phalangeal fractures and strategies for therapeutic intervention. the motion return drops to 66%. extensor digitorum communis. EDC. during the day MP extension block splint to concentrate extensor power at PIP joint. and associated soft tissue injuries. NMES to interossei Isolated FDP tendon glide exercises.79 or 3 to 4 weeks. the splint can be removed for protected ROM at the MP joint. His definitive work on intraarticular fractures showed that continuous passive motion begun in the first postoperative week stimulates both bone and cartilage healing. After 2 to 3 weeks. providing compression of the fracture.78 Table 2 lists potential problems that can occur with phalangeal fractures and strategies for therapeutic intervention. Impending Boutonniere deformity Impending swan neck deformity Pseudo claw deformity 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. However. at night PIP extension gutter splint. rather. These avulsion fractures occur most often at the ulnar collateral ligament of the thumb or 791 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . Loss of DIP extension Loss of DIP flexion CLINICAL Lateral instability any joint COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. oblique retinacular ligament. buddy taped to an adjacent digit. with a predicted 84% return of motion. is avulsed. 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. FDP.81 TABLE 2. flexor digitorum superficialis. interossei tendons. PIP. ORL. stretch ORL tightness. The PIP and DIP joints. Pain Abbreviations: DIP. flexor digitorum profundus. proximal interphalangeal. can be treated with closed immobilization in a radial/ulnar gutter splint with the MP joints flexed to 70°. NMES to FDS Resume night extension splinting.32 depending on callus formation. due to the many small fragments involved. unsatisfactory results are more related to open fractures. distal interphalangeal.

decrease edema. will facilitate all flexor strength directed towards the MP joint (Figure 6A-B). respectively. provide stability to a joint J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . . a splint is made that maintains flexion at the MP joint.A B FIGURE 6. which develops into a fixed joint flexion contracture. FDS.11 Freeland39 recommends that the ‘‘least intrusive technique be used to provide a threshold of strength that reliably holds the fracture securely . index and radial collateral ligament of the ring and small fingers. Initially. with a dorsal hood expansion to securely strap the PIP joint into full extension at rest (Figure 5). called ‘‘no man’s fractures. protecting against MP hyperextension.24 The volar part of the splint stops at the distal palmar crease. emphasizing central slip. Oxford73 recommends a singledigit circumferential splint for stable fractures. and DIP joints immobilized during exercise. with their intimate convex-concave fit on the middle phalanx base.2. Continuous passive motion (CPM) following ORIF with rigid fixation is indicated to maintain joint mobility.81 P1 Shaft Fracture Fractures occurring in digital flexor zone II. a functional blocking splint can be used to counter the pseudo-boutonniere posturing that occurs with less than optimal tendon gliding (Figure 7A-B). miniplates.110 792 Nondisplaced fractures require protection. the use of splints holding the wrist. When active exercises are initiated to regain full MP flexion. Full PIP joint flexion is not promoted until the patient is able to actively extend the PIP joint to 0°. This angulation is due to a volar force at the base of P1 by the interossei insertion.’’17 are renown for the worst prognosis in regaining full mobility. and FDP tendons. lateral bands bilaterally.74 The worst case scenario results when minimal motion at the PIP joint results in a fixed flexed position of the joint. (B) MP joint flexion isolated during exercise with use of dual blocking splints. open internal fixation with miniscrews.110 or screw fixation. This design allows for free active PIP joint motion. unstable fractures include closed transcutaneous insertion of K-wires or intramedullar y rods. percutaneous miniscrews.79 Techniques used for fixation of displaced fractures include tension band wiring using a figure-of-eight weave. Later. Light-resistance exercises for PIP joint flexion and PIP joint extension are facilitated when performed in the splint.40 The most common problem at this level begins with an extensor lag at the PIP joint. but not total immobilization. and mini external fixators. Hourly the distal straps are removed to permit early tendon gliding.8. Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. and the FDP tendon volarly—that can easily become adherent to fracture callus. Inclusion of a neighboring noninjured digit in the splint and buddy strapping permit early AROM.’’ Methods of fixation for displaced. P1 Condylar Fracture The 2 condyles at the head of the proximal phalanx. lateral bands. (A) Wrist and distal joint immobilizer splint used during exercise sessions to promote flexion at the metacarpophalangeal joint (MP).34 Burkhalter17 reminds us that it is far easier to gain flexion than extension at this joint. and stimulate the healing of articular cartilage. and would allow simultaneous early rehabilitation. . A pseudo-claw hand posture is created.62 intraosseous wiring with additional K-wire support. while also directing all flexor and extensor tendon power to the PIP joint. Fractures of the shaft require accurate reduction to allow these soft tissues to glide normally. The splint immobilizes the MP joint in flexion. 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. All rights reserved. protective splinting must rest the MP joint in flexion.31 Ninety percent of the bone’s surface is covered by gliding structures—the central tendon dorsally.50 As MP joint stiffness with loss of flexion is the most common postoperative soft tissue complication of P1 base fractures. Displaced P1 fractures present with apex palmar angulation. PIP. Prevention of this deformity relies on emphasizing PIP joint extension at rest and early tendon glide along all bone surfaces. which is compensated at the MP joint with hyperextension to remove the flexed finger from the palm. while the extensor expansion pulls the distal fragment dorsally.

is ruptured along with a variable portion of the articular surface of the volar middle phalanx. reduction of edema.95 Palmar Plate Avulsion Fracture Also known as dorsal fracture dislocation. 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. The use of continuous passive motion (CPM) following rigid internal fixation of these fractures results in regeneration of hyaline articular cartilage. comminuted fractures of the articular surface occur. This may be partly explained by the mutually dependent role played by the central slip and lateral bands in achieving full PIP joint extension. Swelling will draw the joint into a flexed posture that over time will become a contracture. The percent of articular surface involved and the percent of joint dislocation determine severity of this fracture. However. With severe compressive trauma.72 excising the insertion of the central tendon creating a flap. lateral incision used for screw placement. (B) the blocking splint facilitates flexor and extensor tendon gliding at the proximal interphalangeal joint (PIP). commonly called avulsion fractures. as compared to the group that received closed reduction treatment (8°). 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. or from a fall onto the outstretched hand. hyperflexion.109 This is a common sports injury that is often misdiagnosed as a ‘‘jammed finger’’ as the athlete can move the finger well. Full PIP joint flexion is limited for 3 weeks to prevent splitting the sutured tendon approximation. CLINICAL COMMENTARY Middle Phalanx (P2) Base Fracture This intra-articular fracture is caused by a hyperextension. It is crucial that the patient work to achieve proximal gliding of the extensor mechanism. as occurs in basketball and volleyball injuries. Pilon is derived from the Latin word ‘‘pounder. Pain and swelling at the PIP joint postoperatively are a great barrier to rehabilitation. Splinting must rest the PIP joint in full extension.93 These potentially unstable fractures are best treated with ORIF to assure good joint alignment is achieved. Fractures of moderate severity (20% to 40% of the articular surface involved) are treated with extension block splinting 793 Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. with hourly short-arc AROM performed. All rights reserved. the ORIF group in his study had 3 times greater PIP joint extension lag (27°). as there is continuity of the extensor tendon longitudinally. the lateral approaches that spare direct trauma to the central tendon are more appealing.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.80 Incised and repaired central slip tendons can also be treated with the short-arc-motion protocol.77 incising between the lateral band and the central tendon. tension from the finger extensors on their distal attachment causes the base fracture to dislocate dorsally. this fracture results from a hyperextension injury in which the distal attachment of the volar plate.’’ indicating the force required to create this deformity. while a high loading rate can result in a collateral avulsion fracture. causing depression of the fragments into the bone shaft. (A) Pseudo-boutonniere deformity of ring digit following proximal phalanx fracture. and thus 0° extension to prevent an extensor lag. deprived of much soft tissue support.82 Continued unsupported use of the hand can change a simple nondisplaced fracture into an angulated fracture with painful joint incongruity. or lateral deviation force on an outstretched finger.54 As the most significant complication following P1 fracture is loss of full PIP joint extension. called a pilon fracture. and is painless. Horton48 found that despite the J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . Without the normal restrains provided by an intact volar plate.20 or a lateral midaxial incision. at the base of P2. or a unicondylar (1 side) or bicondylar (2 sides) fracture configuration at the head of P1.A B FIGURE 7. It may be that adhesions in either system will affect PIP joint extension. prevention of adhesions and joint stiffness.83 Buddy taping and immediate active motion are used to manage less severe fractures.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.

to 8-week splinting regime. for greater than 6 weeks. This protocol allows fracture compression with flexion. Central Slip Avulsion Fracture This fracture. 794 full extension and is removed for passive ROM exercises. Usually there is a slight flexion contracture at the end of the 6 . however. is often difficult due to soft tissue constraints. necessitating ORIF with pin. This latter method uses a radial or ulnar gutter splint that blocks the MP joint in flexion. The distal articular surface of the PIP joint is essentially destroyed. All rights reserved. Reduced fractures are immobilized in full PIP joint extension for 4 to 6 weeks. Flexion at the DIP joint will prevent the appearance of a boutonniere deformity post immobilization. This fracture is at risk for displacement with full extension. FIGURE 8. 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.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). FIGURE 10. Rubber band J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . also known as ‘‘dorsal fracture dislocation’’ or ‘‘boutonniere fracture.8 A removable protective fingerbased splint is worn that maintains the PIP joint in FIGURE 9. yet allows full joint flexion (Figure 8). Pins are removed at 2 to 3 weeks. 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.Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. at which time. or tension band wiring. Fortunately it is a rare injury and treatment depends on the ability to restore the volar subluxed P2 back to approximate the avulsed fragment. active motion can begin immediately with the use of the same splint to prevent flexed posturing at the PIP joint. the splint angle is subsequently remolded at less extension block weekly. active ROM can begin to further glide soft tissues.’’ includes a fracture fragment from the dorsal base of P2 that is attached to the central extensor tendon. crushed fracture fragments. 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). creating many small. Dynamic traction splint for comminuted pilon fractures. Rubber band tension is measured to assure 300 g of ligamentotaxis distractive force throughout the range. ORIF seeks to elevate the central depressed articular fragments and maintain their length with bone grafts or external fixators. A dorsal block splint prevents the joint from extending by 30° to 40°.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. permitting gain in extension range. The finger is moved passively along the arc several times per day to stimulate regeneration of articular cartilage and remodel the joint surface. while avoiding fracture separation with extension. screw.22 Closed reduction. As fracture healing ensues. Volar plate avulsion fracture treated with extension block splint that limits full extension at the proximal interphalangeal joint (PIP). With screw fixation. which can be treated with dynamic extension splinting. Pilon Fracture Severe compressive trauma can cause the head of the proximal phalanx to impact into the base of P2.

joint capsule) is placed under longitudinal tension. known as ‘‘mallet fracture’’ or ‘‘baseball fracture.18 Causes of fracture include crush to the distal tuft. 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. P3 Base Fracture Articular avulsion fractures are closed injuries that result when an actively contracting tendon is forcefully pushed into the opposite direction. as FDS tendon action can displace this fracture due to its insertion on the P2 shaft. with loss of active flexion.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. resulting in shortening of the middle phalanx shaft.65 The extensor terminal tendon is avulsed off the dorsal base of P3.95 P2 Neck Fracture Neck or subcapital fractures are more common in young children whose fingers have been trapped in closed doors or electric windows. or an articular fragment of variable size can be avulsed along with the tendon. If the fracture piece represents less that one third of the articular surface. For long oblique or spiral fractures. which is beneficial to articular cartilage healing. due in part to the short. Emphasis is placed on FDS tendon glide at the PIP joint and terminal extension glide at the DIP joint. Two common types of avulsion fractures at this level are ‘‘jersey’’ fracture and ‘‘baseball’’ fracture. indicating good cartilage thickness. place them in jeopardy of adhering to fracture callus with closed methods.58 During the day the dynamic-traction component is moved along the circular outrigger hoop to achieve passive PIP joint motion. the tendon (with the fracture fragment attached) is surgically reattached through P3 using wire pull-out sutures over a dorsal button. as FDP tendon muscle shortening can occur if undetected. ORIF or percutaneous use of screws provides enough stability to allow AROM within 1 week. Loss of full DIP joint extension. collateral ligaments. Distal Phalanx (P3) Fractures The distal exposed portion of the finger is most vulnerable to injury. with a bone chip. due to either lateral band adherence or redundance. Postoperative therapy is based on the stability of the fixation. The digit is splinted in the functional position of MP joint flexion with PIP and DIP joints in full extension. This skeletal shortening will cause an imbalance in extensor tendon-bone length ratio. requiring ORIF. and an extensor lag are the chief complications. causing the FDP tendon.traction from a circular outrigger is attached to exposed K-wires passed through the middle phalanx distal to the fracture. Longitudinally placed pins down the medullary canal try to avoid this soft tissue problem. with frequent removal for FDP tendon gliding is recommended. with fractures at the P3 level accounting for 50% of hand fractures. they maintained their 87° arc of PIP joint motion. blows to an extended finger. to be avulsed from the volar base of P3.8 Limitation of lateral band gliding will result in loss of DIP joint terminal extension.1 Cannon19 recommended 3 weeks immobilization with closed methods or K-wire fixation. resulting in loss of terminal DIP joint extension. as when fingers are caught in closed doors or machines. causing these soft tissues to narrow and compress the fracture. The splint is worn continuously for 6 to 8 weeks (removed briefly for dressing purposes) to prevent displacement of the fracture. All rights reserved. A dorsal blocking splint is fabricated and the postoperative Durand tendon motion protocol is followed. Tendon rupture alone can occur. Midshaft fractures can angulate either dorsally or volarly. countering the swan neck deformity. The path of the lateral bands.’’ is common to all sports and hobbies in which an extended finger is forced into either flexion or hyperextension. spiraling from their lateral position at the PIP joint to become conjoined dorsally over the distal part of this phalanx. leads to the classic swan neck deformity of DIP flexion with excessive extensor force directed at hyperextending the PIP joint. DIP joint stiffness. or of becoming impaled with pins and screws with open methods. Stern’s review93 of complications suggests that K-wires should remain in for a longer duration of 4 to 6 weeks. 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. Loss of terminal joint active flexion requires early and judicious care.19 Large fracture fragments require the additional support of K-wires to assure good joint surface congruence is achieved. omitting DIP joint flexion until the wire is removed.’’ in which the soft tissue envelope that encircles the fracture (intact periosteum.84 A modified Durand program is performed. it may be managed with 795 COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. Protective splinting of the DIP joint in full extension. J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . and sports-related volar and dorsal articular avulsion fractures. and the joint space had been maintained. These fractures are usually markedly displaced and unstable. Dorsal Avulsion Fracture This fracture. The use of dynamic traction for pilon fractures was compared with ORIF and found to produce the same results with fewer complications. with a chip of variable-sized bone attached. broad shaft that is stronger here than in proximal bones.84 CLINICAL P2 Shaft Fracture Fractures at this location are rare. With small fragments.

10. as opposed to a 45% complication rate for closed treatment. soft tissues glide in multidirections mere millimeters away from skeletal structures. then splinting is resumed during the day also. is relatively simple.94 Wehbe106 suggests that due to these findings most mallet fractures should be treated with conservative closed methods. Compression around the tip facilitates fragment approximation and diminishes the very painful effect of bleeding and swelling at this level. A thin.27. Tip protector splint bivalved to maintain distal interphalangeal joint (DIP) extension and accommodate swelling for mallet fractures. Surgical treatment for mallet fractures have been reported to have a 53% complication rate due to infection.49 This is followed by blocking exercises for FDP tendon glide. Care must be taken that the splint does not rub against the exposed pin. including DIP and PIP joints. an intact ORL will serve to passively assist DIP joint extension as PIP joint active extension occurs. proximal to the nail bed. but not including. supportive splinting. If extensor lag at the DIP joint is noted. Because the greatest complication of mallet fractures is a DIP joint extensor lag. and extensor lag. P3 Tuft Fracture Treatment of the tuft fracture. protective splint extending to. nail bed damage. Fibrous union is slow to ossify at this level. closed splinting of the DIP joint in extension for 6 weeks (Figure 11). motion can and should be reintroduced at the DIP level by reducing the length of the protective splint and encouraging joint motion. Blocked DIP joint flexion exercises are not performed. which is secured with coban wrap. It is impossible. Wrapping the digit with coban into an intrinsic minus position and then dipping into paraffin provides simultaneous heat and stretch. then. and swelling with the development of hypersensitivity to touch. as this would stretch out the oblique retinacular ligament (ORL). joint incongruity. composite flexion and extension of the PIP and DIP joints is taught. 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. FIGURE 11. Wound care. to consider skeletal injury as isolated trauma to bone tissue only. and texture tolerance are beneficial to accommodate to normal fingertip use. Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. nail deformity. as with conservative methods. allows accommodation for any swelling. All joints must be immobilized for a minimum of 6 weeks. the fracture pattern shows significant displacement of the 2 fracture fragments.99. Trauma and fracture displacement can harm surrounding soft tissue structures as well as encase both together in P3 Shaft Fracture Trauma at this level. Fracture fragments that are greater than one third of the articular surface can be surgically reattached using various wiring techniques. requiring several months26.19 CONCLUSION Unique to hand anatomy. Splinting is continued at night and during vigorous activities for another 2 to 4 weeks.28. Active ROM at the DIP joint can be initiated after 3 weeks if callus consolidation permits. usually causes an open wound that needs to be supported with external splinting or K-wire and splinting for 3 weeks. Following the 6 weeks of continuous immobilization in extension. Bivalving the splint. All rights reserved. once nail bed healing is complete. Loss of full DIP joint flexion is usually due to soft tissue contracture of joint structures and dorsal skin scar. The more difficult aspect of managing these fractures is the extent of nail bed injury that may be present and require suturing.and motion at the MP and PIP joints is encouraged after the first week.19 The finger pulp region is densely innervated with sensory end organs that painfully respond to the initial crush. which has been shown to have the best effect on soft tissue lengthening. even when comminuted. Occasionally. Use of a TopiGel sleeve. 796 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . initially allows the inflammatory period to resolve. Desensitization programs that include vibration. requiring ORIF with K-wire fixation for 3 weeks. however. edema measures. assists in scar management as well as dampening painful sensory input.108 Damron’s27 analysis of these common fixation methods noted that none of the fixation methods provide enough stability to permit early motion. as excessive irritation can result in a pin tract infection. putty press. the PIP joint is worn for 2 to 3 weeks.2 Protective.

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