Full Length Article

Journal of Hand Surgery

(European Volume)
Current methods, outcomes and 2020, Vol. 45(6) 547–559
! The Author(s) 2020
challenges for the treatment of Article reuse guidelines:
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hand fractures DOI: 10.1177/1753193420928820
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Michel E. H. Boeckstyns

Abstract
In treating hand fractures, we have to make a proper decision about conservative treatment versus surgical
intervention and decide on individual surgical methods. This article reviews recent publications, technical
advances, and outcome measures in treating metacarpal fractures, phalangeal fractures, complex fractures
of the proximal interphalangeal joints, bony mallet fingers, and fractures of the thumb. My personal prefer-
ences and considerations are presented. At the end, the current challenges that hand surgeons are facing in
treating frequent phalangeal and metacarpal fractures are discussed.

Keywords
Hand fractures, metacarpal fractures, phalangeal fractures, decision making

Date received: 18th April 2020; revised: 21st April 2020; accepted: 2nd May 2020

Unfortunately, more often than not, the best available

Introduction
When treating a fracture in the hand, the first ques-
tion the hand surgeon must ask is: ‘Can this
fracture be treated conservatively?’ or ‘Does this
fracture need operative fixation?’ Not: ‘How
does this fracture need to be operatively fixed?’
Indeed, at least 70%–80% of hand fractures can be
managed successfully without operation (Tang et al.,
2015). Everybody needs well-functioning hands, but
not everybody needs radiographs with anatomically
reduced fractures. The surgeon must not fall into
the trap of treating the radiograph rather than the
patient that it relates to. The needs of a professional
violinist are very different from the needs of a
professional rugby player. Most people are neither
violinists nor rugby players, but still may have spe-
cific needs. This should be obvious, but is not always
remembered and practised.
This article will review some of the challenges the
hand surgeon faces when having to make a treatment
decision and includes my personal preferences and
commentaries.
Operation versus no operation
The decision to operate or not is dependent upon
many factors, not just objective medical evidence.
evidence is not of the best quality. Randomized clin-
ical trials are rare. Cadaveric studies are available,
but they may only assess certain mechanical proper-
ties of fixation methods or biomechanical conse-
quences of malunion, and they seldom provide the
best guide for choosing the right treatment. The
cadaveric study by Labèr et al. (2020) in this issue
concludes that intramedullary screw osteosynthesis
yields sufficient strength and stiffness for early active
motion after transverse metacarpal fractures.
Conversely, non-operative treatment of moderately
angulated metacarpal fractures yields good results
without the complications seen with operative treat-
ment (Giddins, 2015). In a cadaveric study, Low et al.
(1995) found that palmar angulation beyond 30 and
metacarpal shortening greater than 3 mm signifi-
cantly decreased digital flexion force and wisely
pointed out that ‘these findings cannot be used
clinically as guides for intervention in displaced
metacarpal fractures, since cadaver hands have no
Capio/CFR Hospital, Hellerup, Denmark
Corresponding Author:
Michel E. H. Boeckstyns, Capio/CFR Hospital, Hans Bekkevold,
Allé 2B, Hellerup 2900, Denmark.
Email: Mibo@dadlnet.dk
548
compensatory mechanism’. Still, these cut-off values
are frequently used in clinical practice to opt for
operative treatment of fifth metacarpal neck frac-
tures (i.e. boxer’s fracture), which is improper. We
must realize the overwhelming evidence that much
greater fracture displacement can be treated non-
operatively.
Metacarpal fractures
The current evidence suggests that conservative
functional techniques are the optimum treatment
for the majority of patients with a single metacarpal
fracture (Yum Man and Trickett, 2017). Overall there
may be a small cosmetic benefit from surgery for
transverse metacarpal shaft and neck fractures, but
the costs and risks are probably not worth the small
potential benefit to most patients and in particular
most healthcare systems. The influence of publica-
tion bias and of the medical implant industry may
lead us away from the best evidence-based choice
of treatment and tempt us to adopt more complicated
fixation methods, like plate and screw fixation, in
situations that could be solved by simpler methods.
Chen et al. (2020) exemplified the preference of
some surgeons for operative treatment of metacar-
pal fractures. They compared the results of patients
with displaced fifth metacarpal neck fractures who
were treated with either medial locking plates or
retrograde intramedullary Kirshner (K)-wires. The
plate group had an earlier return to work and greater
aesthetic satisfaction, but otherwise the results were
similar in both groups and the complication incidence
was higher in the plate group. However, most prob-
ably, many of these patients did not need surgical
treatment at all, and they could have been treated
non-operatively, since palmar angulation is function-
ally well tolerated and rotational deformity very
seldom is a problem of metacarpal fractures due to
the derotating action of the intermetacarpal liga-
ments (Khan and Giddins, 2015). Surgical intervention
should be used only for severely angulated metacar-
pal neck or shaft fractures.
The thresholds for surgical intervention have not
been firmly established, but generally angulation is
better tolerated in the fourth and fifth metacarpals
than in the second or third due to the greater mobility
in the carpometacarpal (CMC) joints of these fingers
and due to the arch configuration of the palm. Most
surgeons agree that less than 40 –50 of dorsal apex
angulation of the fifth metacarpal neck fracture does
not need surgery, and from the small to index finger,
the threshold of performing surgery decreases, from
40 to 30 to 20 . The author’s experience indicates
that even angulation at the fifth metacarpal neck
Journal of Hand Surgery (Eur) 45(6)
exceeding 50 does not always need surgery
(Boeckstyns, 2020). Absolute indications for internal
fixation percutaneously or through an open approach
are the unstable (single or multiple) fractures that
cause functional loss of the hand and the displaced
intra-articular fractures of the first CMC joint. In con-
trast, the second to fifth CMC intra-articular frac-
tures without joint dislocation do not need surgical
fixation (Cobb et al., 2018). Other indications for sur-
gery are open fractures, crush injuries, and displaced
intra-articular fracture-dislocation of the CMC joints.
Deciding which surgical option to be used for
those metacarpal fractures requiring fixation is not
straightforward. Comparative studies are rare and
fracture subtypes are numerous. Ultimately, the sur-
geon must make a personal decision. Unstable
transverse, spiral, or oblique fractures can be stabi-
lized with intramedullary percutaneous K-wires or
screws through mini-incisions. Transverse interme-
tacarpal pinning is another possibility. In the patients
requiring open reduction, cerclage wiring and inter-
fragmentary compression screws may also be used.
External fixation is an option for crush fractures with
severe soft-tissue lesions or bone loss. The current
opinion of many surgeons is that screw fixation can
be used for long oblique fractures of metacarpals or
phalanges, which in fact can almost always be trea-
ted with percutaneous transverse or oblique pinning
instead. Plates have very limited or no indications in
treating metacarpal fractures (Tang et al., 2015).
Phalangeal fractures
Shaft fractures
The decision not to operate based on radiographs
alone, without making a meticulous clinical examin-
ation, is bad clinical practice. Unlike metacarpal frac-
tures, spiral fractures of the phalangeal shaft have a
high risk of rotational deformity, and, despite the
benign radiographic appearance, they more often
require closed or open reduction and internal fixation
(Figure 1). Such fractures are unforgiving. The choice
of treatment and the surgery itself should not be
delegated to unsupervised junior members of the
surgical team or to the occasional hand surgeon.
The services of a team of skilled hand therapists
are essential.
There is a spectrum of available techniques, and
surgeons should favour the method with which they
are most familiar and competent. A robust fixation
with plates and screws of such fractures is difficult
but, ideally, it has the advantage of more stability
and immediate mobilization, as demonstrated by
Katayama et al. (2020). However, the increased
Boeckstyns 549

Figure 1. Spiral fracture in the proximal phalanx of the ring finger. (a) Rotational deformity of a fractured finger.
(b) Radiographic minimal displacement. (c) Fixation with a single K-wire after close manipulation and correction of
rotation.

trauma, the stripping of the periosteum, the division

of the tendon or tendon hood, and the risk of tendon
adhesions could potentially compromise the result
(Page and Stern, 1998). At the other end of the spec-
trum is a single percutaneously inserted K-wire
(Figure 1). Although this would have the advantage
of having inflicted minimal added trauma to the hand,
the fixation may not be sufficiently robust to maintain
reduction and allow early mobilization. Fixation with
two K-wires is more stable, and a limited range of
active finger motion can be started after initial heal-
ing of the fracture within the first 2 weeks (Tang
et al., 2015).
A radiographically more displaced oblique fracture
of the proximal phalangeal shaft with good alignment
clinically usually does not need surgical intervention
and internal fixation (Figure 2). For a patient to whom
cosmetic issues are not too important, it may be best
to accept this fracture displacement and treat it
non-operatively by protecting the finger in a splint
for 2 weeks followed by finger joint mobilization exer-
cises, thus avoiding unnecessary treatment costs,
risk of surgical complications, and finger stiffness.

Fracture at the base Figure 2. Displaced oblique fracture of the proximal

Transverse fractures in the base of the proximal
phalanges are frequently the result of hyperexten-
sion–abduction trauma to the finger. A plate inter-
feres with the extensor tendon function and is not
at all necessary. Shewring et al. (2018) reported out-
comes of treatment of 101 patients with 113 fractures
of the proximal phalanx at the junction of the
phalangeal shaft of the little finger. Clinically, this fracture
was well aligned and was treated non-operatively.
diaphysis with the proximal metaphysis. The frac-
tures were stabilized using a single percutaneous
K-wire passed lateral to the metacarpal head into
the base of the phalanx base and across the fracture.
550 Journal of Hand Surgery (Eur) 45(6)

The K-wire was removed at 24 days, and the hand

then was freely mobilized. There were no cases of
angular or rotational malunion. They conclude that
this simple technique negated the need for close
monitoring for angular displacement of the fracture,
which is frequently seen with non-surgical manage-
ment. Rather, I usually prefer to reduce the fracture
and instruct immediate mobilization with buddy
tapening and explain to the patient that there will
be rapid functional recovery, but also a minor resi-
dual extension deficit in the proximal interphalangeal
(PIP) joint (Vadstrup et al., 2014). The Salter-Harris
Type 2 epiphysiolisis seen often in children can like-
wise be treated with buddy tapening and immediate
mobilization. Surgical intervention in children for this
type of fracture is unnecessary.

Intra-articular fractures of the PIP joint

Intra-articular fractures of the finger joints are chal-
lenging and treatment choice is debatable, especially
when they involve the PIP joint. This joint is particu-
larly important for the function of the hand and it is
unforgiving. Avulsions of the palmar base of the
middle phalanx with dorsal subluxation may be rela-
tively easily managed, but the subluxation is often
overlooked. If, on a true lateral radiograph, the
intact dorsal base of the middle phalanx forms a ‘V’
with the dorsal aspect of the proximal phalangeal
head, then the joint is incongruent, and this should
be corrected (Figure 3). Usually these joints are
unstable. A simple treatment method is to reduce
the joint and to percutaneously insert a K-wire Figure 3. Fractures involving the PIP joint surface.
across the joint (Newington et al., 2001) or as a (a) Presence of a small intra-articular fragment, which
dorsal blocking pin. An alternative method is to fix needs to be evaluated clinically for stability. It can be
the avulsed fragment with a small compression treated with a splint if the joint is stable. If the PIP joint is
screw if the fragment is large enough (Liodaki unstable under lateral stress, the joint needs to be stabi-
et al., 2015). Najd Mazhar et al. (2018) reported lized with pinning. (b) Large palmar avulsion fracture of the
open reduction and fixation through a shotgun base of the middle phalanx with rotation and displacement.
approach. This technique is clearly much more diffi- The V-shape of the space between the articular surfaces
indicates subluxation. (c) Comminuted fracture with dis-
cult but has the theoretical advantage of allowing
ruption of the articular surface.
careful immediate mobilization. However, the results
are not better than after joint transfixation (Aladin
and Davis, 2005). et al., 2015). Today, many hand surgeons opt for
Intra-articular pilon fracture-dislocations of the early mobilization of pilon fractures in a dynamic
PIP joint are the most challenging (Figure 4). They external fixation system (Table 1) (Figure 5), although
can be treated by reduction and joint transfixation complications are frequent and include pin track
as described above, but the risk of ending up with a infection, finger rigidity, and even need for amputa-
stiff and painful joint is high (Miao et al., 2015). tion. The challenges in its treatment are exemplified
Multiple options have been proposed, including in the reports of Finsen (2010) and Liodaki et al.
dynamic external fixation, mini cannulated screw fix- (2015). In Finsen’s series of 18 cases, one finger
ation, conventional screw fixation, plate and screw had to be amputated, and one ended up with a PIP
fixation, and palmar plate arthroplasty (Liodaki joint arthrodesis. In Liodaki’s series of 30 patients,
Boeckstyns
Figure 4. Pilon (axial compression) fracture of the
proximal interphalangeal joint of the ring finger. (a) Lateral
view of the fracture-dislocation. (b) and (c) After reduction
by traction and fixation with a dynamic external fixator
(Compass Hinge External Fixator, Smith & Nephew Inc.,
Memphis, TN, USA).
one finger was amputated, seven were salvaged
with arthrodesis, and two were treated with a silicone
arthroplasty due to painful osteoarthrosis. Open
intra-articular fractures with unstable bony
fragments may be reduced and fixed with multiple
K-wires (Figure 6). Extensor tendons are often
involved, which should be repaired as well.
When the joint surface is crushed to an extent that
precludes reduction of the fragments, excising the
damaged base of the middle phalanx and replacing
it with an osteochondral hemi-hamate autograft can
salvage the joint (Burnier et al., 2017; Frueh et al.,
2015; Williams et al., 2003). The graft is harvested
from the distal dorsal articular ridge of the hamate
and secured with screws to the palmar defect of
the base of the middle phalanx through a shotgun
551
approach. This surgery requires high-level expertise.
The incidence of osteoarthritic degeneration is high,
and its long-term clinical significance is not
established.
Bony mallet injuries
Bony mallet injuries are far less complicated from a
technical point of view but certainly not less dis-
cussed. Multiple operative procedures have been
described to treat these injuries (Salazar Botero
et al., 2016). The main area of dispute is in injuries
with a fracture fragment greater than one-third of
the articular surface on the lateral radiograph
(Figure 7). Recent articles establish that this cut-off
value is unreliable in predicting subluxation (Giddins,
2016; Kim and Kim, 2015; Moradi et al., 2017). In a
randomized clinical trial, Thillemann et al. (2020)
compared splinting with extension block pinning of
displaced mallet fractures with a fragment larger
than one-third of the articular surface but without
initial subluxation. The study demonstrates that
splinting of these fractures is feasible but that radio-
graphic control is advisable during treatment.
Giddins (2016) has demonstrated that extension
stress lateral radiographs are helpful in predicting
subluxation. Pivoting (rotation) of the main fragment
creates a V-shape palmarly between the articular
surfaces and is a more reliable method of predicting
subluxation. However, it is not known to what extent
patients who have had bony mallet injuries with
persistent subluxation will develop symptomatic
osteoarthritis. Most surgeons treat large avulsions
(over one-third of the articular surface) operatively
and consider surgical treatment is more reliable
(Table 2).
Treatment of thumb fractures
Bony avulsion of the ulnar collateral
ligament of the CMC joint
A Stener lesion, interposition of the adductor pollicis
aponeurosis between the avulsed and displaced bony
fragment and the base of the first metacarpal, will
result in a poor long-term outcome when treated
non-operatively (Figure 8). Therefore, surgical reduc-
tion and repair of the ligament insertion should be
performed. If the avulsed fragment is less displaced,
the treatment is more disputed. In a non-operative
series, Dinowitz et al. (1997) reported that all their
patients had persistent pain. Conversely, Kuz et al.
(1999) and Sorene and Goodwin (2003) reported that
552 Journal of Hand Surgery (Eur) 45(6)

Table 1. Review of the recent literature on the treatment of fracture-dislocations of the proximal interphalangeal joint.

Motion in
Follow-up. PIP-joint.
Number Mean (range) Mean (range) Patient reported
Publications Techniques of cases in months in degrees outcomes

Abou Elatta Dynamic EF (Suzuki type) 36 12 (4–22) 86 (60–100) 23 patients pain-free

et al., 2017
Badia et al., 2005 Dynamic EF (Simple frame 6 24 (7–43) 84 (0–90) One patient with
without rubber bands) mild pain
Ellis et al., 2007 Dynamic EF (Suzuki type) 14 26 88 (0–110) Pain score 0.6
(0–1.5) on VAS
Finsen, 2010 Dynamic EF (Suzuki type) 20 49 (17–116) 72 (9–83) QDASH score 2
(0–48)
Hynes and Dynamic EF (Double 8a (6–12) 76 (0–95] NA
Giddins, 2001 K-wire frame)
Ikeda et al., 2011 Miniplate 18 17 (12–18) 85 (62–105) NA
Kodama et al., 2018 Dynamic EF (Micro 9 11 (6–33) 91 (50–110) Pain score 0.3 (0–2)
Ortho Fixator) on NRS
Liodaki et al., 2015 Dynamic EF 30 NA NA Acceptable results in
(Ligamentotaxor b) 20 cases
Lo et al., 2018 Dynamic EF (Suzuki type) 20 8(1–28) 62 DASH score 7 (0–55)
Pain score at rest 0
on NRS
MacFarlane Dynamic EF 28 22(6–52) 85 (60–110) QDASH score 5
et al., 2015 (Ligamentotaxor) (0–36)
Miao et al., 2015c Dynamic EF combined with 22 vs. 23 NA NA Pain score 0.2 vs. 0.7
limited internal fixation vs. on VAS
crossed K-wires fixation
Monreal, 2016 Dynamic EF (simple frame 11 7 (3–16) 91 (0–100) 10 excellent or good
without rubber bands) cases
O’Brien et al., 2014d Dynamic EF (home made) 17 vs. 14 33 (12–93) vs. NAe DASH 6 vs. 6
vs. ORIF 40 (12–76)
Siddiqui et al., 2012 Dynamic EF (home made) 12 8 (1–79) 89 (25–111) All patients satisfied
Wang et al., 2019 Dynamic EF (Suzuki type) 20 22 (12–60) 84 (0–100) MHQ score 88
(84–92)
a
Pilon fractures without dislocation.
b
Ligamentotaxor: Arex, Palaiseau Cedex, France.
c
Comparative study.
d
Retrospective comparative study.
e
Combined motion in proximal and distal interphalangeal joints was significantly better in the EF group.
EF: external fixator; DASH: Disabilities of the Arm, Shoulder and Hand questionnaire; MHQ: Michigan Hand Questionnaire; NRS: nominal
rating scale; ORIF: open reduction and internal fixation; PIP: proximal interphalangeal; QDASH: Quick version of the DASH questionnaire;
VAS: visual analogue scale.

all the patients treated non-operatively in their series
were satisfied with the results, despite nonunions in
25% and 60%, respectively. I would treat a case such
as depicted in Figure 9 with casting or splinting in 6
weeks without surgery.
Bennett’s fracture
In a systematic review, Edwards and Giddins (2017)
assessed the evidence for different treatment
modalities of Bennett’s fracture. They identified 11
different modalities in 38 studies and concluded that:
there is currently no high-quality evidence to guide
us to the optimal treatment method for a Bennett’s
fracture. . . . surgical treatment results in less pain,
but a higher rate of complications when compared
with non-surgical means. However, given the poor
quality of data, this may not be universally true for
all fracture types.
Boeckstyns 553

The cumulated incidence of osteoarthritis was

33% after operative as well as non-operative treat-
ment (Edwards and Giddins, 2017). Since no high-
quality studies indicate which subgroups can benefit
from non-operative treatment, I personally adopt a
defensive medical attitude and operate on these
patients by reducing the subluxation and fixing the
dislocated metacarpal to the trapezium with one or
two K-wires (Figure 10). The most commonly used
methods are shown in Figure 11.
Postoperative motion and therapy
The goal of treating hand fractures is to re-establish
hand function and obtain painless mobility and
strength. There are sparse publications that focus
specifically on the rehabilitation of hand fractures.
When planning rehabilitation, a decision must be
made regarding when to begin therapy, the frequency
of exercises, and whether clinic attendance is neces-
sary. Early protected movement following a fracture

Figure 7. Bony mallet injury. The avulsed fragment

Figure 5. The original Suzuki frame constructed with K- comprises more than 50% of the articular surface on the
wires and rubber bands for dynamic external fixation of a lateral radiograph but the main fragment is not subluxated.
fracture-dislocation of the PIP joint (Suzuki et al., 1994). This case was treated successfully with a volar splint.

Figure 6. An open intra-articular fracture-dislocation of the PIP joint with extensor tendon laceration. (a) X-rays showing
destruction of the articular surface of the proximal phalanx. (b) The two large fragments were immobilized with two
K-wires to restore articular surface continuity. (c) The dislocated PIP joint can be reduced and the fracture fragments
were then fixed with K-wires to the proximal phalanx. (d) The extensor tendon was then repaired. (ß Jin Bo Tang).
 554

Table 2. Outcomes of bony mallet injuries with fracture fragments larger than one-third of the articular surface on lateral radiographs.

Motion in Number of
DIP-join in DIP-joints with
Number Fragment Follow-up degrees, mean osteoarthritis Other notable
Publications Techniques of fingers size (%) a (months) (range) Outcomes at follow-up complications

Damron and Tension band 19 51 97 (24 –147) (1–69) 10 patients pain 7 of 15 4 pull-out suture
Engber, 1994 free, 13 no problems
functional limitation
Darder-Prats Extension block 22 >33 25 (18–48) NA 21 cases 0 1 DIP extension
et al., 1998 pinning excellent/goodb lag of 20o
Fritz et al., 2005 Single K-wire 24 >33 (12–18) 70 (0–90) 22 cases 6 None
across DIP joint successfulc
Hofmeister Extension block 24 40 74 weeks 74 (0–90) 92% of cases 10 None
et al., 2003 pinning excellent or goodb
Takami et al., 2000 Open fixation of 33 33 29 63 (0–90) 3 cases with 6 Fragmentation of
fragment with minor aching avulsion
K-wire þ DIP
joint transfixation
Tetik and Gudemez, Extension block 18 >33 27 79 (40–90) 17 excellent NA None
2002 pinning (patients’ rating)
Thilleman et al., Extension block 14 >33 6 (10–50) QDASH score 13 NA None
2020d pinning
Splinting 14 >33 6 (12–65) QDASH score 5 NA 3 DIP subluxations
a
Percentage of total joint surface on lateral radiographs.
b
According to Crawford criteria (Crawford, 1984).
c
According to criteria of Warren et al. (1988).
d
Randomized clinical study.
DIP: distal interphalangeal; QDASH: short version of the Disabilities of the Arm, Shoulder and Hand questionnaire.
Journal of Hand Surgery (Eur) 45(6)
Boeckstyns
Figure 8. Avulsion of the ulnar collateral ligament at the
first metacarpophalangeal joint. One part of the avulsed
fragment is rotated 180  but still close to the proximal
phalanx. (a) A smaller fragment is much more dislocated,
indicating interposition of the adductor aponeurosis
(Stener lesion). (b) An illustration of ligament disruption
and entrapment by the insertion of the thumb adductor
tendon (copyright of Julia Ruston). An avulsion fracture
may present in some patients (a), but joint instability is
found in all the patients.
Figure 9. Bony avulsion of the ulnar collateral ligament at
the first metacarpophalangeal joint without laxity or lateral
instability clinically. There is only little displacement and
no rotation of the avulsed fragment. This patient was
treated with splinting.
555
Figure 10. Bennett’s fracture after reduction and K-wire
fixation.
is important for preventing joint stiffness, and mobil-
ization usually starts as soon as the stability of the
fracture is robust enough – usually 2–4 weeks after
fracture reduction. Partial range of active digital
motion, which avoids overloading the fracture site,
is sufficient to move the joint and prevent digital stiff-
ness. Do not wait for radiographic evidence of bony
union to start motion or remove the K-wires, as the
radiographically visible callus appears several weeks
after actual robust healing occurs.
Some fractured fingers can be mobilized immedi-
ately without fixation, including fractures of the base
of the proximal phalanges, protected by buddy taping,
and neck fifth metacarpal neck fractures, protected
by a functional splint or even without splinting
(Boeckstyns, 2020; Jardin et al., 2016; Vadstrup
et al., 2014; van Aaken et al., 2016). Other non-opera-
tively treated fractures must be protected for 2 to
3 weeks in a splint. The decision will often be
based on personal experience and beliefs.
After percutaneous K-wire fixation of a single
bone, mobilization can begin after 3–5 days once
patients are off all pain medicines. The patient
moves the finger joints carefully and avoids painful
exercises (Tang et al., 2015). Delaying the initiation of
motion exercise to the end of postsurgical week
two or three, however, is frequently practiced and
appears equally effective in preventing joint stiffness.
Operation with local anaesthesia allows intraopera-
tive visualization of active movement and the possi-
bility of evaluating the range of motion and fracture
stability in adults (Gregory et al., 2014; Hyatt and
Rhee, 2019). The local anaesthesia setting can be
556
Figure 11. Four surgical options of percutaneous pinning of Bennett’s fracture after manual reduction of the fracture,
which is easy and efficient with minimal invasion. Open reduction is rarely necessary for Bennett’s fracture.
used for emergency patients and children and other
bone related procedures in the hand (Xing and Mao,
2018, 2019a, 2019b; Xing et al., 2019; Zhu, 2019).
Though K-wires can be left for 1 to 2 weeks longer
in the presence of soft-tissue damage or for very
unstable or multiple fractures, most K-wires in fin-
gers and metacarpals can be removed at between
10–21 days.
Plate and screw fixation of phalangeal and meta-
carpal fractures carries an increased risk of joint
stiffness and other complications (Facca et al.,
2010; Page and Stern, 1998). If mobilization is not
possible after a few days, this risk is very high. In
the series of Facca et al. (2010), locking plates for
neck fractures of the fifth metacarpal with immediate
mobilization paradoxically provided poorer mobility at
the end of follow-up than intramedullary K-wire with
6 weeks’ immobilization. Ataker et al. (2017) started
active rehabilitation on the fifth postoperative day
after fixation of 22 spiral, oblique, or comminuted
extraarticular fractures of the proximal phalanx,
rigidly stabilized with plate and screws or screws
alone. Eighty-six per cent of the patients had excel-
lent results. Gülke et al. (2018), in a prospective clin-
ical trial, showed that home exercises yielded equally
good results as traditional hand therapy in the clinic.
In a randomized clinical trial, Miller et al. (2016)
showed that synergistic wrist and finger exercises
with constrained or unconstrained metacarpophalan-
geal joints had similar effects after plate and screw
or screw fixation of proximal phalangeal fractures.
Rehabilitation consisted of an unsupervised home
programme of carrying out ten repetitions of the
exercises six times per day, wearing a resting
splint, and performing scar and oedema manage-
ment. Most of the recovery in range of motion, pain,
strength, hand use, and work participation occurred
by week six, with smaller gains by week 12 and week
26 (Miller et al., 2017).
Journal of Hand Surgery (Eur) 45(6)
Patient-reported outcomes measures in
hand fractures
Outcomes after hand fractures can be described in
terms of objective measures, including motion, grip
strength, and alignment, and radiographic findings,
including status of bony union and malunion. These
are obviously important parameters, but nowadays,
the use of patient-reported outcome measures is
equally important in that they better reflect how the
patients experience their condition. A wide variety of
patient-reported outcome measures (PROMs) are
available. For example, a literature review analysing
studies of patients with trapeziometacarpal osteo-
arthritis revealed 21 different questionnaires in use
(Marks et al., 2013). These kinds of measurements
are best when used to describe a group of patients in
a crosssectional assessment or to describe the
change of a patient’s condition after an event com-
pared with an earlier measurement. The most used
is the Disabilities of the Arm, Shoulder and Hand
(DASH) questionnaire or its short version, the
QuickDASH. Its great advantage is that it has been
translated into multiple languages and validated for
many conditions. Still, it reflects the condition of the
whole upper-extremity and can therefore be influ-
enced by other upper-extremity problems.
The selection of an appropriate outcome measure
is not easy because the tool must not only focus on
the specific domain to be measured (e.g. hand func-
tion) but be appropriate for the aim and the target
population (Marks, 2020). Dacombe et al. (2016)
searched for randomized controlled trials of patients
with trauma to the hand and wrist to identify
and assess the PROMs. They concluded that only
the DASH and the Patient Reported Wrist Evaluation
(PRWE) questionnaire have evidence of reliability,
validity, and responsiveness in patients with trauma
to the hand and wrist. Other measures, including the
Boeckstyns
Gartland and Werley score, the Michigan Hand
Questionnaire score, the Mayo Wrist Score, and the
Short Form 36, either had incomplete evidence or
evidence gathered in a nontraumatic population.
Obviously this conclusion is biased by the inclusion
of wrist trauma, but still it is a strong argument.
Thus, disregarding the specific wrist PRWE, the
QuickDASH seems to be a valid and useful PROM in
assessing the impact of hand trauma and the effect-
iveness of treatment for hand fractures.
Summary and current challenges
Treatment of hand fractures can be simple in some
instances and very complicated in others, but almost
all cases require solid experience and expert know-
ledge. The decision on how to treat fractures in the
hand should ideally be based on scientific evidence.
However, due to the paucity of high-level evidence
and the great diversity of fracture types and sub-
groups, our decisions are mostly based on outcomes
of case series, not well documented opinions, and
personal views. The patients’ age, profession, and
leisure activities must always be taken in account
and may lead the surgeon to deviate from standard
treatment. But in some situations, the surgeon is
tempted to adopt a defensive medical attitude and
perform an unnecessary invasive procedure. In
other situations, the power of habit determines a
choice of treatment that is not in accordance with
recently available evidence. Publication bias may
also play a role: favourable results are probably
over-represented in the medical literature.
To optimize the treatment of hand fractures there
is a need of continuous education of senior as well
junior hand surgeons. Defining fracture patterns and
subgroups and conducting prospective studies is
essential. This may need multicentre studies or
registry studies for the less frequent fractures.
Above all, national or international evidence-based
guidelines must be set out for as many fracture
types as possible, not only for the large diagnostic
groups.
Despite all options, it is clear to this author and
perhaps most senior colleagues that the majority
of hand fractures can be and should be treated
non-operatively and the surgeons should avoid
unnecessary surgeries and unnecessarily complex
procedures. If surgical intervention is necessary,
the surgeon should make a careful and precise
decision on a suitable method to be used. A variety
of surgical methods are available, and simple ones
should always be considered first. Many senior sur-
geons consider that almost no hand fractures need
plating. If this is indeed considered, the surgeons
557
should justify why a plate is needed. The decision
on proper surgical options is particularly vital in com-
plex PIP joint and first CMC joint fractures.
Declaration of conflicting interests The author
declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding The author received no financial support for the
research, authorship, and/or publication of this article.
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