CURRENT CONCEPTS
Hand Fractures: A Review of Current
Treatment Strategies
Clifton Meals, MD, Roy Meals, MD
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Fractures of the tubular bones of the hand are common and potentially debilitating. The
majority of these injuries may be treated without an operation. Surgery, however, offers
distinct advantages in properly selected cases. We present a review of hand fracture
management, with special attention paid to advances since 2008. The history and mecha-
nisms of these fractures are discussed, as are treatment options and common complications.
Early mobilization of the fractured hand is emphasized because soft tissue recovery may be
more problematic than that of bone. (J Hand Surg 2013;38A:1021–1031. Copyright © 2013
by the American Society for Surgery of the Hand. All rights reserved.)
Key words Hand, fracture, metacarpal, phalanges.
©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1021
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Learning Objectives
• Appraise the history and epidemiology and mechanics of hand fractures.
• Clarify the diagnosis of hand fractures through clinical and radiographic findings.
• List general operative and nonoperative treatment principles of hand fractures.
• Elucidate the treatment principles of individual hand fractures, including the thumb.
• Discuss the complications of hand fractures and their treatment.
Deadline: Each exam purchased in 2013 must be completed by January 31, 2014, to be
eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to
complete each month’s JHS CME activity is 2 hours.
Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.
Current Concepts
 1022 HAND FRACTURES: CURRENT TREATMENT STRATEGIES
vulnerable. Its ability
T
HE HAND IS VALUABLE AND
to both sense and manipulate its environment is
unique in nature. As such, the hand is fre-
quently injured. Despite its mechanical refinement, the
hand is particularly resilient to fractures, and when they
occur, broken digits can often be treated without an
operation. Surgery, nonetheless, has a place in the man-
agement of carefully chosen cases. Although hand frac-
tures are generally forgiving, soft tissue injury is not. It
is easy for the treating physician to do more harm than
good, even without cutting the skin. Hand surgeons
have special claim to only the most complicated inju-
ries; many fractures of the hand can be treated by a
variety of physicians. The majority of hand fractures are
appropriately treated by emergency physicians, primary
care doctors, and general orthopedic and plastic sur-
geons. The following is intended for an accordingly
broad audience. We present management strategies for
the most representative tubular bone fractures of the
hand. We highlight recent research to avoid rehashing
previous reviews.1– 4
HISTORY
Rudimentary care of hand fractures (eg, rest and eleva-
tion) is presumably as old as humans themselves. Up-
right posture may have contributed to an increase in
these injuries, and today, falls from standing height
remain a major source of hand injuries. The ancient
Egyptian Imhotep described reduction and immobiliza-
tion of fractures in 3000 BC. Hippocrates in 200 BC and
Galen in AD 160 recommended prolonged immobiliza-
tion of broken bones and frequent dressing changes.
More durable, plaster-based splinting materials were
developed in the Middle East as early as the 10th
century. As this technology reached 19th-century Eu-
rope, it permitted less frequent splint exchange in an era
of population expansion and increased demand for
medical attention. Sophisticated splinting of the hand
and the so-called “intrinsic-plus” position were advo-
cated by James in the 20th century. The Belgian sur-
geon Lambotte described operative care of a phalangeal
fracture as early as 1904.5 He stabilized this proximal
Current Concepts
FromtheDepartmentofOrthopedics,GeorgeWashingtonUniversityMedicalCenter,Washington,DC,
and the Department of Orthopedics, UCLA Medical Center, Los Angeles, California.
Received for publication August 7, 2012; accepted February 7, 2013.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Clifton Meals, MD, George Washington University Medical Center, De-
partment of Orthopedics, 22nd & I Street, NW, 7th Floor, Washington, DC 20037; e-mail:
cliftongm@gmail.com.
0363-5023/13/38A05-0032$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2013.02.017
JHS 䉬 Vol A, May 
phalanx with a fixateur externe, a phrase he coined.6
Kirschner developed the use of fine wires for skeletal
traction; this technique and fixation with K-wires are
relevant to the treatment of hand fractures a century
later. Twentieth-century advances in anesthesia, radiol-
ogy, and metallurgy have helped to refine the operative
care of hand fractures. The fact remains, however, as it
was known to ancient physicians, that the majority of
these injuries can be treated without surgery.7
EPIDEMIOLOGY
Hand fractures are among the most common skeletal
injuries. As is the case with many orthopedic injuries,
young men and elderly women are most susceptible.
Modes of injury in different age groups are predictable:
children and young adults are frequently injured in
sports-related activities, middle-age manual laborers are
prone to work-related injuries, and older patients may
experience hand trauma as the result of a fall or motor
vehicle collision. The distal phalanx is the most com-
monly fractured bone in the hand.1 A large subset of
young adult males fracture their fifth metacarpal, clas-
sically the result of violent contact with the fist.3,8
DIAGNOSIS
Diagnosis of hand fractures begins with a thorough
patient interview. The patient should describe the mech-
anism of injury because this may suggest certain reduc-
tion maneuvers, assist in identifying secondary injuries,
and reveal pathological fractures. A very low-impact
injury leading to fracture, for instance, should raise the
suspicion of osteoporosis or enchondroma. In addition
to a history of the injury, it is important to note the
patient’s handedness, their functional status, occupa-
tion, hobbies, and expectations for recovery. A 25-year-
old concert pianist and a retiree with the same fracture
represent different challenges to the treating physician.
Physical examination of the hand begins with noting
skin integrity including abrasions and lacerations and
the location and extent of any bruising, swelling, or
underlying deformity. A neurovascular examination is
undertaken with attention paid to the digits distal to any
injury. Angular and particularly rotational deformity
can be subtle when the patient is unable to make a full
fist and demonstrate parallel digital alignment. In this
instance, examining end-on the digital pulps and the
planar alignment of the nails with respect to the adja-
cent digits and the opposite hand is revealing. Caution
must be exercised, however, when identifying a patho-
logical supination deformity in the small finger because
the uninjured small finger tends to scissor with the ring
finger at midflexion and then come into parallel align-
 HAND FRACTURES: CURRENT TREATMENT STRATEGIES
ment with full flexion. The hand should be lightly
palpated, seeking points of maximal tenderness. Passive
and active range of motion should be documented at all
affected and adjacent joints. Range of motion maneu-
vers may be facilitated by neuroblockade at the meta-
carpophalangeal (MCP) joints or the wrist but not be-
fore recording a neurological examination. In
evaluating a hand fracture, injury to nerves, vessels,
ligaments, and tendons must be identified and treated
with the same attention due any broken bone.
Good-quality radiographs are the cornerstone of
fracture diagnosis. Most metacarpal fractures are accu-
rately characterized with posteroanterior, semiprona-
tion, and lateral views of the hand. A true lateral view
of the hand, evident by the superimposition of the
pisiform and distal pole of the scaphoid and the stag-
gering of each finger, may be difficult to obtain.9 None-
theless, this orthogonal view is necessary to fully char-
acterize fractures and may identify injuries not obvious
in other views (eg, fracture dislocations of the ulnar
carpometacarpal joints).10 To accurately identify and
characterize phalangeal fractures, the same views, per-
haps with the inclusion of a semisupination view and a
fan lateral view, must be obtained with the x-ray beam
centered over the area of concern, not through the
center of the palm as with screening films. Advanced
imaging of the tubular bones of the hand is rarely
necessary, although magnetic resonance imaging (MRI)
may help to evaluate concomitant soft tissue injuries
and pathological fractures.
Fractures are evaluated with respect to their location,
orientation, displacement, angulation, degree of com-
minution, and any associated joint involvement or dis-
location. Especially in the setting of infection or open
injury, the presence of radiopaque foreign bodies must
be noted. X-rays reveal more than fracture lines, and
this information should be noted. Degenerative, onco-
logical, rheumatological, and metabolic processes are
evident on radiographs, and each is potentially more
serious than the patient’s primary complaint.
TREATMENT
General principles
Most hand fractures are well managed without surgery.
This was known to ancient physicians; however, today
we better appreciate the dangers of prolonged immobi-
lization.7 Stiffness, pressure sores, and, rarely, compart-
ment syndrome may result from mismanaged casting or
splinting, and in this sense, “conservative” treatment
may be particularly risky. Surgery is indicated when
early mobilization of soft tissues is critical, when the
fracture is otherwise unreducible, in instances of poly-
JHS 䉬 Vol A, May 
1023
trauma or open fracture, and in the face of concomitant
injury to nerves, vessels, and soft tissue.1
Open fractures of the hand are common and may
necessitate irrigation and debridement in the operating
room. Initial management is case-based but often con-
sists of irrigation, sterile coverage of the wound, anti-
biotics, and tetanus prophylaxis.
Reduction is appropriate in the initial care of dis-
placed fractures, and special techniques for certain frac-
tures are discussed later. All reduction maneuvers rely
on gentle traction. They are in general aided by nerve
blocks and gentle flexion of the MCP joints and wrist.
Splints should selectively limit motion of injured
parts. Plaster molds well and is preferable for holding a
reduction. Fiberglass and other materials may be appro-
priate for soft tissue injuries and stable fractures. Im-
mobilization of the wrist in extension is desirable to
minimize stiffness, although patients are often reluctant
to assume this posture on their own.3 A dorsal splint
extending from the midforearm to the fingertips is use-
ful in this regard. Such a splint holds the wrist in some
extension, flexes the MCP joints to 90°, and permits full
extension of the interphalangeal joints. Patients may be
reluctant to flex their MCP joints, and an overly bulky
splint may obscure residual extension. To aid in flexion
of the MCP joints, the distal end of the splint may be
held down with strips of tape that span the palm and are
attached at the wrist. When properly applied, the dorsal
hand splint has utility in treating a wide variety of hand
fractures.
Splints may be used until the fracture is healed or
exchanged for a cast once soft tissue swelling has
resolved. For the vast majority of metacarpal and pha-
langeal fractures, clinical stability occurs well before
radiographic evidence of healing. Initiation of protected
mobilization should be based on time since injury and
fracture site tenderness rather than x-rays. Over-reliance
on radiographs for confirmation of healing may result in
a permanently stiff hand. Immobilizing hand fractures
for longer than 4 weeks is rarely necessary. Movement
of noninjured portions of the hand, as well as the
forearm, elbow, and shoulder, should be encouraged
from the outset. In this regard, slings are counterpro-
ductive.
Current Concepts
Distal phalanx
Tuft fractures of the distal phalanx result from crush
injuries, and soft tissue trauma is often of greater con-
cern than the broken bone. Large subungual hematomas
should be decompressed by manually drilling a hole in
the nail plate with a hypodermic needle or electrocau-
tery device. Significant injury to the nail matrix is best
 1024 HAND FRACTURES: CURRENT TREATMENT STRATEGIES

FIGURE 1: Kirschner wire fixation technique for a mallet finger injury. The distal interphalangeal DIP joint is flexed, and
Kirschner wires are used to block the avulsed fragment from displacing proximally. The fracture is reduced with extension of the
finger. The DIP joint is cross-pinned.

FIGURE 2: Sutures-over-button technique for mallet finger injuries. The DIP joint is opened dorsally with an H-shaped incision.
Bone holes are made with a Kirschner wire and suture is passed with the aid of hollow-bore needles. The suture exits the finger
pulp and is tied over a button. The DIP joint is cross-pinned.

treated by removal of the nail plate and suture of the
nail bed. This may help to prevent entrapment of nail
matrix in the fracture site and formation of an osseous
inclusion cyst. Open injuries, including those created to
decompress a hematoma or repair the nail bed, require
oral antibiotics and protective splinting of the distal
interphalangeal (DIP) joint alone for 10 to 14 days.
Healing of the bone, often by fibrous union, is predict-
able and alleviates symptoms, although tenderness may
persist for many months.1
Transverse fractures through the shaft of the distal
phalanx may take on apex-volar angulation but are
typically stable owing to the nail plate dorsally and the
pulp’s fibrous septae volarly. Conservative treatment is
appropriate. Comminuted or longitudinal fractures may
be more likely to displace and may be fixed with
Kirschner wires.1 Recent case series highlight a subset
of patients who developed symptomatic nonunions of
Current Concepts
or marked subluxation may be indications for sur-
gery, although this is a matter of debate.13 Both
acute and chronic mallet finger may be addressed
operatively. The use of mini-screws, extension
block pinning, sutures over a button, and Kirschner
wires as joysticks technique have all been de-
scribed (Figs. 1 and 2).14,15 A recent multicenter
comparison of various surgical techniques for mal-
let finger found no significant difference in out-
comes.13
“Jersey finger” is the apex-volar equivalent of mallet
finger and involves avulsion of the flexor digitorum
profundus tendon. Surgery is generally indicated, and
direct repair with a suture-over-button technique may
be accomplished in the first 2 weeks after injury. Lon-
ger delays may involve retraction and degeneration of
the flexor tendon and are treated on a case-by-case
basis.16

distal phalanx fractures. These were effectively treated

open with cortical miniscrews11 or percutaneously with
variable pitch headless screws.12
Dorsal epiphyseal avulsions of the distal phalanx
result in an apex-dorsal, “mallet finger” deformity.
Conservative treatment involves extension splint-
ing and care of soft tissue injury. If avulsed, the
nail plate should be reduced beneath the nail fold
to reapproximate the nail matrix and stabilize the
fracture.1 Greater involvement of the joint surface
Middle and proximal phalanx
Minimally displaced, stable, extra-articular fractures of
the middle and proximal phalanges, in a compliant
patient, may be “buddy-taped” to an adjacent, uninjured
finger. Figl et al17 have recently described a “conser-
vative functional” modification of the buddy-taping
technique in which the wrist and MCP joints are
casted in the safe position for 4 weeks. Motion at the

JHS 䉬 Vol A, May 

 HAND FRACTURES: CURRENT TREATMENT STRATEGIES 1025

FIGURE 3: Percutaneous, intramedullary disimpaction technique for treatment of fractures at the base of the middle phalanx. A
Kirschner wire is inserted retrograde into the middle phalanx and used to reduce fragments at the phalangeal base under
fluoroscopic guidance. The reduced joint is block-pinned in flexion.

interphalangeal joints is encouraged, particularly ex-
tension at the proximal interphalangeal (PIP) joint.
Unstable fractures, especially in older patients and in
the setting of digital arthritis, are likely to result in
stiffness if treated conservatively. Other potentially op-
erative fractures include displaced or intra-articular
fractures in general, volar base injuries to the middle
phalanx, and longitudinal unicondylar fractures of the
head of the proximal phalanx.1 With regard to the latter,
Tan et al18 demonstrated satisfactory short-term out-
come with intra-articularly placed screws. For these
fractures, and for all fractures of the middle and prox-
imal phalanx, a wide variety of procedures have been
described, many involving the use of Kirschner wires.1
Selection of an operative strategy is case-based and
depends heavily on surgeon preference. Regardless of
which hardware is chosen, attention to soft tissue is
paramount, namely with careful operative technique,
brief immobilization in the intrinsic-plus position, and
early motion. Although anatomical fixation of middle
and proximal phalangeal fractures with screws, with or
without plates, is appealing, it is fraught with problems.
Namely, the intra- and postoperative disturbance of the
closely aligned extensor tendon mechanism portends
stiffness. This is particularly vexing when rigid fixation
is not secured and is followed by a period of prolonged
postoperative immobilization. It is better to accept a less
than perfect radiographic reduction and achieve early
motion.
PIP joint fractures are problematic, especially given
the importance of the PIP joint to hand function in
general. As more of the volar base of the middle pha-
cal strategy should adhere to the treatment guide-
lines proposed by Kiefhaber and Stern22: (1) that
gliding reduction of the PIP joint be restored and
subluxation at the fracture site be eliminated, (2)
that early motion be established, and (3) as a
secondary goal, that the joint surface be restored.
Cheah et al23 report satisfactory results with a volar
mini-plate and screw technique at short-term follow-up.
Percutaneous Kirschner wire fixation with dorsal block
pinning has been described, as has a percutaneous in-
tramedullary technique for disimpaction and reduction
of volar fragments, also with dorsal block pinning (Fig.
3).20,24 Dynamic external fixation of the injured PIP
joint is one treatment option (Fig. 4). Advantages in-
clude relative ease of application and the potential for
early motion25–28; however, these wire and elastic con-
structs are not foolproof. Finsen29 reports only modest
restoration of motion with Suzuki pins and rubber trac-
tion, potentially related to their use of stiff vessel loops
rather than more pliable rubber bands.
For chronic PIP joint fracture dislocations, Hamada
et al30 describe a 2-stage procedure in which the injured
joint is held in a distracted position for 1 week before
either percutaneous or open reduction and fixation and
the placement of a second, articulating external fixator.
Initial outcomes were positive, although long-term
studies are lacking.30
Displaced fractures at the base of the proximal pha-
lanx typically assume an apex-volar angulation and
should be reduced. Malunion may lead to a pseudo-
clawing of the digit with hyperextension at the fracture
site, extensor lag of the interphalangeal joints, and ad-
Current Concepts

lanx is detached, the collateral ligaments no longer herence of flexor tendons.28

prevent the middle phalanx from moving dorsally.19,20
Extensive comminution may complicate treatment and
require osteochondral bone grafting. A number of es-
tablished surgical options exist for these injuries, al-
though none is clearly superior.21 Much new literature
exists, as well, regarding novel or modified treat-
ment of PIP joint fracture dislocations. Any surgi-
Metacarpal fractures
Fractures of the metacarpal neck are among the most
common fractures of the hand. These so-called “box-
er’s” fractures are typically incurred by young men, not
necessarily boxers, who strike a solid object with a
clenched fist.1 The fifth metacarpal neck is the most

JHS 䉬 Vol A, May 

 1026 HAND FRACTURES: CURRENT TREATMENT STRATEGIES

FIGURE 4: Dynamic external fixation technique for treatment of fractures at the base of the middle phalanx. Kirschner wires are
inserted in the distal proximal phalanx, proximal middle phalanx, and distal middle phalanx. Leverage on a longitudinal Kirschner
wire may be used to reduce the fracture. Rubber bands are configured to provide longitudinal traction. The interphalangeal joints
are free and may be moved.

vulnerable and most frequently injured. The fifth meta-
carpal is also the most mobile bone of the palm and,
therefore, especially tolerant of the typical apex-dorsal
deformity. Whereas up to 70° of angulation may be
compensated for in the fifth metacarpal, only 10° is
tolerated in the second and third rays.1,31 The Jahss
reduction maneuver involves flexion of the MCP joint,
PIP joint, and DIP joint and use of the curled finger to
push the metacarpal head dorsally.32 Immobilization of
boxer’s fractures may be beneficial; however, success-
ful treatment without immobilization has been de-
scribed.31 Nonsurgical intervention may be particularly
appropriate in patients unlikely to return for follow-
up.33
Surgery is reserved for cases in which an ade-
quate reduction of both angular and rotational de-
formity cannot be maintained or where an adjacent
ray is damaged. High functional demand also is not
necessarily an indication for surgery because even
Current Concepts
splinting. Although the surgical group reported greater
satisfaction with the appearance of the hand, hands
were functionally similar in both groups.36 Hofmeister
et al37 have also recently challenged the dogma that the
fifth MCP joint must be immobilized in flexion. In a
prospective, randomized trial involving young, active
patients, the authors showed equivalent results with
volar-outrigger-type and extension short-arm casts.37
Anterograde pinning of the fractured fifth metacarpal
has been recently recommended as an alternative to
traditional retrograde fixation (Fig. 5).38
Metacarpal shaft fractures may be transverse, in
which case, like their boxer’s fracture counterpart, de-
formity is typically apex-dorsal. As in boxer’s fractures,
surgery is indicated when an acceptable reduction can-
not be maintained. Again, greater deformity is allowed
in the more mobile fourth and fifth rays. Spiral and
oblique fractures are more unstable, and reduction must
restore rotational alignment as a first priority. Mild

with neglect, residual disability is typically negli-
gible to none. Fixation with Kirschner wires either
down the medullary canal or transversely to an
uninjured ray are both effective treatment methods
in properly selected patients.34,35
According to the incidence of this fracture, much
continues to be written regarding its management. Strub
et al36 performed a prospective study in which patients
with boxer’s fractures were treated conservatively and
without reduction or with reduction and intramedullary
shortening encountered in spiral or oblique fractures
may be tolerated to a degree because hands with this
deformity often overcome initial extensor lag and de-
formity-related weakness.39 In general, metacarpal
shaft fractures are biologically splinted by the interpal-
mar plate ligament (intermetacarpal ligaments) and in-
terosseous muscles (less so the second and fifth ray).
The presence of fractures in adjacent ray(s) is a relative
indication for surgery.
A variety of surgical strategies exist, including plate-

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 HAND FRACTURES: CURRENT TREATMENT STRATEGIES 1027

FIGURE 5: Retrograde Kirschner wire technique for fixation of distal metacarpal fractures. With the metacarpophalangeal (MCP)
joints in flexion, parallel (not shown) Kirschner wires are inserted retrograde into the metacarpal shaft and exit the skin dorsally at
the metacarpal base. Under fluoroscopy, the distal ends of the Kirschner wires are positioned in the metacarpal head. The wrist
and protruding Kirschner wires are flexed into extension.

screw constructs and intramedullary fixation.1 Rhee et
al40 recently described a retrograde, intramedullary
splinting technique in which 1 or more wire ends are
left out dorsally at the phalangeal base. The authors
report the ability to stabilize different fracture configu-
rations with few complications.40
Despite the ease with which intramedullary devices
are implanted, they are not foolproof. In a study com-
paring plate and screw fixation with a percutaneous
nailing technique, Ozer et al41 identified a number of
complications in the intramedullary group: loss of re-
duction, joint penetration, tendon irritation, and symp-
tomatic hardware. Fewer such complications were en-
countered with plate and screw constructs.41 Plate
fixation has been shown to be effective in cases of
multiple metacarpal head fractures.42
Fracture dislocations of the metacarpal bases are
unusual, particularly at the more stable second and
third carpometacarpal joints. When they do occur,
they may be missed.10 They are typically unstable
and require Kirschner wire stabilization. When
treatment is delayed, open reduction is often nec-
essary. Late arthritis of the fifth MCP joint is
exceedingly rare; however, arthrodesis of this joint
is a theoretical solution.1
Thumb fractures
Many thumb fractures are treated like finger fractures.
The thumb is distinct from the other digits, however,
care. Geometric deformity, conversely, is well toler-
ated. The slightly deformed thumb has no parallel digit
with which to interfere, and the thumb’s range of mo-
tion makes it additionally resistant to malunion.1 Typ-
ical apex-dorsal angular deformity of the metacarpal
seen radiographically is often masked clinically by con-
tours of the surrounding intrinsic muscles. Because of
the thumb’s oblique orientation with respect to the
palm, radiographs need to be taken orthogonally to the
thumb, the lateral with the thumbnail perpendicular to
the x-ray film, and either the posteroanterior or the
anteroposterior (Robert) view with the thumbnail par-
allel to the cassette.
Phalanges
Simple fractures of the thumb phalanges may be treated
like other phalanx fractures: gentle reduction is fol-
lowed by immobilization, in this case with a thumb
spica splint. Safe splinting of the thumb holds all joints
in extension and the thumb in abduction. When conser-
vative measures fail, percutaneous fixation is usually
appropriate. Rarely do simple fractures of the thumb
require open reduction and internal fixation. Bony mal-
let injuries to the thumb pose no unique problems.
Intra-articular fractures of the thumb deserve special
attention. Fractures at the thumb MCP joint are likely to
involve the collateral ligaments, and testing their integ-
rity is critical. An intact radial collateral ligament is
necessary for joint stability. Injury to the ulnar collateral
Current Concepts

and special consideration is due. The thumb’s unique
orientation gives the hand great capability and predis-
poses the thumb to certain injuries, particularly of the
metacarpal base. Whereas adjacent fingers can compen-
sate for one another, there is no surrogate for the thumb.
Likewise, there are few functions of the hand in which
the thumb does not participate. Given these demands,
intra-articular fractures of the thumb demand the utmost
ligament or its attachment to the base of the proximal
phalanx (gamekeeper’s thumb), prevents effective
pinch and should be corrected. If reapproximation of
bony fragments is impossible or fails, debridement of
bone with reinsertion of the ligament end is possible.
Arthrodesis of the thumb MCP joint, owing to the great
range of motion at the thumb base, is an acceptable
salvage procedure.1

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 1028 HAND FRACTURES: CURRENT TREATMENT STRATEGIES

FIGURE 6: Tension-band technique for fixation of Bennett’s fractures. The fracture is reduced with distraction and pronation of
the thumb. Counterpressure from a clamp is applied while a Kirschner wire is passed across the fracture. A tension band is fixed
in a figure of eight.

First metacarpal
Extra-articular fractures near the base of the thumb are
common, and deforming forces are more complex here
than in other metacarpals. The abductor pollicis brevis,
adductor pollicis, and flexor pollicis brevis muscles flex
the distal fragment, and the abductor pollicis longus
distracts and extends the proximal fragment. Mild de-
formation of this sort is accommodated by the trapezio-
metacarpal joint, although excessive deformity forces
this joint into hyperextension. Closed reduction by vo-
larly directed pressure on the fracture apex followed by
percutaneous Kirschner wire fixation is useful when
angulation exceeds 30°.1
Fracture dislocations at the base of the first metacar-
pal are known by 2 eponyms. Bennett fractures are
avulsions of the ulnar metacarpal base. Rolando frac-
tures are impaction injuries in which both the ulnar and
the radial elements of the thumb base are fractured from
the shaft. At the base of the thumb, the abductor pollicis
longus tendon inserts radially and the deep anterior
oblique ligament inserts ulnarly. In Rolando fractures,
both of these soft tissue attachments are separated from
the shaft.
Current Concepts
(Fig. 6). They offered that the tension band allows for
compression at the fracture site and earlier motion than
with Kirschner wires alone. An obligatory second sur-
gery to remove hardware is a notable drawback.44 Used
with many fixation techniques, an arthroscope may help
ensure anatomical reduction of the basal joint.45
Rolando fractures leave the shaft of the first meta-
carpal in an essentially anatomical position, but without
bony connection to the basal joint. Surgical reduction
and fixation is required in most cases, but it may be
difficult in these fractures that, by definition, are com-
minuted. In these cases, external fixation is advanta-
geous, and various configurations have been advocated.
Marshland et al46 have described a monolateral external
fixation technique with good results.
Severe and combined injuries
The hand may be severely traumatized in motor vehicle
or industrial accidents. Whether the skin is open or
closed, compartment syndrome may develop, necessi-
tating fasciotomies and release of the carpal tunnel,
either for existing symptoms or preemptively.47 Open
fractures should be irrigated, covered, reduced where

In Bennett fractures, the shaft is pulled proximally by
the intact abductor pollicis longus tendon. Given this
deforming force, nonoperative treatment of Bennett
fractures is frequently unsuccessful.43 Fractures with
less displacement may be reduced with longitudinal
traction and fixed with a Kirschner wire through the
trapezium, adjacent metacarpal, or both. More displace-
ment necessitates open reduction and internal fixation.
Zhang et al44 recently described a Kirschner wire and
tension band technique for displaced Bennett fractures
possible, and immobilized.48 Antibiotic and tetanus
prophylaxis may be administered on a case-by-case
basis. In addition to skin, tendons, vessels, nerves, and
other soft tissue are often injured. Repair and recovery
of these tissues is facilitated by a rigid underlying
skeleton, and the doctrine of closed, conservative, frac-
ture care may be inapplicable. True rigidity is achieved
with plate and screw constructs or an external fixator.
Locking plate and screw constructs may be used to fix
comminuted, metaphyseal, or osteoporotic bone. These

JHS 䉬 Vol A, May 

 HAND FRACTURES: CURRENT TREATMENT STRATEGIES
invasive techniques are readily carried out in the setting
of open fractures that must be thoroughly washed out.
Bannasch et al49 showed that postoperative infection
rates after open reduction and internal fixation of open
and closed hand fractures are equally low. Despite the
necessity of more aggressive treatment in combined
injuries, early movement, wherever feasible, remains
the rule.3
Care of the healing fracture
Early movement is once again emphasized. Uninvolved
rays should be unencumbered in order to encourage
early use, and minimally stable parts (eg, reduced joint
surfaces) should be moved when healing is sufficient to
resist displacement, typically at 2 to 3 weeks for me-
taphyseal bone. Pain should be aggressively managed,
meaning the best modality at a given time should be
sought, if even reassurance and long courses of opioids
are avoided. A more comfortable patient has a psycho-
logical and physical reason to follow her or his doctor’s
instructions. These instructions should be explained
clearly, and patients’ questions should be addressed.
Effective communication invests patients in their own
care, and this motivation is perhaps the most powerful
rehabilitative tool.
COMPLICATIONS
Stiffness is a far more common and difficult to treat
complication of metacarpal and phalangeal fractures
than are malunion, nonunion, and arthrosis combined.
Each of these complications may occur with or without
an operation, and each is more easily prevented than
treated. Strictly surgical complications— hardware
prominence, hardware infection, and wound break-
down—are often primarily related to technique. Man-
agement of complications lies on a broad spectrum
from the simple to the complex. A comprehensive ac-
counting of these procedures is outside the scope of this
manuscript, and the reader is referred to more detailed
sources.1– 4 Several specific hand fracture complica-
tions have been addressed in recent literature and they
are presented later.
In a small case series, Ozcelik et al50 described the
successful treatment of distal phalanx nonunions with
olecranon bone graft. Meijs et al51 have treated thumb
distal phalanx nonunions with a percutaneous compres-
sion screw.
Hsu et al,52 in a review of 408 smooth Kirschner
wires implanted for fractures of the hand and wrist,
identified few complications. Only 3% of pins were
associated with a “major complication”: infection re-
quiring surgical drainage, nonunion or malunion requir-
JHS 䉬 Vol A, May 
1029
ing surgical correction, and fracture through a pin track.
Six percent of pins were complicated by superficial
infection. Infections were more likely in the metacar-
pals and phalanges than they were in the wrist. Poor
compliance with pin care was the only other reliable
risk factor for infection. Notably, medical comorbidities
did not increase rates of infection.52 Skin tension on a
Kirschner wire with repeated motion will lead to skin
necrosis and infection. Strategic choice of the Kirschner
wire’s entry point through the skin, and sharp relief of
residual tension minimizes these problems.
Cold intolerance is a known complication of hand
trauma in general, may linger long after the inciting
injury, and affects up to 38% of hand fracture pa-
tients.53 This complication may prompt questions of the
treating physician, and there are few good answers at
present. Smits et al,54 using thermal imaging, identified
no difference in rewarming patterns between previously
fractured hands and their uninjured counterparts.
Even bony injuries that may seem trivial clinically
and radiographically may require many months for
maximal recovery of soft tissue gliding, suppleness, and
comfort. Advising the patient of this pre-emptively al-
lays anxiety and builds trust.
In summary, fractures of the phalanges and
metacarpals are common and at least temporarily
debilitating. They call attention to the hand’s great
capability, vulnerability, and resilience. Most hand
fractures may be treated without an operation;
however, conservative treatment must be exercised
with care and may in fact require greater skill and
sustained attention. Mobilization is vital to support
soft tissue healing, which is often more problem-
atic than healing of underlying bone. In properly
selected cases, surgery may speed recovery and
avoid complications such as malunion and arthro-
sis. A variety of procedures offer either relative or
absolute stability, the latter necessary only after
more severe trauma. Postoperative care is at least
as important as the operation itself. Properly man-
aged, many fractured hands return essentially to
normal—a relief to the patient and satisfaction to
his or her doctor.
Current Concepts
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JOURNAL CME QUESTIONS
Hand Fractures: A Review of Current
Treatment Strategies
Which of the following is appropriate in
nonoperative treatment of hand fractures?
a. Fiberglass is better for holding fracture reduction
than molded plaster.
b. Manipulation is aided by flexion of the metacar-
pophalangeal and wrist joints.
c. Immobilization of the wrist should be in flex-
ion.
d. A splint should maintain the metacarpophalangeal
joint in neutral position.
e. Hand fractures are not aided by nerve blocks.
To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.
JHS 䉬 Vol , May 
1031
fracture: treatment with a percutaneous compression screw. J Hand
Surg Am. 2009;34(6):1127–1129.
52. Hsu L, Schwartz E, Kalainov D, Chen F, Makowiec R. Complica-
tions of K-wire fixation in procedures involving the hand and wrist.
J Hand Surg Am. 2011;36(4):610 – 616.
53. Nijhuis T, Smits E, Jaquet J, Van Oosterom F, Selles R, Hovius S.
Prevalence and severity of cold intolerance in patients after hand
fracture. J Hand Surg Eur Vol. 2010;35(4):306 –311.
54. Smits E, Nijhuis T, Huygen F, Selles R, Hovius S, Niehof S.
Rewarming patterns in hand fracture patients with and without cold
intolerance. J Hand Surg Am. 2011;36(4):670 – 676.
How many degrees are compensated for in index
finger metacarpal neck fractures?
a. 10
b. 20
c. 50
d. 70
e. 100
Current Concepts