Referat Ortho Asli

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 The optimal therapy program ad-
orthopedic practices. Successful rehabilitation of hand fractures addresses the need to (1) maintain dresses these 3 components (bone,
fracture stability for bone healing, (2) introduce soft tissue mobilization for soft tissue integrity, and soft tissue, and scar healing) in
CLINICAL
(3) remodel any restrictive scar from injury or surgery. It is important to recognize the intimate combination.
relationship of these 3 tissues (bone, soft tissue, and scar) when treating hand fractures. Fracture In the 1970s, therapy for hand
terminology precisely defines fracture type, location, and management strategy for hand fractures. fractures was delayed 6 to 8 weeks
These terms are reviewed, with emphasis on their operational definitions, as they relate to the while the hand was immobilized.
course of therapy. The progression of motion protocols is dependent on the type of fracture Stiff joints, adherent tendons,
healing, either primary or secondary, which in turn is determined by the method of fracture muscle atrophy, scar, and pain
fixation. Current closed- and open-fixation methods for metacarpal and phalangeal fractures are were the focus of our interven-
addressed for each fracture location. The potential soft tissue problems that are often associated
tions. Results of corrective surgical
COMMENTARY
with each type of fracture are explained, with preventative methods of splinting and treatment. A
procedures, such as capsulectomies
comprehensive literature review is provided to compare evidence for practice in managing the
for joint release and tenolysis to
variety of fracture patterns associated with metacarpal and phalangeal fractures, following closed-
restore tendon gliding, were poor
and open-fixation techniques. Emphasis is placed on initial hand positioning to protect the fracture
Downloaded from www.jospt.org by 114.125.89.40 on 08/03/17. For personal use only.
reduction, exercise to maintain or regain joint range of motion, and specific tendon-gliding
for patients with frac-
exercises to prevent restrictive adhesions, all of which are necessary to assure return of function tures.16,43,101,113 Joints with stiff-
post fracture. J Orthop Sports Phys Ther 2004;34:781-799. ness and abnormal articular
surfaces, due to limited reduction
Key Words: bone healing, hand, fingers techniques in small bones, faced
the choice of fusion (arthrodesis)
or joint replacement
I
njury to the densely compacted structures of the hand often (arthroplasty). Recent studies on
involves damage to multiple tissues. In this confined area, all fractures requiring combined
neighboring tissues share trauma and its consequence. It is a capsulectomy and tenolysis show
J Orthop Sports Phys Ther 2004.34:781-799.
mistake to consider fracture healing apart from soft tissue that outcomes are still poor, espe-
healing, because successful outcomes require the return of cially for return of active tendon
functional integrity to both tissues. Soft tissues commonly involved with function.25,64,74,86 Add to this di-
fractures include cartilage (with intra-articular fractures), joint capsule, lemma that 24% of digits that
ligaments, fascia, and the enveloping dorsal hood fibers. Occasionally, in require these release procedures
severe polytrauma cases, tendons and nerves adjacent to the fracture are are noninjured, border digits that
also injured. Following open fractures or open reduction procedures, a were included in the immobiliza-
wound is created that must heal with scar tissue—another tissue to be tion, and we lament along with
remodeled and considered during rehabilitation. It is well recognized Lanz,64 who states that ‘‘Damage
that soft tissue scarring affects hand function more than fracture of the gliding ability of tissues
healing, and joint stiffness is the most frequent complication of (around a fractured digit) is al-
fractures.50 most irreparable.’’ Enhanced un-
derstanding of the biology of
1
Director, Hand Management Center, St Dominic Jackson Memorial Hospital, Jackson, MS; Clinical fracture healing, better decision
Assistant Professor, School of Health Related Professions, University of Mississippi Medical Center, making in initial fracture manage-
Jackson, MS.
Address correspondence to Maureen A. Hardy, Hand Management Center, St Dominic Jackson Memorial ment, technical advances in im-
Hospital, 969 Lakeland Dr, Jackson, MS 39216. E-mail: mhardy@stdom.com plant design, improved surgical
Journal of Orthopaedic & Sports Physical Therapy 781

skills with respect for gliding structures, and early immobilization that maintains the reduction or re-
controlled mobilization have contributed to reducing stricts motion in the direction of instability. As
the incidence of complications that we once faced. fracture coalescence occurs, the immobilization can
The purpose of this manuscript is to review current be modified to allow incremental increases in range
concepts of management for metacarpal and of motion (ROM). Alternately, potentially unstable
phalangeal fractures, with special emphasis on poten- fractures can be supported with the introduction of
tial problems that need to be addressed in the course coaptive hardware such as K-wires, pins, or wiring
of rehabilitation. The challenge for the health care techniques that protect against displacement. These
team is to design intervention protocols that recog- devices can be inserted either percutaneously (closed
nize the need to maintain fracture stability for reduction) or via surgical exposure (open reduction).
maximal bone healing, while also introducing early, Coaptive forms of hardware bring about alignment,
controlled-motion protocols to preserve soft tissue but they do not control for rotation stresses, nor do
integrity and facilitate scar remodeling. This paper is they impart any internal strength to the fracture.
based on a thorough review of the literature and Coaptive devices therefore require further external
current practice principles. The information is pre- support to eliminate unwanted deforming stresses as
sented within the context of an overview of fracture the fracture heals.
healing, followed by guidelines for managing specific Unstable fractures will not maintain reduction, as
types of fractures common in the hand. displacement reoccurs despite immobilization. Ex-
amples of unstable fractures include long oblique,
PRINCIPLES FOR FRACTURE MANAGEMENT spiral, condylar and any irreducible fractures, and
fractures with articular fragments greater than 30%
or incongruity greater than 2 mm.39 Stability of these
Is the Fracture Stable? fractures can only be assured with the support
The quest in fracture management is to achieve provided by fixation devices. All fixation implants
fracture stability. Fractures that are stable will heal; promote reduction, but some provide added internal
fractures that are not stable can result in malunions, strength across the fracture line. The more rigid
infections, pseudoarthrosis, or nonunion. Stability of implants, such as screws, plates, dorsal band, and
a fracture is achieved when the fracture maintains its 90-90 wiring techniques, permit immediate motion
reduction and does not displace either spontaneously and only require modest external support for wound
or with motion.39 If the fracture has not distorted the care. The coaptive implants, however, such as pins,
bone’s normal contour and the fracture ends are K-wires, intramedullary rods, staples, and interosseous
wiring, do require more rigid external support as
approximated, it is termed nondisplaced. A bone that

has lost its normal anatomical contour due to separa- previously noted.4,65
tion of the fracture ends is called displaced. The
displaced fracture ends must be reunited for healing
Is the Fracture Healing?
to occur and to prevent deformities. The methods Primary Bone Healing Implant choice drives the
used to bring anatomic order and realignment back course of fracture healing. Implants introduced via
to the fractured bone is called reduction. Reduction open reduction internal fixation (ORIF) that provide
can be achieved by either closed manual techniques, absolute stability and compression of the fracture
by percutaneous fixation, or by open surgical meth- permit primary bone healing to occur. Primary bone
ods. healing is direct bone-to-bone healing without any
Stable fractures will maintain their position at rest external callus. Compression across the fracture line
and will not lose the proper approximation of frac- eliminates the space-occupying hematoma, thus re-
ture ends with inherent muscle tension or when ducing the fracture gap. Compression combined with
controlled-motion protocols are initiated. Some frac- rigid fixation, that eliminates all but micromotion,
ture types are known to have intrinsic stability, such provides an environment suitable for osteoclast cut-
as nondisplaced transverse, and short oblique con- ting cones to form and cross the fracture line. These
figurations. These fractures require no further inter- cutting cones have osteoclasts that forage forward, by
vention other than protective immobilization to allow osteoblastic action, leaving an empty trail behind
healing to commence. Intrinsically stable fractures (haversian canal) that is filled with osteons (a single
are usually treated with conservative, closed methods basic unit of bone).75 For an in-depth review of
of support for 2 to 3 weeks, then supported with fracture healing see LaStayo et al.64
removable splints for initiation of controlled motion. One advantage of primary healing via rigid internal
Fractures that are aligned but subject to misalign- fixation is precise anatomic reduction. This is espe-
ment with certain postures or tensions are termed cially important in articular fractures where joint
potentially unstable. Potentially unstable fractures incongruities can lead to degenerative joint prob-
include oblique, avulsion, and comminuted fractures. lems. As the need for peripheral callus to support the
These fractures can often be managed with protective bone ends is avoided (the metallic implant substitutes
782 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

for the callus), so also is avoided the potential The primary advantage of secondary bone healing
problem of tissue adherence to the callus during is that there is minimal soft tissue disruption. This
immobilization. Once the surgical dressing is re- equates to less scar remodeling. The periosteal sleeve,
moved, usually in 3 to 5 days, there is full access to when intact, envelops the bone adding another inter-
the hand for wound or edema control measures. nal layer of fracture support and is an important
Early initiation of motion is permitted as these blood supply source for the bone. Noninvasive frac-
implants provide sufficient internal support to allow ture management does not violate this tissue, as do
motion without endangering the fracture align- open fixation methods that may require periosteal
ment.65 In polytrauma cases, soft tissue mobilization stripping for implant application.
programs for repaired tendons can begin immedi- One disadvantage of secondary healing is the
relatively long period of protected immobilization
ately without fear of displacing the fracture.
that is required, during which soft tissues can become
A disadvantage of primary healing is that it can
contracted or adherent to the callus. Often, initiation
only occur with mechanical stabilization provided via
of motion at 3 to 4 weeks is still limited to a safe
surgery; consequently, there are 2 wounds to heal:
range dictated by the fracture’s potential instability.
the fracture and the soft tissue incision. Without the Prolonged immobilization results in atrophy of soft
initiation of early motion post-ORIF, there is a greater tissues, osteoporosis, thinning of articular cartilage,
potential for soft tissue adherence. Although new severe joint stiffness, and at times pain.52
bone is formed more quickly in primary healing, it is
not strong bone.75 This newly formed woven bone Is Closed or Open Reduction Required?
(weak) will gain tensile strength as it is remodeled
CLINICAL
The vast majority of metacarpal and phalangeal
based on its environmental stresses and strains to
fractures can be treated without surgery, using closed
become lamellar bone (strong). Bones healing by
methods that emphasize alignment and early pro-
closed conservative management and those treated by
tected motion (Figure 1).69 Fracture immobilization
open reduction methods achieve the same level of
should provide for adequate healing, relief of pain,
tensile strength by 12 weeks. This implies that pri- protection from displacement or reinjury, and resto-
mary healing is not faster healing, so strengthening ration of hand function.45 All splinting programs
programs must be delayed until the remodeling recognize the need to position the metacarpo-
COMMENTARY
phase has begun at 6 to 8 weeks. phalangeal (MP) joints in flexion to avoid extension
Secondary Bone Healing Fractures treated by external contracture. The thumb MP joint is not exempt from
support or coaptive implants, that reduce the fracture this rule and many stiff thumbs result from
but do not provide compression, must rely on callus hyperextended thumb spica immobilization. The
formation to bridge the fracture gap. Because bone interphalangeal (IP) joints are routinely rested in full
formation will not occur in an environment of extension, with the exception of volar plate fractures.
motion, callus is a temporary, biological fixation that Unpublished data by Greer45 states that the following
forms in an area with motion and functions to reduce principles (REDUCE) for effective plaster cast or
this motion as it matures and hardens (soft callus to thermoplastic splinting should be incorporated in all
hard callus).7 Callus then resembles a natural glue designs: (1) reduction of the fracture is maintained,
that holds the fracture ends together. As the callus (2) eliminate contractures through positioning, (3)
gains stiffness, the fracture fragments are rendered don’t immobilize fractures more than 3 weeks, (4)
more stable.42 Excessive, unrestricted motion can uninvolved joints should not be splinted in stable
overwhelm the fragile support offered by early soft fractures, (5) creases of the skin should not be
callus, leading to loss of reduction and possibly obstructed by the splint, and (6) early active tendon
nonunion.104 With secondary healing, ROM exercises gliding is encouraged.
are delayed or limited during the first 3 weeks, or Fractures that cannot be reduced with closed
until the callus has achieved enough tensile strength manipulation (or those that fail to maintain their
to tolerate controlled movement. Callus that is suffi- reduction), open fractures, and displaced articular
ciently ‘‘clinically stiff’’ at 3 weeks to permit motion is fractures are candidates for operative fixation proce-
not strong enough yet to bear functional loads.53 dures. Insertion of the fixation device does not always
After 3 weeks, soft callus transitions into a harder require a surgical incision. Closed reduction with
fibrocartilage callus, then through a process of miner- external fixation or closed reduction with internal
alization true bone is formed. Goodship42 summa- fixation includes percutaneous application of pins,
rized this cascade of connective tissue differentiation K-wires, and external fixators under radiologic C-arm
as one in which, ‘‘The entire spectrum of connective guidance. Limited open reduction and internal fixa-
tissue is seen from blood to bone through hematoma, tion uses small incisions to insert screws or
granulation tissue, fibrous tissue, fibrocartilage, intermedullary fixation. Open methods of internal
hyaline cartilage, woven and ultimately lamellary fixation (ORIF) do require surgical exposure of the
bone.’’ fracture for insertion of K-wires, plates, screws, and
J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 783

that well-placed coaptive implants that allow ROM
exercises without load may be insufficient to protect
the fracture against resistance (motion with load).
One week after surgery a removable splint is applied
in a functional, ‘‘rehabilitation ready’’ position, which
the patient removes for suture/pin site cleaning, and
to perform protected active ROM (AROM) exer-
cises.39 Full motion may not be possible at all joints
due to constraints from the hardware. Controversy
does exist regarding the initiation of motion with
coaptive fixation. Incidence of infection, fracture
displacement, nonunion, and pain have been cited as
reasons to delay motion until the fixators are re-
moved.9,54 Advances in osteosynthesis materials is
believed to provide sufficient stability to permit con-
trolled, protected ROM exercises with this type of
fixation in place.8,32,44,78 Weiss109 investigated initia-
tion of motion at 1, 2, 3, and 4 weeks for individuals
with proximal phalanx (P1) fractures with K-wire
fixation. Results showed no difference in ROM when
motion was initiated between 1 to 21 days. However,
when motion was delayed more than 21 days, there
was a significant loss of mobility.
At 4 to 6 weeks, the K-wires and pins are removed,
the splint is adjusted for proper fit and worn for
continued fracture protection for another 2 weeks.
AROM exercises (out of the splint) are performed
FIGURE 1. Fracture stability achieved with closed reduction meth- hourly to regain full mobility. The callus is consid-
ods (cast, splint, brace, external fixator) or with coaptive forms of ered ‘‘clinically stiff’’ enough for free active motion
fixation (pins, K-wires, intramedullary rods) require a form of but is not stable enough to bear a functional load,
external support to promote callus formation during the inflamma-
tory and repair stages of healing. As healing progresses, therapy
which occurs after 6 to 8 weeks.53 Dynamic or serial
intervention proceeds from edema prevention, to protected mobili- static splints may be initiated after 6 to 8 weeks’ time
zation with tendon gliding of nonimmobilized joints, and to to overcome any soft tissue contractures. Early
acceleration of controlled soft tissue mobilization for full active strengthening exercises with light resistance can be
tendon gliding. Passive range of motion to regain full joint mobility, initiated at 8 weeks, but unrestricted return to sports
and strengthening programs, are delayed to the early and late
and heavy work is delayed until after 10 weeks, as
remodeling phase, respectively, when the hard callus is converting
to bone. Fracture stability achieved with open reduction methods callus remodeling to lamellar bone with increased
(screws, wiring, plates) still require protective, postoperative splint fracture strength does not occur until this later stage
support initially; however, full active motion can and should be of bone healing.21
emphasized early. Because the implant serves as a substitute for Rigid Fixation: Plates, Screws, Tension Band Wiring,
hard callus, passive motion can be initiated during the repair phase.
90-90 Wiring Open reduction with rigid forms of
Strengthening programs are delayed until the remodeling phase to
assure fracture union, under the implant, has occurred. Reprinted fixation provide definitive fixation, assure compres-
from LaStayo64 with permission from Elsevier. sion for stability, and permit early motion for good
restoration of function.69 Full AROM is the early goal
osseous wiring. The hardware used in fracture fixa- as edema diminishes. Dynamic splints may be used at
tion falls into 2 categories: (1) coaptive devices that 2 weeks for soft tissue stretching, because of the
hold the fracture ends together without compression stability provided by the rigid fixation. An exception
(secondary callus healing); and (2) rigid forms of is forced extension with tension band wiring tech-
fixation that immobilize and compress the fracture niques, because the dorsal surface wiring on the
(primary healing). Freeland39 stated that, ‘‘. . . the metacarpal compresses the fracture with flexion but
choice of the implant is less important than achieving will cause gapping of the fracture with forced exten-
a threshold of stabilization that will allow fracture sion. Early strengthening exercises with light resis-
healing in concert with early rehabilitation.’’ tance can be initiated at 6 weeks, but unrestricted
Coaptive Fixation: External Fixators, Intramedullary return to sports and heavy work is delayed until after
Rods, K-wires, Pins, Interosseous Wiring Jabaley57 stated 10 weeks, similar to secondary healing, to assure
that fixation must be good enough to permit move- adequate fracture strength has occurred.
ment, but need not be excessive, given that the small It is important that therapists managing hand
bones in the hand do not bear weight. It is cautioned fractures understand the role and intent of the

various forms of fixation of fractures as they dictate digitorum communis and central slip to prevent
the course of rehabilitation. Ideally the therapist tendon adherence to fracture callus.15
would have access to both the radiographs and an To assure the extensor tendon glide over fractured
operative/emergency department report on the med- metacarpal bones, MP extension is performed in the
ical management of the fracture. In the absence of ‘‘hook fist’’ posture (Figure 2A). To gain extensor
this ideal environment, a minimum of 2 facts must be hood glide over proximal phalanx (P1) fractures, the
provided with the therapy referral: date of fracture intrinsic plus position is performed, facilitated by
and method of fixation. The fracture date starts the manually blocking the MP joint into flexion (Figure
bone-healing timetable, and the method of fixation 2B). Micks71 showed that the central slip is respon-
(dictating the type of healing) influences the rate at sible for initiating extension from a fully flexed PIP
which motion can be reintroduced. The goals of joint position, while the lateral bands (interossei and
hand therapy then are to reintroduce safe early lumbricals) achieve full terminal PIP extension. If full
mobilization while maintaining fracture stability.91 PIP extension is lacking, flexing the wrist may assist
by the addition of passive tenodesis action (stretch of
Is the Edema Under Control? the extensor mechanism).
Selective gliding of flexor tendons is achieved by
Edema after injury is common to all fractures. choosing positions that differentiate movement be-
Patient education for edema control is an essential tween the FDP and FDS to achieve maximal glide of
component of the initial therapy visit. Rest, ice, each. Wehbe106,107 used metal tags on the tendons to
compression, and elevation (‘‘RICE’’) are emphasized demonstrate that the FDP must glide 60 mm, com-
pared to 49 mm of FDS glide, to achieve full fisting.
CLINICAL
for edema control. Edema is poorly tolerated in the
digits due to the confining space. Distended joints This research suggests that for P1 and middle pha-
predictably move into positions that permit the great- lanx (P2) fractures, flexor tendons need to achieve
est expansion of the joint capsule and collateral maximal differential glide to prevent restrictive adhe-
ligaments.35 Edema postures the hand into wrist sions with loss of motion. FDP tendon gliding is
flexion, MP joint extension, IP joint flexion, and performed by manually blocking the PIP joint to
thumb adduction: a dropped ‘‘claw hand.’’ Func- allow full flexor power to be directed to the distal
tional splinting seeks to place the hand in a resting joint (Figure 2C). To promote selective FDP flexor
COMMENTARY
position that will avoid this deformed posturing. Ice tendon glide past the superficialis tendon, the ‘‘claw
can be easily performed with the use of large bags of fist’’ posture of MP extension with PIP and distal
frozen peas (1 bag applied volarly and 1 dorsally) and interphalangeal joint (DIP) maximal flexion is
is effective even over a splint or cast. Coban (sized 1 achieved (Figure 2D). FDS tendon blocking exercise
inch [2.5 cm] for fingers and 2 inches [5 cm] for the requires inhibition of the FDP tendon of the same
hand) is an elastic self-adhering bandage that pro- finger, which also contributes to PIP joint flexion.
vides effective compression. Eccles33 showed that the This inhibition of the profundus is achieved by
greatest reduction in swelling was obtained with the manually restricting DIP motion in the unaffected
hand supported in elevation overnight. digits with attempted PIP flexion in the involved digit
Early mobilization to promote venous return via (Figure 2E). Because the FDP tendons blend into 1
muscle contraction is advocated in stable fractures. multistrand tendon inserting into the muscle belly,
Having the patient adduct the fingers tightly and blocking 1 tendon’s excursion effectively blocks all
maintain this tension while flexing at the MP joint others.14 The only motor that is now free to glide and
flex the PIP joint is the FDS tendon. The ‘‘sublimis
can enhance both intrinsic muscle pumping and

achieve the desired joint positions of full MP flexion fist’’ (Figure 2F) maximally glides the FDS tendon
and IP extension. Double buddy straps, applied past the FDP tendon with full MP and PIP flexion
proximal and distal to the proximal IP joint (PIP), and an extended DIP joint. Full fisting, flexion of all
serve to protect fracture alignment and encourage 3 joints simultaneously, promotes full gliding of all
mobility of the injured digit. Patients are also in- flexor tendons with the FDP tendon gliding past the
structed in shoulder and elbow ROM exercise in FDS tendon.105
elevation to facilitate proximal muscle pumping.
PRINCIPLES FOR MANAGING METACARPAL
Are the Tendons Gliding? FRACTURES
AROM is initiated as soon as possible, based on the The metacarpal bones have intrinsic stability pro-
method of fixation, to prevent osseous adhesions to vided proximally by strong interosseous ligaments
tendons, ligaments, capsules, or skin.82 The most binding them to the carpal bones, and distally by the
important tendon-gliding exercises to initiate early transverse metacarpal ligament linking all metacarpal
are those for the flexor digitorum profundus (FDP), heads. These ligaments serve to tether and anchor
flexor digitorum superficialis (FDS), extensor both ends of the metacarpal, preventing excessive

A B
C D
E F
FIGURE 2. Tendon glide exercises: (A) claw posture to achieve extensor digitorum communis (EDC) tendon glide over metacarpal bone; (B)
intrinsic plus posture to achieve central slip/lateral bands glide over proximal phalanx (P1); (C) flexor digitorum profundus (FDP) blocking
exercises to glide FDP tendon over P1; (D) hook fist posture to promote selective FDP tendon glide; (E) flexor digitorum sublimis (FDS)
blocking exercise to glide FDS tendon over middle phalanx; (F) sublimis fist posture to promote selective FDS tendon glide.

displacement with injury. This is especially true for During this time the fingers are free and encouraged
middle and ring metacarpal fractures as they have the to move. Once clinical signs of healing are present, a
additional support of intact adjacent metacarpals. protective wrist splint is used for 3 to 4 weeks while
Fractures in the border digits, index and small, tend wrist rehabilitation is initiated.
to be more unstable due to loss of surrounding intact
metacarpal pillars. The thumb metacarpal, sitting at
TABLE 1. Potential problems with metacarpal fractures and
47° rotation away from the other digits, is the most strategies for therapeutic intervention.
mobile and most unstable if fractured.100
Metacarpal fractures represent 35% of hand frac- Potential Problems Prevention and Treatment
tures. Due to their good blood supply, these fractures Dorsal hand edema Coban wrap compression, ice,
heal rapidly with osseous restoration in 6 weeks. elevation, high-voltage stimu-
Fractures of this bone are described at 4 distinct lation
locations: base, shaft, neck, and head. The most Dorsal skin scar contracture Silicone TopiGel, simultaneous
important soft tissue concerns with metacarpal frac- that prevents full fist heat and stretch with hand
wrapped in a fisted position;
tures are preserving MP joint flexion and maintaining friction massage
EDC glide. Table 1 lists the potential problems that
can occur and strategies for therapeutic intervention. MP joint contracted in exten- Initially: position MP joint at
sion 70° flexion in protective
splint
Late: dynamic or static progres-
Metacarpal Base Fracture sive MP joint flexion splint
CLINICAL
Adherence of EDC tendon to Initially: teach EDC glide exer-
Base fractures are an intra-articular fracture result- fracture with limited MP joint cises to prevent adherence;
ing from high force that disrupts the rigid carpal flexion splint IP joint in extension
ligaments (index and middle), or overwhelms the during exercise to concen-
trate flexion power at MP
normal flexibility of the ulnar metacarpals (ring and
joint
small).41 The insertions of the wrist flexors and Late: dynamic MP flexion
extensors on the metacarpal base can be a deforming splint; NMES of EDC with
COMMENTARY
force. These are uncommon injuries associated with on ⬎ off cycle
violent accidents resulting in a fracture-dislocation Intrinsic muscle contracture Initially: teach instrinsic stretch
pattern. The most common occurrence is at the fifth secondary to swelling and (instrinsic minus position)
metacarpal-hamate articulation, which is often un- immobilization Late: static progressive splint in
intrinsic minus position

stable due to the pull of the extensor carpi ulnaris,
flexor carpi ulnaris, and abductor digiti minimi that Dorsal sensory radial/ulnar Desensitization program;
nerve irritation iontophoresis with lidocaine
insert on the metacarpal base.12 Fractures at this
location limit the normal descent of the ulnar Attrition and potential rupture Rest involved tendon; contact
metacarpals, causing weakness of grip. The deep of extensor tendon over physician if painful symptoms
prominent dorsal boss or with AROM persist
motor branch of the ulnar nerve, passing beneath large plate
the hook of the hamate, is also vulnerable to injury
Scissoring/overlapping of digits Slight: buddy tape to adjacent
in this fracture.76 The index and middle metacarpal with flexion digit
base fractures are also unstable due to the insertion Severe: malrotation deformity
of the extensor carpi radialis longus and flexor carpi requiring ORIF
radialis on the second metacarpal and extensor carpi Absence of MP head Shortening of metacarpal; may
radialis brevis on the third. not be functional problem
Closed reduction with casting of the wrist for 4 to 6 Absence of MP head and MP Shortening of metacarpal with
weeks is indicated for nondisplaced or minimally joint extension lag redundancy in extensor
displaced fractures. Bora12 reported ‘‘satisfactory’’ length; splint in extension at
return of grip strength and activities in 18 patients night; strengthen intrinsics
treated with this method. Displaced fractures repre- abduction/adduction; NMES
of intrinsics with off ⬎ on
sent an associated carpometacarpal joint dislocation cycle
that can lead to joint incongruity, degenerative joint
disease and ultimately further carpal collapse.41 ORIF Absence of MP head with Neck fracture angulated
volar prominence and pain volarly; minor: padded work
is necessary to restore joint approximation, prevent with grip glove; major: reduction of
pain, and assure return of grip strength. Postopera- angulation required
tively, a cast is worn for 4 to 6 weeks to protect this
injury at the wrist. This prolonged immobilization is Abbreviations: AROM, active range of motion; EDC, extensor
digitorum communis; MP, metacarpophalangeal; IP, interphalangeal;
necessary to protect the healing fracture from the
NMES, neuromuscular electrical stimulation.
deforming forces of the wrist tendon insertions.70

Metacarpal Shaft Fracture A
Shaft fractures are extra-articular fractures caused

by fall, blow, or crushing force that usually angulate
dorsally and may have components of shortening
and/or rotation. They are described by the fracture
configuration as transverse, oblique, or spiral. Intrin-
sic muscle tension, arising from its origin on the volar
proximal metacarpal through its bony insertion on
the proximal phalanx, will cause both ends of the
metacarpal bone to flex towards each other, pushing
the fracture ends dorsally (known as apex dorsal
presentation). 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, causing a B
deleterious effect on the extensor mechanism by
altering the muscle’s normal length-tension relation-
ship. For each 2-mm increment of bone shortening
there is a corresponding 7° extensor lag at the MP
joint.97 The natural ability to hyperextend the MP
joint will overcome this extensor loss for minimal
bone shortening; but this deformity leaves a promi-
nent dorsal boss that has been implicated in attrition
rupture of extensor tendons.96
Stable, nondisplaced transverse metacarpal shaft
fractures with apex dorsal angulation can be treated
closed with glove support,68 buddy taping,112 short
hand casts,29 long ulnar/radial gutter splints, or
hand-based fabricated splints that incorporate 3
points of reduction pressure (1 dorsal point over the FIGURE 3. (A) metacarpal shaft fracture treated with 3-point pres-
fracture site and 2 volar points, proximal and distal to sure fixation built inside splint; (B) straps secured to apply corrective
the fracture, that provide counterpressure).70,102,103 pressure to dorsal apex angulation of fracture.
C-arm visualization of the fracture with the splint on
will assure improvement in the angulation after 1 proposed the concept of ‘‘serial splint reduction,’’ in
week.58 Sorenson92 found poor compliance and skin which the splint is gradually cut down as fracture
breakdown with prefabricated splints as compared to healing proceeds, permiting controlled-motion exer-
ulnar gutter casts. Konradsen,61 using fiberglass cast- cises (Figure 4C-D).
ing, and Jones,58 using thermoplastic material, fabri- Multiple metacarpal fractures may require that all
cated custom-made, hand-based fracture braces with fingers be included in the cast (Figure 5A).
the 3-point reduction technique. Both studies com- Ashkenaze6 described a splint that includes the wrist
pared this functional brace, which allowed wrist and and metacarpal shafts with dorsal support extending
digital motion, with plaster ulnar gutter casting. out to the PIP joint, with the volar support ending at
Together, these 2 studies support the advantages of the distal palmar crease to allow free MP and IP joint
the functional brace with improved motion, de-
motion. Seventy degrees of MP joint flexion reduces
creased pain, ability to deliver corrective reduction
the intrinsic and extrinsic flexors influence on dorsal
force, less extensor lag, and decreased need for
angulation.90 The IP joints are free to move during
postfracture therapy. Current best-practice fracture
the day but strapped into extension at night to
support for managing nondisplaced, angulated
metacarpal shaft fractures is provided by custom- prevent flexion contractures (Figure 5B). Buddy
made casts or splints that incorporate the 3-point strapping of the injured digit to a noninjured adja-
pressure fixation built within the splint and allows cent finger, especially in oblique fractures, is protec-
free active joint motion (Figure 3). tive against malrotation and facilitates early motion.
Fractures that are potentially unstable require addi- Hall47 reported using this type of clam digger immo-
tional support. Ulnar or radial gutter splints that bilization in over 1000 fractures, modified to plaster
immobilize both the injured metacarpal and its adja- in noncompliant patients. This best-practice manage-
cent stable metacarpal, including wrist, MP, and PIP ment technique assures protection of fracture stabil-
joints have been the norm (Figure 4A-B). Feehan36 ity, maintains proper hand posture, and respects the

A B
CLINICAL
C D
COMMENTARY
FIGURE 4. (A) Radial gutter splint for fractures of index or middle metacarpals; (B) ulnar gutter splint for fractures of ring or small
metacarpals; (C) serial reduction of splint to permit motion as fracture healing occurs; (D) passive range of motion in splint.
importance of motion in the early rehabilitation of head prominence of the involved bone. Following
fracture. ORIF, a circumferential, hand-based splint is worn to
Oblique and spiral metacarpal fractures can protect the metacarpal area from direct trauma; no
shorten and rotate. The ill effects of this telescoping joint motion is restricted with this splint. Kuntscher63
and malrotation will be evident when the patient reported that 105 fractures postoperatively provided
attempts to make a fist. The rotated position of the with this type of functional fracture brace resulted in
metacarpal will cause digital overlapping and the decreasing the number of hand therapy visits with
telescoping will cause loss of the normal metacarpal early, pain-free return of hand function.

to their compensatory mobility. If these acceptable
A reduction angles cannot be maintained with external
support alone, then operative treatment is recom-
mended.93
Once the volarly flexed metacarpal head is reduced
back in proper alignment with the shaft, it is impor-
tant to hold the MP joint in over 70° flexion, as the
taught collateral ligaments will aid in securing the
metacarpal head in place. A traditional ‘‘clam dig-
ger’’ or intrinsic plus splint can be used that includes:
(1) keeping the wrist in slight extension; (2) holding
the MP joint in flexion by a dorsal block component
that extends out to the PIP joint; (3) stopping the
volar side of the splint at the MP web area, permit-
ting limited MP and full PIP flexion.5,24 Neck frac-
B tures 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.48,61
Jones58 instructed patients to gradually tighten the
straps as edema subsided, and found that this gradual
application of stress reduced the fracture as effec-
tively as manipulation with anesthesia. It is recom-
mended that reduced fractures use the hand-based
splint that maintains the MP flexed with a dorsal
block.24 If reduction is inadequate or potentially
unstable, the 3-point splint should be used.
Closed reduction percutaneous pinning with
FIGURE 5. (A) Cast for multiple metacarpal fractures permitting K-wires is recommended to maintain reduction in
early active finger flexion; (B) resting volar component added to unstable neck fractures.88 One week postoperatively,
maintain interphalangeal joints in full extension. the surgical dressing is removed and an immobiliza-
tion splint is applied to protect this coaptive fixation
Metacarpal Neck Fracture at that time. The patient is instructed in protected

Neck fractures are the most common metacarpal ROM exercises out of the splint. At 4 to 6 weeks the
fracture, also known as fighter’s or boxer’s fracture. K-wires are removed and the patient should then
The impact of a closed fist hitting an object can regain full AROM.
fracture the metacarpal at its weakest point, the
extra-articular neck. With fight/bite injury, the fist Metacarpal Head Fracture
contact with the mouth of another can result in tooth
penetration into the MP joint. Any skin laceration at Head fractures are intra-articular fractures caused
the MP joint level with fight/bite fractures should be by high axial loads that can involve avulsion of the
suspect for infection. collateral ligaments, including a fracture fragment,

Trauma causes the fractured metacarpal head to fracture of 1 or both condyles, or shattering of the
displace with volar angulation. Debate continues over joint surface into many small-comminuted pieces.
the necessity to reduce and immobilize these frac- Collateral ligament avulsion fractures if undetected
tures.3,14,56 However, angulated neck fractures that can lead to chronic pain and joint instability. If the
heal with volar displacement over 30° place the fracture fragment is nondisplaced, the injury can be
intrinsic muscle in a shortened position, which re- treated with protective splints that hold the MP joint
duces the muscle’s excursion capacity. This loss of full flexed at 50° to 70° for 4 to 6 weeks.38 Displaced
muscle length results in limited ability to initiate fractures require ORIF with fixation that allows early
flexion at the MP joint.3 Other complications of protected motion.93
poorly reduced neck fractures include a metacarpal Fracture displacement of 1 to 2 mm at the articular
head prominence in the palm that is painful with surface is more easily tolerated in the upper extrem-
grip, and compensatory hyperextension of the proxi- ity than in the lower extremity weight-bearing joints;
mal phalanx at the MP joint to clear the fingers for however, ORIF is indicated for fractures that involve
grasp. Acceptable angulation is less than 15° in the more than 20% of the articular surface to prevent
index and middle metacarpals, while the ring and erosive joint changes and to allow AROM by the third
small metacarpals can function with less than 30° due week postfracture.6,50

Comminuted fractures that do not lend themselves
TABLE 2. Potential problems with phalangeal fractures and
well to operative fixation, due to the many small strategies for therapeutic intervention.
fragments involved, can be treated with closed immo-
bilization in a radial/ulnar gutter splint with the MP Potential Problems Prevention and Treatment
joints flexed to 70°. However, comminuted fractures Loss of MP flexion Circumferential PIP and DIP
with substantial loss of bone length are better treated extension splint to concen-
with external fixators or bridging plates that maintain trate flexor power at MP
bone length.23 Immobilization is shortened to 2 to 3 joint; NMES to interossei
weeks, because early motion benefits articular carti- Loss of PIP extension Central slip blocking exercises;
lage repair. Salter80 cautions that excellent reduction during the day MP extension
of the fracture may still lead to a poor result due to block splint to concentrate
extensor power at PIP joint;
the concomitant cartilage injury with its limited at night PIP extension gutter
regenerative capacity. His definitive work on intra- splint; NMES to EDC and
articular fractures showed that continuous passive interossei with dual channel
motion begun in the first postoperative week stimu- setup
lates both bone and cartilage healing.81 Loss of PIP flexion Isolated FDP tendon glide exer-
cises; during the day MP
PRINCIPLES FOR MANAGING PHALANGEAL flexion blocking splint to
concentrate flexor power at
FRACTURES PIP joint; at night flexion
glove; NMES to FDS
Phalangeal fractures are more unstable than
CLINICAL
metacarpal fractures as they lack intrinsic muscle Loss of DIP extension Resume night extension splint-
support and are adversely affected by tension in the ing; NMES to interossei
long finger tendons.112 Phalangeal fractures respond Loss of DIP flexion Isolated FDP tendon glide exer-
more unfavorably to immobilization than metacarpal cises; PIP flexion blocking
fractures, with a predicted 84% return of motion, splint to concentrate flexor
power at DIP joint; stretch
compared to 96% return in metacarpal fractures.88 If ORL tightness; NMES to FDP
immobilization is continued longer than 4 weeks, the
COMMENTARY
motion return drops to 66%.98 In 19% of digital Lateral instability any joint Buddy strap or finger hinged
splint that prevents lateral
fractures, nonfractured neighboring fingers also lose stress
motion.55 Functional outcome in these fractures is
not so dependent on fracture site; rather, unsatisfac- Impending Boutonniere defor- Early DIP active flexion to
mity maintain length of lateral

tory results are more related to open fractures, bands
comminuted fractures, and associated soft tissue inju-
ries.78 Table 2 lists potential problems that can occur Impending swan neck defor- FDS tendon glide at PIP joint
mity and terminal extensor tendon
with phalangeal fractures and strategies for therapeu- glide at the DIP joint
tic intervention.
Pseudo claw deformity Splint to hold MP joint in flex-
ion with PIP joint full exten-
Proximal Phalanx (P1) Base Fracture sor glide
Intra-articular base fractures are due to an abduc- Pain Resume protective splinting
tion force from sports injuries or a fall on an until healing is ascertained;
outstretched hand. These articular fractures require address edema, desensitiza-

tion program
accurate reduction to restore normal joint kinemat-
ics. After reduction, stability of the fracture position Abbreviations: DIP, distal interphalangeal; EDC, extensor digitorum
can be maintained with conservative treatment due to communis; FDP, flexor digitorum profundus; FDS, flexor digitorum
tension in the surrounding intact joint capsule, collat- superficialis; MP, metacarpophalangeal; NMES, neuromuscular elec-
trical stimulation; ORL, oblique retinacular ligament; PIP, proximal
eral ligament complex, interossei tendons, and volar interphalangeal.
plate for fractures in the proximal 6- to 9-mm range
from the joint.111 Positioning the MP joint in 70°
flexion results in balanced tension of these capsular Displaced base fractures can not be reduced with
structures. The PIP and DIP joints, buddy taped to an MP joint positioning alone as often the collateral
adjacent digit, are allowed early active motion. The ligament, attached to the fracture fragment, is
intrinsic plus position of the splint design also causes avulsed. Shewring’s review89 of 33 displaced base
the extensor aponeurosis to be tightened and drawn fractures found a high rate of nonunion with conser-
distally over the base of P1, providing compression of vative management due to displacement of the frac-
the fracture. After 2 to 3 weeks,79 or 3 to 4 weeks,32 ture as the collateral ligament tightens with flexion of
depending on callus formation, the splint can be the MP joint. These avulsion fractures occur most
removed for protected ROM at the MP joint. often at the ulnar collateral ligament of the thumb or

Nondisplaced fractures require protection, but not
A total immobilization. Inclusion of a neighboring
noninjured digit in the splint and buddy strapping
permit early AROM. Oxford73 recommends a single-
digit circumferential splint for stable fractures, which
provides extended lateral support at the PIP joint for
distal shaft fractures or volar and dorsal immobiliza-
tion of the MP joint for proximal shaft fractures. This
design allows for free active PIP joint motion.
Displaced P1 fractures present with apex palmar
angulation. This angulation is due to a volar force at
the base of P1 by the interossei insertion, while the
extensor expansion pulls the distal fragment dor-
B sally.11 Freeland39 recommends that the ‘‘least intru-
sive technique be used to provide a threshold of
strength that reliably holds the fracture
securely . . . and would allow simultaneous early reha-
bilitation.’’ Methods of fixation for displaced, un-
stable fractures include closed transcutaneous
insertion of K-wires or intramedullar y rods,
percutaneous miniscrews, open internal fixation with
miniscrews, miniplates, and mini external fixators.40
The most common problem at this level begins
with an extensor lag at the PIP joint, which develops
into a fixed joint flexion contracture.74 The worst
case scenario results when minimal motion at the PIP
FIGURE 6. (A) Wrist and distal joint immobilizer splint used during joint results in a fixed flexed position of the joint,
exercise sessions to promote flexion at the metacarpophalangeal which is compensated at the MP joint with
joint (MP); (B) MP joint flexion isolated during exercise with use of hyperextension to remove the flexed finger from the
dual blocking splints.
palm. A pseudo-claw hand posture is created. Preven-
index and radial collateral ligament of the ring and tion of this deformity relies on emphasizing PIP joint
small fingers.8,79 Techniques used for fixation of extension at rest and early tendon glide along all
displaced fractures include tension band wiring using bone surfaces. Initially, a splint is made that main-
a figure-of-eight weave,62 intraosseous wiring with tains flexion at the MP joint, with a dorsal hood
additional K-wire support,110 or screw fixation.2,50 As expansion to securely strap the PIP joint into full
MP joint stiffness with loss of flexion is the most extension at rest (Figure 5).24 The volar part of the
common postoperative soft tissue complication of P1 splint stops at the distal palmar crease. Hourly the
base fractures, protective splinting must rest the MP distal straps are removed to permit early tendon
joint in flexion. When active exercises are initiated to gliding, emphasizing central slip, lateral bands, FDS,
regain full MP flexion, the use of splints holding the and FDP tendons, respectively. Full PIP joint flexion
wrist, PIP, and DIP joints immobilized during exer- is not promoted until the patient is able to actively
extend the PIP joint to 0°.34 Burkhalter17 reminds us
cise, will facilitate all flexor strength directed towards

the MP joint (Figure 6A-B). Continuous passive that it is far easier to gain flexion than extension at
motion (CPM) following ORIF with rigid fixation is this joint.
indicated to maintain joint mobility, decrease edema, Later, a functional blocking splint can be used to
and stimulate the healing of articular cartilage.81 counter the pseudo-boutonniere posturing that oc-
curs with less than optimal tendon gliding (Figure
7A-B). The splint immobilizes the MP joint in flexion,
P1 Shaft Fracture protecting against MP hyperextension, while also
Fractures occurring in digital flexor zone II, called directing all flexor and extensor tendon power to the
‘‘no man’s fractures,’’17 are renown for the worst PIP joint. Light-resistance exercises for PIP joint
prognosis in regaining full mobility.31 Ninety percent flexion and PIP joint extension are facilitated when
of the bone’s surface is covered by gliding struc- performed in the splint.
tures—the central tendon dorsally, lateral bands bilat-
erally, and the FDP tendon volarly—that can easily
P1 Condylar Fracture
become adherent to fracture callus. Fractures of the The 2 condyles at the head of the proximal
shaft require accurate reduction to allow these soft phalanx, with their intimate convex-concave fit on the
tissues to glide normally.110 middle phalanx base, provide stability to a joint

lateral incision used for screw placement, the ORIF
A group in his study had 3 times greater PIP joint
extension lag (27°), as compared to the group that
received closed reduction treatment (8°). This may
be partly explained by the mutually dependent role
played by the central slip and lateral bands in
achieving full PIP joint extension. It may be that
adhesions in either system will affect PIP joint exten-
sion.
Pain and swelling at the PIP joint postoperatively
are a great barrier to rehabilitation. Swelling will
draw the joint into a flexed posture that over time
will become a contracture. Splinting must rest the
B PIP joint in full extension, with hourly short-arc
AROM performed. It is crucial that the patient work
to achieve proximal gliding of the extensor mecha-
nism, and thus 0° extension to prevent an extensor
lag. The use of continuous passive motion (CPM)
following rigid internal fixation of these fractures
results in regeneration of hyaline articular cartilage,
reduction of edema, prevention of adhesions and
CLINICAL
joint stiffness, and is painless.80 Incised and repaired
central slip tendons can also be treated with the
short-arc-motion protocol, as there is continuity of
the extensor tendon longitudinally. Full PIP joint
flexion is limited for 3 weeks to prevent splitting the
FIGURE 7. (A) Pseudo-boutonniere deformity of ring digit following sutured tendon approximation.
proximal phalanx fracture; (B) the blocking splint facilitates flexor
COMMENTARY
and extensor tendon gliding at the proximal interphalangeal joint Middle Phalanx (P2) Base Fracture
(PIP).
This intra-articular fracture is caused by a
deprived of much soft tissue support. The type of hyperextension, hyperflexion, or lateral deviation
tissue injury caused with a lateral deviation force is force on an outstretched finger, as occurs in basket-
dependent on the rate of loading: stress applied with ball and volleyball injuries, or from a fall onto the
low loading rate causes collateral ligament injury, outstretched hand.87 Hyperextension or hyperflexion
while a high loading rate can result in a collateral injuries are often severe enough to cause the PIP
avulsion fracture, or a unicondylar (1 side) or joint to dislocate with associated soft tissue damage to
bicondylar (2 sides) fracture configuration at the the volar plate or central slip respectively, commonly
head of P1.60 A ball forcing the digit away from the called avulsion fractures. With severe compressive
center line of the hand most often fractures the trauma, comminuted fractures of the articular surface
condyle towards the middle of the hand.109 This is a occur, causing depression of the fragments into the
common sports injury that is often misdiagnosed as a bone shaft, called a pilon fracture. Pilon is derived
‘‘jammed finger’’ as the athlete can move the finger from the Latin word ‘‘pounder,’’ indicating the force
well.82 Continued unsupported use of the hand can required to create this deformity.95
change a simple nondisplaced fracture into an Palmar Plate Avulsion Fracture Also known as dorsal
angulated fracture with painful joint incongruity.93 fracture dislocation, this fracture results from a
These potentially unstable fractures are best treated hyperextension injury in which the distal attachment
with ORIF to assure good joint alignment is achieved. of the volar plate, at the base of P2, is ruptured along
The problem with ORIF at this level is access to the with a variable portion of the articular surface of the
P1 head directly under the central extensor slip. volar middle phalanx. Without the normal restrains
Authors have advocated various incision locations: provided by an intact volar plate, tension from the
splitting the extensor tendon longitudinally,77 incising finger extensors on their distal attachment causes the
between the lateral band and the central tendon,72 base fracture to dislocate dorsally. The percent of
excising the insertion of the central tendon creating articular surface involved and the percent of joint
a flap,20 or a lateral midaxial incision.54 As the most dislocation determine severity of this fracture.83
significant complication following P1 fracture is loss Buddy taping and immediate active motion are used
of full PIP joint extension, the lateral approaches that to manage less severe fractures. Fractures of moder-
spare direct trauma to the central tendon are more ate severity (20% to 40% of the articular surface
appealing. However, Horton48 found that despite the involved) are treated with extension block splinting

for greater than 6 weeks. This fracture is at risk for
displacement with full extension. A dorsal block
splint prevents the joint from extending by 30° to
40°, yet allows full joint flexion (Figure 8). This
protocol allows fracture compression with flexion,
while avoiding fracture separation with extension. As
fracture healing ensues, the splint angle is subse-
quently remolded at less extension block weekly,
permitting gain in extension range. Usually there is a
slight flexion contracture at the end of the 6 - to
8-week splinting regime, which can be treated with
dynamic extension splinting.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.
Central Slip Avulsion Fracture This fracture, also
known as ‘‘dorsal fracture dislocation’’ or ‘‘bouton- FIGURE 9. Cast for central slip avulsion fracture that maintains full
niere fracture,’’ includes a fracture fragment from proximal interphalangeal joint extension while allowing active distal
interphalangeal joint flexion to maintain the length of oblique lateral
the dorsal base of P2 that is attached to the central ligaments and lateral bands.
extensor tendon. Fortunately it is a rare injury and
treatment depends on the ability to restore the volar
subluxed P2 back to approximate the avulsed frag-
ment. Reduced fractures are immobilized in full PIP
joint extension for 4 to 6 weeks, 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). Flexion at
the DIP joint will prevent the appearance of a
boutonniere deformity post immobilization.22 Closed
reduction, however, is often difficult due to soft tissue
constraints, necessitating ORIF with pin, screw, or
tension band wiring.8 A removable protective finger-

based splint is worn that maintains the PIP joint in
FIGURE 10. Dynamic traction splint for comminuted pilon frac-

tures. The finger is moved passively along the arc several times per
day to stimulate regeneration of articular cartilage and remodel the
joint surface. Rubber band tension is measured to assure 300 g of
ligamentotaxis distractive force throughout the range.
full extension and is removed for passive ROM

exercises. Pins are removed at 2 to 3 weeks, at which

time, active ROM can begin to further glide soft
tissues. With screw fixation, active motion can begin
immediately with the use of the same splint to
prevent flexed posturing at the PIP joint.
Pilon Fracture Severe compressive trauma can cause
the head of the proximal phalanx to impact into the
base of P2, creating many small, crushed fracture
fragments. The distal articular surface of the PIP
joint is essentially destroyed. ORIF seeks to elevate
the central depressed articular fragments and main-
tain their length with bone grafts or external
FIGURE 8. Volar plate avulsion fracture treated with extension fixators.51 Another option is to use a combination of
block splint that limits full extension at the proximal interphalangeal traction and motion to model a new joint through
joint (PIP); the degree of blocking is determined by fracture
displacement with extension. The distal strap (not shown) is the use of dynamic traction splinting (Figure 10).
removed to allow active PIP and distal interphalangeal joint (DIP) This latter method uses a radial or ulnar gutter splint
flexion and extension. that blocks the MP joint in flexion. Rubber band

traction from a circular outrigger is attached to P2 Neck Fracture
exposed K-wires passed through the middle phalanx
distal to the fracture. Tension is measured with a Neck or subcapital fractures are more common in
Halston gauge to assure that adequate distractive young children whose fingers have been trapped in
force of 300 gm is exerted. The distractive force uses closed doors or electric windows. These fractures are
a concept called ‘‘ligamentotaxis,’’ in which the soft usually markedly displaced and unstable, requiring
tissue envelope that encircles the fracture (intact ORIF. Stern’s review93 of complications suggests that
periosteum, collateral ligaments, joint capsule) is K-wires should remain in for a longer duration of 4
placed under longitudinal tension, causing these soft to 6 weeks. Postoperative therapy is based on the
tissues to narrow and compress the fracture.58 During stability of the fixation. DIP joint stiffness, with loss of
the day the dynamic-traction component is moved active flexion, and an extensor lag are the chief
along the circular outrigger hoop to achieve passive complications. Protective splinting of the DIP joint in
PIP joint motion, which is beneficial to articular full extension, with frequent removal for FDP tendon
cartilage healing. The splint is worn continuously for gliding is recommended.
6 to 8 weeks (removed briefly for dressing purposes)
to prevent displacement of the fracture.46 Kearney59 Distal Phalanx (P3) Fractures
reported on a 9-year follow-up of patients treated
The distal exposed portion of the finger is most
with dynamic traction and found that all joints were
vulnerable to injury, with fractures at the P3 level
pain-free and asymptomatic, they maintained their
accounting for 50% of hand fractures.18 Causes of
87° arc of PIP joint motion, and the joint space had
fracture include crush to the distal tuft, as when
been maintained, indicating good cartilage thickness.
CLINICAL
fingers are caught in closed doors or machines, blows
The use of dynamic traction for pilon fractures was
to an extended finger, and sports-related volar and
compared with ORIF and found to produce the same
dorsal articular avulsion fractures.84
results with fewer complications.95
P3 Base Fracture
P2 Shaft Fracture
Articular avulsion fractures are closed injuries that
Fractures at this location are rare, due in part to result when an actively contracting tendon is force-
COMMENTARY
the short, broad shaft that is stronger here than in fully pushed into the opposite direction. Tendon
proximal bones. The path of the lateral bands, rupture alone can occur, or an articular fragment of
spiraling from their lateral position at the PIP joint to variable size can be avulsed along with the tendon.
become conjoined dorsally over the distal part of this Two common types of avulsion fractures at this level
phalanx, place them in jeopardy of adhering to are ‘‘jersey’’ fracture and ‘‘baseball’’ fracture.
fracture callus with closed methods, or of becoming Volar Jersey Avulsion Fracture This fracture is named
impaled with pins and screws with open methods. after the football injury in which one player grabs the
Longitudinally placed pins down the medullary canal shirt of an opponent who pulls away forcefully,
try to avoid this soft tissue problem.8 Limitation of causing the FDP tendon, with a bone chip, to be
lateral band gliding will result in loss of DIP joint avulsed from the volar base of P3. Loss of terminal
terminal extension. Midshaft fractures can angulate joint active flexion requires early and judicious care,
either dorsally or volarly, resulting in shortening of as FDP tendon muscle shortening can occur if
the middle phalanx shaft. This skeletal shortening undetected. With small fragments, the tendon (with
will cause an imbalance in extensor tendon-bone the fracture fragment attached) is surgically reat-
length ratio, resulting in loss of terminal DIP joint tached through P3 using wire pull-out sutures over a
extension. Loss of full DIP joint extension, due to dorsal button. A dorsal blocking splint is fabricated
either lateral band adherence or redundance, leads and the postoperative Durand tendon motion proto-
to the classic swan neck deformity of DIP flexion with col is followed.19 Large fracture fragments require
excessive extensor force directed at hyperextending the additional support of K-wires to assure good joint
the PIP joint.1 Cannon19 recommended 3 weeks surface congruence is achieved.84 A modified Durand
immobilization with closed methods or K-wire fixa- program is performed, omitting DIP joint flexion
tion, as FDS tendon action can displace this fracture until the wire is removed.
due to its insertion on the P2 shaft. The digit is Dorsal Avulsion Fracture This fracture, known as
splinted in the functional position of MP joint flexion ‘‘mallet fracture’’ or ‘‘baseball fracture,’’ is common
with PIP and DIP joints in full extension. For long to all sports and hobbies in which an extended finger
oblique or spiral fractures, ORIF or percutaneous use is forced into either flexion or hyperextension.65 The
of screws provides enough stability to allow AROM extensor terminal tendon is avulsed off the dorsal
within 1 week. Emphasis is placed on FDS tendon base of P3, with a chip of variable-sized bone at-
glide at the PIP joint and terminal extension glide at tached. If the fracture piece represents less that one
the DIP joint, countering the swan neck deformity. third of the articular surface, it may be managed with

and motion at the MP and PIP joints is encouraged
after the first week. Active ROM at the DIP joint can
be initiated after 3 weeks if callus consolidation
permits. Loss of full DIP joint flexion is usually due
to soft tissue contracture of joint structures and
dorsal skin scar. Wrapping the digit with coban into
an intrinsic minus position and then dipping into
paraffin provides simultaneous heat and stretch,
which has been shown to have the best effect on soft
tissue lengthening.49 This is followed by blocking
exercises for FDP tendon glide.
P3 Tuft Fracture
Treatment of the tuft fracture, even when commi-
nuted, is relatively simple. Compression around the
tip facilitates fragment approximation and diminishes
FIGURE 11. Tip protector splint bivalved to maintain distal the very painful effect of bleeding and swelling at this
interphalangeal joint (DIP) extension and accommodate swelling for level. A thin, protective splint extending to, but not
mallet fractures. including, the PIP joint is worn for 2 to 3 weeks.
closed splinting of the DIP joint in extension for 6 Fibrous union is slow to ossify at this level, requiring
weeks (Figure 11). Bivalving the splint, which is several months26; however, motion can and should be
secured with coban wrap, allows accommodation for reintroduced at the DIP level by reducing the length
any swelling. Splinting is continued at night and of the protective splint and encouraging joint mo-
during vigorous activities for another 2 to 4 weeks. If tion. The more difficult aspect of managing these
extensor lag at the DIP joint is noted, then splinting fractures is the extent of nail bed injury that may be
is resumed during the day also. present and require suturing. Dressing changes that
Fracture fragments that are greater than one third do not disturb the repaired nail bed are performed
of the articular surface can be surgically reattached after soaking the tip of the finger in a sterile
using various wiring techniques. 10,27,28,99,108 container filled with saline and part hydrogen perox-
Damron’s27 analysis of these common fixation meth- ide.19
The finger pulp region is densely innervated with
ods noted that none of the fixation methods provide

enough stability to permit early motion. All joints sensory end organs that painfully respond to the
must be immobilized for a minimum of 6 weeks, as initial crush, nail bed damage, and swelling with the
with conservative methods. Surgical treatment for development of hypersensitivity to touch. Use of a
mallet fractures have been reported to have a 53% TopiGel sleeve, once nail bed healing is complete,
complication rate due to infection, joint incongruity, assists in scar management as well as dampening
nail deformity, and extensor lag; as opposed to a 45% painful sensory input. Desensitization programs that
complication rate for closed treatment.94 Wehbe106 include vibration, putty press, and texture tolerance
suggests that due to these findings most mallet are beneficial to accommodate to normal fingertip
fractures should be treated with conservative closed use.
methods. Occasionally, the fracture pattern shows significant

Following the 6 weeks of continuous immobiliza- displacement of the 2 fracture fragments, requiring
tion in extension, composite flexion and extension of ORIF with K-wire fixation for 3 weeks.2 Protective,
the PIP and DIP joints is taught. Blocked DIP joint supportive splinting, including DIP and PIP joints,
flexion exercises are not performed, as this would initially allows the inflammatory period to resolve.
stretch out the oblique retinacular ligament (ORL). Care must be taken that the splint does not rub
Because the greatest complication of mallet fractures against the exposed pin, as excessive irritation can
is a DIP joint extensor lag, an intact ORL will serve result in a pin tract infection.
to passively assist DIP joint extension as PIP joint
active extension occurs.19 CONCLUSION
P3 Shaft Fracture Unique to hand anatomy, soft tissues glide in

multidirections mere millimeters away from skeletal
Trauma at this level, proximal to the nail bed, structures. It is impossible, then, to consider skeletal
usually causes an open wound that needs to be injury as isolated trauma to bone tissue only. Trauma
supported with external splinting or K-wire and and fracture displacement can harm surrounding soft
splinting for 3 weeks. Wound care, edema measures, tissue structures as well as encase both together in

the healing processes of callus and scar. Successful 9. Belsky MR, Eaton RG, Lane LB. Closed reduction and
rehabilitation of hand fractures addresses the need to internal fixation of proximal phalangeal fractures.
J Hand Surg [Am]. 1984;9:725-729.
maintain fracture stability, introduce soft tissue mobi-
10. Bischoff R, Buechler U, De Roche R, Jupiter J. Clinical
lization, and remodel restrictive scar. results of tension band fixation of avulsion fractures of
A review of the literature found a paucity of studies the hand. J Hand Surg [Am]. 1994;19:1019-1026.
on fracture rehabilitation. Until recently, therapists 11. Black DM, Mann RJ, Constine RM, Daniels AU. The
did not treat fractures; rather, they treated the soft stability of internal fixation in the proximal phalanx.
J Hand Surg [Am]. 1986;11:672-677.
tissue complications secondary to prolonged immobi-
12. Bora FW, Jr., Didizian NH. The treatment of injuries to
lization. These complications have been the impetus the carpometacarpal joint of the little finger. J Bone
for development of early controlled-motion programs Joint Surg [Am]. 1974;56:1459-1463.
during the appropriate phase of fracture healing. 13. Brand PW. Clinical Mechanics of the Hand. St Louis,
With few prospective or controlled studies to guide MO: C.V. Mosby Co; 1985.
us, evidence for best-practice strategies in fracture 14. Breddam M, Hansen TB. Subcapital fractures of the
fourth and fifth metacarpals treated without splinting
rehabilitation is often gleaned from failure experi- and reposition. Scand J Plast Reconstr Surg Hand Surg.
ences. 1995;29:269-270.
The anatomy and biology of bone healing assists in 15. Bryan BK, Kohnke EN. Therapy after skeletal fixation in
directing the position and duration of immobiliza- the hand and wrist. Hand Clin. 1997;13:761-776.
tion, the initiation of motion protocols, and strength- 16. Buch VI. Clinical and functional assessment of the hand
after metacarpophalangeal capsulotomy. Plast Reconstr
ening exercises to meet functional demands. The Surg. 1974;53:452-457.
course and progression of bone healing is directly 17. Burkhalter WE. No man’s land fracture. Fort Lauderdale
CLINICAL
related to the chosen fracture fixation mode. Both Hand Clinic Newsletter. 1991;2-4.
operative and nonoperative methods of fracture man- 18. Butt WD. Fractures of the hand. II. Statistical review.
Can Med Assoc J. 1962;86:775-779.
agement share the common goal of assuring that 19. Cannon NM. Rehabilitation approaches for distal and
fractures heal in correct alignment, while permitting middle phalanx fractures of the hand. J Hand Ther.
early mobility protocols. Lee66 summarized this con- 2003;16:105-116.
cept: ‘‘The outcome of any fracture is influenced by 20. Chamay A. A distally based dorsal and triangular
tendinous flap for direct access to the proximal
the choice of treatment as well as the type and interphalangeal joint. Ann Chir Main. 1988;7:179-183.
COMMENTARY
duration of immobilization.’’ This article describes 21. Chehade MJ, Pohl AP, Pearcy MJ, Nawana N. Clinical
fracture management choices, immobilization posi- implications of stiffness and strength changes in fracture
tions, early motion protocols, and intervention strate- healing. J Bone Joint Surg Br. 1997;79:9-12.
22. Chinchalkar SJ, Gan BS. Management of proximal
gies for potential problems unique to each interphalangeal joint fractures and dislocations. J Hand
metacarpal and phalangeal fracture location in the Ther. 2003;16:117-128.
hand. 23. Claes L, Heitemeyer U, Krischak G, Braun H,
Hierholzer G. Fixation technique influences
osteogenesis of comminuted fractures. Clin Orthop.
1999;221-229.
24. Colditz JC. Functional fracture bracing. In: Hunter JM,
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Principles of Metacarpal and Phalangeal

Fracture Management: A Review of

Journal of Orthopaedic & Sports Physical Therapy 781

approximated, it is termed nondisplaced. A bone that

782 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 783

784 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

can enhance both intrinsic muscle pumping and

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 785

786 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

intrinsic minus position

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 787

Shaft fractures are extra-articular fractures caused

788 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 789

Metacarpal Neck Fracture at that time. The patient is instructed in protected

suspect for infection. collateral ligaments, including a fracture fragment,

790 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

mity maintain length of lateral

outstretched hand. These articular fractures require address edema, desensitiza-

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 791

cise, will facilitate all flexor strength directed towards

792 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 793

tension band wiring.8 A removable protective finger-

FIGURE 10. Dynamic traction splint for comminuted pilon frac-

full extension and is removed for passive ROM

exercises. Pins are removed at 2 to 3 weeks, at which

794 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 795

ods noted that none of the fixation methods provide

methods. Occasionally, the fracture pattern shows significant

P3 Shaft Fracture Unique to hand anatomy, soft tissues glide in

796 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 797

randomized study of three different types of treatment. 1994;19:597-600.

798 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004

J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 799

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