Overview
Functional impairment can follow seemingly minor hand trauma, through secondary sensory loss, motion restriction and weakness. Anatomic and radiographic perfection does not always lead to normal function, and early, accurate detection of soft-tissue injury may call for more specialized and urgent treatment. It is often better to accept a less than anatomic fracture position and strive for good function through proper splinting and early motion. When surgery is needed, choose the least complicated procedure that achieves the desired functional result. With few exceptions, prolonged immobilization (over 3 weeks) is not indicated for hand injuries. Clinical union often precedes radiographic union, so early motion can be encouraged once clinical stability is reached. (Campbell)
Assessment
Rotation. Angulation and lack of apposition are more obvious on radiographs than clinically. Rotation may become obvious only when a composite fist is attempted and shows finger override or deviation. All fingers normally point toward the scaphoid tuberosity when flexed. Observe the plane of the fingernails at the time of reduction or fixation, compare with the opposite hand, and passively flex all fingers fully at the MCP, PIP and DIP joints together to verify rotation. (Campbell)
The small finger normally tends to overlap the ring finger because of rotation allowed at the fifth CMC joint. Proper rotational alignment can be judged only when full composite small finger flexion is possible with the ring finger. (Campbell)
Radiographs. AP, lateral and oblique views are needed to determine fragment positions before and after reduction. Splay lateral views of the digits in varying flexion avoid phalangeal overlap. Oblique views help assess articular reduction. True lateral views of the ring and small finger metacarpals can be obtained with the hand in 10 degrees of supination and the index and middle fingers in 10 degrees of pronation. Occasionally lateral tomograms or sagittal CT are needed. Check for small fragments not seen before reduction, even when reducing under direct vision. Shaft fractures are best evaluated with the bone parallel to the film, and articular fractures with the joint surfaces perpendicular to the beam. (Campbell)
Principles of Treatment (Campbell)
For most metacarpal and phalangeal fractures, closed manipulation, proper splinting and protected motion generally produce good results. Exceptions are fractures where open reduction and internal fixation or closed reduction and percutaneous pinning give superior results.
Perform percutaneous pinning before edema obliterates external landmarks. If needed, elevate for 24 to 48 hours before reduction and pinning. Fixation, especially open, is preferably done before marked swelling, though a 7- to 10-day delay is sometimes warranted.
Rotationally unstable fractures treated closed: taping the injured finger to an uninjured one may help correct or prevent rotational change. The authors prefer not to use gauze or cast padding between fingers and sometimes use the tape as a derotation device.
Dislocations can usually be managed by manipulation and early function, with buddy taping. Always examine for associated ligamentous injury or tendon avulsion.
Instances warranting fixation (Campbell's Concepts)
Displaced fracture involving a significant portion of the articular surface.
Fracture that is part of a major ligamentous or tendinous avulsion.
Fracture so displaced that tendon or other soft-tissue interposition prevents realignment by manipulation.
Multiple fractures such that the hand cannot be held in a position of function without internal fixation.
Open fracture, where fixation allows wound care without loss of reduction.
Severely comminuted closed fractures usually should not be opened if fixation seems futile. Limited percutaneous pinning or external fixation is occasionally indicated.
Open Fractures and Dislocations (Campbell)
Debride and irrigate the wound, then reduce. If an open dislocation self-reduced and contamination is suspected, redislocate and cleanse.
Begin finger motion as soon as soft-tissue healing and fracture or joint stability permit. Fixation should permit wound inspection and dressing changes without loss of alignment.
Severely traumatized hands often have soft-tissue defects, so additional incisions are usually unnecessary to access the fracture. Fix under direct vision or percutaneously. Segmental defects of tubular bones may be held to length by wire spacers or rods while the wound heals.
Use loose skin-edge approximation if primary closure is attempted, because edema over 48 hours will increase tension. Re-evaluate in the OR at 48 hours. The goal is wound closure within the first 4 to 5 days, before granulation tissue forms and contractures develop. Exposed tendons without paratenon or sheath soon necrose without coverage.
The authors no longer routinely culture acute open hand injuries in the ED. Thorough irrigation and debridement is usually adequate. Routine antibiotics for fresh injuries are probably unnecessary, but are justified when essential tissue has borderline viability and contamination persists after debridement.
Basic Fracture Fixation Techniques (Campbell)
Choosing implants. Plating of small tubular bones, especially phalanges, can cause skin sloughs, tendon adherence or rupture and joint contracture. External fixation pins can impinge on tendons or ligaments, and percutaneous pins can damage nerves or tether tendons and ligaments.
Rarely is more fixation needed than that provided by external splinting, Kirschner wires and minifragment screws. Unstable, long oblique or spiral fractures may be best treated with interfragmentary screw fixation alone.
Reduction aids. The same instruments used on soft tissue (straight Kocher clamp, hemostat, towel clip) can provisionally reduce metacarpal or phalangeal shaft fractures before fixation.
K-wire technique. Wires sharpened at both ends allow antegrade and retrograde drilling. A small handheld wire driver helps accurate in-plane placement. A trocar-pointed wire has greater initial holding power than a diamond or diagonally cut wire and engages bone better at acute angles. Let the wire project as short a distance as possible to prevent bending during insertion. Cut wires flat and leave ends protruding or beneath the skin. K-wires can usually be removed under local anesthesia, and a diamond or carbide-tipped needle holder helps grip small wires.
Regardless of method, the bone ends should be in close apposition. Sometimes a second wire is needed to control rotation. Before definitive rotational control, fully flex the finger at the MCP, PIP and DIP joints and compare it with adjacent uninjured fingers.
Setting and anesthesia
Outpatient surgery centers are usually selected when wounds are grossly contaminated or fractures need implants beyond K-wires. Young children and patients with medical conditions requiring cardiovascular monitoring should be treated at a surgical center.
WALANT (wide-awake local anesthesia, no tourniquet): can be used in the office for less complex fractures treated with K-wires. Patients with Raynaud or Berger disease and others intolerant of epinephrine may not be candidates. Technique: a 30-gauge needle to infiltrate in tumescent fashion the operative region, including subperiosteal regions of the fractures. Fill a 10-mL syringe with 10 mL of 1% lidocaine with 1:100,000 epinephrine and add 1 mL of 8.4% sodium bicarbonate (1:10), which normalizes the lidocaine pH of 4.2 and reduces burning. Less complicated procedures need 10 to 20 mL. Up to 50 mL is permissible in an average 70-kg man, assuming a maximum lidocaine dose of 7 mg/kg. (Campbell)
Postoperative Care
Begin motion as soon as stability permits, avoid immobilization longer than 3 weeks, and use splints and buddy taping to protect healing while maintaining motion. (Campbell)
Complications
Malunion, especially malrotation, which must be corrected because it causes finger override or deviation. (Campbell)
Nonunion and joint contracture or stiffness, which the chapter treats under "complications of hand fractures". (Campbell)
Skin sloughs, tendon adherence or rupture with plating of small bones; pin-related tendon, ligament or nerve injury. (Campbell)
References
Calandruccio JH. Fractures, dislocations and ligamentous injuries of the hand and wrist. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 72, Principles of treatment and basic fracture techniques.