Hand Fractures and Dislocations
Fractures and dislocations of the bones and joints of the hand are common - the hand being the most frequently injured part of the body. Photos and x-rays of some cases are presented here. Fractures of the distal radius and scaphoid are discussed elsewhere.
The great variety of fractures and dislocations of the hand means that it is difficult to generalise about this topic. Each injury requires careful assessment and treatment, and this is almost always carried out with the help of a hand therapist, whether or not surgery is required.
One of the reasons that metacarpal fractures can need surgery is if the fracture has led to rotation of the bone. This X-ray shows a spiral fracture of the fifth metacarpal shaft, which is causing scissoring of the fingers when the patient tries to make a fist, as shown in the first video. This has been corrected by the operation that has been carried out, with three screws holding the metacarpal in the correct position, as shown in the second video.
An operation was carried out to correct the rotation of the bone and stabilize the fracture with three screws. 3 months later the bone had fully healed, and the patient had recovered a full range of motion of the fingers without any scissoring.
Scissoring of the little and ring fingers pre-operatively
Full finger flexion post-operatively without scissoring of the little finger
It is important nevertheless to be aware of the following points:
- An injury to the skeleton of the hand is always accompanied by an injury to the surrounding soft tissues, which must not be underestimated. It is often the soft tissue component of the injury and subsequent swelling that lead to the commonest complication of hand fractures, that of stiffness. It is for this reason that movement of the fingers under the supervision of a hand therapist is important. Mr. Gidwani and his hand therapy colleagues will advise you on the appropriate exercises, and at what point they should be started. This varies depending on the stability of the fracture/dislocation and the treatment that is being used.
- Fractures that are associated with overlying lacerations are known as open fractures, and their treatment should be undertaken as an emergency because of the risk of infection. This is most likely to be accomplished on an urgent basis through one of London's NHS regional hand trauma units, such as the one Mr. Gidwani is a part of at St. Thomas' Hospital. Other London hospitals with hand trauma units are St. George's Hospital in Tooting, Chelsea and Westminster Hospital, and the Royal Free in Hampstead. Large hand surgery units also exist at the Queen Victoria Hospital in East Grinstead, and Broomfield Hospital in Chelmsford.
- Dislocations require that the joint is manipulated and "reduced" back to the appropriate position urgently, and again acute treatment for dislocations should be sought at a minor injuries or accident and emergency department. Once the dislocation has been reduced and splinted in a cast, the patient will need on-going treatment under the supervision of a hand surgery specialist.
- The majority of closed hand fractures, particularly those that are undisplaced or minimally displaced, can be treated without surgery. A combination of immobilisation in a cast or more often a made-to-measure splint, elevation in a sling, and hand therapy will usually allow a return to full function over a period of a few months. Typically these fractures take 8 to 12 weeks to heal fully. There are specific situations however where surgery is required, and if this is the case Mr. Gidwani will explain the reasons for this, and the potential risks of surgery. Depending on the fracture or dislocation, Mr. Gidwani will use simple manipulation and splintage techniques, wiring, external wire frames, fixation with screws alone, or fixation with plates and screws. Regular hand therapy sessions are even more important after surgery for hand fractures.
- Seemingly innocuous injuries to the small joints of the fingers can, if not properly treated, lead to significant problems. The best example of this are neglected volar plate injuries of the proximal interphalangeal joints of the fingers. In this injury a thick ligament is sprained or sometimes avulsed, but the finger does not actually dislocate. Pain and swelling ensue and if not appropriately splinted the finger can develop a fixed flexion deformity of that joint - in other words, the finger becomes impossible to straighten. Any hand or finger injury therefore that causes significant pain or swelling, merits assessment by a qualified hand surgeon.