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Finger Fractures

Phalangeal and metacarpal fractures of the hand — non-operative care and indications for fixation.

Overview

Open finger fractures present a significant surgical burden, with approximately one-quarter requiring more than one procedure [1]. Reoperation is more likely in severely injured digits due to crush injury or vascular impairment [1], and injuries to the thumb and index finger are particularly prone to unplanned reoperation compared to other fingers [4]. In contrast, the majority of metacarpal fractures are simple, closed, and stable, achieving excellent outcomes without surgery [3, 6, 9]. These metacarpal injuries are common but have a minimal effect on patient well-being and are mostly managed nonoperatively [9].

Pediatric hand fractures generally follow a different trajectory; most are treated nonoperatively with good results [2]. However, a subset of pediatric phalangeal fractures requires prompt recognition and surgical intervention to minimize complications [2]. Specific techniques for complex injuries show promise, such as percutaneous compressive bone tie for intraarticular proximal phalangeal fractures of the thumb, which yielded full range of movement within 3 weeks with no complications or need for implant removal [10]. Similarly, retrograde intramedullary screw fixation (RIS) in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications [29], though more high-quality studies are needed to fully examine this modality [29].

Management strategies vary by fracture type and patient age. For displaced extra-articular phalangeal finger fractures in children, buddy taping is recommended irrespective of the degree of displacement or the need for reduction [17]. Excellent outcomes are also achieved following open reduction and internal fixation (ORIF) of proximal phalangeal fractures [13]. Regarding follow-up, radiographs are not indicated for most fifth metacarpal base and neck fractures [11].

Anatomy & Pathophysiology

Hand and finger fractures represent the second most common fracture presenting to emergency departments in the pediatric population, exhibiting a bimodal age distribution with peaks at 0 to 2 years and 12 to 16 years of age [8]. Etiology: Toddlers and preschool-age children typically sustain crush injuries at home, whereas adolescents most often sustain injuries outside the home during sporting activities [8]. Common Locations: The base of the proximal phalanx of the border rays is the most frequently injured site (67%), specifically involving the little finger (52.2%) and thumb (23.5%) [8].

Phalangeal Neck and Condyle Fractures: These injuries often present similarly to a simple "jammed" finger but frequently require surgical intervention [8]. Salter-Harris II Fractures: These are extremely common, with the little finger proximal phalanx (the "extra octave fracture") being the most frequently injured [8]. They typically result from jamming or hyperextension injuries causing an abduction deformity [8]. Rotational Deformity: This is less obvious on radiographs than coronal plane deformity in Salter-Harris II fractures [8]. Because malrotation does not remodel, it can result in problems with grip formation [8]. Treatment: Displaced phalangeal neck fractures require reduction and pin fixation, while condyle fractures can often be treated with closed reduction and pinning [8]. Open procedures for these fractures increase the risk for osteonecrosis [8].

Seymour Fractures: Defined as a Salter-Harris I/II or juxtaphyseal fracture of the distal phalanx with interposed nail bed at the fracture site, these are open fractures that are often missed [8]. Missed Seymour fractures carry a high rate of complications, including infection and nail or physeal growth disturbance [8]. Diagnosis: The key is the disruption of the nail plate/cuticle, indicating disruption of the nail bed and likelihood of an open fracture with interposed tissue [8]. Management: Treatment involves removal of the nail plate, débridement of the fracture site, extrication of the interposed nail bed, and reduction of the fracture [8]. Unstable fractures may require Kirschner wire placement in addition to immobilization in a splint or cast [8]. Antibiotic Prophylaxis: As open fractures, antibiotics are necessary, with a recommended regimen of IV antibiotic in the emergency department followed by a 7- to 10-day course of oral antibiotic [8]. A first-generation cephalosporin is the preferred antibiotic [8].

General Management and Biomechanics: Injuries to the thumb and index finger are more likely to undergo unplanned reoperation [4]. Treatment of metacarpal and phalangeal fractures must be individualized based on fracture pattern, displacement, and soft tissue status [14]. Early controlled passive mobilization after a closed, potentially unstable, diaphyseal hand fracture warrants further clinical consideration for improving early fracture alignment and structural properties [26]. Fixation Considerations: A closer distance between the plate edge and joint line is associated with a more limited range of finger motion in unstable metacarpal and phalangeal fractures treated with a locking plate system [30]. Biomechanical stability during simulated active motion did not differ in simulated proximal phalanx fractures treated with 2 lag screws or 3 [36]. All percutaneous fixation techniques were equivalent in their ability to resist axial loading, regardless of the complexity of technique, the number of pins used, or finger that was pinned [38]. The tested metacarpal fracture model had equivalent biomechanical properties when fixed with a standard dorsal plate and either six bicortical nonlocking screws or four bicortical locking screws [44]. The shorter, thinner 3-dimensional metacarpal plates demonstrated increased resistance to failure in a cyclic loading model and increased load to failure compared with the relatively longer, thicker 2-dimensional metacarpal plates [47]. Retrograde metacarpal screw fixation produces a focal cartilage defect on the metacarpal head that tracks across the entire proximal phalanx articular surface during MCP joint motion [48]. There was no significant biomechanical difference found between four different fixation techniques with regard to both displacement and ultimate failure strength of constructs for oblique metacarpal fractures [51]. Bicortical screws in metacarpal fracture plating under cyclic loading offer a biomechanical advantage, with significantly higher load to failure and less plastic deformation compared to unicortical fixation [53]. Surgical Approach: The terminology in the discussion of hand fracture management with the approach of traction application should include the term 'tendinotaxis' in describing the neutralization of deforming forces to restore anatomic bony alignment [50]. Metacarpal head entry point and cascade angle can help identify the appropriate reduction with the guide pin starting point in the dorsal 25% to 35% of the metacarpal head [52]. With restoration of articular alignment and meticulous soft tissue dissection, bony healing and functional interphalangeal joint motion can be achieved in most patients with pediatric unicondylar phalangeal fractures regardless of the timing of intervention [54].

Classification

Gustilo–Anderson: Open finger fractures demonstrate significant complexity, with one-quarter requiring more than one surgical procedure [1]. Reoperation is especially likely in fingers with severe crush or vascular impairment [1].

Pediatric Phalangeal: Phalangeal fractures represent the most common hand fractures in children, with Salter-Harris type II fractures of the proximal phalanx being the most frequent subtype [55]. While most pediatric hand fractures are treated nonoperatively with good results [2], a subset requires prompt recognition and surgical intervention to minimize complications [2]. For displaced extra-articular phalangeal finger fractures in children, buddy taping after reduction is recommended irrespective of the degree of displacement or the need for reduction [17].

Metacarpal: The majority of metacarpal fractures are simple, closed, and stable, often achieving excellent outcomes without surgery [3]. Consequently, the majority are managed nonoperatively [6]. There appears to be very little role for surgery in the management of closed spiral metacarpal fractures [20], though intramedullary fixation may have a role in treating certain metacarpal fractures [32]. Optimal management strategies for athletes with metacarpal and phalangeal fractures remain equivocal [19].

Other Considerations: Treatment for metacarpal and phalangeal fractures must be individualized based on fracture pattern, displacement, and soft tissue status [14]. Hand therapy management pathways for metacarpal fractures account for the location of the fracture, stability, and surgical or non-surgical management [15]. Phalangeal fractures tend to deteriorate in percentage total active motion (%TAM) more than metacarpal fractures [16]. The definition of metacarpal nonunion remains highly variable and lacks standardization with respect to clinical and radiographic criteria [46]. The interrater reliability of the Kellgren & Lawrence and OARSI classification systems for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed [43].

Clinical Presentation

Hand and finger fractures represent the second most common fracture presenting to emergency departments in the pediatric population [8]. The incidence follows a bimodal age distribution with peaks at 0 to 2 years and 12 to 16 years of age [8]. Etiology correlates with age: toddlers and preschool children typically sustain crush injuries at home, whereas adolescents most often sustain injuries outside the home during sporting activities [8]. The most frequently injured locations are the base of the proximal phalanx (67%) of the border rays, specifically the little finger (52.2%) and thumb (23.5%) [8]. Salter-Harris II fractures are extremely common, with the little finger proximal phalanx (the "extra octave fracture") being the most frequently injured site [8].

History of a jamming or hyperextension injury often presents with a swollen, painful proximal interphalangeal (PIP) joint, typically involving a volar plate injury or a small nondisplaced avulsion fracture off the volar base of the middle finger epiphysis [8]. Salter-Harris II fractures from this mechanism frequently result in an abduction deformity [8]. Phalangeal neck and condyle fractures share this "jammed" finger presentation but often necessitate surgical intervention [8]. Displaced phalangeal neck fractures require reduction and pin fixation, usually achievable via closed fashion [8]. Open procedures for condyle fractures increase the risk for osteonecrosis [8].

Inspection must identify disruption of the nail plate or cuticle to diagnose Seymour fractures, which are Salter-Harris I/II or juxtaphyseal fractures of the distal phalanx with interposed nail bed at the fracture site [8]. Missed Seymour fractures carry a high rate of complications including infection and nail or physeal growth disturbance [8]. Treatment involves removal of the nail plate, débridement of the fracture site, extrication of the interposed nail bed, and reduction of the fracture [8]. Unstable Seymour fractures may require Kirschner wire placement in addition to immobilization [8]. Antibiotics are necessary, with a recommended dose of IV antibiotic in the emergency department followed by a 7- to 10-day course of oral antibiotic [8]. A first-generation cephalosporin is the preferred antibiotic for Seymour fractures [8].

Malrotation in pediatric finger fractures does not remodel and can result in problems with grip formation [8]. Most pediatric hand fractures are treated nonoperatively with good results, though a subset of phalangeal fractures requires prompt recognition and surgical intervention [2]. In a retrospective review of 105 patients treated with closed reduction pin fixation for displaced proximal phalanx fractures, the average age was 11 years [8]. The majority of displaced proximal phalanx fractures requiring surgical treatment involved the physis, followed by phalangeal neck and then shaft fractures [8]. The complication rate for displaced proximal phalanx fractures treated with closed reduction pin fixation was 4.8%, including infection, pin site complications, and malunion [8]. Thirty-six of 105 patients treated for displaced proximal phalanx fractures had postoperative stiffness, with 31 requiring therapy [8]. Phalangeal neck fractures had the highest rate of postoperative stiffness among displaced proximal phalanx fractures [8].

The majority of metacarpal fractures are simple, closed, and stable, often achieving excellent outcomes without surgery [3]. Most metacarpal fractures are managed nonoperatively [6]. Metacarpal fractures are common and mostly treated nonsurgically, having a minimal effect on patient well-being [9]. The estimated incidence of metacarpal fractures presenting for acute hospital care in the USA is 13.6 per 100,000 person-years [22]. Follow-up radiographs are not indicated for most fifth metacarpal base and neck fractures [11]. Isolated fifth metacarpal fractures can be managed definitively in the emergency department without further face-to-face review, with good patient satisfaction and acceptable functional results [24]. Complications following intramedullary screw fixation for metacarpal fractures are relatively uncommon [28].

Open finger fractures require careful assessment as a quarter require more than one surgical procedure, particularly in severely injured fingers due to crush or vascular impairment [1]. Injuries to the thumb and index finger are more likely to undergo unplanned reoperation compared to other digits [4]. Complications of distal phalanx fractures in children are frequent [27]. The phalangeal fractures tend to deteriorate in percentage total active motion (%TAM) more than metacarpal fractures [16]. Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend [23]. Optimal management strategies for athletes with metacarpal and phalangeal fractures remain equivocal [19].

Investigations

Plain radiography: Clinical evaluation of hand and finger fractures requires radiographs including PA, lateral, and oblique views of the injured location [8]. In pediatric populations, hand and finger fractures are the second most common fracture presenting to emergency departments, with a bimodal age distribution peaking at 0 to 2 years and 12 to 16 years of age [8]. In toddlers and preschool children, injuries typically occur at home as crush injuries, whereas adolescents most often sustain injuries outside the home during sporting activities [8]. The most commonly injured locations are the base of the proximal phalanx (67%) of the border rays, specifically the little finger (52.2%) and thumb (23.5%) [8].

Plain radiography: Specific fracture patterns require distinct radiographic assessment. Salter-Harris II fractures of the digits are extremely common, with the little finger proximal phalanx (extra octave fracture) being the most frequently injured [8]. These injuries result from jamming or hyperextension causing an abduction deformity; while coronal plane deformity is easily assessed, extra care must be taken to identify rotational deformity, which is not obvious on radiographs [8]. Malrotation does not remodel and can result in problems with grip formation [8]. Seymour fractures present as a displaced fracture of the distal phalanx on radiographs but are often missed [8]. The key to diagnosing Seymour fractures is identifying disruption of the nail plate/cuticle, indicating disruption of the nail bed and likelihood of an open fracture with interposed tissue [8]. Phalangeal neck and condyle fractures have a similar presentation to a simple "jammed" finger and are often missed [8].

Plain radiography: For displaced phalangeal neck fractures, radiographs guide the need for reduction and pin fixation, which can usually be achieved through a closed fashion [8]. Condyle fractures can often be treated with closed reduction and pinning, though open procedures increase a risk for osteonecrosis [8]. In a retrospective review of 105 patients treated with closed reduction pin fixation for displaced proximal phalanx fractures, the average age was 11 years [8]. In this review, the majority of fractures involved the physis followed by phalangeal neck and then shaft fractures [8]. The complication rate for closed reduction pin fixation of displaced proximal phalanx fractures was 4.8%, including infection, pin site complication, and malunion [8]. Thirty-six of 105 patients had postoperative stiffness, with 31 requiring therapy [8]. Phalangeal neck fractures had the highest rate of postoperative stiffness [8]. In follow-up of 31 patients at 1 year or greater, all reported return of full motion, no pain, and happiness with function and appearance despite 22% having a measurable coronal plane deformity on radiograph [8].

Plain radiography: Follow-up radiographs are not indicated for most fifth metacarpal base and neck fractures [11]. Intra-operative fluoroscopic imaging provides an accurate assessment of articular step-off and displacement in comparison with radiographs and direct visualization for intra-articular thumb metacarpal fractures [25]. When evaluating post-traumatic ulnar-sided hand pain, if the 2-5 intermetacarpal angle (IMA) or the 3-5 IMA is greater than 10 degrees, advanced imaging should be considered [64]. Delayed diagnosis of carpometacarpal fracture-dislocations makes closed reduction difficult and is associated with less favorable radiographic outcomes [58].

Ultrasonography: Ultrasonography may provide greater accuracy in fracture diagnostics by revealing small avulsed bony fragments missed on radiographs and can be beneficial in diagnosing occult fractures, especially in children [62].

CT: Careful evaluation of intraoperative and postoperative imaging, particularly CT, is important to detect rare persistent palmar trapezoid dislocations that may be missed on standard radiographs [56].

Other Considerations: A quarter of open finger fractures require more than one surgical procedure, particularly in severely injured fingers due to crush or vascular impairment [1]. Most pediatric hand fractures are treated nonoperatively with good results, though a subset of phalangeal fractures requires prompt recognition and surgical intervention to minimize complications [2]. Detailed information on various types of finger fractures is available from the Swedish Fracture Register for use as a clinical reference [5]. The majority of metacarpal fractures are managed nonoperatively [6]. An evidence-based pathway for metacarpal fractures resulted in 92% of patients returning to full function without complications at 10 weeks following injury [7]. The majority of pediatric hand and finger fractures can be treated with closed reduction, appropriate immobilization, and early motion [8]. Appropriate evaluation includes clinical examination and radiographs [8]. Clinical examination must assess for open injuries and angular and rotational malalignment of the injured ray [8]. Rotational alignment is confirmed by ensuring that all fingers point to the scaphoid tubercle when the fingers are flexed [8]. Phalangeal neck and condyle fractures and Seymour fractures require special attention and some surgical intervention [8]. These injuries usually occur because of a jamming or hyperextension injury to the finger resulting in an abduction deformity [8]. A classic "jammed" finger with a swollen, painful PIP joint usually involves a volar plate injury or a small nondisplaced avulsion fracture off the volar base of the middle finger epiphysis [8]. Simple "jammed" finger injuries do not require surgical intervention and should be splinted in approximately 30° of flexion for a week followed by 3 weeks of buddy tape [8]. Prolonged immobilization of simple "jammed" finger injuries can result in significant joint stiffness [8]. Phalangeal neck and condyle fractures usually require surgery, making early diagnosis essential [8]. In the review of displaced proximal phalanx fractures, the majority of fractures involved the physis followed by phalangeal neck and then shaft fractures [8]. Postoperative finger stiffness occurred in 43% of unstable proximal phalangeal fractures treated with titanium plates and/or screws [12]. Phalangeal fractures tend to deteriorate in percentage of total active motion (%TAM) more than metacarpal fractures [16]. Complications following intramedullary screw (IMS) fixation of metacarpal fractures are relatively uncommon [28]. Cellular bone matrix (CBM) shows excellent radiographic outcomes for metacarpal defects [57]. Radiological fracture union occurred in all patients treated with extended indications for retrograde intramedullary cannulated headless screws for proximal phalanx fractures at a mean of 5 weeks [59]. Metacarpal fractures are common, mostly treated nonsurgically, and have a minimal effect on patient well-being [9]. Seymour fractures are a Salter-Harris I/II or juxtaphyseal fracture of the distal phalanx with interposed nail bed at the fracture site [8]. Seymour fractures are open fractures but are often missed [8]. Missed Seymour fractures have a high rate of complications including infection and nail or physeal growth disturbance [8]. Treatment for Seymour fractures involves removal of the nail plate with débridement of the fracture site, extrication of the interposed nail bed, and reduction of the fracture [8]. If a Seymour fracture is unstable, it may require Kirschner wire placement in addition to immobilization in splint/cast [8]. Antibiotics are necessary for Seymour fractures to prevent infection as these are open fractures [8]. Recommended treatment for Seymour fractures includes a dose of IV antibiotic in the emergency department followed by a 7- to 10-day course of oral antibiotic [8]. A first-generation cephalosporin is the preferred antibiotic for Seymour fractures [8].

Treatment

Non-Operative

The majority of metacarpal fractures are simple, closed, and stable, often achieving excellent outcomes without surgery [3], and are managed nonoperatively [6]. These fractures are common, mostly treated nonsurgically, and have a minimal effect on patient well-being [9]. There appears to be very little role for surgery in the management of closed spiral metacarpal fractures [20]. Isolated fifth metacarpal fractures can be managed definitively in the emergency department without further face-to-face review, with good patient satisfaction and acceptable functional results [24]. Follow-up radiographs are not indicated for most fifth metacarpal base and neck fractures [11]. An evidence-based patient pathway for metacarpal fractures resulted in 92% of patients returning to full function without complications at 10 weeks following injury [7].

For pediatric hand fractures, most are treated nonoperatively with good results [2]. Buddy taping is a non-inferior treatment modality for most pediatric finger fractures compared to splint immobilization [42]. Taping finger fractures in children can be recommended irrespective of the degree of displacement or the need for reduction [17]. A non-surgical, conservative protocol can be used for patients with isolated proximal phalangeal fractures without uncorrectable finger rotation or fracture angulation exceeding 25 degrees in the sagittal plane or 10 degrees in the coronal plane following closed reduction [34].

Operative

Indications: Reoperation for open finger fractures is more likely in severely injured fingers, particularly those with crush injury or vascular impairment [1]. Injuries to the thumb and index finger are more likely to undergo unplanned reoperation compared to other fingers [4]. Approximately 25% of open finger fractures require more than one surgical procedure [1]. A subset of pediatric phalangeal fractures requires prompt recognition and surgical intervention to minimize complications [2].

Surgical Approach / Technique: Accurate reduction and rigid fixation allowing active use of the hand were achieved in all patients treated with manipulation and external fixation for metacarpal fractures [21]. Intra-operative fluoroscopic imaging provides an accurate assessment of articular step-off and displacement in comparison with radiographs and direct visualization, making it an adequate tool for use in the treatment of fractures of the hand [25]. Open reduction and interfragmentary screw fixation is an effective treatment modality for symptomatic non-union of distal phalangeal fractures with minimal morbidity, resulting in union and normal function in all patients [41]. Percutaneous compressive bone tie was used to treat two intraarticular proximal phalangeal fractures of the thumb with satisfactory outcomes, including full range of movements within 3 weeks, no complications, and no need for implant removal [10].

Implant Selection: Postoperative finger stiffness occurred in 43% of unstable proximal phalangeal fractures treated with titanium plates and/or screws [12]. Patients may be counseled about the higher risk of implant removal when periarticular metacarpal plating is performed [31]. Intramedullary screw fixation is a viable option in the treatment of extra-articular middle phalangeal fractures [61]. Intramedullary fixation may have a role in the treatment of certain metacarpal fractures [32]. Premeasured intramedullary nails offer a method for the minimally invasive treatment of unstable metacarpal fractures [35].

Other Considerations: Hand therapy management of metacarpal fractures accounts for the location of the fracture, stability, and surgical or non-surgical management based on best available evidence [15]. The use of a bivalve finger fracture orthosis demonstrated an alternative approach to surgical treatment for PIP fracture dislocation injuries, proving successful in reducing challenges associated with the injury [60].

Complications

Stiffness / Arthrofibrosis: Postoperative stiffness is a frequent complication across various finger and metacarpal fracture treatments. Phalangeal neck fractures exhibit the highest rate of stiffness following closed reduction pin fixation [8], while 34% of patients treated with this method for displaced proximal phalanx fractures experienced stiffness [8]. Unstable proximal phalangeal fractures treated with titanium plates and/or screws resulted in stiffness in 43% of cases [12]. Prolonged immobilization of simple "jammed" finger injuries can also lead to significant joint stiffness [8]. In pediatric populations, malrotation in phalangeal fractures does not remodel and may cause grip formation problems [8].

Infection (PJI): Common preoperative comorbidities, specifically smoking status and diabetes mellitus, increase the likelihood of postoperative surgical site infection in patients treated for hand or finger fractures and/or dislocations [69]. However, prophylactic antibiotics fail to show any effect on the rate of superficial infections following open distal phalanx fractures [70]. When comparing wire, plate, and intramedullary nail fixation for open metacarpal and phalangeal fractures, there was no difference in infection rates or reoperation for infection [76]. Missed Seymour fractures carry a high rate of complications including infection [8].

Wound complications: Approximately 25% of open finger fractures require more than one surgical procedure [1]. Reoperation for open finger fractures is more likely in severely injured fingers, particularly those with crush injury or vascular impairment [1]. Unplanned reoperation is more likely for injuries sustained in the thumb and index finger [4].

Other Considerations: The majority of metacarpal fractures are simple, closed, and stable, often achieving excellent outcomes without surgery [3]. Most pediatric hand fractures are treated nonoperatively with good results, though a subset of phalangeal fractures requires surgical intervention to minimize complications [2]. Excellent outcomes were achieved following open reduction and internal fixation (ORIF) of proximal phalangeal fractures [13]. Percutaneous compressive bone tie for condylar phalangeal fractures resulted in no complications in the reported cases [10]. Percutaneous elastic intramedullary nailing of metacarpal fractures resulted in good hand function with few complications [18]. Retrograde intramedullary screw (RIS) fixation for metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications [29]. Intramedullary screw fixation of metacarpal fractures has a low incidence of complications (2.5%) [73]. After a minimum of 1 year of follow-up, none of the tuft nonunions required revision surgery [75]. Nonunion, malunion, and infection rates for phalangeal fractures in severely injured hands were similar to other studies [77].

Regarding metacarpal fixation specifically, the unplanned early reoperation rate after operative fixation of acute metacarpal fractures is 8.0% [68]. The majority of these early reoperations involve removal of symptomatic hardware [68], with an average time to early reoperation of approximately 2.1 months [68]. Patients may be counseled about a higher risk of implant removal when periarticular metacarpal plating is performed [31]. Incidences of loss of reduction, penetration to the metacarpal-phalangeal joint, and secondary surgeries for hardware removal were much higher in the intramedullary nailing group compared to plate-screw fixation for extra-articular metacarpal fractures [74]. A secondary metacarpal fracture in a patient with a previous little metacarpal fracture is more likely to occur at the original fracture site in patients with a previous shaft fracture than in those with a neck fracture [67]. The complication rate for displaced proximal phalanx fractures treated with closed reduction pin fixation is 4.8% [8].

Recovery

Light activity (weeks): Patients with simple, closed, and stable metacarpal fractures often achieve excellent outcomes without surgical intervention, allowing for early functional recovery [3]. In fifth metacarpal fracture cases, splinting the hand in a functional position for ten days followed by mobilization and early use facilitates an early return to active duty with a fully functional hand [39]. For displaced metacarpal shaft fractures, surgical treatment permits an immediate return to play as tolerated in in-season football players [49].

Full activity (months): Evidence-based patient pathways for metacarpal fractures demonstrate that 92% of patients return to full function without complications at 10 weeks post-injury [7]. NBA players sustaining metacarpal fractures can reasonably expect to return to their preinjury performance levels following appropriate treatment [63], while Major League Baseball players can expect similar returns following both nonoperative and operative treatment [66]. Involvement of lesser digit metacarpals and operative intervention for thumb metacarpal fractures are the only variables that reduce return-to-play time in National Football League players [37].

Complete recovery / outcome plateau (months): Commencing active finger exercise early following proximal phalanx fracture surgical fixation is associated with greater total active range of motion at 6 weeks post-operatively compared to delayed exercise [33]. Dual antegrade intramedullary headless screw fixation of proximal phalanx fractures results in excellent postoperative motion, near-normal grip strength, positive self-reported patient outcomes, and no complications at 1-year follow-up [72]. Excellent outcomes serve as a benchmark for recovery following open reduction and internal fixation (ORIF) of proximal phalangeal fractures [13]. Hemi-hamate arthroplasty restores proximal interphalangeal (PIP) function in chronic injuries, albeit with more modest outcome performance [71].

Rehabilitation protocol: Percutaneous elastic intramedullary nailing of metacarpal fractures yields good hand function with few complications [18]. Early controlled passive mobilization after a closed, potentially unstable, diaphyseal hand fracture warrants further clinical consideration for improving early fracture alignment and structural properties [26]. A closer distance between the plate edge and the joint line in locking plate fixation is associated with a more limited range of finger motion [30].

Functional milestones: The inclusion of disability outcome measures in hand trauma evaluation may facilitate more individualized, activity-of-daily-living–oriented treatment regimens for severe injuries with multiple phalangeal fractures [40].

Other Considerations: Approximately 25% of open finger fractures require more than one surgical procedure, particularly in cases of severe injury, crush mechanism, or vascular impairment [1]. Injuries to the thumb and index finger are more likely to undergo unplanned reoperation compared to other digits [4]. Patients who miss a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who attend [23]. There is a lack of agreement in the literature regarding criteria for rehabilitation and returning to sport after surgical repair of metacarpal fractures [65].

Key Evidence

  • [L3] A quarter of open finger fractures will likely need more than one surgical procedure, especially in more severely injured fingers, due to crush or with vascular impairment. (10.1177/15589447211043191)
  • [L5] Most pediatric hand fractures are treated nonoperatively with good results, but a subset of phalangeal fractures requires prompt recognition and surgical intervention to minimize complications. (10.1097/01.blo.0000205890.88952.97)
  • [L5] The majority of metacarpal fractures are simple, closed, and stable, often achieving excellent outcomes without surgery. (10.1007/s11552-013-9562-1)
  • [L3] Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up. (10.1177/15589447221109635)
  • [L3] This study presents detailed information about the various types of finger fractures which can be used as point of reference in clinical work and for future studies. (10.1371/journal.pone.0288506)
  • [L5] The majority of metacarpal fractures are managed nonoperatively. (10.1177/17531934231184119)
  • [L4] The metacarpal fracture evidence-based pathway was successful with 92% of patients returning to full function without complications at 10 weeks following injury. (10.1258/ht.2010.010026)
  • [L2] Metacarpal fractures are common and mostly treated nonsurgically and have a minimal effect on patient well-being. (10.1016/j.jhsg.2025.02.015)
  • [L4] The technique was used to treat two intraarticular proximal phalangeal fractures of the thumb with satisfactory outcomes, including full range of movements within 3 weeks, no complications, and no need for implant removal. (10.1177/1753193415615032)
  • [L4] Follow-up radiographs are not indicated for most fifth metacarpal base and neck fractures. (10.1177/1558944717733278)
  • [L2] Postoperative finger stiffness occurred in 43% of fractures. (10.1016/j.jhsa.2014.06.107)
  • [L3] Excellent outcomes were achieved, providing a benchmark for recovery after ORIF of proximal phalangeal fractures. (10.1177/1753193416670591)
  • [L4] The hand therapy management of metacarpal fracture pathway accounts for the location of the fracture, stability and surgical or non-surgical management based on best available evidence. (10.1258/ht.2010.010018)
  • [L2] The phalangeal fractures tend to deteriorate %TAM than metacarpal fractures. (10.1016/s0363-5023(11)60047-6)
  • [L1] With the current data, we can conclude that taping these finger fractures can be recommended irrespective of the degree of displacement or the need for reduction. (10.1177/17531934241293338)
  • [L4] The general outcome was good hand function with few complications. (10.1186/1749-799x-6-37)
  • [L4] Optimal management strategies for athletes with metacarpal and phalangeal fractures remain equivocal. (10.1177/2325967120980013)
  • [L4] There appears to be very little role for surgery in the management of closed spiral metacarpal fractures. (10.1177/1753193414540408)
  • [L4] Accurate reduction and rigid fixation that allowed active use of the hand was achieved in all patients. (10.2106/00004623-198264050-00027)
  • [L3] The estimated incidence of metacarpal fractures presenting for acute hospital care in the USA is 13.6 per 100,000 person-years. (10.1007/s11552-012-9442-0)
  • [L4] Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend. (10.1016/j.jhsa.2011.08.003)
  • [L4] Isolated fifth metacarpal fractures can be managed definitively in the ED without further face to face review, with good patient satisfaction and acceptable functional results. (10.1007/s11552-015-9749-8)
  • [L5] Intra-operative fluoroscopic imaging provides an accurate assessment of articular step-off and displacement in comparison with radiographs and direct visualization, making it an adequate tool for use in the treatment of fractures of the hand. (10.1177/1753193412468565)
  • [L5] Therefore, early controlled passive mobilization after a closed, potentially unstable, diaphyseal hand fracture warrants further clinical consideration. (10.1016/j.jhsa.2006.11.004)
  • [L4] Complications of distal phalanx fractures in children are frequent. (10.1016/j.jhsa.2017.03.042)
  • [L4] Complications following IMS fixation of metacarpal fractures are relatively uncommon. (10.1016/j.jhsa.2023.01.012)
  • [L2] RIS use in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications, although more high-quality studies are needed to fully examine this modality. (10.1177/1558944720988073)
  • [L2] Closer distance between the plate edge and joint line is associated with a more limited range of finger motion, and clinical outcomes approached an acceptable level at final follow-up. (10.1177/1753193419899332)
  • [L4] Patients may be counseled about the higher risk of implant removal when periarticular metacarpal plating is performed. (10.1016/j.jhsa.2022.01.026)
  • [L1] IM fixation may have a role in the treatment of certain metacarpal fractures. (10.1007/s11552-013-9531-8)
  • [L4] Patients who commence active finger exercise early following proximal phalanx fracture surgical fixation may achieve greater total active ROM at 6 weeks post-operatively than if active exercise is delayed. (10.1177/1758998316679386)
  • [L4] A non-surgical, conservative protocol can be used for patients with isolated proximal phalangeal fractures without uncorrectable finger rotation or fracture angulation exceeding 25 degrees in the sagittal plane or 10 degrees in the coronal plane following closed reduction. (10.1177/1753193419881086)
  • [L4] The presented technique proposes both novel instrumentation and a method for the minimally invasive treatment of unstable metacarpal fractures. (10.1016/j.jhsg.2020.04.009)
  • [L5] Biomechanical stability during simulated active motion protocol did not differ in simulated proximal phalanx fractures treated with 2 lag screws or 3. (10.1016/j.jhsa.2015.02.012)
  • [L4] The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. (10.1016/j.jhsa.2022.01.011)
  • [L5] All of the techniques were equivalent in their ability to resist axial loading, regardless of the complexity of technique, the number of pins used, or finger that was pinned. (10.1177/15589447211017224)
  • [L3] The inclusion of disability outcome measures in the evaluation of hand trauma regimens might help to expand the clinician's view to more individualized, activity-of-daily-living–oriented, treatment regimens. (10.1016/j.jhsa.2006.05.017)
  • [L4] Open reduction and interfragmentary screw fixation is an effective treatment modality for symptomatic non-union of distal phalangeal fractures with minimal morbidity, resulting in union and normal function in all patients. (10.1177/1753193407087866)
  • [L1] Buddy taping is a non-inferior treatment modality for most paediatric finger fractures compared to splint immobilization. (10.1177/1753193418822692)
  • [L4] The interrater reliability of the Kellgren & Lawrence and OARSI classification systems for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed. (10.1016/j.jhsa.2024.03.012)
  • [L5] The tested metacarpal fracture model had equivalent biomechanical properties when fixed with a standard dorsal plate and either six bicortical nonlocking screws or four bicortical locking screws. (10.1007/s11552-013-9544-3)
  • [L1] The definition of metacarpal nonunion remains highly variable and lacks standardization with respect to clinical and radiographic criteria. (10.1016/j.jhsg.2023.04.014)
  • [L5] The shorter, thinner 3-dimensional metacarpal plates demonstrated increased resistance to failure in a cyclic loading model and increased load to failure compared with the relatively longer, thicker 2-dimensional metacarpal plates. (10.1016/j.jhsa.2017.01.003)
  • [L5] Retrograde metacarpal screw fixation produces a focal cartilage defect on the metacarpal head that tracks across the entire proximal phalanx articular surface during MCP joint motion. (10.1016/j.jhsg.2025.100847)
  • [L4] This study provides support for the surgical treatment of displaced metacarpal shaft fractures with immediate return to play as tolerated for in-season football players. (10.1177/2325967114s00074)
  • [L5] It is proposed that the terminology in the discussion of hand fracture management with the approach of traction application should be considered to also include the term 'tendinotaxis' in describing the neutralization of deforming forces to restore anatomic bony alignment. (10.1177/17531934241297509)
  • [L5] There was no significant biomechanical difference found between the four different fixation techniques with regard to both displacement and ultimate failure strength of the constructs. (10.1007/s11552-008-9108-0)
  • [L4] Metacarpal head entry point and cascade angle can help identify the appropriate reduction with the guide pin starting point in the dorsal 25% to 35% of the metacarpal head. (10.1177/1558944720919897)
  • [L5] A biomechanical advantage was found when using bicortical screws in metacarpal fracture plating under cyclic loading, with significantly higher load to failure and less plastic deformation compared to unicortical fixation. (10.1177/1753193411424557)
  • [L4] With restoration of articular alignment and meticulous soft tissue dissection, bony healing and functional interphalangeal joint motion can be achieved in most patients regardless of the timing of intervention. (10.1016/j.jhsa.2022.11.002)
  • [L5] Phalangeal fractures are the most common hand fractures in children, with Salter-Harris type II fractures of the proximal phalanx being the most frequent. (10.5435/jaaos-d-16-00199)
  • [L4] This report highlights the importance of careful evaluation of intraoperative and postoperative imaging, particularly CT, to detect rare persistent palmar trapezoid dislocations that may be missed on standard radiographs. (10.1016/j.jhsg.2025.100769)
  • [L4] This series shows excellent radiographic outcomes using CBM for metacarpal defects. (10.1016/j.jhsg.2025.100924)
  • [L4] Delayed diagnosis makes closed reduction difficult and was associated with less favorable radiographic outcome. (10.1177/1558944719852743)
  • [L4] Radiological fracture union occurred in all patients at a mean of 5 weeks. (10.1177/17531934211009684)
  • [L4] The use of a bivalve finger fracture orthosis demonstrated an alternative approach to surgical treatment for PIP fracture dislocation injuries in this patient, proving successful in reducing challenges associated with the injury. (10.1016/j.jht.2014.08.002)
  • [L4] Intramedullary screw fixation is a viable option in the treatment of extra-articular middle phalangeal fractures. (10.1016/j.jhsa.2023.12.011)
  • [L4] Ultrasonography may provide greater accuracy in fracture diagnostics by revealing small avulsed bony fragments missed on radiographs and can be beneficial in diagnosing occult fractures, especially in children. (10.1016/j.jhsa.2015.02.022)
  • [L3] NBA players sustaining metacarpal fractures can reasonably expect to return to their preinjury performance levels following appropriate treatment. (10.1177/1558944716628500)
  • [L4] When evaluating post-traumatic ulnar-sided hand pain, if the 2-5 IMA or the 3-5 IMA is greater than 10 degrees, advanced imaging should be considered. (10.1016/s0363-5023(11)60044-0)
  • [L4] In the literature, there is a lack of agreement on the criteria for rehabilitation and returning to sport after surgical repair of metacarpal fractures. (10.1016/j.asmr.2025.101107)
  • [L3] Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. (10.1177/15589447221081565)
  • [L4] A secondary metacarpal fracture in a patient with a previous little metacarpal fracture is more likely to occur at the original fracture site in patients with a previous shaft fracture than in those with a neck fracture. (10.1177/17531934251313978)
  • [L3] An unplanned early reoperation rate of 8.0% after operative fixation of acute metacarpal fractures was observed, with the majority involving removal of symptomatic hardware and an average time to reoperation of approximately 2.1 months. (10.1016/j.jhsg.2023.08.003)
  • [L3] Common preoperative comorbidities, including smoking status and diabetes mellitus, increase the likelihood of postoperative complication in patients with hand and finger fractures and/or dislocations undergoing surgical treatment. (10.1177/15589447221120847)
  • [L1] The results fail to show any effect of prophylactic antibiotics on the rate of superficial infections following open distal phalanx fractures. (10.1177/1753193415601055)
  • [L4] Reconstruction of chronic injuries by this method restores PIP function, albeit with more modest outcome performance. (10.1016/j.jhsa.2009.04.027)
  • [L4] Dual antegrade IMHS fixation of proximal phalanx fractures resulted in excellent postoperative motion, near-normal grip strength, positive self-reported patient outcomes, and no complications with follow-up of at least 1 year. (10.1177/1558944717750919)
  • [L4] Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed. (10.1177/1558944719836214)
  • [L3] Although operative time was shorter in the IMN group, incidences of loss of reduction, penetration to the metacarpal-phalangeal joint, and secondary surgeries for hardware removal were much higher in the IMN group. (10.1016/j.jhsa.2008.07.011)
  • [L4] However, after a minimum of 1 year of follow-up, none of the tuft nonunions required revision surgery. (10.1016/j.jhsa.2023.10.003)
  • [L3] There was no difference in infection rate and reoperation for infection when comparing different methods of fixation. (10.1177/17531934241277949)
  • [L4] Nonunion, malunion, and infection rates were similar to other studies. (10.1054/jhsb.2000.0486)

See Also

References

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6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.