The Treatment of Closed Finger and Metacarpal Fractures

Background: Fractures of the fingers and metacarpal bones are the most common fracture type in the upper limb, with an incidence of 114 to 1483 per 100 000 persons per year. The clinical importance of closed finger and metacarpal fractures is often underestimated; inadequate diagnostic and therapeutic measures may result in serious harm. This review concerns the basic elements of the diagnosis and treatment of finger and metacarpal fractures.

Methods: This review of the incidence, diagnosis and treatment of finger and metacarpal fractures is based on pertinent publications retrieved by a selective search of the literature.

Results: The main focus of treatment lies on restoration of hand function in consideration of the requirements of the individual patient. The currently available evidence provides little guidance to optimal treatment (level II evidence). Although most closed fractures can be managed conservatively, individualized surgical treatment is advisable in comminuted fractures and fractures with a relevant degree of torsional malposition, axis deviation, or shortening, as well as in intra-articular fractures. Minimally invasive techniques are, in principle, to be performed wherever possible, yet open surgery is sometimes needed because of fracture morphology. Postsurgical complication rates are in the range of 32–36%, with joint fusion accounting for 67–76% of the complications. 15% involve delayed fracture healing and pseudarthrosis.

Conclusion: Individualized treatment for finger and metacarpal fractures can improve patients’ outcomes, with major socio-economic and societal benefits. Further high-quality studies evaluating the relative merits of the available treatments are needed as a guide to optimized therapy.

With its highly specialized precision pinch and power grip, its opposing thumb, and tactile organ function – the only tactile organ that can be brought to the object – the hand serves as an essential instrument for perceiving and making contact with its immediate surroundings (1).

Whereas fracture of the distal radius is one of the most common injuries, with an incidence of 73 to 202 per 100 000 in men and 309 to 767 per 100 000 in women, the number of inpatients in Germany with a diagnosis of “metacarpal fracture” or “finger fracture” recorded in 2021 by the Federal Statistics Office was, in each case, below one percent of all fractures (2, 3, 4, 5, 6, 7). Given the fact that these injuries can be treated on an outpatient basis, however, the true incidence overall is significantly higher, resulting in a general underestimation of frequency (5). On the other hand, with an incidence of 114 to 1483 per 100 000 population, fractures of the fingers and metacarpals are the most common fractures of the upper limbs and account for up to ten percent of all fractures (Tables 1 and 2) (8, 9, 10, 11, 12, 13, 14, 15). Furthermore, finger fractures represent up to one quarter of all missed fractures (1).

Table 1

Incidences of metacarpal and finger fractures

Table 2

Comparison of international incidences of fractures of the metacarpals and fingers (8, 9, 10, 11, 12, 13)

The present review article addresses the fundamental principles of diagnostics and treatment of finger and metacarpal fractures, the knowledge of which is essential to non-hand surgery colleagues in particular, given the relevant frequency and possibility of outpatient management of these injuries. So, the primary aim of this article is to distinguish between patients who can be managed conservatively in an interdisciplinary setting and those who require surgical treatment.

Methods

A selective search of the literature was conducted and included the most relevant and high-quality studies (Table 3). In order to assess incidence, a second selective literature search was performed and requests were made with the Central Institute for Statutory Health Insurance in Germany and the German Social Accident Insurance (Tables 1 and 2). A detailed presentation of the literature searches can be found in the eMethods (eMethods, eFigures 1 and 2).

Table 3

Meta-analyses and randomized controlled studies on the treatment of finger and metacarpal fractures (23, 24, 25, 26, 27)

eFigure 1

Flow diagram demonstrating the approach for a selective literature search

eFigure 2

Flow diagram demonstrating the approach for a selective literature search

Basic anatomical principles

The 27 bones of the hand are divided into three groups: carpal bones, metacarpals (MCs), and phalanges. The metacarpophalangeal (MCP) joints allow flexion and extension of the fingers as well as some degree of abduction and adduction. While the three phalanges of the fingers are connected by the proximal and distal interphalangeal (PIP, DIP) joints, the two phalanges of the thumb are connected to the first metacarpal by the thumb metacarpophalangeal joint and to each other by the interphalangeal joint. The thumb enjoys a special position in the hand and is thus different from the fingers. However, for simplicity’s sake, it is dealt with in this manuscript together with the fingers (1). Each digit is primarily supplied by two (radial and ulnar) palmar neurovascular bundles (16).

Functionally, the fingers diverge when extended, whereas when their joints are flexed to make a fist, rotation of the phalangeal joints makes them converge parallel to one another, without crossing over, and point towards the scaphoid (Figures 1 and 2) (1, 17, 18, 19). While rotational deformity has a dynamic component, torsional malalignment refers to a static situation.

Figure 1

Biomechanics of finger flexion

Figure 2

Assessing for the presence of torsion by making a fist with both hands

Diagnostic investigations

History, clinical examination, and radiography form the corner stone of the diagnostic workup (20). History includes not only the exact mechanism of the accident and the forces involved but should also take into account hand dominance and occupation/hobbies together with their required dexterity (17). The clinical examination should look for any swelling and hematoma as well as locate the site of pain (21). Hematoma color provides information about the time of the fracture. Examination of the hand is always performed by comparison with the contralateral side to gain adequate appreciation of any axial deviation, dysfunction, and deformity, especially torsion (Figure 2) (17, 20). Distal phalangeal fractures, in particular, with their small bony dimensions, can present less pain, hematoma formation, and axial deformity and so be easily missed and not taken seriously, which is why appropriate radiological diagnostics are essential (22). Radiographs in at least two projections (dorsopalmar, strict lateral, possibly with an additional oblique view) are obtained, while computed tomography (CT) scans should be conducted where there is any suspicion of joint involvement or for comminuted fractures (20). A thin-slice CT scan allows more exact assessment of fracture morphology and facilitates planning of access and choice of fracture fixation technique for surgical management.

Principles of treatment

Table 3 provides a summary of the most relevant clinical studies, based on a selective search of the literature (level II evidence) (Table 3) (23, 24, 25, 26, 27).

In principle, when treating a fracture, the question of the optimal form of fracture fixation should not be the primary consideration, but rather whether conservative or surgical management will achieve the best functional outcome (28, 29). Furthermore, emphasis should not be on treating radiological findings but rather always on treating the patient and their individual needs (28).

The general aim is to restore the original range of motion, strength, and dexterity. However, the main challenge is presented by the contradiction between immobilization required for fracture healing and mobilization to achieve relevant function. Non-operative treatment runs the risk of delayed bone union, joint stiffness from prolonged immobilization, and tendon adhesions. This typically happens when immobilization includes joints which are not necessarily involved (Box).

Box

Immobilization regimes for conservative fracture management of finger and metacarpal fractures

The surgical approach also entails risks such as local infections, neurovascular injury, functional loss due to soft-tissue adhesions, and the possible need for implant removal together with tenolysis and arthrolysis (20).

Surgical fracture treatment requires immediate post-operative mobilization because soft-tissue adhesions secondary to the open approach are more pronounced than after conservative treatment procedures (24, 25, 30, 31). Patients should also be informed about the risk of posttraumatic osteoarthritis (32). All therapeutic approaches therefore have the common aim of minimizing immobilization to a maximum of five to six weeks and ensuring early mobilization to restore function (3, 26, 33, 34, 35).

Selecting the appropriate therapeutic approach

While stable extra-articular and non-displaced/mildly displaced fractures can usually be treated non-operatively with special splints, there is an indication for surgical management for non-reducible and unstable fractures, multiple fractures, torsional malalignment, and fractures with displaced joint involvement and a marked comminution zone (20, 32). Fractures treated in the first instance by conservative management should also have radiographical follow-up within one week to detect secondary displacement and initiate appropriate treatment (32).

Conservative management

If conservative treatment is planned, fracture reduction may be required, that is to say, brought into largely anatomical alignment. Reduction can be achieved under local anesthesia (2, 17). A digital nerve block (ring block) of the corresponding nerves is placed for those finger fractures presenting further proximally (20). Alternatively, a distal hand block with infiltration of the major nerves of the hand (radial, ulnar, and median nerves) can be performed (36).

Splinting of finger fractures requires the so-called intrinsic-plus position with full extension of the interphalangeal joints together with 70 to 90-degree flexion of the MCP joints (Box). In this intrinsic plus position, the ligamentous structures around the joints are taut and therefore less susceptible to shortening (eMethods Section, eFigure 3) (17, 37). In addition, the recommended immobilization of the joints either side of the fracture together with application of the splint serves to prevent renewed displacement (17). While stable fractures of the fifth MC are splinted by buddy strapping to the ring finger, fractures of the base of the second to fourth MCs are immobilized with a wrist splint (Box) (26, 32, 38).

eFigure 3

Metacarpal brace, including the metacarpophalangeal joints in 90 degrees of flexion and applied buddy loop, for example, for a stable fracture of the proximal phalanx

Conservative measures for fractures of the distal phalanx involve retention with a DIP joint splint, without including the PIP and MCP joints, whereas fractures of the proximal phalanx of the thumb require inclusion of the wrist in the immobilization (33). Duration of retention is usually four weeks (17).

Surgical management

In principle, minimally invasive approaches are favored. If fracture morphology does not allow this, however, an open procedure is required. An overview of surgical techniques and illustrating radiographs is provided in the eMethods Section (eMethods, eTable and eFigures 4–8).

eFigure 4

Extension block pinning (modified Ishiguro technique) for a dorsal shear fracture of the distal phalanx

eFigure 5

Fifth metacarpal neck fracture (also known as a boxer’s fracture) in a 17-year-old, associated with significant palmar angulation of more than 50 degrees and rotational deformity of the little finger

eFigure 6

13-year-old patient with fractures of the second to fourth MC shafts; anatomical reduction and screw fixation of the second MC and plate fixation of the third and fourth MCs

eFigure 7

Dorsal shear fracture of the distal phalanx of the middle finger with still open growth plate

eFigure 8

67-year-old patient with an intra-articular fracture of the middle phalanx of the ring finger with dorso-ulnar subluxation of the base of the fractured middle phalanx

eTable

Fundamentals of the surgical management of phalangeal and metacarpal fractures

Given the appropriate indication, closed fractures should be operated within a few days after injury or after failed conservative treatment. An upper arm or forearm tourniquet provides a bloodless operative field for a maximum of two hours and thus optimal surgical conditions, especially for open procedures (17).

The “wide awake local anesthesia no torniquet” (WALANT) technique is also enjoying increasing application, providing adequate analgesia and local vasoconstriction by the administration of local anesthetic plus epinephrine (20, 39). Motor function is maintained, allowing intraoperative assessment of function, and perioperative costs are reduced (20, 40).

There are many different surgical techniques available for treating fractures of the fingers and metacarpals: dynamic distraction with external fixators, intramedullary splinting or transfixation with Kirschner wires (K-wires), screw/plate fixation, and external fixators (17, 23, 25, 27, 32, 33, e1). While K-wires are associated with shorter surgery times and sometimes longer postoperative immobilization compared with screws or plates, no significant difference was found with respect to postoperative limitation of motion (e2). Plate and screw fixation, supported by edema prophylaxis by elevation and lymph drainage, are functionally stable for light exercises, while postoperative treatment of fractures stabilized by K-wire fixation often needs to be adapted during the first four weeks to avoid wire migration (30, 31). External fixation techniques are applied for comminuted fractures where no other forms of fracture fixation are possible. They may be temporary to allow concomitant soft-tissue injury to subside until definitive care (17).

Postoperative management

Whereas immobilization is required for bony healing and to minimize pain, early exercising reduces tendon adhesions and ligament contracture and thus ensures a better functional final outcome. Elevation of the involved limb, local cooling, and anti-inflammatory measures reduce postoperative swelling and are also useful for conservative fracture management. Careful and active mobilization of all joints not immobilized should be encouraged. Specialized hand therapy is recommended in particular for complicated fractures. This form of treatment is intended in the first instance for protective reasons but also ensures stability while measures to control pain and reduce swelling are conducted. Functionality of the hand is restored by passive, and then actively assisted, and finally active exercises (1, 17, 20).

Complications

Complication rates of between 32 and 36 percent develop after surgery for fractures of the fingers and metacarpals (32). In general, the most common complication is joint stiffness in 67 to 76 percent of cases (32, e3, e4). Delayed or absent bony consolidation of the fracture may be observed in 15 percent of cases, while infections develop in 0.5 percent of closed fractures after surgical management (e3, e5).

Impending extension and flexion deficit of the metacarpal phalangeal joints should also be looked for in metacarpal, phalangeal neck, and shaft fractures (32, e3). Torsion malalignment has already been highlighted (Figure 2).

A further serious complication is complex regional pain syndrome (CRPS) which develops in 0.2 to nine percent of cases after peripheral bone and joint injury and in one to 13 percent after surgery of the peripheral limb. Here in particular, surgery involving as less tissue trauma as possible, use of tissue-sparing and targeted reduction maneuvers, adequate analgesia, and early mobilization are all crucial for the prevention of complications (e6).

Fractures of the fingers and metacarpals also have a huge socio-economic impact on the healthcare system: A study from the Netherlands found that fractures of the hand and wrist were the most expensive fractures of the healthcare system with 740 million US dollars, of which 63 percent (470 million US dollars) involved fractures of the fingers and metacarpals (e7).

Special features of finger fractures

Subungual hematomas often develop after fractures of the distal phalanx and should be drained by trephination. The dorsal nail plate and palmar fibrous septa of the pulp usually provide stability to transverse fractures of the distal phalangeal shaft, rendering them suitable for conservative treatment (37).

Fractures of the dorsal base of the distal phalanx, also referred to as mallet fractures, are usually the result of a hyperextension injury with axial compression of the DIP joint (shear fracture), while a subcutaneous extensor tendon avulsion fracture (mallet finger) is caused by forced flexion. Surgical treatment has proven of value for larger fragments (more than 30 percent on the strictly lateral radiograph) and dislocation or subluxation of the DIP joint. Otherwise, conservative management by immobilization of the joint in extension with free PIP joint movement (for example, in a Stack splint) is sufficient (Box) (37). Despite adequate treatment of distal phalangeal fractures, complications do develop in 45 percent of cases treated by conservative management and in 53 percent of those treated by surgery. These include infection, joint incongruence, nail deformity, and implant failure. Regular follow-up is essential here (e8, e9).

Comminuted fractures, dislocation fractures, and oblique/spiral fractures carry a high risk of secondary displacement, not only from compression of the comminution zone but also from proximal traction by the intrinsic muscles. So, there is usually an indication for surgery here using, for example, screw or dorsal plate fixation (37, e10).

Specific features of metacarpal fractures

The eMethods Section contains details of specific hand surgery features relating to metacarpal and finger fractures. Metacarpal fractures account for around ten percent of all fractures in general and 18 to 44 percent of all fractures of the hand (32, e11). Whereas 88 percent of fractures involve the second to fifth MCs, the fifth MC is the most often affected and is also referred to as a boxer’s fracture, although this type of fracture is hardly encountered in professional boxers and is more likely to occur in non-sporting pugilists (21, e12).

Metacarpal fractures are classified by their location as fractures of the head, neck, shaft, and base, or based on fracture morphology into transverse, short or long oblique fractures, and comminuted fractures (21).

Specific diagnostic features

Clinical examination often reveals loss of knuckle contour and dorsal proximal prominence of the MC. This is compounded by the fact that fracture-related shortening of two millimeters can result in an extension deficit of seven degrees. Given that the MCP joint normally allows hyperextension of around 20 degrees, shortening by up to six millimeters is tolerated before a relevant extension lag is evident, which might prevent achieving neutral position (0 degrees of extension) (20, 21, 32).

Additional special radiographs are required to complete the general diagnostic workup. Thin-slice computed tomography has proven itself for diagnosing comminution zones or intra-articular involvement (20, 32).

Special indications

With metacarpal fractures, torsional malalignment in particular is fundamental to the treatment decision, as each degree of torsion of a metacarpal bone results in a five-degree rotation of the corresponding fingertip, which in turn produces scissoring of the figures of 1.5 cm when making a fist (Figure 2) (32). Therefore, even minimal torsional malalignment requires appropriate treatment (20). The severity of any dorsal axial deviation, of which 30 degrees already restricts grip strength of the hand, is relevant for therapeutic decision-making (21). Surgical treatment is recommended for associated fracture-related shortening by six millimeters and more, as there is no further compensation to be expected from the MCP joint here. Intra-articular fractures require surgical correction if there is a step-off of more than one millimeter, or if more than 25 percent of the joint surface is involved, in order to minimize joint deformity and subsequent osteoarthritis (32).

Fractures of the thumb

With its exposed position and marked mobility, the thumb is frequently susceptible to bony injury. Fractures of the thumb are divided into fractures of the distal phalanx, proximal phalanx, and first metacarpal. These are then further classified into base, shaft, and head fractures, with or without joint involvement (33).

While fractures of the distal phalanx of the thumb are rare and only require surgery in exceptional cases, fractures of the first metacarpal are more common in the form of an extra-articular Winterstein fracture and intra-articular Bennett or Rolando fracture. They usually require surgical treatment (1, 33, e15). Details regarding fractures of the thumb are to be found in the eSupplement.

Conclusions

In summary, there are no standardized international or national guidelines on the treatment of fractures of the fingers and metacarpals. There are only a few high-quality studies which are dedicated in particular to specific methods of managing unstable longitudinal and spiral fractures of the metacarpals. Overall, the available data is inadequate, which argues against the formulation of standardized treatment recommendations for the various fracture morphologies and individual treatment requirements for finger and metacarpal fractures.

An individual approach should therefore be discussed with the patient, based on the available treatment options.

Conflict of interest statement

ML has received lecture fees from Synthes, AO, Johnson & Johnson, Medartis, IBRA, KLS-Martin, and BIRG for courses and congresses. He received reimbursement of travel expenses and congress fees from Synthes, AO, Johnson & Johnson, Medartis, IBRA, KLS-Martin, and BIRG. He is a member of the Advisory Board AO – Hand Expert Group of KLS Martin. He is currently President of the German Society for Hand Surgery

FU has a consultancy contract with Medartis regarding the development of a hand fixation instrument tray.

The other authors declare that there are no conflicts of interest.

Manuscript received on 19 June 2023, revised version accepted on 11 October 2023.

Translated from the original German by Grahame Larkin MD.

Corresponding author
Dr. med. Adrian Cavalcanti Kussmaul
Department of Orthopedics and Trauma Surgery

Musculoskeletal University Center Munich (MUM)

Munich University Hospital, LMU Munich
Marchioninistrasse 15
81377 Munich

Cite this as:
Cavalcanti Kussmaul A, Kuehlein T, Langer MF, Ayache A, Unglaub F: The treatment of closed finger and metacarpal fractures. Dtsch Arztebl Int 2023; 120: 855–62. DOI: 10.3238/arztebl.m2023.0226

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