Function of the hand skeleton
The bones of our hands form a stable scaffold and establish the basic conditions for the high functionality of our prehensile organs.
With fractures (broken bones) of the hand skeleton, this stability is lost. If fractures involve joints, irregularities of the surface can develop. If these are not repaired, there is a high risk of premature joint wear and development of arthritis at this site. Bony fractures of the hands or fingers are among the most common fractures of all.
Causes of hand fractures
The most common cause of fracture is high force, usually through a fall or impact. A fracture without trauma is called a pathologic fracture. Here bones break already under slight stress. This can be due to generalized weakening of the bony structure (osteoporosis) or to a localized weakening (cyst, tumor)
The primary symptoms are pain, swelling, bruising, and limited mobility. Greater dislocations can result in abnormal movement, axial malposition of the bone, or bony protrusion from the wound (open fracture).
In General fractures are accompanied by more or less significant soft tissue injuries. Especially in open fractures injuries of vessels, tendons or nerves occur frequently.
The diagnosis can already be made clinically based on dislocation and instability. Detailed assessment of fractures is always made with X-ray. If a suspected fracture is not confirmed with conventional radiography, a CT-Scan can be performed.
The goal of fracture treatment is stable healing of the affected bone with anatomic alignment.
This involves restoring the original configuration of the bone and fixing it with appropriate measures (plaster cast, plate, screws, wires, etc.) in this position until the bone has consolidated. Depending on the site of the fracture, a slight malalignment might be acceptable without risking functional loss. Joint fractures, however, must always be aligned as anatomically accurate as possible to avoid inappropriate stress and premature wear.
Conservative therapy (without operation)
Simple, minimally displaced fractures can be treated with splinting or casting. Dislocated fractures should be reduced where necessary under local or regional anesthesia before application of the cast. Immobilization must be consistently performed for four to six weeks. During this time, follow-up radiographs must be taken to monitor bone position and consolidation.
Certain displaced fractures may be realigned with external (closed) reduction, but cannot be adequately immobilized with casts. Such fractures can be secured in place with wires introduced through the skin (percutaneous). If closed reduction is not possible, the affected bone is exposed through a cutaneous incision, aligned and fixed in place. This mainly involves the use of screws and plates. In cases of an extensive bony defect it may be necessary to harvest bone from another part of the body (e.g. the iliac crest) and graft it on the existing defect in order to increase stability.
The advantage of open fracture treatment with screws/plates is a stable fixation, which allows for immediate mobilization of the affected limb. However, especially after plate fixation in the region of the finger bones adhesions of the extensor tendons often develop and therefore require a second operation for release of these adhesions.
Follow up care
Depending on fixation and stability achieved, mobilization can be started right after surgery, or else a protective splint or cast must be worn/applied. Hand therapy is almost always involved in the course of follow-up care to restore full mobility as quickly as possible. Plates inserted are often relatively bothersome and therefore can be removed in a second operation after the bone has healed. Potential tendon adhesions can be released at the same time. If plates and/or screws are not troublesome they can be left in place.