Principles of Metacarpal and Phalangeal Fracture Management: A Review of Rehabilitation Concepts

Principles of Metacarpal and Phalangeal Fracture Management: A Review of Rehabilitation ConceptsMaureen A. Hardy, PT, MS, CHT 1 Patients with common hand fractures are likely to present in a wide variety of outpatient orthopedic practices. Successful rehabilitation of hand fractures addresses the need to (1) maintain fracture stability for bone healing, (2) introduce soft tissue mobilization for soft tissue integrity, and (3) remodel any restrictive scar from injury or surgery. It is important to recognize the intimate relationship of these 3 tissues (bone, soft tissue, and scar) when treating hand fractures. Fracture terminology precisely defines fracture type, location, and management strategy for hand fractures. These terms are reviewed, with emphasis on their operational definitions, as they relate to the course of therapy. The progression of motion protocols is dependent on the type of fracture healing, either primary or secondary, which in turn is determined by the method of fracture fixation. Current closed- and open-fixation methods for metacarpal and phalangeal fractures are addressed for each fracture location. The potential soft tissue problems that are often associated with each type of fracture are explained, with preventative methods of splinting and treatment. A comprehensive literature review is provided to compare evidence for practice in managing the variety of fracture patterns associated with metacarpal and phalangeal fractures, following closedand open-fixation techniques. Emphasis is placed on initial hand positioning to protect the fracture reduction, exercise to maintain or regain joint range of motion, and specific tendon-gliding exercises to prevent restrictive adhesions, all of which are necessary to assure return of function post fracture. J Orthop Sports Phys Ther 2004;34:781-799. Key Words: bone healing, hand, fingers njury to the densely compacted structures of the hand often involves damage to multiple tissues. In this confined area, all neighboring tissues share trauma and its consequence. It is a mistake to consider fracture healing apart from soft tissue healing, because successful outcomes require the return of functional integrity to both tissues. Soft tissues commonly involved with fractures include cartilage (with intra-articular fractures), joint capsule, ligaments, fascia, and the enveloping dorsal hood fibers. Occasionally, in severe polytrauma cases, tendons and nerves adjacent to the fracture are also injured. Following open fractures or open reduction procedures, a wound is created that must heal with scar tissue—another tissue to be remodeled and considered during rehabilitation. It is well recognized that soft tissue scarring affects hand function more than fracture healing, and joint stiffness is the most frequent complication of fractures.50 1 Director, Hand Management Center, St Dominic Jackson Memorial Hospital, Jackson, MS; Clinical Assistant Professor, School of Health Related Professions, University of Mississippi Medical Center, Jackson, MS. Address correspondence to Maureen A. Hardy, Hand Management Center, St Dominic Jackson Memorial Hospital, 969 Lakeland Dr, Jackson, MS 39216. E-mail: [email protected] I The optimal therapy program addresses these 3 components (bone, soft tissue, and scar healing) in combination. In the 1970s, therapy for hand fractures was delayed 6 to 8 weeks while the hand was immobilized. Stiff joints, adherent tendons, muscle atrophy, scar, and pain were the focus of our interventions. Results of corrective surgical procedures, such as capsulectomies for joint release and tenolysis to restore tendon gliding, were poor for patients with fractures.16,43,101,113 Joints with stiffness and abnormal articular surfaces, due to limited reduction techniques in small bones, faced the choice of fusion (arthrodesis) or joint replacement (arthroplasty). Recent studies on fractures requiring combined capsulectomy and tenolysis show that outcomes are still poor, especially for return of active tendon function.25,64,74,86 Add to this dilemma that 24% of digits that require these release procedures are noninjured, border digits that were included in the immobilization, and we lament along with Lanz,64 who states that ‘‘Damage of the gliding ability of tissues (around a fractured digit) is almost irreparable.’’ Enhanced understanding of the biology of fracture healing, better decision making in initial fracture management, technical advances in implant design, improved surgical 781 CLINICAL COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. Journal of Orthopaedic & Sports Physical Therapy These cutting cones have osteoclasts that forage forward. Examples of unstable fractures include long oblique. plates. The information is presented within the context of an overview of fracture healing. pins. then supported with removable splints for initiation of controlled motion. and 90-90 wiring techniques. fractures that are not stable can result in malunions. as displacement reoccurs despite immobilization. by percutaneous fixation. Compression across the fracture line eliminates the space-occupying hematoma. The methods used to bring anatomic order and realignment back to the fractured bone is called reduction. Implants introduced via open reduction internal fixation (ORIF) that provide absolute stability and compression of the fracture permit primary bone healing to occur. or nonunion. All rights reserved. infections. Alternately. such as nondisplaced transverse. with special emphasis on potential problems that need to be addressed in the course of rehabilitation. Compression combined with rigid fixation. such as screws. spiral. These devices can be inserted either percutaneously (closed reduction) or via surgical exposure (open reduction). do require more rigid external support as previously noted. however. leaving an empty trail behind (haversian canal) that is filled with osteons (a single basic unit of bone). the immobilization can be modified to allow incremental increases in range of motion (ROM). This is especially important in articular fractures where joint incongruities can lead to degenerative joint problems. Coaptive devices therefore require further external support to eliminate unwanted deforming stresses as the fracture heals. and interosseous wiring. Fractures that are stable will heal. and early controlled mobilization have contributed to reducing the incidence of complications that we once faced. PRINCIPLES FOR FRACTURE MANAGEMENT Is the Fracture Stable? The quest in fracture management is to achieve fracture stability. The displaced fracture ends must be reunited for healing to occur and to prevent deformities. provides an environment suitable for osteoclast cutting cones to form and cross the fracture line. dorsal band. closed methods of support for 2 to 3 weeks. but they do not control for rotation stresses. The more rigid implants. and comminuted fractures. As the need for peripheral callus to support the bone ends is avoided (the metallic implant substitutes J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . controlled-motion protocols to preserve soft tissue integrity and facilitate scar remodeling. These fractures require no further intervention other than protective immobilization to allow healing to commence. Stability of a fracture is achieved when the fracture maintains its reduction and does not displace either spontaneously or with motion. potentially unstable fractures can be supported with the introduction of coaptive hardware such as K-wires. intramedullary rods. Fractures that are aligned but subject to misalignment with certain postures or tensions are termed potentially unstable. The coaptive implants. nor do they impart any internal strength to the fracture. pseudoarthrosis. This paper is based on a thorough review of the literature and current practice principles.4. All fixation implants promote reduction.39 If the fracture has not distorted the bone’s normal contour and the fracture ends are approximated.39 Stability of these fractures can only be assured with the support provided by fixation devices. The purpose of this manuscript is to review current concepts of management for metacarpal and phalangeal fractures.75 For an in-depth review of fracture healing see LaStayo et al. avulsion. it is termed nondisplaced. and fractures with articular fragments greater than 30% or incongruity greater than 2 mm. permit immediate motion and only require modest external support for wound care. These fractures can often be managed with protective 782 Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. Coaptive forms of hardware bring about alignment. and short oblique configurations. Reduction can be achieved by either closed manual techniques. followed by guidelines for managing specific types of fractures common in the hand.skills with respect for gliding structures. staples. Primary bone healing is direct bone-to-bone healing without any external callus. thus reducing the fracture gap.65 Is the Fracture Healing? Primary Bone Healing Implant choice drives the course of fracture healing. but some provide added internal strength across the fracture line. A bone that has lost its normal anatomical contour due to separation of the fracture ends is called displaced. immobilization that maintains the reduction or restricts motion in the direction of instability. Unstable fractures will not maintain reduction. or wiring techniques that protect against displacement. As fracture coalescence occurs.64 One advantage of primary healing via rigid internal fixation is precise anatomic reduction. while also introducing early. or by open surgical methods. The challenge for the health care team is to design intervention protocols that recognize the need to maintain fracture stability for maximal bone healing. Potentially unstable fractures include oblique. condylar and any irreducible fractures. Stable fractures will maintain their position at rest and will not lose the proper approximation of fracture ends with inherent muscle tension or when controlled-motion protocols are initiated. Intrinsically stable fractures are usually treated with conservative. such as pins. Some fracture types are known to have intrinsic stability. K-wires. by osteoblastic action. that eliminates all but micromotion. 45 All splinting programs recognize the need to position the metacarpophalangeal (MP) joints in flexion to avoid extension contracture. The thumb MP joint is not exempt from this rule and many stiff thumbs result from hyperextended thumb spica immobilization. soft callus transitions into a harder fibrocartilage callus. Limited open reduction and internal fixation uses small incisions to insert screws or intermedullary fixation.75 This newly formed woven bone (weak) will gain tensile strength as it is remodeled based on its environmental stresses and strains to become lamellar bone (strong). woven and ultimately lamellary bone.69 Fracture immobilization should provide for adequate healing. biological fixation that forms in an area with motion and functions to reduce this motion as it matures and hardens (soft callus to hard callus). thinning of articular cartilage. Goodship42 summarized this cascade of connective tissue differentiation as one in which. initiation of motion at 3 to 4 weeks is still limited to a safe range dictated by the fracture’s potential instability. Early initiation of motion is permitted as these implants provide sufficient internal support to allow motion without endangering the fracture alignment.65 In polytrauma cases. J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . Unpublished data by Greer45 states that the following principles (REDUCE) for effective plaster cast or thermoplastic splinting should be incorporated in all designs: (1) reduction of the fracture is maintained. Although new bone is formed more quickly in primary healing.for the callus). unrestricted motion can overwhelm the fragile support offered by early soft callus. Because bone formation will not occur in an environment of motion. hyaline cartilage.’’ The primary advantage of secondary bone healing is that there is minimal soft tissue disruption. then through a process of mineralization true bone is formed. fibrous tissue. screws. Without the initiation of early motion post-ORIF. Callus that is sufficiently ‘‘clinically stiff’’ at 3 weeks to permit motion is not strong enough yet to bear functional loads. The periosteal sleeve. osteoporosis. A disadvantage of primary healing is that it can only occur with mechanical stabilization provided via surgery. open fractures. there is full access to the hand for wound or edema control measures. Often. usually in 3 to 5 days. (3) don’t immobilize fractures more than 3 weeks. and (6) early active tendon gliding is encouraged. Secondary Bone Healing Fractures treated by external support or coaptive implants. so also is avoided the potential problem of tissue adherence to the callus during immobilization. that reduce the fracture but do not provide compression.53 After 3 weeks. K-wires. it is not strong bone. (2) eliminate contractures through positioning. Open methods of internal fixation (ORIF) do require surgical exposure of the fracture for insertion of K-wires. during which soft tissues can become contracted or adherent to the callus. Bones healing by closed conservative management and those treated by open reduction methods achieve the same level of tensile strength by 12 weeks. there are 2 wounds to heal: the fracture and the soft tissue incision. the fracture fragments are rendered more stable. and external fixators under radiologic C-arm guidance. using closed methods that emphasize alignment and early protected motion (Figure 1). (4) uninvolved joints should not be splinted in stable fractures. This equates to less scar remodeling. leading to loss of reduction and possibly nonunion. callus is a temporary. Insertion of the fixation device does not always require a surgical incision. Once the surgical dressing is removed. One disadvantage of secondary healing is the relatively long period of protected immobilization that is required. As the callus gains stiffness. and 783 COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®.42 Excessive.104 With secondary healing. so strengthening programs must be delayed until the remodeling phase has begun at 6 to 8 weeks. soft tissue mobilization programs for repaired tendons can begin immediately without fear of displacing the fracture. severe joint stiffness. envelops the bone adding another internal layer of fracture support and is an important blood supply source for the bone.52 Is Closed or Open Reduction Required? CLINICAL The vast majority of metacarpal and phalangeal fractures can be treated without surgery. and restoration of hand function. Prolonged immobilization results in atrophy of soft tissues. plates. ‘‘The entire spectrum of connective tissue is seen from blood to bone through hematoma. with the exception of volar plate fractures. and at times pain. there is a greater potential for soft tissue adherence. ROM exercises are delayed or limited during the first 3 weeks. must rely on callus formation to bridge the fracture gap. The interphalangeal (IP) joints are routinely rested in full extension. as do open fixation methods that may require periosteal stripping for implant application. relief of pain. Fractures that cannot be reduced with closed manipulation (or those that fail to maintain their reduction). (5) creases of the skin should not be obstructed by the splint. Noninvasive fracture management does not violate this tissue. Closed reduction with external fixation or closed reduction with internal fixation includes percutaneous application of pins. fibrocartilage.7 Callus then resembles a natural glue that holds the fracture ends together. or until the callus has achieved enough tensile strength to tolerate controlled movement. protection from displacement or reinjury. This implies that primary healing is not faster healing. consequently. and displaced articular fractures are candidates for operative fixation procedures. All rights reserved. granulation tissue. when intact. and permit early motion for good restoration of function. and to acceleration of controlled soft tissue mobilization for full active tendon gliding.78 Weiss109 investigated initiation of motion at 1. Reprinted from LaStayo64 with permission from Elsevier. splint. external fixator) or with coaptive forms of fixation (pins. under the implant. given that the small bones in the hand do not bear weight.54 Advances in osteosynthesis materials is believed to provide sufficient stability to permit controlled. . K-wires. therapy intervention proceeds from edema prevention. full active motion can and should be emphasized early.’’ Coaptive Fixation: External Fixators. because of the stability provided by the rigid fixation. . Pins. ‘‘. respectively.69 Full AROM is the early goal as edema diminishes. however. AROM exercises (out of the splint) are performed hourly to regain full mobility. but need not be excessive.Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. when motion was delayed more than 21 days. An exception is forced extension with tension band wiring techniques. wiring. has occurred. 2. Early strengthening exercises with light resistance can be initiated at 8 weeks. and (2) rigid forms of fixation that immobilize and compress the fracture (primary healing). but unrestricted return to sports and heavy work is delayed until after 10 weeks. protected ROM exercises with this type of fixation in place. plates) still require protective. It is important that therapists managing hand fractures understand the role and intent of the J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . because the dorsal surface wiring on the metacarpal compresses the fracture with flexion but will cause gapping of the fracture with forced extension. ‘‘rehabilitation ready’’ position. and to perform protected active ROM (AROM) exercises. Incidence of infection. Because the implant serves as a substitute for hard callus. Strengthening programs are delayed until the remodeling phase to assure fracture union. Early strengthening exercises with light resistance can be initiated at 6 weeks.32.53 Dynamic or serial static splints may be initiated after 6 to 8 weeks’ time to overcome any soft tissue contractures. as callus remodeling to lamellar bone with increased fracture strength does not occur until this later stage of bone healing. Controversy does exist regarding the initiation of motion with coaptive fixation. Tension Band Wiring. and pain have been cited as reasons to delay motion until the fixators are removed. Passive range of motion to regain full joint mobility. osseous wiring. K-wires. nonunion. 3.21 Rigid Fixation: Plates. Results showed no difference in ROM when motion was initiated between 1 to 21 days. Fracture stability achieved with closed reduction methods (cast. the K-wires and pins are removed. postoperative splint support initially. which occurs after 6 to 8 weeks. the splint is adjusted for proper fit and worn for continued fracture protection for another 2 weeks. Intramedullary Rods. Screws. assure compression for stability. It is cautioned 784 that well-placed coaptive implants that allow ROM exercises without load may be insufficient to protect the fracture against resistance (motion with load). and strengthening programs. are delayed to the early and late remodeling phase. which the patient removes for suture/pin site cleaning. One week after surgery a removable splint is applied in a functional. Freeland39 stated that. there was a significant loss of mobility. The hardware used in fracture fixation falls into 2 categories: (1) coaptive devices that hold the fracture ends together without compression (secondary callus healing).9.8.44. to protected mobilization with tendon gliding of nonimmobilized joints. As healing progresses. FIGURE 1. However. but unrestricted return to sports and heavy work is delayed until after 10 weeks. similar to secondary healing. passive motion can be initiated during the repair phase. Interosseous Wiring Jabaley57 stated that fixation must be good enough to permit movement. and 4 weeks for individuals with proximal phalanx (P1) fractures with K-wire fixation. The callus is considered ‘‘clinically stiff’’ enough for free active motion but is not stable enough to bear a functional load. to assure adequate fracture strength has occurred. the choice of the implant is less important than achieving a threshold of stabilization that will allow fracture healing in concert with early rehabilitation.39 Full motion may not be possible at all joints due to constraints from the hardware. fracture displacement. 90-90 Wiring Open reduction with rigid forms of fixation provide definitive fixation. intramedullary rods) require a form of external support to promote callus formation during the inflammatory and repair stages of healing. Dynamic splints may be used at 2 weeks for soft tissue stretching. All rights reserved. At 4 to 6 weeks. when the hard callus is converting to bone. Fracture stability achieved with open reduction methods (screws. brace. facilitated by manually blocking the MP joint into flexion (Figure 2B). Distended joints predictably move into positions that permit the greatest expansion of the joint capsule and collateral ligaments. a minimum of 2 facts must be provided with the therapy referral: date of fracture and method of fixation. Because the FDP tendons blend into 1 multistrand tendon inserting into the muscle belly. based on the method of fixation. promotes full gliding of all flexor tendons with the FDP tendon gliding past the FDS tendon. To promote selective FDP flexor tendon glide past the superficialis tendon. digitorum communis and central slip to prevent tendon adherence to fracture callus. The goals of hand therapy then are to reintroduce safe early mobilization while maintaining fracture stability. compared to 49 mm of FDS glide. All rights reserved. IP joint flexion. flexor digitorum superficialis (FDS). These ligaments serve to tether and anchor both ends of the metacarpal. FDS tendon blocking exercise requires inhibition of the FDP tendon of the same finger. Rest. to achieve full fisting. and thumb adduction: a dropped ‘‘claw hand. extensor PRINCIPLES FOR MANAGING METACARPAL FRACTURES The metacarpal bones have intrinsic stability provided proximally by strong interosseous ligaments binding them to the carpal bones.14 The only motor that is now free to glide and flex the PIP joint is the FDS tendon. blocking 1 tendon’s excursion effectively blocks all others. and elevation (‘‘RICE’’) are emphasized for edema control. Ice can be easily performed with the use of large bags of frozen peas (1 bag applied volarly and 1 dorsally) and is effective even over a splint or cast. to prevent osseous adhesions to tendons. The fracture date starts the bone-healing timetable.various forms of fixation of fractures as they dictate the course of rehabilitation. Selective gliding of flexor tendons is achieved by choosing positions that differentiate movement between the FDP and FDS to achieve maximal glide of each. FDP tendon gliding is performed by manually blocking the PIP joint to allow full flexor power to be directed to the distal joint (Figure 2C). the intrinsic plus position is performed. Wehbe106. serve to protect fracture alignment and encourage mobility of the injured digit.35 Edema postures the hand into wrist flexion. This inhibition of the profundus is achieved by manually restricting DIP motion in the unaffected digits with attempted PIP flexion in the involved digit (Figure 2E). or skin.15 To assure the extensor tendon glide over fractured metacarpal bones. Early mobilization to promote venous return via muscle contraction is advocated in stable fractures. and the method of fixation (dictating the type of healing) influences the rate at which motion can be reintroduced. flexing the wrist may assist by the addition of passive tenodesis action (stretch of the extensor mechanism). MP joint extension. Patients are also instructed in shoulder and elbow ROM exercise in elevation to facilitate proximal muscle pumping. Double buddy straps. Patient education for edema control is an essential component of the initial therapy visit. capsules.5 cm] for fingers and 2 inches [5 cm] for the hand) is an elastic self-adhering bandage that provides effective compression. Full fisting. Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. Coban (sized 1 inch [2. which also contributes to PIP joint flexion.’’ Functional splinting seeks to place the hand in a resting position that will avoid this deformed posturing.82 The most important tendon-gliding exercises to initiate early are those for the flexor digitorum profundus (FDP).107 used metal tags on the tendons to demonstrate that the FDP must glide 60 mm. To gain extensor hood glide over proximal phalanx (P1) fractures. Micks71 showed that the central slip is responsible for initiating extension from a fully flexed PIP joint position. and distally by the transverse metacarpal ligament linking all metacarpal heads. In the absence of this ideal environment. ice. Eccles33 showed that the greatest reduction in swelling was obtained with the hand supported in elevation overnight. Edema is poorly tolerated in the digits due to the confining space.105 CLINICAL COMMENTARY Are the Tendons Gliding? AROM is initiated as soon as possible. flexion of all 3 joints simultaneously. applied proximal and distal to the proximal IP joint (PIP). The ‘‘sublimis fist’’ (Figure 2F) maximally glides the FDS tendon past the FDP tendon with full MP and PIP flexion and an extended DIP joint. the ‘‘claw fist’’ posture of MP extension with PIP and distal interphalangeal joint (DIP) maximal flexion is achieved (Figure 2D). while the lateral bands (interossei and lumbricals) achieve full terminal PIP extension. ligaments. flexor tendons need to achieve maximal differential glide to prevent restrictive adhesions with loss of motion. MP extension is performed in the ‘‘hook fist’’ posture (Figure 2A). This research suggests that for P1 and middle phalanx (P2) fractures.91 Is the Edema Under Control? Edema after injury is common to all fractures. Having the patient adduct the fingers tightly and maintain this tension while flexing at the MP joint can enhance both intrinsic muscle pumping and achieve the desired joint positions of full MP flexion and IP extension. preventing excessive 785 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . If full PIP extension is lacking. Ideally the therapist would have access to both the radiographs and an operative/emergency department report on the medical management of the fracture. compression. 786 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . E F FIGURE 2. Tendon glide exercises: (A) claw posture to achieve extensor digitorum communis (EDC) tendon glide over metacarpal bone. (B) intrinsic plus posture to achieve central slip/lateral bands glide over proximal phalanx (P1). (E) flexor digitorum sublimis (FDS) blocking exercise to glide FDS tendon over middle phalanx. (D) hook fist posture to promote selective FDP tendon glide.A B C D Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. (C) flexor digitorum profundus (FDP) blocking exercises to glide FDP tendon over P1. All rights reserved. (F) sublimis fist posture to promote selective FDS tendon glide. extensor digitorum communis. sitting at 47° rotation away from the other digits. neck. high-voltage stimulation Silicone TopiGel. a cast is worn for 4 to 6 weeks to protect this injury at the wrist. and head. Postoperatively. All rights reserved. During this time the fingers are free and encouraged to move. TABLE 1. index and small. Bora12 reported ‘‘satisfactory’’ return of grip strength and activities in 18 patients treated with this method. which is often unstable due to the pull of the extensor carpi ulnaris.41 The insertions of the wrist flexors and extensors on the metacarpal base can be a deforming force. Scissoring/overlapping of digits Slight: buddy tape to adjacent with flexion digit Severe: malrotation deformity requiring ORIF Absence of MP head Absence of MP head and MP joint extension lag Shortening of metacarpal. shaft. Once clinical signs of healing are present. may not be functional problem Shortening of metacarpal with redundancy in extensor length. and abductor digiti minimi that insert on the metacarpal base. Table 1 lists the potential problems that can occur and strategies for therapeutic intervention. NMES. splint in extension at night.12 Fractures at this location limit the normal descent of the ulnar metacarpals. Fractures in the border digits. major: reduction of angulation required Absence of MP head with volar prominence and pain with grip Abbreviations: AROM. The most important soft tissue concerns with metacarpal fractures are preserving MP joint flexion and maintaining EDC glide. active range of motion. prevent pain. IP. or overwhelms the normal flexibility of the ulnar metacarpals (ring and small). Due to their good blood supply. minor: padded work glove. these fractures heal rapidly with osseous restoration in 6 weeks. flexor carpi ulnaris. contact physician if painful symptoms with AROM persist COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. Fractures of this bone are described at 4 distinct locations: base. This is especially true for middle and ring metacarpal fractures as they have the additional support of intact adjacent metacarpals. MP. J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 787 . is the most mobile and most unstable if fractured. flexion splint IP joint in extension during exercise to concentrate flexion power at MP joint Late: dynamic MP flexion splint. strengthen intrinsics abduction/adduction. friction massage Initially: position MP joint at 70° flexion in protective splint Late: dynamic or static progressive MP joint flexion splint Dorsal skin scar contracture that prevents full fist MP joint contracted in extension Metacarpal Base Fracture Base fractures are an intra-articular fracture resulting from high force that disrupts the rigid carpal ligaments (index and middle).41 ORIF is necessary to restore joint approximation. iontophoresis with lidocaine Rest involved tendon. These are uncommon injuries associated with violent accidents resulting in a fracture-dislocation pattern. EDC. simultaneous heat and stretch with hand wrapped in a fisted position.100 Metacarpal fractures represent 35% of hand fractures. tend to be more unstable due to loss of surrounding intact metacarpal pillars. degenerative joint disease and ultimately further carpal collapse. NMES of intrinsics with off Ͼ on cycle Neck fracture angulated volarly.76 The index and middle metacarpal base fractures are also unstable due to the insertion of the extensor carpi radialis longus and flexor carpi radialis on the second metacarpal and extensor carpi radialis brevis on the third. The deep motor branch of the ulnar nerve. neuromuscular electrical stimulation. ice. a protective wrist splint is used for 3 to 4 weeks while wrist rehabilitation is initiated. Potential Problems Dorsal hand edema Prevention and Treatment Coban wrap compression. Displaced fractures represent an associated carpometacarpal joint dislocation that can lead to joint incongruity. Closed reduction with casting of the wrist for 4 to 6 weeks is indicated for nondisplaced or minimally displaced fractures. is also vulnerable to injury in this fracture. The thumb metacarpal. interphalangeal. causing weakness of grip. The most common occurrence is at the fifth metacarpal-hamate articulation. passing beneath the hook of the hamate. metacarpophalangeal. and assure return of grip strength. Potential problems with metacarpal fractures and strategies for therapeutic intervention.displacement with injury. elevation. NMES of EDC with on Ͼ off cycle Intrinsic muscle contracture secondary to swelling and immobilization Dorsal sensory radial/ulnar nerve irritation Attrition and potential rupture of extensor tendon over prominent dorsal boss or large plate Initially: teach instrinsic stretch (instrinsic minus position) Late: static progressive splint in intrinsic minus position Desensitization program.70 CLINICAL Adherence of EDC tendon to Initially: teach EDC glide exerfracture with limited MP joint cises to prevent adherence. This prolonged immobilization is necessary to protect the healing fracture from the deforming forces of the wrist tendon insertions. and Jones. is protective against malrotation and facilitates early motion.97 The natural ability to hyperextend the MP joint will overcome this extensor loss for minimal bone shortening. permiting controlled-motion exercises (Figure 4C-D). pushing the fracture ends dorsally (known as apex dorsal presentation). fabricated custom-made. less extensor lag. proximal and distal to the fracture. Resting tension of the long extrinsic finger flexors contributes to the deformity. these 2 studies support the advantages of the functional brace with improved motion. FIGURE 3. MP. Hall47 reported using this type of clam digger immobilization in over 1000 fractures.68 buddy taping. Both studies compared this functional brace. that provide counterpressure).58 using thermoplastic material. For each 2-mm increment of bone shortening there is a corresponding 7° extensor lag at the MP joint.90 The IP joints are free to move during the day but strapped into extension at night to prevent flexion contractures (Figure 5B). proposed the concept of ‘‘serial splint reduction. and respects the J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . will cause both ends of the metacarpal bone to flex towards each other. ability to deliver corrective reduction force. angulated metacarpal shaft fractures is provided by custommade casts or splints that incorporate the 3-point pressure fixation built within the splint and allows free active joint motion (Figure 3). decreased pain.112 short hand casts. or spiral. This best-practice management technique assures protection of fracture stability.70. Feehan36 788 A B Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. Seventy degrees of MP joint flexion reduces the intrinsic and extrinsic flexors influence on dorsal angulation. (A) metacarpal shaft fracture treated with 3-point pressure fixation built inside splint. They are described by the fracture configuration as transverse. with plaster ulnar gutter casting. arising from its origin on the volar proximal metacarpal through its bony insertion on the proximal phalanx. nondisplaced transverse metacarpal shaft fractures with apex dorsal angulation can be treated closed with glove support. Together. causing a deleterious effect on the extensor mechanism by altering the muscle’s normal length-tension relationship. Multiple metacarpal fractures may require that all fingers be included in the cast (Figure 5A).58 Sorenson92 found poor compliance and skin breakdown with prefabricated splints as compared to ulnar gutter casts. especially in oblique fractures.96 Stable. Buddy strapping of the injured digit to a noninjured adjacent finger.102. Current best-practice fracture support for managing nondisplaced. which allowed wrist and digital motion.61 using fiberglass casting. Fractures that are potentially unstable require additional support. with the volar support ending at the distal palmar crease to allow free MP and IP joint motion. Konradsen. but this deformity leaves a prominent dorsal boss that has been implicated in attrition rupture of extensor tendons. Metacarpal fractures with apex dorsal angulation cause the metacarpal bone to be shortened. oblique. (B) straps secured to apply corrective pressure to dorsal apex angulation of fracture. modified to plaster in noncompliant patients.103 C-arm visualization of the fracture with the splint on will assure improvement in the angulation after 1 week. Ashkenaze6 described a splint that includes the wrist and metacarpal shafts with dorsal support extending out to the PIP joint. Intrinsic muscle tension.Metacarpal Shaft Fracture Shaft fractures are extra-articular fractures caused by fall.’’ in which the splint is gradually cut down as fracture healing proceeds. hand-based fracture braces with the 3-point reduction technique. Ulnar or radial gutter splints that immobilize both the injured metacarpal and its adjacent stable metacarpal. maintains proper hand posture. All rights reserved. including wrist. blow. or hand-based fabricated splints that incorporate 3 points of reduction pressure (1 dorsal point over the fracture site and 2 volar points. and PIP joints have been the norm (Figure 4A-B).29 long ulnar/radial gutter splints. or crushing force that usually angulate dorsally and may have components of shortening and/or rotation. and decreased need for postfracture therapy. (A) Radial gutter splint for fractures of index or middle metacarpals. Following ORIF. a circumferential. importance of motion in the early rehabilitation of fracture. Oblique and spiral metacarpal fractures can shorten and rotate. 789 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . Kuntscher63 reported that 105 fractures postoperatively provided with this type of functional fracture brace resulted in decreasing the number of hand therapy visits with early.A B CLINICAL C D COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. FIGURE 4. The rotated position of the metacarpal will cause digital overlapping and the telescoping will cause loss of the normal metacarpal head prominence of the involved bone. pain-free return of hand function. (B) ulnar gutter splint for fractures of ring or small metacarpals. hand-based splint is worn to protect the metacarpal area from direct trauma. (D) passive range of motion in splint. The ill effects of this telescoping and malrotation will be evident when the patient attempts to make a fist. (C) serial reduction of splint to permit motion as fracture healing occurs. All rights reserved. no joint motion is restricted with this splint. then operative treatment is recommended. Metacarpal Head Fracture Head fractures are intra-articular fractures caused by high axial loads that can involve avulsion of the collateral ligaments. the surgical dressing is removed and an immobilization splint is applied to protect this coaptive fixation at that time.3 Other complications of poorly reduced neck fractures include a metacarpal head prominence in the palm that is painful with grip. also known as fighter’s or boxer’s fracture. which reduces the muscle’s excursion capacity. If the fracture fragment is nondisplaced. and found that this gradual application of stress reduced the fracture as effectively as manipulation with anesthesia. the extra-articular neck. (B) resting volar component added to maintain interphalangeal joints in full extension. including a fracture fragment. If these acceptable reduction angles cannot be maintained with external support alone.93 Fracture displacement of 1 to 2 mm at the articular surface is more easily tolerated in the upper extremity than in the lower extremity weight-bearing joints.88 One week postoperatively. Acceptable angulation is less than 15° in the index and middle metacarpals.24 Neck fractures have also been treated with a hand-based splint that incorporates the 3 points of pressure and must extend volarly over the palmar aspect of the metacarpal head to apply the correct dorsal force. the fist contact with the mouth of another can result in tooth penetration into the MP joint. The patient is instructed in protected ROM exercises out of the splint. Metacarpal Neck Fracture Neck fractures are the most common metacarpal fracture. while the ring and small metacarpals can function with less than 30° due 790 to their compensatory mobility. This loss of full muscle length results in limited ability to initiate flexion at the MP joint.6. it is important to hold the MP joint in over 70° flexion. All rights reserved. fracture of 1 or both condyles.50 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 .A B Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. The impact of a closed fist hitting an object can fracture the metacarpal at its weakest point. Trauma causes the fractured metacarpal head to displace with volar angulation. Any skin laceration at the MP joint level with fight/bite fractures should be suspect for infection. however. ORIF is indicated for fractures that involve more than 20% of the articular surface to prevent erosive joint changes and to allow AROM by the third week postfracture. Closed reduction percutaneous pinning with K-wires is recommended to maintain reduction in unstable neck fractures.24 If reduction is inadequate or potentially unstable.48. the injury can be treated with protective splints that hold the MP joint flexed at 50° to 70° for 4 to 6 weeks. angulated neck fractures that heal with volar displacement over 30° place the intrinsic muscle in a shortened position.56 However.61 Jones58 instructed patients to gradually tighten the straps as edema subsided. (2) holding the MP joint in flexion by a dorsal block component that extends out to the PIP joint. Debate continues over the necessity to reduce and immobilize these fractures.3. or shattering of the joint surface into many small-comminuted pieces.5.93 Once the volarly flexed metacarpal head is reduced back in proper alignment with the shaft. the 3-point splint should be used. (A) Cast for multiple metacarpal fractures permitting early active finger flexion.38 Displaced fractures require ORIF with fixation that allows early protected motion. and compensatory hyperextension of the proximal phalanx at the MP joint to clear the fingers for grasp. (3) stopping the volar side of the splint at the MP web area. It is recommended that reduced fractures use the hand-based splint that maintains the MP flexed with a dorsal block. A traditional ‘‘clam digger’’ or intrinsic plus splint can be used that includes: (1) keeping the wrist in slight extension.14. Collateral ligament avulsion fractures if undetected can lead to chronic pain and joint instability. At 4 to 6 weeks the K-wires are removed and the patient should then regain full AROM. FIGURE 5. With fight/bite injury. permitting limited MP and full PIP flexion. as the taught collateral ligaments will aid in securing the metacarpal head in place. 81 TABLE 2. The PIP and DIP joints. unsatisfactory results are more related to open fractures. All rights reserved.32 depending on callus formation.112 Phalangeal fractures respond more unfavorably to immobilization than metacarpal fractures. metacarpophalangeal. flexor digitorum superficialis.98 In 19% of digital fractures. These avulsion fractures occur most often at the ulnar collateral ligament of the thumb or 791 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 .79 or 3 to 4 weeks. extensor digitorum communis. at night PIP extension gutter splint. oblique retinacular ligament. providing compression of the fracture. NMES to FDP Buddy strap or finger hinged splint that prevents lateral stress Early DIP active flexion to maintain length of lateral bands FDS tendon glide at PIP joint and terminal extensor tendon glide at the DIP joint Splint to hold MP joint in flexion with PIP joint full extensor glide Resume protective splinting until healing is ascertained. His definitive work on intraarticular fractures showed that continuous passive motion begun in the first postoperative week stimulates both bone and cartilage healing. NMES to EDC and interossei with dual channel setup Isolated FDP tendon glide exercises. Potential problems with phalangeal fractures and strategies for therapeutic intervention. stability of the fracture position can be maintained with conservative treatment due to tension in the surrounding intact joint capsule. are allowed early active motion.111 Positioning the MP joint in 70° flexion results in balanced tension of these capsular structures. compared to 96% return in metacarpal fractures. and associated soft tissue injuries. because early motion benefits articular cartilage repair. NMES. is avulsed. at night flexion glove. during the day MP extension block splint to concentrate extensor power at PIP joint. NMES to interossei Isolated FDP tendon glide exercises.55 Functional outcome in these fractures is not so dependent on fracture site. the splint can be removed for protected ROM at the MP joint. flexor digitorum profundus. interossei tendons.78 Table 2 lists potential problems that can occur with phalangeal fractures and strategies for therapeutic intervention. stretch ORL tightness. After reduction. Pain Abbreviations: DIP. MP. desensitization program Loss of PIP extension Loss of PIP flexion PRINCIPLES FOR MANAGING PHALANGEAL FRACTURES Phalangeal fractures are more unstable than metacarpal fractures as they lack intrinsic muscle support and are adversely affected by tension in the long finger tendons. comminuted fractures with substantial loss of bone length are better treated with external fixators or bridging plates that maintain bone length. comminuted fractures. After 2 to 3 weeks. due to the many small fragments involved.Comminuted fractures that do not lend themselves well to operative fixation. FDP. Potential Problems Loss of MP flexion Prevention and Treatment Circumferential PIP and DIP extension splint to concentrate flexor power at MP joint. NMES to interossei Central slip blocking exercises. the motion return drops to 66%. and volar plate for fractures in the proximal 6. with a predicted 84% return of motion. EDC. ORL. Shewring’s review89 of 33 displaced base fractures found a high rate of nonunion with conservative management due to displacement of the fracture as the collateral ligament tightens with flexion of the MP joint. address edema. rather. PIP. neuromuscular electrical stimulation. Displaced base fractures can not be reduced with MP joint positioning alone as often the collateral ligament. FDS. nonfractured neighboring fingers also lose motion. Loss of DIP extension Loss of DIP flexion CLINICAL Lateral instability any joint COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. proximal interphalangeal. collateral ligament complex. during the day MP flexion blocking splint to concentrate flexor power at PIP joint. distal interphalangeal. However. can be treated with closed immobilization in a radial/ulnar gutter splint with the MP joints flexed to 70°. buddy taped to an adjacent digit.88 If immobilization is continued longer than 4 weeks. NMES to FDS Resume night extension splinting. PIP flexion blocking splint to concentrate flexor power at DIP joint. Salter80 cautions that excellent reduction of the fracture may still lead to a poor result due to the concomitant cartilage injury with its limited regenerative capacity.to 9-mm range from the joint.23 Immobilization is shortened to 2 to 3 weeks. attached to the fracture fragment. The intrinsic plus position of the splint design also causes the extensor aponeurosis to be tightened and drawn distally over the base of P1. These articular fractures require accurate reduction to restore normal joint kinematics. Impending Boutonniere deformity Impending swan neck deformity Pseudo claw deformity Proximal Phalanx (P1) Base Fracture Intra-articular base fractures are due to an abduction force from sports injuries or a fall on an outstretched hand. Displaced P1 fractures present with apex palmar angulation. Prevention of this deformity relies on emphasizing PIP joint extension at rest and early tendon glide along all bone surfaces. Fractures of the shaft require accurate reduction to allow these soft tissues to glide normally. This angulation is due to a volar force at the base of P1 by the interossei insertion. while also directing all flexor and extensor tendon power to the PIP joint. protecting against MP hyperextension. which develops into a fixed joint flexion contracture. P1 Condylar Fracture The 2 condyles at the head of the proximal phalanx. Hourly the distal straps are removed to permit early tendon gliding. but not total immobilization. Initially.110 792 Nondisplaced fractures require protection. Continuous passive motion (CPM) following ORIF with rigid fixation is indicated to maintain joint mobility. FDS. decrease edema. index and radial collateral ligament of the ring and small fingers. Oxford73 recommends a singledigit circumferential splint for stable fractures. the use of splints holding the wrist. open internal fixation with miniscrews.’’ Methods of fixation for displaced.62 intraosseous wiring with additional K-wire support.79 Techniques used for fixation of displaced fractures include tension band wiring using a figure-of-eight weave. which is compensated at the MP joint with hyperextension to remove the flexed finger from the palm. a splint is made that maintains flexion at the MP joint. emphasizing central slip. and would allow simultaneous early rehabilitation. Later.A B FIGURE 6.40 The most common problem at this level begins with an extensor lag at the PIP joint. which provides extended lateral support at the PIP joint for distal shaft fractures or volar and dorsal immobilization of the MP joint for proximal shaft fractures.’’17 are renown for the worst prognosis in regaining full mobility. lateral bands. (B) MP joint flexion isolated during exercise with use of dual blocking splints. with a dorsal hood expansion to securely strap the PIP joint into full extension at rest (Figure 5). and mini external fixators. and FDP tendons.81 P1 Shaft Fracture Fractures occurring in digital flexor zone II.8. This design allows for free active PIP joint motion. and stimulate the healing of articular cartilage. percutaneous miniscrews. while the extensor expansion pulls the distal fragment dorsally. unstable fractures include closed transcutaneous insertion of K-wires or intramedullar y rods.110 or screw fixation.50 As MP joint stiffness with loss of flexion is the most common postoperative soft tissue complication of P1 base fractures.34 Burkhalter17 reminds us that it is far easier to gain flexion than extension at this joint. . PIP. provide stability to a joint J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . protective splinting must rest the MP joint in flexion.74 The worst case scenario results when minimal motion at the PIP joint results in a fixed flexed position of the joint. (A) Wrist and distal joint immobilizer splint used during exercise sessions to promote flexion at the metacarpophalangeal joint (MP). When active exercises are initiated to regain full MP flexion.2. respectively.31 Ninety percent of the bone’s surface is covered by gliding structures—the central tendon dorsally.24 The volar part of the splint stops at the distal palmar crease. a functional blocking splint can be used to counter the pseudo-boutonniere posturing that occurs with less than optimal tendon gliding (Figure 7A-B). Light-resistance exercises for PIP joint flexion and PIP joint extension are facilitated when performed in the splint.11 Freeland39 recommends that the ‘‘least intrusive technique be used to provide a threshold of strength that reliably holds the fracture securely . Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. miniplates. Full PIP joint flexion is not promoted until the patient is able to actively extend the PIP joint to 0°. called ‘‘no man’s fractures. and the FDP tendon volarly—that can easily become adherent to fracture callus. A pseudo-claw hand posture is created. The splint immobilizes the MP joint in flexion. All rights reserved. lateral bands bilaterally. Inclusion of a neighboring noninjured digit in the splint and buddy strapping permit early AROM. will facilitate all flexor strength directed towards the MP joint (Figure 6A-B). with their intimate convex-concave fit on the middle phalanx base. and DIP joints immobilized during exercise. . Swelling will draw the joint into a flexed posture that over time will become a contracture. lateral incision used for screw placement.72 excising the insertion of the central tendon creating a flap. or lateral deviation force on an outstretched finger.109 This is a common sports injury that is often misdiagnosed as a ‘‘jammed finger’’ as the athlete can move the finger well.54 As the most significant complication following P1 fracture is loss of full PIP joint extension. Horton48 found that despite the J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 .93 These potentially unstable fractures are best treated with ORIF to assure good joint alignment is achieved. the ORIF group in his study had 3 times greater PIP joint extension lag (27°). and thus 0° extension to prevent an extensor lag. The percent of articular surface involved and the percent of joint dislocation determine severity of this fracture. reduction of edema. This may be partly explained by the mutually dependent role played by the central slip and lateral bands in achieving full PIP joint extension. as occurs in basketball and volleyball injuries. (B) the blocking splint facilitates flexor and extensor tendon gliding at the proximal interphalangeal joint (PIP). prevention of adhesions and joint stiffness. while a high loading rate can result in a collateral avulsion fracture. Authors have advocated various incision locations: splitting the extensor tendon longitudinally.95 Palmar Plate Avulsion Fracture Also known as dorsal fracture dislocation.A B FIGURE 7.77 incising between the lateral band and the central tendon. hyperflexion. comminuted fractures of the articular surface occur. All rights reserved. is ruptured along with a variable portion of the articular surface of the volar middle phalanx. and is painless. deprived of much soft tissue support. However. The use of continuous passive motion (CPM) following rigid internal fixation of these fractures results in regeneration of hyaline articular cartilage. It may be that adhesions in either system will affect PIP joint extension. It is crucial that the patient work to achieve proximal gliding of the extensor mechanism.80 Incised and repaired central slip tendons can also be treated with the short-arc-motion protocol. CLINICAL COMMENTARY Middle Phalanx (P2) Base Fracture This intra-articular fracture is caused by a hyperextension.83 Buddy taping and immediate active motion are used to manage less severe fractures. at the base of P2. commonly called avulsion fractures. as compared to the group that received closed reduction treatment (8°). called a pilon fracture. The problem with ORIF at this level is access to the P1 head directly under the central extensor slip.’’ indicating the force required to create this deformity. Pain and swelling at the PIP joint postoperatively are a great barrier to rehabilitation.20 or a lateral midaxial incision. Full PIP joint flexion is limited for 3 weeks to prevent splitting the sutured tendon approximation. or a unicondylar (1 side) or bicondylar (2 sides) fracture configuration at the head of P1. Pilon is derived from the Latin word ‘‘pounder. the lateral approaches that spare direct trauma to the central tendon are more appealing. (A) Pseudo-boutonniere deformity of ring digit following proximal phalanx fracture. this fracture results from a hyperextension injury in which the distal attachment of the volar plate. or from a fall onto the outstretched hand. Without the normal restrains provided by an intact volar plate.82 Continued unsupported use of the hand can change a simple nondisplaced fracture into an angulated fracture with painful joint incongruity.60 A ball forcing the digit away from the center line of the hand most often fractures the condyle towards the middle of the hand. with hourly short-arc AROM performed. tension from the finger extensors on their distal attachment causes the base fracture to dislocate dorsally. With severe compressive trauma. Splinting must rest the PIP joint in full extension. The type of tissue injury caused with a lateral deviation force is dependent on the rate of loading: stress applied with low loading rate causes collateral ligament injury. Fractures of moderate severity (20% to 40% of the articular surface involved) are treated with extension block splinting 793 Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®.87 Hyperextension or hyperflexion injuries are often severe enough to cause the PIP joint to dislocate with associated soft tissue damage to the volar plate or central slip respectively. causing depression of the fragments into the bone shaft. as there is continuity of the extensor tendon longitudinally. is often difficult due to soft tissue constraints. The distal strap (not shown) is removed to allow active PIP and distal interphalangeal joint (DIP) flexion and extension. The distal articular surface of the PIP joint is essentially destroyed. As fracture healing ensues. A dorsal block splint prevents the joint from extending by 30° to 40°. Rubber band J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . Dynamic traction splint for comminuted pilon fractures. or tension band wiring. Pilon Fracture Severe compressive trauma can cause the head of the proximal phalanx to impact into the base of P2. for greater than 6 weeks. With screw fixation. creating many small. at which time. which can be treated with dynamic extension splinting.22 Closed reduction. The finger is moved passively along the arc several times per day to stimulate regeneration of articular cartilage and remodel the joint surface.51 Another option is to use a combination of traction and motion to model a new joint through the use of dynamic traction splinting (Figure 10).to 8-week splinting regime. Volar plate avulsion fracture treated with extension block splint that limits full extension at the proximal interphalangeal joint (PIP). FIGURE 10. Usually there is a slight flexion contracture at the end of the 6 . This fracture is at risk for displacement with full extension. yet allows full joint flexion (Figure 8).30 Fractures with greater than 40% of joint surface involvement usually do not remain congruent in any limited arc of motion and are therefore managed with ORIF. Rubber band tension is measured to assure 300 g of ligamentotaxis distractive force throughout the range. crushed fracture fragments. active ROM can begin to further glide soft tissues. and the patient is instructed in active DIP joint flexion exercises to maintain gliding and length of the lateral bands and oblique retinacular ligament (Figure 9). FIGURE 8. active motion can begin immediately with the use of the same splint to prevent flexed posturing at the PIP joint. Reduced fractures are immobilized in full PIP joint extension for 4 to 6 weeks. This latter method uses a radial or ulnar gutter splint that blocks the MP joint in flexion. This protocol allows fracture compression with flexion. necessitating ORIF with pin.’’ includes a fracture fragment from the dorsal base of P2 that is attached to the central extensor tendon. permitting gain in extension range. Fortunately it is a rare injury and treatment depends on the ability to restore the volar subluxed P2 back to approximate the avulsed fragment. however. while avoiding fracture separation with extension. also known as ‘‘dorsal fracture dislocation’’ or ‘‘boutonniere fracture. the splint angle is subsequently remolded at less extension block weekly. Cast for central slip avulsion fracture that maintains full proximal interphalangeal joint extension while allowing active distal interphalangeal joint flexion to maintain the length of oblique lateral ligaments and lateral bands. Pins are removed at 2 to 3 weeks.Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. the degree of blocking is determined by fracture displacement with extension. All rights reserved. Flexion at the DIP joint will prevent the appearance of a boutonniere deformity post immobilization. 794 full extension and is removed for passive ROM exercises. screw.8 A removable protective fingerbased splint is worn that maintains the PIP joint in FIGURE 9. Central Slip Avulsion Fracture This fracture. ORIF seeks to elevate the central depressed articular fragments and maintain their length with bone grafts or external fixators. the tendon (with the fracture fragment attached) is surgically reattached through P3 using wire pull-out sutures over a dorsal button. Loss of terminal joint active flexion requires early and judicious care. P3 Base Fracture Articular avulsion fractures are closed injuries that result when an actively contracting tendon is forcefully pushed into the opposite direction. it may be managed with 795 COMMENTARY Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. These fractures are usually markedly displaced and unstable. Dorsal Avulsion Fracture This fracture. Longitudinally placed pins down the medullary canal try to avoid this soft tissue problem. Tendon rupture alone can occur. countering the swan neck deformity. or of becoming impaled with pins and screws with open methods. place them in jeopardy of adhering to fracture callus with closed methods. ORIF or percutaneous use of screws provides enough stability to allow AROM within 1 week. Volar Jersey Avulsion Fracture This fracture is named after the football injury in which one player grabs the shirt of an opponent who pulls away forcefully.’’ in which the soft tissue envelope that encircles the fracture (intact periosteum. Midshaft fractures can angulate either dorsally or volarly. as FDS tendon action can displace this fracture due to its insertion on the P2 shaft. The splint is worn continuously for 6 to 8 weeks (removed briefly for dressing purposes) to prevent displacement of the fracture. with loss of active flexion. collateral ligaments. causing the FDP tendon. with a bone chip. The digit is splinted in the functional position of MP joint flexion with PIP and DIP joints in full extension. If the fracture piece represents less that one third of the articular surface. to be avulsed from the volar base of P3. known as ‘‘mallet fracture’’ or ‘‘baseball fracture.18 Causes of fracture include crush to the distal tuft. J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . which is beneficial to articular cartilage healing. indicating good cartilage thickness. blows to an extended finger.46 Kearney59 reported on a 9-year follow-up of patients treated with dynamic traction and found that all joints were pain-free and asymptomatic. A dorsal blocking splint is fabricated and the postoperative Durand tendon motion protocol is followed. requiring ORIF. with fractures at the P3 level accounting for 50% of hand fractures.19 Large fracture fragments require the additional support of K-wires to assure good joint surface congruence is achieved. DIP joint stiffness. Stern’s review93 of complications suggests that K-wires should remain in for a longer duration of 4 to 6 weeks. they maintained their 87° arc of PIP joint motion. resulting in shortening of the middle phalanx shaft. or an articular fragment of variable size can be avulsed along with the tendon. and an extensor lag are the chief complications.8 Limitation of lateral band gliding will result in loss of DIP joint terminal extension.95 P2 Neck Fracture Neck or subcapital fractures are more common in young children whose fingers have been trapped in closed doors or electric windows. with frequent removal for FDP tendon gliding is recommended.65 The extensor terminal tendon is avulsed off the dorsal base of P3. due in part to the short. spiraling from their lateral position at the PIP joint to become conjoined dorsally over the distal part of this phalanx. Distal Phalanx (P3) Fractures The distal exposed portion of the finger is most vulnerable to injury.84 CLINICAL P2 Shaft Fracture Fractures at this location are rare. and the joint space had been maintained. resulting in loss of terminal DIP joint extension. Emphasis is placed on FDS tendon glide at the PIP joint and terminal extension glide at the DIP joint. For long oblique or spiral fractures. causing these soft tissues to narrow and compress the fracture. Tension is measured with a Halston gauge to assure that adequate distractive force of 300 gm is exerted. Postoperative therapy is based on the stability of the fixation. The use of dynamic traction for pilon fractures was compared with ORIF and found to produce the same results with fewer complications. Protective splinting of the DIP joint in full extension.traction from a circular outrigger is attached to exposed K-wires passed through the middle phalanx distal to the fracture. The path of the lateral bands. as FDP tendon muscle shortening can occur if undetected. joint capsule) is placed under longitudinal tension. With small fragments. This skeletal shortening will cause an imbalance in extensor tendon-bone length ratio. with a chip of variable-sized bone attached. and sports-related volar and dorsal articular avulsion fractures. All rights reserved.1 Cannon19 recommended 3 weeks immobilization with closed methods or K-wire fixation. omitting DIP joint flexion until the wire is removed.84 A modified Durand program is performed.’’ is common to all sports and hobbies in which an extended finger is forced into either flexion or hyperextension. Loss of full DIP joint extension. due to either lateral band adherence or redundance.58 During the day the dynamic-traction component is moved along the circular outrigger hoop to achieve passive PIP joint motion. The distractive force uses a concept called ‘‘ligamentotaxis. as when fingers are caught in closed doors or machines. Two common types of avulsion fractures at this level are ‘‘jersey’’ fracture and ‘‘baseball’’ fracture. leads to the classic swan neck deformity of DIP flexion with excessive extensor force directed at hyperextending the PIP joint. broad shaft that is stronger here than in proximal bones. 796 J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 . including DIP and PIP joints. however.99. as with conservative methods. Surgical treatment for mallet fractures have been reported to have a 53% complication rate due to infection.19 CONCLUSION Unique to hand anatomy. edema measures. motion can and should be reintroduced at the DIP level by reducing the length of the protective splint and encouraging joint motion. is relatively simple. Dressing changes that do not disturb the repaired nail bed are performed after soaking the tip of the finger in a sterile container filled with saline and part hydrogen peroxide. and texture tolerance are beneficial to accommodate to normal fingertip use. Splinting is continued at night and during vigorous activities for another 2 to 4 weeks. usually causes an open wound that needs to be supported with external splinting or K-wire and splinting for 3 weeks.and motion at the MP and PIP joints is encouraged after the first week. It is impossible.27. as this would stretch out the oblique retinacular ligament (ORL). and extensor lag. allows accommodation for any swelling. Wrapping the digit with coban into an intrinsic minus position and then dipping into paraffin provides simultaneous heat and stretch.108 Damron’s27 analysis of these common fixation methods noted that none of the fixation methods provide enough stability to permit early motion.28. protective splint extending to. If extensor lag at the DIP joint is noted. Loss of full DIP joint flexion is usually due to soft tissue contracture of joint structures and dorsal skin scar. then. All joints must be immobilized for a minimum of 6 weeks. supportive splinting. Blocked DIP joint flexion exercises are not performed. as opposed to a 45% complication rate for closed treatment.94 Wehbe106 suggests that due to these findings most mallet fractures should be treated with conservative closed methods. Active ROM at the DIP joint can be initiated after 3 weeks if callus consolidation permits. to consider skeletal injury as isolated trauma to bone tissue only. as excessive irritation can result in a pin tract infection. FIGURE 11. putty press. Occasionally. soft tissues glide in multidirections mere millimeters away from skeletal structures. Tip protector splint bivalved to maintain distal interphalangeal joint (DIP) extension and accommodate swelling for mallet fractures. Following the 6 weeks of continuous immobilization in extension. an intact ORL will serve to passively assist DIP joint extension as PIP joint active extension occurs. even when comminuted. then splinting is resumed during the day also.2 Protective. composite flexion and extension of the PIP and DIP joints is taught. the fracture pattern shows significant displacement of the 2 fracture fragments. Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. Trauma and fracture displacement can harm surrounding soft tissue structures as well as encase both together in P3 Shaft Fracture Trauma at this level. Fracture fragments that are greater than one third of the articular surface can be surgically reattached using various wiring techniques. joint incongruity. once nail bed healing is complete. Use of a TopiGel sleeve. Wound care. proximal to the nail bed. assists in scar management as well as dampening painful sensory input. requiring several months26. nail bed damage. initially allows the inflammatory period to resolve. The more difficult aspect of managing these fractures is the extent of nail bed injury that may be present and require suturing. P3 Tuft Fracture Treatment of the tuft fracture. but not including. 10. Fibrous union is slow to ossify at this level. Care must be taken that the splint does not rub against the exposed pin. Desensitization programs that include vibration.49 This is followed by blocking exercises for FDP tendon glide. Bivalving the splint. and swelling with the development of hypersensitivity to touch. the PIP joint is worn for 2 to 3 weeks. Because the greatest complication of mallet fractures is a DIP joint extensor lag. closed splinting of the DIP joint in extension for 6 weeks (Figure 11). A thin. Compression around the tip facilitates fragment approximation and diminishes the very painful effect of bleeding and swelling at this level. All rights reserved. which has been shown to have the best effect on soft tissue lengthening. requiring ORIF with K-wire fixation for 3 weeks. which is secured with coban wrap.19 The finger pulp region is densely innervated with sensory end organs that painfully respond to the initial crush. nail deformity. Hand Clin. early motion protocols. 6. 26. Krischak G. Buch VI. 7. Treatment principles for proximal and middle phalangeal fractures. J Bone Joint Surg [Am]. The treatment of injuries to the carpometacarpal joint of the little finger. Al Qattan MM. Malone W. 31.79:9-12. Treatment of mallet finger fractures by the extension-block K-wire technique. Pohl AP. Subcapital fractures of the fourth and fifth metacarpals treated without splinting and reposition. Baratz ME. Fixation of phalangeal fractures. 9. 8.9:725-729. J Hand Surg [Am]. Colditz JC. 1986. Zimmer TJ. Steichen JB. Claes L. 1974. Therapy after skeletal fixation in the hand and wrist. 1999. 27. J Hand Surg [Br]. Bischoff R. Brand PW.53:452-457.19:1019-1026. Nawana N. Jupiter J. 1992. Nassab RS. Jr. The use of power-driven staples in fracture surgery. 1997. 3. J Hand Surg [Am].23:802-805. Duncan RW. Management of proximal interphalangeal joint fractures and dislocations. A review of the literature found a paucity of studies on fracture rehabilitation. 1995. Buechler U. 29. et al.221-229. Callahan AD. Successful rehabilitation of hand fractures addresses the need to maintain fracture stability. J Hand Surg [Br]. Clinical implications of stiffness and strength changes in fracture healing. These complications have been the impetus for development of early controlled-motion programs during the appropriate phase of fracture healing. Mackin EJ. Hansen TB. 16. J Hand Ther. Ashkenaze DM. Open hand fractures: an analysis of the recovery of active motion and of complications. 11. Chinchalkar SJ. 28. Can Med Assoc J. Mann RJ. Rehabilitation approaches for distal and middle phalanx fractures of the hand. Hamman J. Augat P. Fractures of the hand. Agee J. 797 CLINICAL COMMENTARY J Orthop Sports Phys Ther • Volume 34 • Number 12 • December 2004 .Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. Contemp Orthop. 1994. Hashem F. Statistical review. Injury. Darder-Garcia A. Darder-Prats A.86:775-779. J Bone Joint Surg Br. Lee66 summarized this concept: ‘‘The outcome of any fracture is influenced by the choice of treatment as well as the type and duration of immobilization. Slade RJ.23:19-33. Ruby LK. Burkhalter WE. Appleby D. 24. Oni JA. De Roche R. Fractures of the distal phalanges. 23. Blair WE. evidence for best-practice strategies in fracture rehabilitation is often gleaned from failure experiences. Chamay A. 1993. 2003. Noble J. Braun H.29:269-270. 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