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Orthopedic Trauma
Orthopedic Trauma

Common Hand Injuries


Distal Radius Fracture (Colles' Fracture)

When someone falls on their outstretched hand, they sometimes get a "broken wrist." The bone that is usually broken is called the radius. The end toward the wrist is called the distal end. The medical term for "broken bone" is fracture. Therefore, the medical term for the most common type of "broken wrist" is a distal radius fracture (that is, the larger forearm bone is broken near the wrist).

This kind of fracture is very common. In fact, the radius is the most commonly broken bone in the arm. The break usually happens when you fall and land on your outstretched hands. It can also happen in a car accident, a bike accident, a skiing accident, and similar situations. Sometimes, the other forearm bone (the ulna) is also broken. When this happens, it is called a distal ulna fracture.

This fracture was first described by an Irish surgeon and anatomist, Abraham Colles, in 1814; hence the name, "Colles'" fracture.

A broken wrist usually causes pain and swelling, and frequently causes a deformity, causing the wrist to look bent. See your doctor for a diagnosis. The doctor will take an X-ray of the wrist. The fracture is almost always about 1 inch from the end of the bone. If the fracture extends into the joint, it is called an intra-articular fracture; if it does not, it is called an extra-articular fracture. ("Articular" means "joint.") If the fractured bone breaks the skin, it is called an open fracture. If the bone is broken into more than two pieces, it is called a comminuted fracture. A fracture is more difficult to treat if it is intra-articular, open or comminuted.

Symptoms

When you have a distal radius fracture, you will almost always have a history of a fall or some other kind of trauma. You will usually have pain and swelling in the forearm or wrist. You may have a deformity in the shape of the wrist if the fracture is bad enough. The presence of bruising (black and blue discoloration) is common. See your doctor if you have enough pain in your arm to stop you from using it normally. You may want to go directly to an orthopaedist (bone doctor), who can usually take an X-ray right in the office and tell you what is going on. If your doctor's office is closed, the injury is not very painful and the wrist is not deformed, you can usually wait until the next day. Go to the emergency room if the injury is very painful, the wrist is deformed, you have numbness, or your fingers are not pink. You may want to protect the wrist with a splint and apply ice to the wrist and elevate it until you get to the doctor's office.

Treatment options

There are many treatment choices. Your orthopedic surgeon will describe what options are right for you. The choice depends on many factors, such as the nature of your fracture, your age and activity level, and your surgeon's personal preferences. The following is a general discussion of the possible options, just so you have a better idea of what your orthopedic surgeon might recommend for you.

One choice is to leave the bone the way it is, if the bone is in a pretty good position. Your doctor may apply a plaster cast until the bone heals. Or if the position (alignment) of your bone is not good and likely to limit the future use of your arm, your orthopedic surgeon may suggest correcting the deformity (the medical term for correcting the deformed bone is reduction). If the bone is straightened out (reduced) without cutting into the skin (incision), this is called a closed reduction. After the bone is properly aligned, a splint or cast may be placed on your arm. A splint is usually used for the first few days, to allow for a small amount of normal swelling. A cast is usually added a few days to a week or so later, after the swelling goes down, and changed 2 or 3 weeks later as the swelling goes down more and the cast gets loose. X-rays are taken, depending on the nature of the facture, either at weekly intervals for 3 weeks and then at 6 weeks (if the fracture was reduced or felt to be unstable), or less often if the fracture was not reduced and thought to be stable. The cast is removed about 6 weeks after the fracture happened. At that point, physical therapy is often started to help improve motion and function of the injured wrist.

Treatment options: surgical

If your orthopedic surgeon feels that the position of the bone is not acceptable for the future function of your arm, and that it cannot be corrected or kept corrected in a cast, he or she may recommend an operation. There are many ways of performing surgery, including reducing the fracture in the operating room without making an incision (closed reduction), or by making an incision (open reduction) to improve the alignment of the bone. In the operating room, your orthopedic surgeon may choose to hold the bone in the correct position with only a cast, or by inserting metal (usually stainless steel or titanium) pins, a plate and screws, an external fixator, or any combination of these techniques.

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Fracture of the Finger

You might think a broken finger is a minor injury, but without proper treatment it can cause major problems. The bones in a normal hand line up precisely, letting you perform many specialized functions like grasping a pen or manipulating small objects in your palm. When you fracture a finger bone, it can put your whole hand out of alignment. Without treatment, your broken finger might stay stiff and painful.

Signs of a fractured finger

  • Swelling.
  • Tenderness.
  • Inability to move it completely.
  • Deformity.

Diagnosis

If you think you broke your finger, tell your doctor right away exactly what happened and when. You have three bones (phalanges) in each finger and two in each thumb. Your doctor must determine not only which bone fractured, but also how it broke: straight across, in a spiral, into several pieces, or shattered completely. Your doctor may want to see how your fingers line up when you extend your hand or make a fist. Does any finger overlap its neighbor? Angle in the wrong direction? Look too short? Your doctor may X-ray both of your hands for comparison.

Treatment and rehabilitation

Your doctor will put your broken bone back into place, usually without surgery. Sometimes you need pins, screws or wire to hold it together, especially if you have a complicated injury. You'll get a splint or cast to hold your finger straight and protect it from further injury while it heals. Sometimes your doctor may splint the fingers next to the fractured one for support. Your doctor will tell you how long to wear the splint—usually about 3 weeks. Sometimes you may need more X-rays as you heal so your doctor can check your progress.

Begin using your hand again as soon as your doctor determines it is okay to move your finger. Doing simple rehabilitation exercises each day will help reduce the finger's stiffness and swelling. You may be required to see a physical therapist to assist you in these exercises.

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Hand Fractures

Have you ever been so frustrated that you wanted to slam your fist into a wall? If you do, you could break one of the bones in your hand (metacarpals). Fractures of the hand bones account for about one-third of all hand fractures. In fact, fractures of the fifth bone (the one that leads to your little finger) are commonly known as "boxer's fractures."

The hand bones can break near the knuckle, mid-bone, or near the wrist. Signs and symptoms of a broken bone include:

  • Swelling.
  • Tenderness.
  • Deformity.
  • Inability to move the fingers.
  • Shortened finger.
  • Depressed knuckle.
  • Finger crosses over its neighbor when you make a partial fist.

Diagnosis and treatment

Your physician will request X-rays to identify the fracture location and type. The physical examination may include some range of motion tests and an assessment of sensation in the fingers to ensure that there is no damage to the nerves.

Most of the time, the physician can realign the bones by manipulating them without surgery. Then, a cast, splint or fracture-brace is applied to immobilize the bones and hold them in place. The cast will probably extend from the fingertips down past the wrist almost to the elbow to ensure that the hand bones remain fixed in place. Your physician will probably request a second set of X-rays about a week later to ensure that the bones remain in the proper position. You will usually have to wear the cast for 3 to 4 weeks, but you can probably begin gentle hand exercises after 3 weeks. Afterwards, the finger may be slightly shorter, but this should not affect your ability to use your hand and fingers.

Surgical options

Some hand fractures, such as those that break through the skin or result from a crushing accident, require surgery to stabilize and align the bones. The orthopedic surgeon implants wires, screws or plates in the hand to hold the fracture in place. If the bone rotates while healing, loss of function could result.

After the bone has healed, the surgeon may remove the implants, or they may be left in the hand. Research to develop implants that are resorbed into the body is ongoing. Your physician may ask you to return frequently for checkups to ensure that the joint doesn't tighten (contract) during healing. You may experience some joint stiffness in your hand because of the long immobilization period. Your physician may prescribe exercises to help restore strength and range of motion or recommend that you see a physical therapist.

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Scaphoid (wristbone) Fracture

The scaphoid is one of the small bones in the wrist (carpal bones), and the one that is most likely to break. The scaphoid is located on the thumb side of the wrist, in the area where the wrist bends. When you hold your thumb in a "hitchhiking" position, the scaphoid is at the base of the depression made by your thumb tendons. Pain or tenderness in this area can be a sign that the scaphoid is injured.

A fracture of the scaphoid usually happens when you fall on an outstretched hand, with your weight landing on the palm. The end of the forearm bone (radius) may also break in this type of fall, depending on the position of the hand when you land. Pain and swelling in the wrist will usually cause a person with a scaphoid fracture to see a doctor. If the wrist is not deformed, however, you might not know that you have a broken bone—people sometimes think they have just sprained the wrist.

It is important to see your doctor if you have pain on the thumb side of the wrist that starts after a fall or accident and does not go away within a few days.

The doctor will probably order X-rays to look at the bone. Sometimes, a broken scaphoid does not show up on an X-ray right away. When this is the case, the doctor may put your wrist in a splint and wait to take a new X-ray in a week or two, when the fracture may become visible. Keep the splint on and do not do any heavy lifting during the waiting time. Your doctor might also recommend an MRI (magnetic resonance image) to see the bones and soft tissues. An MRI can sometimes show a fracture of the scaphoid before it can be seen on an X-ray.

Treatment options

Treatment of scaphoid fractures depends on the location of the break in the bone.

Sometimes, the scaphoid is broken at the end near the thumb. This part of the bone has a good blood supply. Scaphoid fractures in this location usually heal in a matter of weeks with proper protection. The time frame to healing is best determined by X-rays or other imaging studies such as a CT scan, which confirm that the bone has healed. Most fractures here heal well when they are placed in a cast. The cast will usually be below the elbow. It may or may not include the thumb.

More commonly, the scaphoid is broken in the middle (waist) or at the part closer to the forearm (proximal pole). This part of the scaphoid does not have a very good blood supply, so it is more difficult to heal. If your orthopaedist recommends that your scaphoid fracture be treated in a cast, it will probably include the thumb. Sometimes the cast will extend to above your elbow and may also include your index finger.

Treatment options: surgical

Often, when the scaphoid is broken at the waist or proximal pole, an orthopaedist will recommend surgery using a screw or wire to stabilize the scaphoid from the inside while the bone heals. Depending on what part of the scaphoid is broken, the incision will be on the front or the back of the wrist. Sometimes the screw or wire is placed with just a small incision. Other times a bigger incision is needed to ensure that the pieces of the scaphoid are put back together well. Usually your wrist will be placed in a cast after the surgery, sometimes for a few months. Even with surgery, fractures in this area can take a long time to heal, and it is possible that a nonunion or avascular necrosis will occur.

If the scaphoid does not heal, either with or without initial surgery, your orthopaedist may recommend an operation to add bone graft to the scaphoid to help it heal. The surgeon may order an MRI or CT (computed tomography) scan to show more detail about position of the broken pieces of the scaphoid, to help plan the operation. Many kinds of bone graft can be used—your surgeon will discuss which one is best for you. Bone graft may be taken from a bone in the forearm or the pelvis or it may be manufactured. Sometimes a special kind of bone graft with its own blood supply (vascularized graft) may be used.

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Thumb Fracture

A broken thumb is a serious problem because it affects your ability to grasp items in your hand and can increase the risk of arthritis later in life.

Anatomy

The thumb has two finger bones connected to a hand bone. The first finger bone (distal phalange) extends from the tip of the thumb to the knuckle. The second finger bone (proximal phalange) extends from the knuckle to the webbing between the thumb and the first finger. There, it connects with the hand bone (first metacarpal), which extends from the webbing down to the wrist.

Although a break can occur in any of these bones, the most serious breaks happen near the joints, particularly at the base of the thumb near the wrist. These fractures have specific names, depending on the type of break. The Bennett and Rolando fractures are breaks at the base of the thumb, involving the joint between the thumb metacarpal and a specific wrist bone. Fractures that involve the joints are always more difficult to treat and are at increased risk of an unfavorable outcome.

How it happens

Thumb fractures are usually caused by direct stress, such as when you fall or when a ball catches and pulls the thumb back. Some fractures may be caused indirectly, from twisting or muscle contractions. People who play contact sports such as wrestling, hockey or football; skiers; and people with a history of bone disease or calcium deficiency are especially at risk.

The risk of a thumb fracture can be lessened by using protective taping, padding or other equipment and by developing strength in your hands through exercise and proper nutrition.

Symptoms of a fracture

  • Severe pain at the fracture site.
  • Swelling.
  • Limited or no ability to move the thumb.
  • Extreme tenderness.
  • A misshapen or deformed look to the thumb.
  • Numbness or coldness in the thumb.

Treatment options

See a doctor as soon as possible. Without immediate treatment, the joint will be unstable and you will be unable to grip or pinch properly. Continued swelling may make it more difficult to align the bones properly. Delayed treatment will make the fracture much more difficult to treat and can lead to a poor outcome. Use of a padded splint to prevent the bone from moving further out of alignment is encouraged prior to definitive treatment.

The physician will examine the injury, take your medical history and have X-rays taken of the injury. You may need surgery, depending on the location of the fracture and the amount of movement between the broken pieces of bone. If there is little movement (displacement) or if the break is located in the middle (shaft) of the bone, an orthopaedist may be able to use a specially designed cast (spica cast) to hold the bone fragments in place. You will have to wear the cast for at least 4 to 6 weeks, and your doctor may request regular X-rays to ensure that the bone hasn't slipped out of alignment.

Often, Bennett and other more severe fractures of the thumb require surgical treatment. The hand surgeon may use one of several operative fixation techniques to restore boney anatomy and hold the bones in place while they heal. These techniques include the use of wire, pins, plates and screws as internal fixation. Another technique uses pins in bone that exit the skin and are attached to an external fixation device. You will likely be required to wear a cast or splint for 2 to 6 weeks after surgery. When the cast is removed, your physician may recommend hand therapy to restore movement. It can take 3 months or more to regain full use of the hand, depending on the severity of the injury.

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