Orthopaedic Surgery/Fractures and Dislocations:Hand

Fifty years ago phalangeal fractures were treated according to "hearsay" or what recommendations were available in text books. There were few clinical studies to be found and conclusions from the first of these studies being retrospective with a heterogeneous collection of injuries had little power to illuminate an optimal course of treatment. The early studies by Moberg and Stener and by Watson-Jones concerned avulsion fractures to the interphalangeal joints and Mallet fractures respectively. Then as now we can sort these injuries pretty readily between good actors and bad actors. Experience in exam and interpretation of x-rays is required to distinguish the good actor from the bad. This distinction made early allows for appropriately minimalistic treatment (early motion) for the good actors and for the bad actors, surgical treatment that then allows for early motion or selective immobilization targeted to a specific structure e.g. central slip in an acute boutonierre. There is little sense in considering fractures and sprains separately as either can be a good or bad actor. (Lee 43-B (1), 1963).

Torn between assuming the best and fearing the worst, early treatment in inexperienced hands tends to lead to the muddled middle course of immobilization, then referral at or about 4 weeks when things proceed badly. Unfortunately at this point the problems related to immobilization and edema now maturing into fibrosis considerably compound the problem of management.

History helps in that the mechanism and events in the immediate aftermath of the injury are often telling. Patients tend to recall quite vividly the appauling sight of one of their fingers pointing hideously askew. The severe nature of the injury may not be quite so immediately apparent if the hand is first seen only after the initial reflexive effort to straighten the finger actually accomplishes substantial improvement. Eliciting the history as to the initial distorted appearance is helpful.

Inspection alone cannot reliably distinguish the good actor from the bad and an early quality x-ray with the beam properly centered on the injured area is critical to proper decision making. Noting the extent and location of swelling and of course any associated lacerations is essential.

Regarding the issue of closed vs open fractures there remain some common misconceptions. Subungual hematoma without displacement of the nail plate appears to have no increased risk of infection. Sterile decompression for subungual hematoma for pain relief or for hematoma greater than 50% of the length of the nail bed is recommended. If the nail plate is dislodged from the eponychial fold even partially there is likely a nail-bed laceration warranting repair, and the presence of a fracture of the underlying distal phalanx adds the risk of infection which warrants direct irrigation of the bone. In the absence of gross contamination, treatment within 24 hours for such an injury with provisional irrigation by the urgent-care physician appears to be both satisfactory and practically manageable in most practice settings.

A laceration overlying a joint where the mechanism does not suggest a penetrating trauma is usually an indication that the underlying fracture or the bone in the case of a dislocation, has penetrated the skin e.g. the open dorsal dislocation of the proximal interphalangeal joint. In this case the proper irrigation of the joint within 6 hours is the recommended treatment. Suitable exposure of the joint by the urgent-care physician usually cannot be reliably accomplished as surgical extension of the wound may be required or retraction of the flexor tendons and volar plate may be necessary to irrigate the joint.