Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

140.e1
Reconstruction of fingertip injuries
Fig. 6.34  (A) Distal fingertips with exposed bone of the index and long fingers in a 23-year-old female.
(B) A thenar crease flap is elevated based on the radial aspect of the MP joint of the thumb. The index
finger is flexed at the PIP joint and the flap is inset onto the defect of the fingertip. A heterodigital flap is
elevated on the index finger and transposed to cover the tip of the long finger. (C) Flaps are divided and
definitively inset after 2–3 weeks per time to provide appropriate coverage for the distal fingertips of the
index and long fingers.
A
B
C

141
Reconstruction of fingertip injuries
Fig. 6.30  52-year-old male suffered (A)
volar oblique injury to his left thumb during
an industrial accident with (B) exposed
bone. (C) A Moberg volar advancement flap
was performed to prevent skeletal
shortening. Many modifications have been
made to increase the flap advancement
including (D) the V–Y proximal incision
(different patient pictured). This technique
islandizes the flap on the volar
neurovascular bundles.
A
B
C
D

142
SECTION II
CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
Fig. 6.31  (A) Mutilated fingertip with exposed bone requiring soft-tissue coverage. (B) Cross-finger flap from the adjacent digit is used to cover the volar defect of the
index finger. The flap is elevated at the level of the paratenon and the donor site is then closed with a full-thickness skin graft. (C) 2–3 weeks later the flap is divided and
inset. (D) Long-term outcome after soft-tissue healing and nail regrowth.
A
B
C
D
Fig. 6.32  (A) A finger injury with tip amputation and soft-tissue avulsion from the
dorsal aspect of the index finger with exposed tendon. A reverse cross finger flap is
designed. The dorsal skin of the long finger is de-epithelialized. (B) The flap is
elevated at the level of the paratenon and transposed like a page in a book over the
dorsal aspect of the index finger. (C) Both digits are covered with a full-thickness
skin graft and the flaps are then divided and are inset 2–3 weeks later. (D,E) Final
outcome of the reverse cross-finger flap and donor site is shown.
A
B
C
D
E

143
Reconstruction of fingertip injuries
A
Fig. 6.33  (A) The long finger has a distal amputation with exposed bone. To
preserve length, the defect will be closed with a thenar crease flap. (B) The flap
was designed with approximately 1 cm width and based radially. The recipient
finger was flexed at the PIP joint for flap inset.
B
Hints and tips
Reverse dorsal metacarpal artery flap
To gain pedicle length, continue the dissection between the
proximal phalanges on either side. The pedicle is easily
mobilized to reach the volar or dorsal fingertip area.
Littler neurovascular island flap
This neurovascular island flap utilizes the donor skin from the
ulnar aspect of the long or ring finger to provide sensate
vascularized tissue to a given recipient site (Fig. 6.35
).64
However, donor site compromise may be significant resulting
in stiff fingers with contractures making this flap less desir­
able than others for fingertip or thumb pulp reconstruction.
Arteriograms and digital Allen’s tests have been advocated
prior to performing this flap to confirm an adequate
co-dominant arterial supply to the donor and adjacent finger
because the dissection of the flap requires extension beyond
the bifurcation of the common digital artery. The contralateral
branch will need to be ligated and divided. Dividing this
contralateral branch in a finger that does not have another
means of circulation can result in significant digital ischemia.
Therefore, before ligating and dividing the contralateral
branch, a temporary clip should be applied, the tourniquet
released, and the viability of the finger verified.80
Fig. 6.35 appears online only.
The flap may be tunneled through a subcutaneous plane to
the defect on the volar aspect of the thumb or, alternatively,
through a zig-zag Brunner type incision to allow easy trans­
position of the flap without fear of compression or compromise
to the pedicle. The donor site is closed with a split-thickness
skin graft. Creating chevron incisions lateral to the DIP and
PIP creases is important to prevent contractures at these joints
following healing of the skin graft. Protective sensation
has been observed with two-point discrimination averaging
6–7 mm.68 Although there is a potential for cortical relearning
or plasticity, most patients perceive the sensation as that of
the donor site and not the recipient site. Cortical relearning
may only be present in 25–40% of individuals.64,81
Dorsal metacarpal artery flaps
Foucher described the first dorsal metacarpal artery flap for
reconstruction of thumb defects involving the volar thumb
pulp (Fig. 6.36A
). This is also known as a kite flap because
of its distinct appearance of a distal skin paddle pedicled on
a tail of neurovascular structures. This flap utilizes the skin
and subcutaneous tissue of the proximal phalanx of the index
finger and is based on the neurovascular bundle that rests
within or under the fascia of the first dorsal interosseous
muscle (Fig. 6.36B–F).82 The first dorsal metacarpal artery
supplies vascularity in the vena comitantes and some super­
ficial veins supply the venous outflow of the flow. Branches
of the superficial radial nerve provide sensibility to this flap.
The flap is elevated at the plane above the paratenon so that
the donor site can accept the skin graft for closure. The rest of
the pedicle is dissected and the flap can either be transposed
through a tunnel or through a zig-zag incision into the volar
thumb defect.70 Although this flap provides protective sensa­
tion, cortical relearning is required. The morbidity from
harvesting tissue from an undamaged digit must also be
considered.
Fig. 6.36 appears online only.
A reverse dorsal metacarpal artery flap based on perfora­
tors from the palmar digital arteries (Fig. 6.37
) can be used
as an adipofascial flap or with a skin paddle.70 These perfora­
tors arise between the metacarpophalangeal joints and at the
neck of each metacarpal. This flap is a reverse-flow island flap
where the skin paddle is taken from the dorsum of the hand
closer to the wrist. It is elevated off the fascia of the interos­
seous muscles and transposed to resurface distal finger
defects. In order to get adequate pedicle length to cover the
distal finger, the pedicle should be dissected down into the
web space. This flap is not typically used for distal fingertips
but for dorsal defects of the finger as the dissection is some­
what tedious between the digits.
Fig. 6.37 appears online only.

143.e1
Reconstruction of fingertip injuries
Fig. 6.35  (A) The Littler neurovascular island flap utilizes the skin subcutaneous tissue and neurovascular bundle from the nondominant side of the long or ring fingers.
The dissection is carried down into the palm and the flap is transposed to the defect on the thumb. (B) This flap was elevated on the neurovascular bundle involving the
nondominant side of the long finger. (C) The donor defect closed with a full-thickness graft and then the flap transposed onto the dorsum of the thumb. (D) The healed
defect on the thumb with the neurovascular island flap well inset. The donor finger that may result in a contracture if the flap is harvested in a more volar aspect of the
finger.
A
B
C
D

143.e2
SECTION II
CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
Fig. 6.36  (A) Significant defect of the volar pulp of the thumb with exposed bone and tendon. (B) First
dorsal metacarpal artery flap is designed over the dorsal aspect of the index finger. The first dorsal
metacarpal artery lies within the fascia of the first dorsal interosseous muscle. (C) The pedicle is elevated
with the fascia and care is taken to keep the superficial veins to allow appropriate drainage of the flap.
(D) Final appearance of the defect on the thumb as well as the donor site.
A
B
C
D

143.e3
Reconstruction of fingertip injuries
Fig. 6.37  (A) Dorsal defects of the finger with a designed reversed dorsal metacarpal artery flap. (B) The
flap is based between the metacarpal heads as perforators from the palmar side communicate with the dorsal
metacarpal arteries. The venous drainage is retrograde. (C) The flap is tunneled and inset into place to the
dorsal aspect of the finger. This flap can be carried out to the distal aspect of the finger if further dissection
is carried down within the web space.
A
B
C

144
SECTION II
CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
Conclusions
The choice of treatment for fingertip injuries relies heavily on
the patient’s primary outcome goal, namely speed to recovery
vs. skeletal preservation. Revision amputation returns a
laborer to work faster and minimizes chances for complica­
tions, including wound breakdown, joint stiffness and flap
failure. Women or patients interested in preservation of ana­
tomic normalcy may prefer a potentially longer and possibly
multi-stage procedure to return the fingertip as closely as
possible to its normal state. The classic flaps described for
reconstructing the fingertip, including the Moberg, Atasoy,
Foucher and others, remain excellent viable options.
Additional developments have included use of adipofascial
reverse-flow turnover flaps, use of volar perforating branches
from the digital arteries to design custom homodigital flaps
and otherwise considered randomly based flaps (i.e. keystone
design). These allow creation of variable skin paddle designs
to cover defects and speed healing. Additional modalities
include use of negative-pressure dressings and neodermis
(e.g., Integra) to promote granulation and prevent tendon
desiccation.
Recent experiences have demonstrated that many simple
nail bed injuries with an intact nail plate can be observed
with a comparable or potentially superior long-term aesthetic
outcome. More complex injuries or extensive subungual
hematomas still require repair and drainage, however; if
possible the proximal nail plate can be left in situ. A good
understanding of fingertip anatomy and treatment options
remains important, as these types of injuries continue to
be some of the most commonly seen presenting complaints
in emergency and urgent care settings. Avoiding complica­
tions and preventing delayed return of function remains
the continued challenge for practitioners treating these
injuries.
Future directions
Managing joint stiffness, hyperesthesia and nerve injuries
remain the most difficult and unpredictable issues to resolve
after fingertip injuries. The mainstays of treatment include
early range-of-motion therapy to improve gliding and prevent
internal scarring from limiting motion. For patients with
hypersensitivity of the fingertip, desensitization therapy,
smoking cessation, and neurologic medications including
gabalin and pregabalin along with the tincture of time are the
best methods currently available. The use of neuromodula­
tors, including botulinum toxin, may prove to have an added
benefit for these patients. Use of vitamin C has proven useful
for preventing complex regional pain syndrome (CRPS) after
repair of distal radius fractures and may have a benefit for
preventing CRPS in fingertip injuries, too. Regaining full
sensation in transected nerves in the digit also remains an
incompletely solved issue. The current gold standard in order
of preference includes a tension-free primary repair, followed
by autograft, allograft and lastly a nerve conduit. However,
evidence in the literature can be found to support a wide
range of reconstructive strategies. Future directions will need
to be directed towards solving the ongoing unsolved problem
of restoring normal nervous function after injury, preventing
hypersensitivity of the injured fingertip and restoring normal
range of motion.
Bonus images for this chapter can be found online at

Fig. 6.2 Components of the nail are produced in three areas.
Fig. 6.3 Of nail bed injuries: (A) 36% are classified as simple lacerations;
(B) 27% as stellate lacerations; (C) 22% as crushing injuries of the nail bed;
(D) 15% as avulsions of the germinal or sterile matrix.
Fig. 6.7 An example of a stitch in the silicone sheeting to hold it in place.
Fig. 6.8 A longitudinal pin was placed to maintain fracture reduction but was
between the periosteum and sterile matrix, causing scarring in the ridge.
Fig. 6.9 (A) A split nail may occur within the sterile matrix with minimal
problems. (B) An injury to the germinal matrix can cause a split in the entire
nail, causing significant pain secondary to trauma and disfigurement.
Fig. 6.10 (A) A horizontal laceration in the sterile matrix with a resultant
transverse scar can cause a separation so that two nails grow out. If the volar
nail is adequate, surgical removal of the dorsal nail-producing matrix will
correct the problem. (B) The patient’s index finger postoperatively.
Fig. 6.12 (A) A split of the nail due to scarring between the dorsal roof and the
ventral floor of the nail fold. (B) End-on view of the nail deformity. (C) With the
two portions of nail removed, the cicatrix between the dorsal roof and the ventral
floor of the nail fold can be seen. (D) The cicatrix is divided with the resultant
defect on the dorsal roof. (E) A split-thickness sterile matrix graft is removed
from the sterile matrix and sutured in place on the dorsal roof of the nail fold.
(F) One-year follow-up with an improved appearance and reduced functional
problems. (G) An end-on view of the nail demonstrating the improved contour.
Fig. 6.14 (A) Nonadherence of nail to the sterile matrix thought to be due to an
episode of pulling the nail free from the nail bed traumatically and then repeated
attempts to clean under the nail. The area of nonadherence is marked on the
nail. (B) That area of nail is removed, showing the hyperkeratinous sterile
matrix. The hypertrophic keratinous material is scraped off with a scalpel blade
to bare the vascular sterile matrix. (C) The patient 1 year later with improved
adherence of the nail.
Fig. 6.15 (A) Nonadherence of the nails to the nail bed after a crushing injury
and then application of artificial nails. The cause of the detachment could be
either of these. (B) A split-thickness sterile matrix graft from the large toe donor
site is placed over the defect. (C) The patient 1 year later with much improved
attachment.
Fig. 6.17 (A) A hypertrophic hyponychium (arrowhead) causing pain and
discomfort with upper traction on the nail. (B) Dorsal view of the same patient.
(C) Same patient with relief of pain after resection of the hypertrophic
hyponychium and a split-thickness sterile matrix graft in its place. (D) Same
patient, dorsal view with hyponychial attachment.
Fig. 6.29 (A) Homodigital flaps are based on the nondominant digital artery to
the fingers and used to transpose either in a retrograde or an antegrade fashion.
(B) Exposed PIP joint necessitates closure, the homodigital flap is elevated,
care is taken to incorporate the digital artery proper into the flap. (C,D) The flap
is transposed and the donor site closed with a full-thickness skin graft. The flap
can be elevated without transecting the skin paddle proximally. This improves
the venous outflow of the flap. (E) Healed flap, dorsal aspect of finger.
Fig. 6.34 (A) Distal fingertips with exposed bone of the index and long fingers
in a 23-year-old female. (B) A thenar crease flap is elevated based on the radial
aspect of the MP joint of the thumb. The index finger is flexed at the PIP joint
and the flap is inset onto the defect of the fingertip. A heterodigital flap is
elevated on the index finger and transposed to cover the tip of the long finger.
(C) Flaps are divided and definitively inset after 2–3 weeks per time to provide
appropriate coverage for the distal fingertips of the index and long fingers.
Fig. 6.35 (A) The Littler neurovascular island flap utilizes the skin
subcutaneous tissue and neurovascular bundle from the nondominant side of
the long or ring fingers. The dissection is carried down into the palm and the
flap is transposed to the defect on the thumb. (B) This flap was elevated on the
neurovascular bundle involving the nondominant side of the long finger. (C) The
donor defect closed with a full-thickness graft and then the flap transposed onto
the dorsum of the thumb. (D) The healed defect on the thumb with the
neurovascular island flap well inset. The donor finger that may result in a
contracture if the flap is harvested in a more volar aspect of the finger.

145
Future directions
5. Zook EG, Van Beek AL, Russell RC, Beatty ME. Anatomy and
physiology of the perionychium: a review of the literature and
anatomic study. J Hand Surg Am. 1980;5:528–536. This article offers
complete analysis of the normal architecture of the nail bed unit. They
compile a literature review with their own cadaveric dissection for the
purpose of applied anatomy in nail bed repair and reconstruction.
8. Zook EG, Brown RE. Injuries of the fingernail. In: Green DP,
Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed.
New York: Churchill Livingstone; 1999:1353–1380.
16. Ashbell TS, Kleinert HE, Putcha SM, Kutz JE. The deformed finger
nail, a frequent result of failure to repair nail bed injuries. J Trauma.
1967;7:177–190.
17. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes,
treatment, and prognosis. J Hand Surg Am. 1984;9:247–252.
30. Zook EG, Russell RC. Reconstruction of a functional and esthetic
nail. Hand Clin. 1990;6:59–68. This article is an extensive review of the
options to correct a variety of nail deformities. All pictures are clinical
photographs, with excellent long-term follow-up.
31. Yong FC, Teoh LC. Nail bed reconstruction with split-thickness nail
bed grafts. J Hand Surg Am. 1992;17:193–197.
32. Pessa JE, Tsai TM, Li Y, Kleinert HE. The repair of nail deformities
with the nonvascularized nail bed graft: indications and results. J
Hand Surg Am. 1990;15:466–470.
39. Buncke HJ Jr, Gonzalez RI. Fingernail reconstruction. Plast Reconstr
Surg Transplant Bull. 1962;30:452–461.
45. Achauer BM, Welk RA. One-stage reconstruction of the postburn
nailfold contracture. Plast Reconstr Surg. 1990;85:937–940, discussion
941. This article describes reconstruction of the eponychium for burn
reconstruction. Various local flaps are described with indications and
outcomes.
63. Russell R. Fingertip injuries. In: May JW Jr, Littler JW, eds. The
Hand. Philadelphia: WB Saunders; 1990:4477.
64. Ganchi PALW. Fingertip reconstruction. In: Mathes SJ, ed. Plastic
Surgery. Vol. 7. Philadelphia: Elsevier; 2006:153.
70. Neumeister M. Intrinsic flaps of the hand. In: Guyuron B, ed. Plastic
Surgery, Indications and Practice. Philadelphia: WB Saunders;
2009:1001. A review of the vast variety of flaps used for closure of the
finger. Technical details and indications are provided.
82. Omokawa S, Tanaka Y, Ryu J, Kish VL. The anatomical basis for
reverse first to fifth dorsal metacarpal arterial flaps. J Hand Surg
Am. 2005;30:40–44. Many local or regional flaps require flexion of the
PIP joint to permit tension-free coverage. The article describes the
practical anatomy and defining features of the reverse dorsal artery
metacarpal arterial flaps.
Access the complete reference list online at

Fig. 6.36 (A) Significant defect of the volar pulp of the thumb with exposed
bone and tendon. (B) First dorsal metacarpal artery flap is designed over the
dorsal aspect of the index finger. The first dorsal metacarpal artery lies within
the fascia of the first dorsal interosseous muscle. (C) The pedicle is elevated
with the fascia and care is taken to keep the superficial veins to allow
appropriate drainage of the flap. (D) Final appearance of the defect on the
thumb as well as the donor site.
Fig. 6.37 (A) Dorsal defects of the finger with a designed reversed dorsal
metacarpal artery flap. (B) The flap is based between the metacarpal heads as
perforators from the palmar side communicate with the dorsal metacarpal
arteries. The venous drainage is retrograde. (C) The flap is tunneled and inset
into place to the dorsal aspect of the finger. This flap can be carried out to the
distal aspect of the finger if further dissection is carried down within the web
space.

145.e1
References
References
1. AW Ham DC. Histology. 8th ed. Philadelphia: JB Lippincott; 1979.
2. Gonzalez-Serva A. Structure and Function. 2nd ed. Philadelphia: WB
Saunders; 1997.
3. Moore K. The Developing Human. 3rd ed. Philadelphia: WB
Saunders; 1982.
4. Zaias N. Embryology of the human nail. Arch Dermatol.
1963;87:37–53.
5. Zook EG, Van Beek AL, Russell RC, Beatty ME. Anatomy and
physiology of the perionychium: a review of the literature and
anatomic study. J Hand Surg Am. 1980;5:528–536. This article offers
complete analysis of the normal architecture of the nail bed unit. They
compile a literature review with their own cadaveric dissection for the
purpose of applied anatomy in nail bed repair and reconstruction.
6. Flint MH. Some observations on the vascular supply of the nail
bed and terminal segments of the finger. Br J Plast Surg. 1955;8:
186–195.
7. Zook EG. Anatomy and physiology of the perionychium. Hand Clin.
2002;18:553–559, v.
8. Zook EG, Brown RE. Injuries of the fingernail. In: Green DP,
Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed.
New York: Churchill Livingstone; 1999:1353–1380.
9. Piraccini BM, Starace M. Nail disorders in infants and children.
Curr Opin Pediatr. 2014;26:440–445.
10. Baden HP. Regeneration of the nail. Arch Dermatol. 1965;91:619–620.
11. Jones F. The Principles of Anatomy as Seen in the Hand. 2nd ed.
London: Baillière, Tindall & Cox; 1941.
12. Fleckman P. Basic Science of the Nail Unit. 2nd ed. Philadelphia: WB
Saunders; 1997.
13. Barron JN. The structure and function of the skin of the hand. Hand.
1970;2:93–96.
14. De Berker D, Mawhinney B, Sviland L. Quantification of regional
matrix nail production. Br J Dermatol. 1996;134:1083–1086.
15. Lewis BL. Microscopic studies of fetal and mature nail and
surrounding soft tissue. AMA Arch Derm Syphilol. 1954;70:
733–747.
16. Ashbell TS, Kleinert HE, Putcha SM, Kutz JE. The deformed finger
nail, a frequent result of failure to repair nail bed injuries. J Trauma.
1967;7:177–190.
17. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes,
treatment, and prognosis. J Hand Surg Am. 1984;9:247–252.
18. Tzeng YS. Use of an 18-gauge needle to evacuate subungual
hematomas. J Emerg Med. 2013;44:196–197.
19. Khan MA, West E, Tyler M. Two millimetre biopsy punch: a
painless and practical instrument for evacuation of subungual
haematomas in adults and children. J Hand Surg Eur Vol.
2011;36:615–617.
20. Kain N, Koshy O. Evacuation of subungual haematomas using
punch biopsy. J Plast Reconstr Aesthet Surg. 2010;63:1932–1933.
21. Horn B. Treatment of subungual hematoma in office and outdoor
conditions]. Ther Umsch. 2015;72:58.
22. Soyuncu S, Bektas F. Nail bed injury detected by ultrasonography.
Am J Emerg Med. 2012;30:1323.e5–1323.e6.
23. Simon RR, Wolgin M. Subungual hematoma: association with occult
laceration requiring repair. Am J Emerg Med. 1987;5:302–304.
24. Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual
hematomas with nail trephination: a prospective study. Am J Emerg
Med. 1991;9:209–210.
25. Roser SE, Gellman H. Comparison of nail bed repair versus nail
trephination for subungual hematomas in children. J Hand Surg Am.
1999;24:1166–1170.
26. Dean B, Becker G, Little C. The management of the acute traumatic
subungual haematoma: a systematic review. Hand Surg.
2012;17:151–154.
27. Shepard GH. Management of acute nail bed avulsions. Hand Clin.
1990;6:39–56, discussion 57–58.
28. Johnson RK. Nailplasty. Plast Reconstr Surg. 1971;47:275–276.
29. Shepard GH. Nail grafts for reconstruction. Hand Clin. 1990;6:79–
102, discussion 103.
30. Zook EG, Russell RC. Reconstruction of a functional and esthetic
nail. Hand Clin. 1990;6:59–68. This article is an extensive review of the
options to correct a variety of nail deformities. All pictures are clinical
photographs, with excellent long-term follow-up.
31. Yong FC, Teoh LC. Nail bed reconstruction with split-thickness nail
bed grafts. J Hand Surg Am. 1992;17:193–197.
32. Pessa JE, Tsai TM, Li Y, Kleinert HE. The repair of nail deformities
with the nonvascularized nail bed graft: indications and results.
J Hand Surg Am. 1990;15:466–470.
33. McCash C. Free nail grafting. Br J Plast Surg. 1955;8:19–33.
34. Lille S, Brown RE, Zook EE, Russell RC. Free nonvascularized
composite nail grafts: an institutional experience. Plast Reconstr
Surg. 2000;105:2412–2415.
35. Koshima I, Soeda S, Takase T, Yamasaki M. Free vascularized nail
grafts. J Hand Surg Am. 1988;13:29–32.
36. Shibata M, Seki T, Yoshizu T, et al. Microsurgical toenail transfer to
the hand. Plast Reconstr Surg. 1991;88:102–109, discussion 110.
37. Nakayama Y, Iino T, Uchida A, et al. Vascularized free nail grafts
nourished by arterial inflow from the venous system. Plast Reconstr
Surg. 1990;85:239–245, discussion 246–247.
38. Endo T, Nakayama Y. Short-pedicle vascularized nail flap. Plast
Reconstr Surg. 1996;97:656–661.
39. Buncke HJ Jr, Gonzalez RI. Fingernail reconstruction. Plast Reconstr
Surg Transplant Bull. 1962;30:452–461.
40. Baruchin AM, Nahlieli O, Vizethum F, Sela M. Utilizing the
osseointegration principle for fixation of nail prostheses. Plast
Reconstr Surg. 1995;96:1665–1671.
41. Kumar VP, Satku K. Treatment and prevention of “hook nail”
deformity with anatomic correlation. J Hand Surg Am.
1993;18:617–620.
42. Bubak PJ, Richey MD, Engrav LH. Hook nail deformity
repaired using a composite toe graft. Plast Reconstr Surg.
1992;90:1079–1082.
43. Hayes CW. One-stage nail fold reconstruction. Hand. 1974;6:74–75.
44. Kasai K, Ogawa Y. Nailplasty using a distally based ulnar finger
dorsum flap. Aesthetic Plast Surg. 1989;13:125–128.
45. Achauer BM, Welk RA. One-stage reconstruction of the postburn
nailfold contracture. Plast Reconstr Surg. 1990;85:937–940, discussion
941. This article describes reconstruction of the eponychium for burn
reconstruction. Various local flaps are described with indications and
outcomes.
46. Bakhach J. [Eponychial flap]. Ann Chir Plast Esthet. 1998;43:
259–263.
47. Chen HY, Hsu CC, Lin YT, et al. Functional and aesthetic outcomes
of the fingertips after nail lengthening using the eponychial flap. J
Plast Reconstr Aesthet Surg. 2015;68:1438–1446.
48. Baran RHE. Tumours of the Nail Apparatus and Adjacent Tissues.
Oxford: Blackwell Scientific; 1984.
49. Stephen S, Tosti A, Rubin AI. Diagnostic applications of nail
clippings. Dermatol Clin. 2015;33:289–301.
50. Fleegler EJ, Zeinowicz RJ. Tumors of the perionychium. Hand Clin.
1990;6:113–133, discussion 135–116.
51. Piraccini BM, Dika E, Fanti PA. Tips for diagnosis and treatment of
nail pigmentation with practical algorithm. Dermatol Clin.
2015;33:185–195.
52. Phan A, Touzet S, Dalle S, et al. Acral lentiginous melanoma: a
clinicoprognostic study of 126 cases. Br J Dermatol. 2006;
155:561–569.
53. Krementz ET, Feed RJ, Coleman WP 3rd, et al. Acral lentiginous
melanoma. A clinicopathologic entity. Ann Surg. 1982;195:632–645.
54. Patterson RH, Helwig EB. Subungual malignant melanoma: a
clinical-pathologic study. Cancer. 1980;46:2074–2087.
55. Das Gupta T, Brasfield R. Subungual melanoma: 25-year review of
cases. Ann Surg. 1965;161:545–552.
56. Park KG, Blessing K, Kernohan NM. Surgical aspects of subungual
malignant melanomas. The Scottish Melanoma Group. Ann Surg.
1992;216:692–695.

145.e2
SECTION II
CHAPTER 6 • The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction
57. Cochran AM, Buchanan PJ, Bueno RA Jr, Neumeister MW.
Subungual melanoma: a review of current treatment. Plast Reconstr
Surg. 2014;134:259–273.
58. Suzuki K, Yagi I, Kondo M. Surgical treatment of pincer nail
syndrome. Plast Reconstr Surg. 1979;63:570–573.
59. Brown RE, Zook EG, Williams J. Correction of pincer-nail deformity
using dermal grafting. Plast Reconstr Surg. 2000;105:1658–1661.
60. Miller AJ, Rivlin M, Kirkpatrick W, et al. Fingertip amputation
treatment: a survey study. Am J Orthop (Belle Mead NJ).
2015;44:E331–E339.
61. Allen MJ. Conservative management of finger tip injuries in adults.
Hand. 1980;12:257–265.
62. Browne EZ, Pederson WC. Skin grafts and skin flaps. In: Green DP,
Hotchkiss RN, Pederson WC, et al., eds. Green’s Operative Hand
Surgery. 5th ed. Philadelphia: Elsevier; 2005:1629.
63. Russell R. Fingertip injuries. In: May JW Jr, Littler JW, eds. The
Hand. Philadelphia: WB Saunders; 1990:4477.
64. Ganchi PALW. Fingertip reconstruction. In: Mathes SJ, ed. Plastic
Surgery. Vol. 7. Philadelphia: Elsevier; 2006:153.
65. Moiemen NS, Elliot D. Composite graft replacement of digital tips.
2. A study in children. J Hand Surg Am. 1997;22:346–352.
66. Eberlin KR, Busa K, Bae DS, et al. Composite grafting for pediatric
fingertip injuries. Hand (N Y). 2015;10:28–33.
67. Kiuchi T, Shimizu Y, Nagasao T, et al. Composite grafting for distal
digital amputation with respect to injury type and amputation
level. J Plast Surg Hand Surg. 2015;49:224–228.
68. Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction of the
amputated finger tip with a triangular volar flap. A new surgical
procedure. J Bone Joint Surg Am. 1970;52:921–926.
69. Gharb BB, Rampazzo A, Armijo BS, et al. Tranquilli-Leali or Atasoy
flap: an anatomical cadaveric study. J Plast Reconstr Aesthet Surg.
2010;63:681–685.
70. Neumeister M. Intrinsic flaps of the hand. In: Guyuron B, ed. Plastic
Surgery, Indications and Practice. Philadelphia: WB Saunders;
2009:1001. A review of the vast variety of flaps used for closure of the
finger. Technical details and indications are provided.
71. Karamursel S, Kayikcioglu A, Aksoy HM, et al. Dorsal visor flap in
fingertip reconstruction. Plast Reconstr Surg. 2001;108:1014–1018.
72. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for
fingertip reconstruction. Ann Plast Surg. 1989;22:495–500.
73. Koshima I, Urushibara K, Fukuda N, et al. Digital artery perforator
flaps for fingertip reconstructions. Plast Reconstr Surg.
2006;118:1579–1584.
74. Mitsunaga N, Mihara M, Koshima I, et al. Digital artery perforator
(DAP) flaps: modifications for fingertip and finger stump
reconstruction. J Plast Reconstr Aesthet Surg. 2010;63:1312–1317.
75. Kawakatsu M, Ishikawa K. Dorsal digital perforator flap for
reconstruction of distal dorsal finger defects. J Plast Reconstr Aesthet
Surg. 2010;63:e46–e50.
76. Karamese M, Akatekin A, Abac M, et al. Fingertip Reconstruction
With Reverse Adipofascial Homodigital Flap. Ann Plast Surg.
2015;75:158–162.
77. Shen XF, Xue MY, Mi JY, et al. Innervated digital artery perforator
propeller flap for reconstruction of lateral oblique fingertip defects.
J Hand Surg Am. 2015;40:1382–1388.
78. Melone CP Jr, Beasley RW, Carstens JH Jr. The thenar flap–An
analysis of its use in 150 cases. J Hand Surg Am. 1982;7:291–297.
79. Porter RW. Functional assessment of transplanted skin in volar
defects of the digits. A comparison between free grafts and flaps. J
Bone Joint Surg Am. 1968;50:955–963.
80. Lee YH, Baek GH, Gong HS, et al. Innervated lateral middle
phalangeal finger flap for a large pulp defect by bilateral
neurorrhaphy. Plast Reconstr Surg. 2006;118:1185–1193, discussion
1194.
81. Henderson HP, Reid DA. Long term follow up of neurovascular
island flaps. Hand. 1980;12:113–122.
82. Omokawa S, Tanaka Y, Ryu J, Kish VL. The anatomical basis for
reverse first to fifth dorsal metacarpal arterial flaps. J Hand Surg
Am. 2005;30:40–44. Many local or regional flaps require flexion of the
PIP joint to permit tension-free coverage. The article describes the
practical anatomy and defining features of the reverse dorsal artery
metacarpal arterial flaps.

SECTION II • Acquired Traumatic Disorders
7 
Hand fractures and joint injuries
Joseph S. Khouri and Warren C. Hammert
SYNOPSIS
■ Diagnosis of hand fractures and joint injuries requires history,
examination, and adequate imaging studies.
■ Treatment decisions are based on fracture geometry, stability, and
individual patient needs.
■ Non-operative principles include reduction, maintenance of reduction
through casting or splinting, followed by protected motion.
■ Operative treatment includes closed reduction with or without
percutaneous pinning, external fixation, and open reduction and internal
fixation.
■ Rehabilitation is an important aspect of caring for patients with hand
fractures and joint injuries and involves splinting and restoring motion.
■ Secondary procedures may be considered when the desired outcome
is not achieved. These include correction of malunion, tenolysis, and
capsulotomy.
Introduction
Phalangeal and metacarpal fractures are estimated to account
for 16.2 and 12.5 fractures per 10 000 persons, respectively.1
Appropriate diagnosis and treatment can minimize deformity
and maximize function. Although many of these fractures can
be managed non-operatively, appropriate follow-up is crucial
for a good outcome. These injuries can result in time away
from work and activities and can be complicated by stiffness
and weakness. The goal of the treating physician should be to
minimize deformity and maximize function. The decision
to operate depends on multiple factors, including stability,
location, geometry, configuration, and associated injuries, but
ultimately is chosen when the anticipated outcome is better
than non-operative management.2
The goal of treatment of fractures in the hand is to reduce
and stabilize the fracture, maintain the reduction and begin
rehabilitation to restore function. The treating physician must
take into account the vocation and avocation of the injured
patient, as this may affect the treatment.
Anatomy
The metacarpals and proximal and middle phalanges are
anatomically divided into the head, neck, shaft, and base. The
distal phalanx is divided into the tuft, shaft, and base. The
carpometacarpal (CMC) joints of the index and middle fingers
have little mobility, while the ring and small fingers have
some motion to allow for grasp and power grip. The metacar­
pophalangeal (MCP) joints are stabilized by the volar plate
and the collateral ligaments: the proper collateral ligaments
are thicker and run between the head of the metacarpal and
the base of the proximal phalanx, while the accessory collat­
eral ligaments are thinner and have a more vertical direction,
running from the metacarpal head to the volar plate. The cam
shape of the metacarpal head contributes to the tightening of
the collateral ligaments when the joint is flexed, stabilizing the
joint and decreasing abduction and adduction, whereas in
extension, the collateral ligaments are lax and allow some
radial–ulnar motion. The thick intermetacarpal ligaments
stabilize the second through fifth metacarpals distally, often
providing stability with fractures of the metacarpal shaft. The
MCP joint articulations of the thumb are hinged, allowing
flexion and extension whereas MCP joints of the index through
little fingers are condyloid in nature and allow flexion/
extension, abduction/adduction, and circumduction.3
The proximal phalanx acts as an intercalated segment, with
tendons running on all sides, but nothing inserting on this
bone. The collateral ligaments of the proximal interphalangeal
(PIP) joint contain a proper and accessory component, with
insertions into the base of the middle phalanx and the volar
plate, respectively. They function to provide lateral stability.
The head is bicondylar in shape (as opposed to the cam shape
of the metacarpal head) and the collateral ligaments of the PIP
joint are tightest with the joint in extension. The middle
phalanx has insertions of the extensor mechanism (central
slip) and flexor tendon (flexor digitorum superficialis – FDS).
The distal interphalangeal (DIP) joint is anatomically similar
to the PIP joint and the distal phalanx contains the insertion
  Access video and video lecture content for this chapter online at expertconsult.com

147
Classification of fractures and dislocations
Articular fractures are more common in the PIP and DIP joints
than the MCP joints. They may occur through the head or the
base. Fractures through the head of the phalanges are classi­
fied as unicondylar or bicondylar and can occur in the sagittal
and/or coronal plane. Fractures through the shaft can occur
as transverse, oblique, or spiral planes. In addition, fractures
can be classified as comminuted when there are multiple
fragments.
The angular deformity of the fracture is dependent upon
the forces acting on the distal bones. The deformity is classi­
fied according to the position of the distal fracture segment
relative to the proximal segment. Metacarpal fractures most
commonly have an apex dorsal angulation while fractures of
the proximal phalanx tend to have apex volar angulation
secondary to the pull of the interosseous muscles. Fractures
of the middle phalanx have a variable deformity, depending
on the location of the fracture. Those proximal to the insertion
of the FDS have dorsal angulation due to flexion of the distal
portion of the bone from the FDS, while fractures distal to the
FDS insertion have apex volar angulation due to flexion of the
proximal fragment (Fig. 7.1).
For a dislocation to occur, the stabilizing structures
(collateral ligaments, volar plate, dorsal capsule) must be
of the terminal portion of the extensor mechanism and the
flexor digitorum profundus (FDP).
The volar plates of the MCP joints differ from the IP joints
in that the MCP joint volar plate has more of an accordion-like
structure, allowing for the volar plate to be compressed with
flexion and expanded with extension. The volar plates of the
IP joints have stout proximal extensions known as checkrein
ligaments. When contracted, these can contribute to PIP
flexion contractures.
The thumb has a greater degree of motion at the CMC joint,
allowing for opposition to the fingers. The CMC joint of the
thumb is classified as a saddle joint allowing flexion/
extension, abduction/adduction as well as circumduction.
The shape of the metacarpal head (radial condyle has greater
dorsal–volar dimension) allows for pronation of the thumb to
assist with opposition.
Classification of fractures
and dislocations
Fractures of the phalanges and metacarpals may occur through
the joints (articular) or along the shaft (extra-articular).
A
Fig. 7.1  Angular deformity associated with fractures of the
metacarpal and phalanges. (A) Metacarpal fractures typically
have apex dorsal angulation secondary to the location of the
interosseous muscles, while the proximal phalanx fractures
(B) have an apex volar angulation. The angulation of middle
phalanx fractures is dependent on the location of the fracture,
relative to the insertion of the FDS tendon: fractures proximal
to the insertion (C) will have apex dorsal angulation while
those distal (D) will have apex volar angulation.
B
C
D
Proximal phalanx
Proximal middle phalanx (metaphysis)
Distal middle phalanx

148
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
Fig. 7.2  Classification of Salter–Harris fractures. Type 1 is through the physis.
Type 2 extends from the physis toward the shaft. Type 3 extends from the physis
toward the joint. Type 4 starts in the shaft and extends through the physis and into
the joint. Type 5 is a crush injury of the physis.
Normal
Type 1–5%
Type 2–75%
Type 3–10%
Type 4–10%
Type 5–uncommon
Table 7.1  Classification of Salter–Harris fractures
Type 1
Fracture is confined to the physis, often with normal
radiographs
Type 2
Fracture starts in the physis and extends through the
shaft (away from the joint)
Type 3
Fracture starts in the physis and extends into the joint
Type 4
Fracture starts in the shaft and extends through the
physis and into the joint
Type 5
The physis is crushed, and there may be sheering
through the physis
disrupted. Dislocations are similarly described by the location
of the distal bone and are classified as dorsal, volar, radial, or
ulnar.
Fracture dislocations commonly occur at the PIP joints of
the fingers, and the base of the thumb and ring/small meta­
carpals. PIP joint and ulnar sided CMC joint fracture disloca­
tions are most commonly dorsal. Thumb CMC joint fracture
dislocations are referred as Bennett or Rolando, depending on
the configuration and size of the fractured segments.
Fracture stabilization/fixation and
return to function
The goal of fracture treatment in the hand is to reduce the
fracture and maintain the reduction while restoring motion.
Prolonged immobilization will lead to stiffness and should be
avoided. Open reduction requires exposure of the fracture
sites and stripping of the periosteum. This will induce scaring
that impedes motion, so when open reduction is performed,
it is important that fixation be stable enough to allow early
motion.
For non-displaced fractures, often protection with buddy
straps and active motion without resistance is adequate. For
displaced or unstable fractures, reduction and fixation is
necessary. Rigid internal fixation with plates and/or screws
can provide an anatomic reduction, and the fractures can heal
by primary bone healing, but this is not always necessary for
hand fractures. This can be particularly problematic for proxi­
mal and middle phalanx fractures as there are tendons on all
sides that must glide for full motion. The presence of plates
and screws in this area will produce scarring and often require
removal to maximize motion and ultimately function.
Functionally stable fixation implies the fracture is stable
enough to begin motion. This can often be accomplished by
closed reduction with percutaneous Kirschner wire (K-wire)
insertion. The K-wires can be removed, leaving no internal
hardware and minimizing additional scarring.
Pediatric fractures
Pediatric fractures, or fractures in patients with open growth
plates require special attention. The physes are located in the
metacarpal neck regions in the index, long, ring, and small
fingers and at the metacarpal base in the thumb. The physes
of the phalanges are located at the base. Growth plate fractures
are described by the Salter–Harris classification (Fig. 7.2 and
Table 7.1), with type II being the most common. An extra-
articular fracture of the proximal phalanx is the most common
pediatric fracture of the proximal phalanx. This is a Salter–
Harris type II fracture with angulation distal to the physis.
The physeal fracture is secondary to the proximal attachment
of the collateral ligament.
General principles include early reduction and stabiliza­
tion. An initial reduction attempt should be completed for
displaced fractures, but remanipulating a fracture involving
the growth plate should be minimized as this can lead to
physeal arrest and premature closure of the growth plate.
Generally, the use of plates and screws is avoided and hard­
ware is removed when the fracture is healed. Stabilization of
fractures can be accomplished with smooth K-wires and if
necessary to cross the physis, effort should be made to mini­
mize the number of passes and thus further injury to the
growth plate.
Open fractures
Open fractures of the distal phalanx are treated with irrigation
and debridement. If the circulation is intact and the patient is

149
Treatment: fingers
for phalangeal fractures). Three views of the injured part are
required to adequately evaluate a fracture in the hand.
Occasionally, additional studies will be necessary for diag­
nosis or to further define the injury. For example, a collateral
ligament injury at the metacarpophalangeal (MCP) of the
thumb may not be apparent with plain radiographs, but will
become apparent with stress views when the joint space is
increased. Magnetic resonance imaging (MRI) can also be
used to evaluate collateral ligament injuries and determine if
a Stener lesion is present, guiding treatment. Computerized
tomography (CT) scans can be used to determine bony
alignment/fracture configuration and may be helpful in some
joint injuries.
Treatment: fingers
Once the diagnosis of a fracture has been made, a decision
must be made regarding the best treatment. Options include
protection with early motion, immobilization alone or reduc­
tion by closed or open techniques. The goal should be to
reduce the fracture, maintain the reduction and return the
patient to function with early motion, while minimizing
stiffness.
Phalangeal fractures and dislocations
Fractures of the distal phalanx are among the most common
fractures encountered.6 They can involve the tuft, shaft, or
base, often extending into the articular surface of the DIP joint.
Tuft fractures are often associated with nail bed injuries and
repair of the nail bed often reduces and stabilizes the fracture.
Shaft fractures are often stable and patients may function well
after healing with a fibrous union. For those cases where the
fibrous union is symptomatic, correction of the non-union/
fibrous union can be performed.
DIP joint
Bony mallet fractures involve the dorsal aspect of the base of
the distal phalanx. The dorsal aspect contains the terminal
extensor tendon and the goal of treatment should be to allow
healing of a congruent joint without an extension lag. Most of
these can be treated with a splint, maintaining the alignment
of the joint.7,8 These fractures tend to have palpable and
sometimes visible prominence along the dorsal aspect of the
finger following healing, even when the radiographic align­
ment is anatomical, but this typically does not adversely affect
their function. Fractures with volar subluxation of the distal
phalanx should be reduced and often require pinning of the
joint to maintain the reduction.9 Several techniques have been
described, but all involve reduction of the joint surface.10–12
Attempted screw placement into the fragment is difficult,
even when the fragment appears large on radiograph, and
often results in fragmentation of the dorsal bone. Surgical
treatment of stable fractures without subluxation is generally
reserved for patients who cannot wear the splint continuously
during the healing process, as complications such as pin
breakage, pin tract infections and subsequent osteomyelitis
can occur, and the risks must be carefully considered.
DIP joint dislocations are typically in a dorsal direction
(distal phalanx is dorsal to the middle phalanx) (Fig. 7.4).
Acute dislocations can often be managed by closed reduction.
immunocompetent, antibiotics are not necessary. Fractures of
other bones in the hand are treated with antibiotics in addition
to irrigation and debridement. Cephalosporins are generally
used and with crush injuries or heavy contamination, an
aminoglycoside is added. Bite wounds (human or animal)
should have penicillin added to cover anaerobes (Eikenella in
human bites) and Pasteurella in animal bites (see Chapter 16,
Infections of the hand).
Bone gaps
In high-energy injuries such as gunshot wounds, the hand
surgeon may be faced with a bone defect. These defects are
divided into non-critical (less than 6–8 cm) and critical (greater
than 6–8 cm). In a non-critical bone deficit of the hand, recon­
struction with autologous bone graft allows rigid fixation to
promote optimal healing.4 Free vascularized bone flaps are
necessary when treating critical bone gap (greater than
6–8 cm), but require microsurgical expertise. Osteoconductive
substrates such as calcium phosphate cement and demineral­
ized bone are contraindicated in infected or potentially
infected wounds; they also require a previously stabilized
defect, as they will add no structural support.5
Diagnosis
The diagnosis of hand injuries begins with a history, including
hand dominance and occupation as well as the mechanism of
injury. The appearance of the hand should be evaluated with
the fingers extended as well as flexed. The alignment of the
digits may appear normal in extension, but the patient should
be asked to flex the fingers as a rotational deformity may
become apparent, even with limited flexion (Fig. 7.3).
Specific areas of edema, ecchymosis or tenderness are
noted as well as any wounds that may be present. While
general screening radiographs of the hand may be beneficial
for initial evaluation, specific X-rays provide better detail and
should be used once the diagnosis is made (radiographs of
the injured finger are preferred over radiographs of the hand
Fig. 7.3  Clinical example of malrotation of the middle finger secondary to a
metacarpal fracture.

150
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
injuries, making postoperative rehabilitation important to
optimize the outcome. Plate and screw fixation can provide
good stability and allow early motion, but hardware tends to
irritate extensor tendons, often resulting in adhesions, neces­
sitating removal and tenolysis to improve tendon gliding. Lag
screws are better tolerated than plates, but still require soft
tissue dissection, which can result in adhesions and limit
postoperative motion. K-wire fixation can often be accom­
plished with minimal soft-tissue stripping and can easily be
removed following healing, but the fixation is not rigid, so the
rehabilitation program cannot be as aggressive. These frac­
tures take a longer to heal due to the higher ratio of cortical
to cancellous bone (in comparison to the proximal phalanx
and metacarpal), but are usually stable enough to remove the
K-wires between 4 and 6 weeks. Radiographic healing may
take up to 4 months. A removable splint for protection and
protected motion with buddy strapping is instituted to maxi­
mize motion.
PIP joint injuries
Injuries around the PIP joint are challenging to treat and good
outcomes can be difficult to obtain. Stiffness is common and
causes difficulty with gripping and grasping activities, as well
as fine dexterity. The small size of the articular fracture frag­
ments can make it difficult to maintain reduction. The goal in
treating injuries of the PIP joint is to create a congruent joint
and begin a rehabilitation program aimed at restoring motion.
The PIP joint functions as a hinge joint with approximately
100° of motion in the sagittal plane (flexion/extension) and
minimal motion in the coronal or axial planes. The base of the
middle phalanx is a biconcave surface with a central ridge.
The volar lateral aspects of the bone are the sites of insertion
of the proper collateral ligaments. The volar plate is a fibro­
cartilaginous structure, which provides additional stability to
the joint. It has thicker fibers that insert laterally and thinner
fibers, which insert centrally, to the base of the middle phalanx
and proximal extensions (checkrein ligaments), which attach
to the periosteum on the proximal phalanx. The volar base of
the middle phalanx and its curvature play an important role
in stability, preventing dorsal subluxation of the middle
phalanx.
The head of the proximal phalanx contains two condyles,
separated by a groove or sulcus. There is a slight difference
on the size of each condyle, allowing the fingers to converge
in flexion. The index and middle have a slightly larger radial
condyle while the small finger has a slightly larger ulnar
condyle.
Injuries involving the PIP joint can involve fracture of the
base of the middle phalanx, the head of the proximal phalanx,
a pure dislocation, or any combination of these. Fractures
involving the base of the middle phalanx include dorsal base
fractures (involving the insertion of the central slip of the
extensor mechanism), the volar base, resulting dorsal sublux­
ation of the middle phalanx, avulsion of the collateral liga­
ments, or pilon type of fracture involving the dorsal and volar
margins, with a depressed central articular fragment (Fig. 7.5).
Fractures involving the proximal phalanx head can involve
one or both condyles and can occur with or without proximal
extension.
Pure dislocations result from hyperextension and an axial
load. They are often dorsal dislocations and are managed
Flexing the wrist and MCP joints to take the tension off the
flexor tendons, and applying distal pressure to the base of the
distal phalanx will often reduce the joint. If this is unsuccess­
ful, it is often due to tissue interposed in the joint – most
commonly the volar plate – and an open reduction is neces­
sary.13 This can be completed through a volar zig-zag incision
or midlateral incisions. The joint is exposed and any interven­
ing tissue is removed, taking care to avoid damaging the
articular cartilage, and the joint is reduced. Late presentation
of DIP joint dislocations will usually require open reduction,
using the same technique. Following reduction, these injuries
are typically stable and immediate motion can be started
using a dorsal blocking splint.
Fractures involving the proximal aspect of the DIP joint can
occur as isolated middle phalanx articular fractures, involving
one or both condyles and may extend proximally into the
shaft (diaphysis). Stable fractures can be managed with pro­
tective splinting and followed closely with radiographs. If
alignment is maintained, buddy taping and range-of-motion
(ROM) exercises can begin around 3 weeks and can be con­
tinued for an additional 3 weeks or until radiographic healing
is present. Unstable or displaced fractures should be reduced
and stabilized either with K-wires or screws.
Middle phalanx shaft fractures
Treatment of middle phalanx shaft fractures depends on sta­
bility and fracture pattern (transverse versus oblique/spiral).
Stable, non-displaced fractures can be managed with a short
period of immobilization (typically 2–3 weeks) followed by
protected motion with buddy taping. They should be fol­
lowed closely, checking for displacement and clinical signs of
malrotation. This should be checked with the fingers in
flexion. Any evidence of malrotation is an indication for
reduction and stabilization.
Oblique fractures tend to be unstable, even following
closed reduction, and often result in shortening, which is
poorly tolerated by the extensor mechanism. Spiral fractures
shorten and rotate. Therefore, these fractures are usually best
treated with stabilization. Stiffness is common following these
Fig. 7.4  Radiograph of DIP dorsal dislocation of index finger.

151
Treatment: fingers
is slightly flexed. These injuries are classified according to the
amount of the articular surface involved. Fractures involving
<30% of the articular surface of the base of the middle phalanx
are typically stable and can be managed non-operatively.
Fractures involving 30–50% of the articular surface are tenuous
and often are unstable. Fractures involving >50% are unstable
and result in dorsal subluxation of the middle phalanx
(Fig. 7.6).16
Lateral radiographs should be carefully evaluated for the
“V sign”, indicative of dorsal subluxation (Fig. 7.7). The two
condyles of the proximal phalanx should be superimposed
and the base of the middle phalanx should be collinear with
the head of the proximal phalanx. There should be a smooth
curvature of the joint surface, with a consistent space between
the proximal and middle phalanx. If there is convergence of
the joint space creating a dorsal “V”, the patient may be able
to flex the digit at the PIP joint, but this occurs through a
hinge process rather than rotation, and the joint surface will
degenerate.
Treatment is directed at recreating a congruent joint surface
and restoring motion. Stable fractures and those which are
classified as tenuous but maintain stable reduction and
a congruent joint with no more than 30° of flexion can be
managed non-operatively with a dorsal extension block
splint. Active flexion is initiated and extension is allowed
short of the point of subluxation. These patients should be fol­
lowed closely to ensure that subluxation of the joint does not
develop. Unstable fractures, or those which a congruent joint
similar to the DIP joint, with an initial trial of closed reduction
(with the wrist and fingers flexed and distal pressure on the
base of the middle phalanx). When successful, a dorsal block­
ing splint and early active flexion can produce good results.
When reduction cannot be completed by closed means, open
reduction is indicated, either through a volar or midlateral
approach.14
Volar dislocations are less common, but can lead to late
deformities if not recognized and treated.15 The central slip is
often injured and can result in late boutonniere deformities.
Following reduction, splinting the PIP joint in extension and
active flexion of the DIP joint will allow gliding of the lateral
bands. Active flexion can be started following three weeks, as
further immobilization of the PIP joint may result in perma­
nent stiffness. Irreducible dislocations are due to an interposed
central slip or collateral ligament and require open reduction
through a dorsal approach, allowing direct inspection of the
central slip.
Middle phalanx base articular fractures
Fracture dislocations of the PIP joint result from an axial load
in a dorsal direction or longitudinal direction when the finger
Fig. 7.5  Classification of PIP joint fracture dislocations. (A) Volar base fracture
resulting in dorsal subluxation of the middle phalanx. (B) Dorsal base fracture
resulting in volar subluxation of the middle phalanx. (C) Pilon type fracture with
dorsal and volar base fractures and comminuted, depressed central articular
surface.
A
B
C
Fig. 7.6  Stability of PIP fracture dislocations. Fractures involving <30% of the
articular surface are typically stable. Those involving 30–50% are tenuous and
those involving >50% are unstable and have resultant dorsal subluxation.
Unstable
Tenuous
Stable
Fig. 7.7  The lateral “V” sign indicating dorsal subluxation of the middle phalanx
and associated hinging with flexion.

152
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
Hints and tips
• Fluoroscopy can be helpful to determine stability of PIP
dorsal fracture dislocations.
• The patient can actively flex and extend the digit and the
point of subluxation can be determined.
• If this is <30°, an extension blocking splint with active
flexion can be used.
• If this is >30°, operative treatment is indicated.
cannot be established with <30° of flexion, require operative
treatment.
A variety of techniques have been described, including
extension block pinning,17,18 open reduction and internal fixa­
tion,17 volar plate arthroplasty,18,19 replacement arthroplasty,20,21
and external fixation. All of these techniques have case reports
or small series illustrating good outcomes, but there are no
prospective studies indicating one technique is better than
others for a particular injury.22–24
Internal fixation
Internal fixation of middle phalanx base fractures can be
demanding, but good results can be obtained. Postoperative
rehabilitation is critical to a good outcome, so the patient must
be compliant or the result can be a good radiograph with a
stiff non-functional finger. Larger fragments can often be
stabilized with small screws, reconstructing the volar base of
the middle phalanx (Fig. 7.9
). Dorsal fragments can be
stabilized with screws or K-wires to reinsert the central slip.
Comminution at the base of the middle phalanx creates a
greater challenge and the surgeon should be prepared for this
as often what appears as a large piece on X-ray is found to be
multiple smaller pieces. If the articular surface can be reduced,
a cerclage wire may be used to hold the bone fragments in
place (Fig. 7.10
).26 his may provide adequate stability to
allow early motion.
If the remaining fragments are too small to stabilize, they
can be excised and the joint surface is reconstructed. The two
most common methods to accomplish this are by advancing
the volar plate (volar plate arthroplasty) or replacement of the
volar base of the middle phalanx. This can be accomplished
by using a portion of the hamate (hemi-hamate graft/
replacement arthroplasty, HHRA).
The volar plate arthroplasty was described by Eaton and
Malerich in 198019 and involves excision of the collateral liga­
ments, removing the comminuted portion of bone along the
volar aspect of the base of the middle phalanx, creating a
trough parallel to the dorsal surface of the middle phalanx,
and advancing the volar plate to resurface the joint. The volar
plate is attached to the bone, either through drill holes or with
a permanent suture at the lateral aspect. The joint is temporar­
ily pinned in slight flexion. At 3 weeks, the pin is removed
and motion is begun.18 The volar plate serves to prevent
dorsal subluxation of the middle phalanx. The results with
this technique can be unpredictable as stiffness and recurrent
dorsal subluxation can occur. Long-term follow-up of Dr.
Eaton’s patients have been published with good results,27 but
there are few recent reports of this procedure.
More recently, the hemi-hamate replacement arthroplasty
has been described (Hastings et al., ASSH annual meeting,
1999) and subsequently published. The dorsal distal portion
of the hamate has similar anatomy to the volar base of the
middle phalanx. Osseous cuts must be precise and the curva­
ture of the volar base of the middle phalanx must be repro­
duced or persistent dorsal subluxation will occur. This can be
rigidly fixed and early motion can be instituted. Published
series have shown promising results.21,28
Technique of HHRA (Video 7.2 )
The finger is approached from the volar aspect with a Bruner
incision from the palmodigital crease to the DIP flexion crease
(Fig. 7.11). Skin flaps are elevated and retracted. The digital
neurovascular bundles are freed so they are not under tension
when the joint is exposed. A radial or ulnar based flap of the
flexor sheath is created between the A2 and A4 pulleys. The
collateral ligaments are released from the middle phalanx,
leaving a small stump for later repair, and the volar plate is
released from fragments at the base of the middle phalanx.
The neurovascular bundles are inspected to make sure they
will not tether as the joint is exposed. The flexor tendons are
External fixation
A variety of devices have been described for management of
PIP joint fracture dislocations.22–25 The common principle is to
produce distraction across the joint, allowing alignment to be
maintained through ligamentotaxis. In addition, some devices
provide a volar directed force on the middle phalanx to assist
in maintaining alignment. They all allow immediate PIP joint
motion. Careful attention should be paid to the fragments
along the volar base of the middle phalanx as dorsal sublux­
ation can recur if these do not heal in proper position (the
volar lip of the base of the middle phalanx is a restraint to
dorsal subluxation, so healing of the fracture fragments must
recreate the normal curvature).
External fixation systems can be fabricated from
K-wires with or without the use of rubber bands, or com­
mercially available devices can be used. Fig. 7.8 illustrates
an example of a PIP joint fracture dislocation in the small
finger managed with an external fixator fabricated from
K-wires.
Technique of external fixation
A 0.045-inch K-wire is inserted through the head of the
proximal phalanx, perpendicular to the joint surface (Fig.
7.8). A second 0.045-inch K-wire is inserted through the
distal shaft of the middle phalanx, parallel to the DIP joint
surface. The proximal wire is bent distally along the radial
and ulnar aspects, paralleling the digit. Distal to the second
wire, a dorsal proximal bend is created, followed by a dorsal
distal bend. The bends should be at the same level on both
the radial and ulnar sides. This creates a groove in the
proximal wire for the distal wire to be positioned, allowing
slight distraction across the joint, which will aid the reduc­
tion via ligamentotaxis. Increasing or decreasing the first
bend on the proximal wire can adjust the distraction across
the joint. This can be performed under local anesthesia and
immediate motion is initiated. The fixator is left in place for
approximately six weeks and rehabilitation focuses on motion
of the PIP and DIP joints. The joint surface will remodel
over time.

152.e1
Treatment: fingers
Fig. 7.9  (A) Preoperative and (B) postoperative radiographs of patient with middle
phalanx base fracture treated with ORIF. (C) Clinical photograph in flexion following
rehabilitation.
A
B
C

152.e2
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
Fig. 7.10  Postoperative radiograph of cerclage wire (and K-wire) used to repair
middle phalanx base articular fracture. Radiographically, the wire does not appear
secure dorsally because this is secured around the articular cartilage (not seen on
radiograph) and cannot be placed further distally due to the central slip insertion.

153
Treatment: fingers
correct location of the incision. Care is taken to preserve the
dorsal sensory branch of the ulnar nerve and a transverse
capsulotomy is performed exposing the joint CMC joint of the
4th and 5th metacarpals. The dimensions of the graft are
outlined and the graft is harvested slightly larger than neces­
sary, so it can be trimmed to the appropriate dimensions. The
axial and sagittal cuts are made using a small saw. A portion
of the dorsal hamate can be removed proximal to the axial cut
to facilitate the coronal cut from proximal to distal. Alterna­
tively, a portion of the dorsal fourth and fifth metacarpal base
can be removed to allow better visualization and access for
the osteotomy from distal to proximal. This can be completed
with a curved osteotome. The graft is removed and the donor
site is closed. The graft is placed along the base of the middle
phalanx and provisionally fixed with small K-wires. This step
is crucial as proper positioning is necessary for a good
outcome. The graft must be placed so the normal curvature
retracted and the joint is shot gunned open exposing the joint.
If resistance is encountered, it is usually due to the collateral
ligaments; these are inspected, ensuring complete release
from the middle phalanx.
Once the joint is exposed, the loose fragments are removed
and a smooth surface is created along the joint surface and
along the volar margin of the middle phalanx. This will be
the site of insertion of the hemi-hamate graft. Care must be
taken to preserve as much of the dorsal cortex as possible as
this becomes prone to fracture if insufficient bone remains.
The defect for the graft should be large enough to allow fixa­
tion of the graft with at least two screws. The dimensions of
the defect are measured so an appropriate size graft can be
obtained.
Next, a dorsal transverse incision is outlined proximal to
the base of the ring and small metacarpals to expose the distal
aspect of the hamate. Fluoroscopy can be used to confirm the
Fig. 7.8  (A) Fabrication of external fixator from K-wires. (B) Preoperative radiograph of PIP fracture dislocation
involving the small finger. (C) Radiograph with external fixator in place, allowing motion. (D) Postoperative results
in flexion.
K2
K1
1 cm
A
B
C
D

154
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
A
B
C
D
E
A
A
B
B
D
D
D
G
C
C
E
E
F
F
4th MC
5th MC
Hamate
Volar view
PIP joint
Middle phalanx
Lateral view
Dorsal view
F
Fig. 7.11  Technique of hemi-hamate replacement
arthroplasty. Preoperative PA (A) and lateral (B)
radiographs and clinical photographs in extension (C) and
flexion (D). Diagram (E) of configuration of hemi-hamate
graft. Intraoperative photograph (F) of graft secured (note
articular wear on the head of the proximal phalanx due to
delay in presentation.

155
Treatment: fingers
Hints and tips
• When positioning the hemi-hamate graft, ensure the graft is
positioned to recreate the concavity and volar buttress to
prevent dorsal subluxation.
• Postoperative therapy and a motivated patient are critical to
obtain a good result following PIP joint fracture dislocations.
• The patient should be informed that the goal is to create a
stable joint with motion, but the return of motion to the
pre-injury level is rare.
• Some degree of post-traumatic PIP joint arthritis is
inevitable, but this does not always correlate with functional
outcomes.
Postoperative clinical photograph (G) and lateral radiograph (H).
G
H
Fig. 7.11, cont’d
of the middle phalanx base is recreated. If the graft is posi­
tioned too vertically, dorsal subluxation of the middle phalanx
will occur. The joint is reduced and visualized with fluoros­
copy. The joint should now appear congruent, with appropri­
ate curvature of the middle phalanx base and without evidence
of the dorsal “V”, The cartilage on the graft is typically thicker
than the middle phalanx, so images may appear as if the graft
is not in proper position. This can be ignored since direct
visualization will ensure alignment of the joint surface. The
joint is opened and the K-wires are replaced with small screws
(1.0–1.5 mm), rigidly securing the graft to the middle phalanx.
The joint is reduced and fluoroscopy is used to confirm appro­
priate length of the screws and position of the graft.
The volar plate is repositioned and can be repaired to the
collateral ligament stumps or to the graft. K wires can be used
to create small holes in the graft to secure the volar plate.
The stability of the reconstructed PIP joint (and prevention
of dorsal subluxation) is created by the shape and position
of the hemi-hamate graft. The flexor sheath can be placed
dorsal to the flexor tendons and secured to the opposite side.
The skin is closed, the tourniquet is deflated and perfusion
of the digit is evaluated. Occasionally, the vessels are in
spasm, but the perfusion should be restored within a few
minutes. A volar splint is placed from the forearm to the
fingertips.20,29 Rehabilitation is begun around day five with
attention to edema control and motion. A figure-of-eight
splint is used to prevent the final 10–15° of extension. A
removable wrist orthosis is used for comfort to support the
donor site.
The average arc of motion at the PIP joint has been
reported between 65° and 100° (average 85°) with return
to light activities at one month and return to manual labor at
2 months.21,28
If the entire base of the middle phalanx is involved, replace­
ment arthroplasty can be considered, but there are only a few
case reports of this technique. Hemiarthroplasty has been
reported, but currently, the use of the PyroCarbon and surface
replacement arthroplasty requires special approval and is not
available for routine use in the PIP joint.
Proximal phalanx head fractures
Fractures involving the head of the proximal phalanx are
intra-articular and anatomic reduction and early motion of
these injuries is the goal. Fractures can involve one or both
condyles and classification systems have been described.30
These fractures are often unstable and require treatment.
Stable, non-displaced fractures can be treated with a short
period of immobilization with frequent radiographic evalua­
tion. Motion is typically started at three weeks and the finger
is protected with buddy taping to an adjacent digit. Displaced
or unstable fractures require reduction and stabilization.30
Fixation is dependent on the size of the fragment and the
ability to reduce the joint with closed manipulation. If ana­
tomic alignment can be obtained with closed reduction and
the fragment can be stabilized with K-wires, these can be
treated as a stable non-displaced fracture. Often, anatomic
reduction requires open exposure. The fragments are often
large enough to hold at least one small (1.0 mm) screw and a
K-wire or two screws. This provides enough stability to begin
early motion and minimizes adhesions to the extensor
tendons. When both condyles are involved, initial alignment
and stabilization of the articular surface is preferred. Then, the

156
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
Proximal phalanx shaft and base fractures
Fractures of the shaft of the proximal phalanx can be trans­
verse or oblique. Transverse fractures typically have apex
volar angulation and are unstable. Fractures of the base are
typically transverse. If not reduced and stabilized, the exten­
sor mechanism will shorten, creating an extensor lag at the
PIP joint. Percutaneous fixation has the advantage of stabiliz­
ing the fracture and allowing early motion while minimizing
soft-tissue injury.31 Two crossed K-wires typically provide
enough stability to allow early motion. The wires can be
inserted proximally through the base with one on each side
of the metacarpal head or distally, with one entering along the
head or neck. Alternatively, the K-wires can be placed through
the MCP joint in flexion (Fig. 7.13). The disadvantage is the
K-wire is passed through the articular surface, but in cases
with substantial soft-tissue edema, this may help prevent
MCP joint extension contractures. By 3–4 weeks, the fracture
is usually stable enough for removal of the K-wires. Protected
motion should occur until complete fracture healing. Radio­
graphic healing lags behind clinical healing, which typically
occurs around 6 weeks. ORIF with plates and screws can
allow immediate motion, but adherence of the tendon to the
hardware can be problematic, often resulting in stiffness and
need for secondary procedures.32
Oblique or spiral fractures should be evaluated in flexion
as well as extension. These often shorten obliquely, resulting
in a rotational deformity. Fixation can be accomplished with
either K-wires or interfragmentary screws if the length of the
fracture is two times the length of the diameter of the bone.
ORIF with interfragmentary screws allows enough stability to
proceed with early active motion and when anatomically
articular surface can be secured to the shaft either with K-wires
or plates and screws. Although plates and screws provide
good stability, they require more dissection, and adhesions to
the extensor tendons are likely to occur, often requiring a
secondary procedure to remove the hardware and perform a
tenolysis.
Technique of open reduction and internal fixation
(ORIF) of unicondylar fractures
A straight or curvilinear dorsal approach is used from the
middle of the proximal phalanx to the middle of the middle
phalanx. Skin flaps are elevated to expose the extensor tendon
distal to the insertion of the central slip on the middle phalanx.
The joint can be exposed by splitting the extensor tendons or
an incision to the side of the central slip with release of the
lateral band. Better visualization is obtained through exposure
along the side of the central slip on the side with the fracture.
The tendon is elevated off the proximal phalanx, taking care
to preserve the insertion of the central slip. A capsulotomy is
performed, exposing the head of the proximal phalanx. The
fragments are reduced under direct visualization and tempo­
rarily stabilized with small K-wires. Fluoroscopy is used to
confirm alignment and the K-wires are replaced with screws.
The capsule can be repositioned, but does not need to be
closed with sutures. If the tendons were split, they are repaired
with a non-absorbable suture. The central slip insertion is
inspected to confirm it has not been disrupted. The skin is
closed and a splint is applied. Rehabilitation begins around
the fifth postoperative day with edema control and a figure-
of-eight splint, allowing flexion and blocking the final 10° of
extension (Fig. 7.12).
A
Fig. 7.12  Preoperative lateral radiograph (A)
of displaced unicondylar fracture.
Postoperative lateral (B) radiograph in flexion.
B

157
Treatment: fingers
Fig. 7.13  Preoperative and postoperative PA radiograph of proximal phalanx shaft (A,B) and base (C,D) fractures
treated with K-wires.
A
B
C
D

158
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
Dislocations of the MCP joint can occur in any direction,
with dorsal being the most common. The border digits (index
and small finger) are most commonly involved (Fig. 7.15).32
The volar plate ruptures from the proximal phalanx, allowing
it to sublux dorsally, with the proximal phalanx extended in
relation to the metacarpal. If the volar plate does not become
interposed in the joint, these can be treated with closed reduc­
tion. The wrist is flexed to relax the flexor tendons and distal
pressure is applied to the base of the proximal phalanx. A
snap or pop is often felt, which is the reduction of the joint.
Radiographs are obtained to confirm the reduction. The joint
is typically stable following reduction, but an extension block
splint can be used if instability exists.
When the volar plate becomes interposed in the joint, the
dislocation is complex and closed reduction attempts are
unsuccessful. Dimpling of the skin is seen over the disloca­
tion. Radiographs will show the proximal phalanx and
metacarpal collinear (as opposed to the convergence seen
with simple dislocations). In the index finger, the lumbrical
displaces around the radial side and the flexor tendons around
the ulnar side. Distal pressure on the proximal phalanx
base tightens the lumbrical and flexor tendons around the
metacarpal neck, creating a noose effect and preventing
reduction.
In the small finger, the flexor tendons and lumbrical dis­
place radially while the flexor digiti minimi displaces ulnarly,
creating the same noose-like effect when closed reduction is
attempted.
reduced, primary bone healing (Fig. 7.14). Adhesions between
the screws and tendons are less when plates are not used, and
although removal is sometimes necessary, often the screws
can be left in place.
MCP joint fractures and dislocations
Fractures extending into the articular surface of the MCP joint
should be reduced anatomically and stabilized, in an effort to
minimize the development of post-traumatic arthritis.
A
Fig. 7.14  Preoperative (A) and postoperative (B) radiographs of proximal phalanx
fracture treated with interfragmentary screws.
B
Fig. 7.15  Radiographs of MCP dorsal dislocation.

159
Treatment: fingers
An open wound over the MCP joint region should be
treated as a “fight bite”, with irrigation of the wound and
inspection of the extensor tendon and joint capsule. Align­
ment of the fingers is evaluated with the fingers in flexion to
check for rotation. Three views of the hand (posterior–anterior,
lateral, and oblique) are often adequate for diagnosis of
metacarpal fractures. Additional images include a Brewerton
view to improve visualization of the metacarpal heads. This
is an A-P view with the phalanges flexed to 45–60° and in
contact with the film (the metacarpals are elevated at a 45–60°
angle and the beam is directed 15° from ulnar to radial). A 30°
pronated oblique view improves visualization of the ring and
small finger CMC joints, while a 30° supinated view helps
visualize the index and middle finger CMC joints. CT scans
can be used when plain radiographs are inconclusive, multiple
CMC fracture dislocations are present, or for complex meta­
carpal head fractures.
Many metacarpal fractures are stable and can be treated
non-operatively. Boxer’s fractures (fifth metacarpal neck) are
impaction fractures and although there is angulation of the
metacarpal neck, they are stable. This term is a misnomer as
professional boxers rarely sustain this injury; this injury com­
monly occurs when a firm object, such as a wall, is struck. The
intermetacarpal ligaments stabilize fractures involving the
middle and ring metacarpals and often alignment is main­
tained with minimal shortening.
Forces on the metacarpal bases result in proximal displace­
ment and shortening, due to deforming forces that act on each
digit, including the adductor pollicis longus (on the first
metacarpal), the extensor carpi radialis longus and brevis (on
the second and third metacarpal), and the extensor carpi
ulnaris (on the fifth metacarpal). More distal metacarpal shaft
or neck fractures result in apex dorsal angulation due to the
pull of the intrinsic muscles of the hand.
Metacarpal head fractures
Treatment of fractures involving the metacarpal head involves
anatomic reduction and stabilization. A dorsal approach is
used and the extensor tendon is split or the sagittal band
incised to expose the metacarpal head and MCP joint. Rigid
fixation is preferred when possible, so use of small screws
placed through the collateral recess or headless screws are
preferred, with the goal of early motion. Severely comminuted
fractures are problematic as stiffness and arthritis often result.
Hemi-arthroplasty, replacing the metacarpal head, has been
described, but there is no long-term data to support its routine
use.
Metacarpal neck fractures
Metacarpal neck fractures are the most common metacarpal
fracture and are more common on the ulnar side of the hand
(fifth metacarpal, Boxer’s fracture), but can occur in any of
the fingers. The amount of apex dorsal angulation that is
acceptable varies between patients depending on vocation
and avocations, but increases from radial to ulnar. Due to
the mobility at the ring and little finger CMC joints, allowing
20°–30° mobility in the sagittal plane. The lack of mobility
at the index and middle fingers makes angulation of greater
than 15° unacceptable. Acceptable angulation for the ring
finger is between 20° and 40°, and the small finger up to
60°.36 This deformity will result in loss of prominence of the
Open reduction through a dorsal or volar approach is
necessary.33 The volar approach is more direct, but the meta­
carpal head pushes the digital nerves closer to the skin and
care must be taken to avoid injuring them with the skin inci­
sion. The A-1 pulley is released, exposing the metacarpal
head, and the volar plate is removed from the joint. The flexor
tendons are pulled over the metacarpal, allowing reduction.
The dorsal approach does not allow direct visualization, but
avoids the risk of injuring the digital nerves with the incision.
The extensor tendons are split longitudinally. If the volar plate
cannot be easily removed from the joint, it can be split longi­
tudinally, allowing each side to be pushed out of the joint. The
joint can then be reduced with distal pressure on the proximal
phalanx base while pushing the flexor tendons around the
metacarpal head. The joint is typically stable following reduc­
tion, but extension block splinting can be used if instability
exists.
Hints and tips
• For MCP joint dislocations, attempt closed reduction with
the wrist maximally flexed; if unsuccessful, proceed to open
reduction.
• The volar open approach is more direct, but it places the
digital nerves at risk during the skin incision as they will be
tented beneath the skin.
• The dorsal open approach often requires splitting the volar
plate to allow complete reduction.
Volar dislocations of the MCP joint are rare. Interposed struc­
tures can include the dorsal capsule, extensor tendon junctura,
collateral ligament or the volar plate.33,34 When closed reduc­
tion is unsuccessful, open reduction is performed through a
dorsal approach.
Metacarpal fractures
Relative to phalangeal anatomy, the metacarpals have more
soft tissue between bone and tendons, making them less
susceptible to adhesion formation. As such, stiffness follow­
ing recovery is less common. Metacarpal fractures commonly
occur as a result of a direct blow. They can occur through the
head, neck, shaft, or base.35 Fracture configuration is usually
transverse, oblique, or spiral. Transverse fractures occur as a
result of an axial load with bending and result in apex dorsal
deformity. Oblique or spiral patterns occur with torsional
stress when an axial load is received.
Indications for operative treatment of
metacarpal fractures
A rotational deformity is an indication for operative treat­
ment. Malrotation of 1° at the metacarpal translates to 5°
rotation at the fingertip, furthermore malrotation of 5° in the
metacarpal can result in 1.5 cm of overlap at the fingertips and
thus, evaluation of the fingers in flexion is imperative. Other
indications include: shortening of 2–3 mm, articular step-off
greater than 1 mm, greater than 25% articular involvement,
and multiple fractures. As the amount of energy increases, the
amount of comminution increases and stability decreases, and
the incidence of multiple fractures increases.

160
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
(CRPP), intramedullary (IM) wires, and open reduction inter­
nal fixation (ORIF). The distal location of metacarpal neck
fractures makes stabilization with plates difficult.
The MCP joint is flexed and alignment is evaluated, cor­
recting any malrotation. Percutaneous K-wires can be placed
from distal, through the collateral recess, or proximal through
the metacarpal base. Alternatively, the wires can be placed
transverse, stabilizing the fifth metacarpal to the fourth meta­
carpal, or multiple wires as intramedullary nails (bouquet
pinning). This is completed through an incision proximally
near the metacarpal base. After exposing the bone, an awl or
similar instrument is used to creating an opening in the bone
and wires are placed into the shaft. The reduction is confirmed
with fluoroscopy and the wires are advanced across the
fracture site and into the bone distally. These wires are typi­
cally left out of the bone proximally to allow removal follow­
ing healing, but can be cut and left within the bone. Depending
on stability, postoperative immobilization is often required for
4–6 weeks, followed by therapy to regain motion.
ORIF is performed when reduction cannot be attained by
closed means or when there is a desire to minimize postopera­
tive immobilization. It is completed through a dorsal approach,
either splitting the extensor tendons (small or index finger) or
along the side. If adequate stability is achieved, the patient
can be transitioned to a removable splint and begin active
motion within the first week.
Metacarpal shaft fractures
Isolated metacarpal shaft fractures are often stable and ame­
nable to non-operative management. The intermetacarpal
ligaments stabilize the distal metacarpal and maintain align­
ment. Similar to metacarpal neck fractures, the amount of
acceptable apex dorsal angulation is debated, but increases
ulnarly and distally. The amount of acceptable angulation is
less in the shaft than in the neck, with <10° in the index and
middle fingers and approximately 20° in the ring and 30° in
the small finger.
Non-operative treatment includes immobilization for about
4 weeks, with the MCP joints flexed and the IP joints free.
Operative indications include open fractures, malrotation and
unacceptable angulation (Fig. 7.17). Similar to metacarpal
neck fractures, closed reduction and pinning can be completed
from distal or proximal, transversely into the adjacent meta­
carpal40 or with IM wires.41
ORIF can be completed with interfragmentary screws for
spiral or oblique fractures or with plates and screws for
transverse fractures.42 Coverage of the plate with periosteum,
when possible, will decrease tendon irritation and need for
later removal. Early motion should be initiated following
ORIF to prevent tendon adhesions.
Severely comminuted fractures, those with segmental bone
or soft tissue loss can be treated with external fixation, either
temporarily until adequate soft-tissue healing for internal
fixation, or in some cases definitively.43–45
Multiple metacarpal fractures
Multiple metacarpal fractures are often the result of higher
energy and result in greater soft-tissue disruption. In addi­
tion, the stability provided by the transverse intermetacarpal
ligament is lost and stabilization is often necessary.
“knuckle” (metacarpal head) with a proximal prominence
along the metacarpal neck and occasionally noticeable
prominence in the palm; the flexed metacarpal head. This
is unlikely to cause functional limitations. Occasionally,
pseudo-clawing will develop secondary to the flexed position
of the metacarpal head, MCP hyperextension, and PIP joint
flexion.
Treatment is dependent on the existing deformity. Closed
reduction and immobilization often provides adequate align­
ment and can be used for definitive management.37 Flexing
the MCP joint to 90°, which relaxes the deforming intrinsic
muscles and simultaneously tightens the collateral ligaments,
allows for control of the distal metacarpal fragment. The Jahss
maneuver involves flexion of the distal interphalangeal,
proximal interphalangeal, and metacarpophalangeal joints
followed by dorsally directed pressure over the flexed PIP
while applying a volar directed force over the apex of the
fracture.38 This maneuver delivers the three-point fixation
needed for fracture immobilization and ensures reduction
with appropriate angulation and rotation. After the Jahss
maneuver has been performed, the hand can be immobilized,
either in intrinsic plus position or with MCP and PIP joints
extended, as outcomes are similar.39 A cast or splint is not
always successful in maintaining reduction, especially with
the swelling associated with the fracture (Fig. 7.16).
Indications for operative treatment include malrotation or
unacceptable alignment following closed reduction. Surgical
options include closed reduction and percutaneous pinning
Fig. 7.16  The Jahss maneuver for reduction of a metacarpal neck fracture. The DIP
and PIP joints are flexed and dorsal pressure is applied to the PIP joint while
counter pressure is applied to the metacarpal shaft proximal to the fracture.

161
Treatment: thumb
The adjacent metacarpal is exposed in a similar manner.
Beginning with the most radial fractured metacarpal, any
interposed tissue is removed from the fracture site. The frac­
ture is reduced and provisionally stabilized (either with a
fracture reduction forceps or K-wires), while alignment of the
fingers is checked, making sure there is no malrotation. Inter­
fragmentary screws or plate and screws are applied; fluoros­
copy is used to confirm positioning of the hardware and the
adjacent metacarpal is addressed. After all fractures are stabi­
lized, the periosteum is closed, creating a layer of tissue
between the hardware and the extensor tendons. A splint is
applied for comfort and motion can begin as the swelling
subsides, typically between 3 and 5 days postoperatively.
CMC dislocations/fracture dislocations
Fractures of the metacarpal base, fracture dislocations of the
CMC joint and dislocations involving the CMC joint usually
involve the ring and small fingers. Fracture dislocations may
involve the capitate and hamate in addition to the metacarpal
base.46,47 These patients will have a prominence along the
ulnar side of the hand in the region of the CMC joints. Diag­
nosis is confirmed in the pronated oblique view, observing the
relationship between the carpus and base of the metacarpal.
The dorsal aspect should be collinear and when subluxation
is present, the metacarpal will be positioned dorsal to the
carpus. CT scan can be used when the diagnosis is not clear
on plain radiographs or to define fracture geometry. These
injuries are often unstable and require operative treatment.
Closed reduction and percutaneous pinning is usually suc­
cessful when performed within the first several days (Fig.
7.18). Delayed presentation usually requires open reduction.
Stabilization is obtained using K-wires across the CMC joints.
The K-wires are removed at four to six weeks and motion is
resumed with protective splinting for comfort. Alternatively,
a plate can be applied across the CMC joints with planned
removal once soft-tissue healing has occurred.
Treatment: thumb
Injuries to the thumb distal and proximal phalanges can be
managed similarly to the fingers. Metacarpal shaft fractures
can tolerate more rotation and angulation due to the greater
degree of freedom in three planes (flexion/extension, radial/
ulnar deviation, pronation/supination) of the CMC joint.
Injuries involving the MCP joint, specifically collateral liga­
ment injuries and those involving the CMC joints require
special consideration.
MCP joint injuries
The primary motion of the MCP joint is flexion/extension.
The radial condyle of the metacarpal head has a greater height
(dorsal/volar dimension), allowing rotation (pronation) with
increasing flexion. Stability of this joint is provided by the
collateral ligaments, the dorsal capsule and the volar plate,
the thenar muscles and the adductor pollicis.
Injuries involving the ulnar collateral ligament are more
common than the radial collateral ligament (RCL) and have
been reported to occur at a 10 : 1 ratio.48,49 This typically results
from forced abduction (radial directed stress), such as falling
with an object, such as a ski pole, in the first web space. The
Technique of ORIF of multiple metacarpal fractures
For two metacarpal fractures, the skin incision can be placed
between them. The incision can be curved proximally or
distally as necessary as the locations of the fractures are often
different in each bone. When three or four fractures are
present, more than one incision will be necessary. Dissection
is carried to the level of the extensor tendons, taking care to
protect sensory branches of the ulnar (fourth and fifth meta­
carpals) and the radial (second and third metacarpals) nerves.
The extensor tendons are retracted and the metacarpal is
visualized. There is often hematoma and disruption of the
periosteum around the fracture site. A longitudinal incision is
made off axis of the metacarpal and the fracture is exposed.
A
Fig. 7.17  Radiographs of metacarpal shaft fracture treated with ORIF due to
malrotation (A,B). (See the preoperative clinical picture in Fig. 7.3.)
B

162
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
those with articular incongruity are best treated with open
reduction and stabilization.49,50
Isolated ligamentous injuries can be more challenging to
diagnose. Avulsion from the proximal phalanx is five times
more common than midsubstance tears or avulsion from the
metacarpal.51
Stener lesion
In 1962, Stener described the injury where the complete ulnar
collateral ligament tear retracted proximally and the adductor
aponeurosis was interposed between the ligament and the site
of avulsion along the base of the proximal phalanx (Fig. 7.19).
Without contact between the ligament and bone, healing
A
Fig. 7.18  Preoperative radiograph (A) and intraoperative flouroscopic image (B) of fourth and fifth CMC dislocations.
B
Fig. 7.19  Stener lesion of the MCP joint of the thumb.
(A) Normal relationship of the adductor aponeurosis.
With a radial directed stress (B), the ligament is
avulsed from the bone and retracts proximal to the
adductor aponeurosis (C). When the joint is reduced,
the adductor is interposed between the ligament and
bone (D), preventing healing.
A
B
C
D
Adductor
aponeurosis
Adductor
aponeurosis
Ulnar
collateral
ligament
dorsal capsule tears along the ulnar aspect of the joint and the
proximal phalanx supinates around the intact RCL, creating
a prominence of the ulnar aspect of the metacarpal head.
Although commonly used to describe this injury, the term
“gamekeeper’s thumb” more accurately defines a chronic
injury from repetitive radial directed stress resulting in attenu­
ation of the ligament. This occurred in Scottish gamekeepers
while breaking the necks of rabbits between their thumb and
index fingers. The term “skier’s thumb” is more accurate and
the preferred term when referring to acute injuries.
Injuries typically involve disruption of the ligament from
the base of the proximal phalanx. This can occur as a bony
avulsion or pure ligamentous injury. Larger fractures (those
>2 mm), those involving >10% of the articular surface, or

163
Treatment: thumb
proximal phalanx pronates around the intact UCL, creating a
prominence of the radial aspect of the metacarpal head. The
location of the tear is more variable than the UCL counterpart,
with equal frequency between proximal and distal avulsions48
and mid-substance tears.49
Surgical repair of an acute UCL tear
The skin incision is outlined in a straight or lazy “S” configu­
ration from the ulnar base of the proximal phalanx to the
dorsal aspect of the metacarpal head/neck region (Fig. 7.21).
After the skin incision is completed, spreading to the level of
the adductor aponeurosis is carefully performed. Care should
be taken to identify the cutaneous branch of the radial nerve,
as injury to this structure can cause a painful neuroma, com­
promising the final outcome. When a Stener lesion is present,
the ligament will be identified proximal to the adductor
aponeurosis. The adductor aponeurosis is incised, splitting
the fibers until the base of the proximal phalanx can be identi­
fied. The ligament is debrided of hematoma and fibrous tissue
in preparation for repair. The joint can be opened and irrigated
to remove hematoma and the site of attachment is identified.
When a larger fragment of bone is present, this can be reduced
and secured with a screw or K-wires. When the fragment is
small, it can be excised and the ligament repaired to the site
of avulsion with a suture anchor. The adductor aponeurosis
is repaired and the skin is closed. If there is a concern about
the stability of the repair, a K-wire can be placed across the
joint, but this is generally not necessary.
A plaster thumb spica splint is applied, leaving the IP joint
free and converted to a short arm cast at 1 week. Motion of
the IP joint is encouraged to prevent adhesions of the extensor
tendons. At 4 weeks, the cast is removed and a therapy
program is instituted to regain motion. A thermoplastic ortho­
sis is used between exercises with avoidance of radial directed
stress. Pinch strengthening is begun at 10 weeks and unre­
stricted activities are allowed at 12 weeks. Final motion is
typically 80% of the non-injured side with grip and pinch
strength approximately 90% of the contralateral side.
cannot occur and chronic instability will result.52 A complete
rupture and retraction of the ligament is necessary for the
Stener lesion to occur and therefore it is important to differ­
entiate between partial or complete tears without retraction
and those where the ligament has retracted proximal to the
adductor aponeurosis. Unfortunately, there is not an absolute
clinical criterion for making this diagnosis. The MCP joint is
observed for swelling and tenderness along the ulnar side. A
palpable mass at the level of the metacarpal neck may be
consistent with the retracted ulnar collateral ligament (UCL).
The joint should be tested in both flexion and extension,
checking for a definite endpoint and comparing to the oppo­
site thumb. Multiple reports exist in the literature, all using
different clinical criteria for diagnosis of a complete tear.53–56
Stress radiographs may assist in making the diagnosis. In
addition, MRI and ultrasound can be used in cases of uncer­
tainty following clinical exam and plain radiographs.
When a Stener lesion is present, operative treatment is
required. Open ligament repair is the most common procedure
performed, but arthroscopic repositioning of the ligament has
been described, placing the ligament deep to the adductor
aponeurosis and allowing it to heal to the bone.57,58 Delayed
presentation may make it difficult to repair the ligament pri­
marily and reconstruction may be indicated. With late presen­
tation, radiographs should be evaluated for presence of
arthritis and when present, arthrodesis should be considered.
Reconstruction techniques produce dynamic (tendon transfers
and adductor advancement) and static reconstructions (cre­
ation of a static restraint to radial directed stress with a graft).
Dynamic reconstructions typically involve transfer of a
tendon to stabilize the MCP joint. Procedures include transfer
of the extensor indicis proprius (EIP) to the extensor mecha­
nism, transfer of the extensor pollicis brevis (EPB) to the ulnar
side of the proximal phalanx59,60 and advancement of the
adductor.61 The adductor is transferred from its insertion on
the sesamoid to the proximal phalanx. Static reconstructions
involve replacement of the ligament with a graft, such as
palmaris longus tendon, through holes created in the meta­
carpal and proximal phalanx.49,62
Primary repair can be completed as long as there is adequate
ligament to repair. When the procedure is greater than 6
weeks following the injury, the surgeon should be prepared
to proceed with reconstruction in the event the ligament is not
amenable to primary repair. Repair or reattachment too distal
or volar will result in loss of flexion and placement too dorsal
may result in persistent instability. With an acute injury, it is
often possible to determine the site of avulsion and reattach
it to the site of avulsion. The ligament runs from dorsal to
volar in a proximal to distal direction. The origin of the proper
collateral ligament is 7 mm proximal to the joint and 3 mm
from the dorsal cortex. The insertion of the base of the proxi­
mal phalanx is located 3 mm distal to the joint and 3 mm from
the volar cortex (Fig. 7.20).63 Reattachment can be completed
using suture anchors or a pull-out suture exiting the opposite
side tied over a button or directly over the bone.
Radial collateral ligament injuries are much less common
than their ulnar counterparts. On the radial side of the thumb,
the abductor aponeurosis is broad, covering a larger percent­
age of the joint and there is no interposition of the aponeurosis
between the ligament and the bone (Stener lesion). Tear of the
RCL typically results from forced adduction on a flexed joint.
The dorsal capsule tears along the radial aspect and the
Fig. 7.20  Location of thumb MCP joint UCL on metacarpal and proximal phalanx.
The ligament runs from dorsal to volar in a proximal to distal direction. The origin
of the proper collateral ligament is 7 mm proximal to the joint and 3 mm from the
dorsal cortex. The insertion of the base of the proximal phalanx is located 3 mm
distal to the joint and 3 mm from the volar cortex.
7 mm
Proper collateral
ligament
Accessory collateral
ligament
3 mm
8 mm
8 mm
3 mm
3 mm

164
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
adductor aponeurosis and skin incisions are closed and a
thumb spica splint is applied. Postoperative rehabilitation is
similar to acute repairs except the joint is immobilized for 6
weeks and pinching is avoided for 3 months. Unrestricted
activities are allowed at 4–5 months. Motion tends to be less
following reconstructions than acute repairs, but 70% of the
flexion/extension and 80% grip and pinch strength can often
be obtained. The goal of the reconstruction is to produce a
stable painless thumb and the slight loss of motion is compen­
sated for at the CMC joint.
Thumb metacarpal fractures
Fractures of the thumb metacarpal are more tolerant of
displacement and rotation due to the motion in three
planes (flexion/extension, abduction/adduction, pronation/
supination). Fractures can occur through the shaft or the base
at the metaphyseal–diaphyseal junction. Angulation <20° can
be tolerated, but greater than this may result in compensatory
MCP joint hyperextension, compromising the function of the
thumb. The distal fragment tends to supinate, so closed reduc­
tion is performed by applying longitudinal traction, down­
ward pressure of the apex of the thumb, and pronation and
A
Fig. 7.21  Surgical repair of thumb MCP joint UCL. (A) Preoperative clinical
photograph illustrating laxity at MCP joint. (B) Intraoperative photograph illustrating
suture anchor in base of proximal phalanx with suture through the UCL.
B
Reconstruction of chronic UCL tear with
tendon graft
This creates a static restraint to radial directed stress and
although not the same as the ligament prior to the injury, can
provide a stable thumb MCP joint. The approach to the joint
is the same as for acute repairs. After exposing the joint, the
remaining collateral ligament is excised. The site of origin and
insertion of the graft is identified (Fig. 7.22). A tendon graft is
harvested using palmaris longus when present or a strip of
flexor carpi radialis (FCR) in the event the palmaris longus is
not present. The graft can be attached either through drill
holes or with tenodesis screws (alternatively, the collateral
ligament can be left attached to the metacarpal and the graft
secured to the native ligament). The tendon is attached to the
metacarpal head just dorsal to the dorsal volar axis, approxi­
mately 8 mm from the joint surface. The proximal phalanx
insertion site is 3 mm from the volar cortex and 3 mm distal
to the joint. The tendon can be attached to the bone with
suture anchors, biotenodesis screws or transosseous sutures.
The joint is pinned in slight flexion and ulnar deviation. The
A
Fig. 7.22  Technique of thumb MCP joint UCL reconstruction with palmaris longus
tendon graft. (A) Intraoperative exposure of the joint following resection of scar and
remnants of UCL. (B) Tendon graft secured to the proximal phalanx in preparation
for securing to metacarpal.
B

165
Treatment: thumb
small screws or K-wires. If screw fixation is used, a removable
orthosis and motion can be initiated at one week.
The Rolando fracture, as originally described, is a metacarpal
base fracture with a “T”- or “Y”-shaped intra-articular
pattern.73 Currently, the term is used to describe any commi­
nuted intra-articular fracture of the base of the thumb meta­
carpal. The treatment goals are the same as for the Bennett
fracture, but may be more difficult to obtain, as the comminu­
tion often makes it difficult to align the articular surface. The
true Rolando fracture can be treated with closed reduction,
using the same technique as for the Bennett fracture. Com­
minuted fractures are more difficult to treat and open reduc­
tion can lead to devascularization of the small fracture
segments. Bone grafting can be used if there is extensive com­
minution or a void in the metaphysis, to assist with healing.
Stabilization is best accomplished with K-wires from the
thumb to index metacarpal or an external fixator. Various
designs have been described, including stabilization to the
trapezium, or multiple rods securing the thumb to the index
metacarpal74 or in a triangular configuration, securing the
thumb and index metacarpals to the radius.75
extension of the distal fragment. K-wires can be used to sta­
bilize the fracture or, alternatively, plates and screws.
Thumb CMC joint injuries
The anatomy of the thumb CMC joint resembles two inter­
locking saddles (thumb metacarpal and trapezium), which
allow motion parallel (abduction and adduction) and perpen­
dicular (pronation and supination). Joint stability is main­
tained through multiple ligaments, with the anterior oblique,
posterior oblique, anterior and posterior intermetacarpal and
dorsal radial ligaments being the major stabilizers.64 Com­
pressive forces are 12 times greater at the CMC joint than the
tip of the thumb, so arthritis may develop if incongruence is
present at the CMC joint.65,66
Isolated dislocations occur much less frequently than CMC
fracture dislocations (Bennett and Rolando fractures). When
pure dislocations occur, they are dorsal and result from an
axial compression of a flexed thumb. There are 16 ligaments
that stabilize the thumb CMC joint, with some considered
major and other considered minor stabilizers. The anterior
oblique (volar beak ligament) and the dorsal radial ligament
are disrupted to allow dorsal dislocation of the metacarpal.
Partial ligament tears may result in subluxation and may be
treated with reduction and immobilization, typically with
K-wires. Complete ligament tears result in dorsal dislocation
and are unstable. Because these injuries are rare, most reports
in the literature are case reports or small series.67,68 For
acute and chronic dislocations, ligament reconstruction with
a portion of the FCR, as described by Eaton and Littler69,70
should provide reasonable results.
Fracture dislocations are much more common. The Bennett
fracture (Video 7.1
) is a fracture subluxation, which occurs
when a flexed metacarpal receives an axial load (Fig. 7.23).71
The Bennett fragment is maintained due to the attachment of
the anterior oblique ligament, while the remainder of the
metacarpal subluxes radially, dorsally, and proximally, due to
the abductor pollicis longus and adductor pollicis muscles.
The goals of treatment of this injury are to restore stability to
the joint by allowing the displaced metacarpal to heal to the
Bennett fragment and restoration of articular congruity to the
base of the thumb. Bennett fractures can be treated with closed
reduction and pinning. Indications for ORIF include inability
to reduce the fracture by closed means. Some surgeons advo­
cate ORIF when the Bennett fragment involves a substantial
amount of the joint.72
The reduction is performed with longitudinal traction on
the thumb, pressure at the metacarpal base, and pronation. It
is not necessary to secure the Bennett fragment as long as
alignment is maintained and K-wires can be placed in a
variety of configurations, most commonly, either through the
metacarpal base and into the trapezium or trapezoid, or
through the thumb metacarpal and into the index metacarpal.
The hand is immobilized in a thumb spica cast, with the
fingers and IP joint of the thumb free, for 4–5 weeks, followed
by a protective orthosis for an additional 4 weeks.
When ORIF is performed, a Wagner incision is used, along
the junction of the glabrous and non-glabrous skin, extending
from the mid-metacarpal to the region of the FCR tendon. The
thenar muscles are reflected subperiosteally, and the capsule
is incised to expose the joint. Hematoma is removed from the
joint, and then the fracture is reduced and stabilized with
Hints and tips
• Metacarpal base articular fractures are often more
comminuted than the appearance on radiographs, and the
thumb does not develop stiffness following immobilization,
so the authors prefer K-wire fixation for these fractures.
• Reduction of thumb metacarpal base articular fractures
requires distraction, pronation and abduction of the
metacarpal base.
• K-wires can be placed in the metacarpal, the fracture
reduced and the K-wires advanced into the trapezium.
Pediatric fractures
Classification of pediatric fractures has been described in
Fig. 7.2, Salter–Harris classification of fractures, but fractures
of the distal phalanx and the proximal phalanx head deserve
special mention. Generally, pediatric fractures are stabilized
with smooth K-wires. Effort should be made to minimize the
number of passes through the physis and remanipulation of
the fracture.
The Seymour fracture is a fracture involving the epiphyseal
region of the distal phalanx (Fig. 7.24).76 This injury appears
as an open mallet fracture, with extension of the proximal
segment with the attachment of the extensor tendon and
flexion of the distal fragment with the FDP attached. There is
a transverse laceration of the nail matrix, which is often
interposed in the physeal fracture site. The nail plate is dis­
placed proximally out of the eponychial fold. Treatment is
irrigation and debridement with reduction of the fracture and
repair of the nail matrix. The nail plate is used as a stent on
the proximal nail fold to help maintain reduction. A splint of
longitudinal K-wire is used to maintain the reduction.77–79
Proximal phalanx neck fractures
Fractures of the proximal phalanx neck and occasionally the
middle phalanx neck are common in children and result from
withdrawal of a finger when caught in a door. These are
visualized on a lateral X-ray and are classified according to

166
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
Fig. 7.23  (A) Comparison of Bennett and Rolando fracture (Bennett fracture has one articular segment while Rolando fracture has at least two articular segments,
commonly in “Y” or “T” configuration). (B) Reduction (distraction, pronation, and dorsal pressure) and pinning of thumb CMC fracture dislocation (Bennett fracture and
Rolando fracture).
A
Bennett fracture
Rolando fracture
B
1
2
3
the amount of displacement (Fig. 7.25).80–82 The distal frag­
ment can rotate 90°, so the head is directed dorsally and the
fracture surface is volar. These should be reduced anatomi­
cally and stabilized with K-wires. If alignment is not restored,
a bony block may occur in the retrocondylar fossa resulting
in decreased flexion. If this occurs, an ostectomy of the volar
spike can be performed to remove the bony block and restore
flexion.
Complications
Many patients with phalangeal fractures have some residual
stiffness following treatment. This is not a complication, but
a result of the need for tendons to glide along all sides of the
proximal and middle phalanx and the adhesions that form
between the bone and the tendon.32
True complications include infection, loosening of K-wires,
malunion, non-union and compartment syndrome. Infections
should be managed with antibiotics. If K-wires have been
used, a course of antibiotics will often allow enough healing
prior to removal of the implant that the fracture is stable.83
Malunions can be extra-articular or intra-articular and can
occur in any bone in the hand and may cause cosmetic or
functional problems. Angular and rotational malunions often
cause dysfunction, which must be corrected. Non-unions are
uncommon and typically occur with infection, substantial
bone loss or associated severe soft tissue injuries. They can be

167
Secondary procedures
Fig. 7.24  (A) Seymour fracture with nail bed interposed into physis and nail plate
dorsal to eponychial fold and (B) following repair of nail matrix.
Matrix repair
A
B
Fig. 7.25  Pediatric proximal phalanx neck fractures. Type I
is a stable, non-displaced fracture. Type II is a fracture with
dorsal displacement of the condyles, but contact between
the bony surfaces. Type III fractures are defined by dorsal
displacement of the condyles with rotation of 90°, so the
fracture surface is perpendicular to the dorsal aspect of the
proximal phalanx.
Collateral ligament
Type II
Type III
Type I
Volar plate
(entrapped)
Volar plate
Volar plate
atrophic or hypertrophic and are managed with resolution of
the infection, providing a stable soft tissue environment and
reconstruction with stable fixation and, in some instances,
bone grafting (atrophic non-unions).
Compartment syndromes are not common in the hand, but
may occur with crush injuries. Notable pain following a crush
injury to the hand, which is exacerbated by passive stretching
of the digit, should raise the suspicion for compartment
syndrome. In the unresponsive patient with substantial swell­
ing, compartment pressures can be measured. Pressures
>30 mmHg or within 30 mm of diastolic pressure should be
treated with urgent fasciotomies, thereby releasing the inter­
osseous, thenar, hypothenar, adductor pollicis muscles and
transverse carpal ligament.
Secondary procedures
Secondary procedures can be performed to correct a problem,
such as malunion or non-union, or in an attempt to improve
motion for stiff digits. All wounds should be healed and soft
tissues supple before secondary procedures are performed.
Malunion correction
Malunion typically occurs as angular or rotational deformi­
ties. Correction of an angular malunion involves an opening
or closing wedge osteotomy with internal fixation.84 Closing
wedge osteotomies are easier to perform and are stable, while
opening wedge osteotomies often require bone graft. These are
best treated at the site of the malunion. Rotational malunions
are treated with derotational osteotomies. These can be per­
formed as transverse85,86 or step-cut osteotomies87–89 and rigid

168
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
Future directions
There have not been substantial advances in management of
hand fractures over the last decade. K-wires are still com­
monly used and provide functionally stable fixation. Ideally,
something to minimize adhesions, whether something used
locally or systemically, or increase the rate of bony healing
could improve motion and ultimate outcome. Comparative
studies including randomized trials comparing fixation
methods may help surgeons determine better treatments.
fixation is used to provide stability and early motion (Fig. 7.26
). Intra-articular malunions can be corrected with an intra-
articular90 (Fig. 7.27
) or extra-articular91 osteotomy.
Figs. 7.26 & 7.27 appear online only.
Non-union correction
Non-unions are rare in the hand, but can be managed by
following principles of non-union reconstruction in long
bones.92 Any underlying infection should be treated and a
good soft-tissue envelope should be present prior to recon­
struction. Hypertrophic non-unions demonstrate bone forma­
tion around the fracture without bridging bone at the
non-union site. These will typically heal if stability and com­
pression are provided at the non-union site. Atrophic non-
unions require bone grafting in addition to internal fixation.
Metabolic conditions, such as vitamin D deficiency, should be
evaluated with blood tests and corrected if necessary, as low
vitamin D levels will prevent ossification.
Hardware removal, tenolysis, capsulotomy
Patients with residual stiffness may benefit from secondary
procedures to improve motion. When internal fixation with
plates and screws has been used for initial treatment of the
fracture, adhesions between the plate and the extensor tendons
often occur. Removal of the hardware and extensor tenolysis
will often improve flexion. Indications include a motivated
patient who will be compliant with the postoperative therapy
program, complete osseous healing and supple soft tissues
with passive motion that is greater than active motion. When
joints become stiff, the results are much less predictable and
outcomes not as good. Results following release of MCP
extension contractures are better than PIP flexion or extension
contracture release.
Hints and tips
• Tenolysis can be performed as a wide-awake procedure,
using local anesthesia with epinephrine, avoiding the use of
a tourniquet.
• Tenolysis knives are specifically designed to free adhesions
between tendon and bone, flexor sheath and the tendons
themselves.
• Active motion after releasing adhesions will often allow
rupture of additional adhesions, illustrating when adequate
release has been completed.
• Begin therapy, focusing on active motion, immediately
following the release. This can be demonstrated in the OR
when done wide-awake.
Bonus images for this chapter can be found online at

Fig. 7.9 (A) Preoperative and (B) postoperative radiographs of patient with
middle phalanx base fracture treated with ORIF. (C) Clinical photograph in
flexion following rehabilitation.
Fig. 7.10 Postoperative radiograph of cerclage wire (and K-wire) used to repair
middle phalanx base articular fracture. Radiographically, the wire does not
appear secure dorsally because this is secured around the articular cartilage
(not seen on radiograph) and cannot be placed further distally due to the central
slip insertion.
Fig. 7.26 (A–C) Step-cut osteotomy for correction of malunion. This can be
used in the metacarpal or phalanx. The distal transverse cut is in the direction of
malrotation, so the dorsal surface closes as the malrotation is corrected.
Fig. 7.27 Technique for correction of intra-articular malunion of the proximal
phalanx head with condylar advancement osteotomy. (A) A longitudinal
osteotomy is created into the site of the intra-articular malunion, the condyle is
advanced and rotated into proper alignment and secured with screws, leaving
the proximal shaft defect to heal secondarily. Clinical example (B) preoperative
radiograph; (C) intraoperative photograph of articular malunion prior to
osteotomy. (D) Intraoperative photograph following condylar advance osteotomy
and fixation. Postoperative PA (E) and lateral (F) radiographs and clinical
example in flexion (G).
10. Leinberry C. Mallet finger injuries. J Hand Surg Am. 2009;34:
1715–1717. An evidence-based review, discussing the literature of
operative and nonoperative (splinting) for the treatment of mallet finger
injuries.
16. Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal
interphalangeal joint. J Hand Surg Am. 1998;23:368–380. This article
provides excellent overview of the diagnosis of injuries of the base of the
middle phalanx and indications for operative treatment. This article was
written prior to hemi-hamate arthroplasty, so this technique is not
covered.
21. Williams RM, Kiefhaber TR, Sommerkamp TG, et al. Treatment of
unstable dorsal proximal interphalangeal fracture/dislocations
using a hemi-hamate autograft. J Hand Surg Am. 2003;28:856–865.
22. Badia A, Riano F, Ravikoff J, et al. Dynamic intradigital external
fixation for proximal interphalangeal joint fracture dislocations. J
Hand Surg Am. 2005;30:154–160.
Access the complete reference list online at

168.e1
Future directions
Fig. 7.26  (A–C) Step-cut osteotomy for correction of malunion. This can be used in the metacarpal or phalanx. The distal transverse cut is in the direction of malrotation,
so the dorsal surface closes as the malrotation is corrected.
A
C
B

168.e2
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
A
B
C
D
Fig. 7.27  Technique for correction of intra-articular malunion of the proximal phalanx head with condylar advancement osteotomy. (A) A longitudinal osteotomy is created
into the site of the intra-articular malunion, the condyle is advanced and rotated into proper alignment and secured with screws, leaving the proximal shaft defect to heal
secondarily. Clinical example (B) preoperative radiograph; (C) intraoperative photograph of articular malunion prior to osteotomy. (D) Intraoperative photograph following
condylar advance osteotomy and fixation.

168.e3
Future directions
E
F
G
Fig. 7.27, cont’d Postoperative PA (E) and lateral (F) radiographs and clinical
example in flexion (G).

168.e4
SECTION II
CHAPTER 7 • Hand fractures and joint injuries
References
1. Karl JW, Olson PR, Rosenwasser MP. The epidemiology of upper
extremity fractures in the United States, 2009. J Orthop Trauma.
2015;29:e242–e244.
2. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of
metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg.
2000;8:111–121.
3. Leversedge FJ. Anatomy and pathomechanics of the thumb. Hand
Clin. 2008;24:219–229, v.
4. Seitz WH, Shimko P, Patterson RW. Long-term results of callus
distraction-lengthening in the hand and upper extremity for
traumatic and congenital skeletal deficiencies. J Bone Joint Surg Am.
2010;92:47–58.
5. Marino JT, Ziran BH. Use of solid and cancellous autologous bone
graft for fractures and nonunions. Orthop Clin North Am.
2010;41:15–26.
6. Schneider LH. Fractures of the distal phalanx. Hand Clin.
1988;4:537–547.
7. Wehbé MA, Schneider LH. Mallet fractures. J Bone Joint Surg Am.
1984;66:658–669.
8. Kalainov DM, Hoepfner PE, Hartigan BJ, et al. Nonsurgical
treatment of closed mallet finger fractures. J Hand Surg Am.
2005;30:580–586.
9. Hamas RS, Horrell ED, Pierret GP. Treatment of mallet finger due to
intra-articular fracture of the distal phalanx. J Hand Surg Am.
1978;3:361–363.
10. Leinberry C. Mallet finger injuries. J Hand Surg Am. 2009;34:1715–
1717. An evidence-based review, discussing the literature of operative
and nonoperative (splinting) for the treatment of mallet finger
injuries.
11. Rocchi L, Genitiempo M, Fanfani F. Percutaneous fixation of mallet
fractures by the “umbrella handle” technique. J Hand Surg Br.
2006;31:407–412.
12. Schneider LH. A simple fixation method for unstable bony mallet
finger. J Hand Surg Am. 2005;30:626–627, author reply 627.
13. Palmer AK, Linscheid RL. Irreducible dorsal dislocation of the
distal interphalangeal joint of the finger. J Hand Surg Am.
1977;2:406–408.
14. Green SM, Posner MA. Irreducible dorsal dislocations of the
proximal interphalangeal joint. J Hand Surg Am. 1985;10:85–87.
15. Peimer CA, Sullivan DJ, Wild DR. Palmar dislocation of the
proximal interphalangeal joint. J Hand Surg Am. 1984;9A:39–48.
16. Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal
interphalangeal joint. J Hand Surg Am. 1998;23:368–380. This article
provides excellent overview of the diagnosis of injuries of the base of the
middle phalanx and indications for operative treatment. This article was
written prior to hemi-hamate arthroplasty, so this technique is not
covered.
17. Hamilton SC, Stern PJ, Fassler PR, Kiefhaber TR. Mini-screw
fixation for the treatment of proximal interphalangeal joint dorsal
fracture-dislocations. J Hand Surg Am. 2006;31:1349–1354.
18. Blazar PE, Robbe R, Lawton JN. Treatment of dorsal fracture/
dislocations of the proximal interphalangeal joint by volar plate
arthroplasty. Tech Hand Up Extrem Surg. 2001;5:148–152.
19. Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal
interphalangeal joint: a review of ten years’ experience. J Hand Surg
Am. 1980;5:260–268.
20. Williams RMM, Hastings H, Kiefhaber TR. PIP Fracture/dislocation
treatment technique: use of a hemi-hamate resurfacing arthroplasty.
Tech Hand Up Extrem Surg. 2002;6:185–192.
21. Williams RM, Kiefhaber TR, Sommerkamp TG, et al. Treatment of
unstable dorsal proximal interphalangeal fracture/dislocations
using a hemi-hamate autograft. J Hand Surg Am. 2003;28:856–865.
22. Badia A, Riano F, Ravikoff J, et al. Dynamic intradigital external
fixation for proximal interphalangeal joint fracture dislocations. J
Hand Surg Am. 2005;30:154–160.
23. Ellis SJ, Cheng R, Prokopis P, et al. Treatment of proximal
interphalangeal dorsal fracture-dislocation injuries with dynamic
external fixation: a pins and rubber band system. J Hand Surg Am.
2007;32:1242–1250.
24. Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of dynamic
distraction external fixation for unstable fracture-dislocations of the
proximal interphalangeal joint. J Hand Surg Am. 2008;33:19–25.
25. Agee JM. Unstable fracture dislocations of the proximal
interphalangeal joint. Treatment with the force couple splint. Clin
Orthop. 1987;214:101–112.
26. Weiss AP. Cerclage fixation for fracture dislocation of the proximal
interphalangeal joint. Clin Orthop. 1996;327:21–28.
27. Dionysian E, Eaton RG. The long-term outcome of volar plate
arthroplasty of the proximal interphalangeal joint. J Hand Surg Am.
2000;25:429–437.
28. Calfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate
arthroplasty provides functional reconstruction of acute and chronic
proximal interphalangeal fracture-dislocations. J Hand Surg Am.
2009;34:1232–1241.
29. McAuliffe JA. Hemi-hamate autograft for the treatment of unstable
dorsal fracture dislocation of the proximal interphalangeal joint. J
Hand Surg Am. 2009;34:1890–1894.
30. Weiss AP, Hastings H. Distal unicondylar fractures of the proximal
phalanx. J Hand Surg Am. 1993;18:594–599.
31. Belsky MR, Eaton RG, Lane LB. Closed reduction and internal
fixation of proximal phalangeal fractures. J Hand Surg Am.
1984;9:725–729.
32. Page SM, Stern PJ. Complications and range of motion following
plate fixation of metacarpal and phalangeal fractures. J Hand Surg
Am. 1998;23:827–832. This paper illustrates the challenges associated
with plate and screw fixation of fractures in the hand and although often
necessary due to open fractures and other conditions, complications,
including stiffness, plate prominence, infection and tendon rupture can
occur.
33. Patel MR, Bassini L. Irreducible palmar metacarpophalangeal joint
dislocation due to junctura tendinum interposition: a case report
and review of the literature. J Hand Surg Am. 2000;25:166–172.
34. Betz RR, Browne EZ, Perry GB, Resnick EJ. The complex volar
metacarpophalangeal-joint dislocation. A case report and review of
the literature. J Bone Joint Surg Am. 1982;64:1374–1375.
35. Chin SH, Vedder NB. MOC-PSSM CME article: Metacarpal
fractures. Plast Reconstr Surg. 2008;121:1–13.
36. Kuokkanen HO, Mulari-Keränen SK, Niskanen RO, et al. Treatment
of subcapital fractures of the fifth metacarpal bone: a prospective
randomised comparison between functional treatment and
reposition and splinting. Scand J Plast Reconstr Surg Hand Surg.
1999;33:315–317.
37. Hunter JM, Cowen NJ. Fifth metacarpal fractures in a compensation
clinic population. A report on one hundred and thirty-three cases. J
Bone Joint Surg Am. 1970;52:1159–1165.
38. Jahss S. Fractures of the metacarpals: A new method of reduction
and immobilzation. J Bone Jt Surg Am. 1938;20:726–731.
39. Hofmeister EP, Kim J, Shin AY. Comparison of 2 methods of
immobilization of fifth metacarpal neck fractures: a prospective
randomized study. J Hand Surg Am. 2008;33:1362–1368.
40. Brown PW. The management of phalangeal and metacarpal
fractures. Surg Clin North Am. 1973;53:1393–1437.
41. Foucher G. Bouquet” osteosynthesis in metacarpal neck fractures: a
series of 66 patients. J Hand Surg Am. 1995;20:S86–S90.
42. Hastings H. Unstable metacarpal and phalangeal fracture treatment
with screws and plates. Clin Orthop. 1987;214:37–52.
43. Seitz WH, Gomez W, Putnam MD, Rosenwasser MP. Management
of severe hand trauma with a mini external fixateur. Orthopedics.
1987;10:601–610.
44. Drenth DJ, Klasen HJ. External fixation for phalangeal and
metacarpal fractures. J Bone Joint Surg Br. 1998;80:227–230.
45. Ashmead D, Rothkopf DM, Walton RL, Jupiter JB. Treatment of
hand injuries by external fixation. J Hand Surg Am. 1992;17:
954–964.
46. Garcia-Elias M, Bishop AT, Dobyns JH, et al. Transcarpal
carpometacarpal dislocations, excluding the thumb. J Hand Surg
Am. 1990;15:531–540.

168.e5
References
47. Gurland M. Carpometacarpal joint injuries of the fingers. Hand Clin.
1992;8:733–744.
48. Camp RA, Weatherwax RJ, Miller EB. Chronic posttraumatic radial
instability of the thumb metacarpophalangeal joint. J Hand Surg Am.
1980;5:221–225.
49. Smith RJ. Post-traumatic instability of the metacarpophalangeal
joint of the thumb. J Bone Joint Surg Am. 1977;59:14–21.
50. Husband JB, McPherson SA. Bony skier’s thumb injuries. Clin
Orthop. 1996;327:79–84.
51. Bowers WH, Hurst LC. Gamekeeper’s thumb. Evaluation by
arthrography and stress roentgenography. J Bone Joint Surg Am.
1977;59:519–524.
52. Stener B. Skeletal injuries associated with rupture of the ulnar
collateral ligament of the metacarpophalangeal joint of the thumb.
A clinical and anatomical study. Acta Chir Scand. 1963;125:583–586.
53. Smith RJ, Peimer CA. Injuries to the metacarpal bones and joints.
Adv Surg. 1977;11:341–374.
54. Palmer AK, Louis DS. Assessing ulnar instability of the
metacarpophalangeal joint of the thumb. J Hand Surg Am.
1978;3:542–546.
55. Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the
ulnar collateral ligament of the thumb metacarpophalangeal joint.
Biomechanical and prospective clinical studies on the usefulness of
valgus stress testing. Clin Orthop. 1993;292:165–171.
56. Heyman P. Injuries to the ulnar collateral ligament of the thumb
metacarpophalangeal joint. J Am Acad Orthop Surg. 1997;5:224–229.
57. Ryu J, Fagan R. Arthroscopic treatment of acute complete thumb
metacarpophalangeal ulnar collateral ligament tears. J Hand Surg
Am. 1995;20:1037–1042.
58. Slade JF, Gutow AP. Arthroscopy of the metacarpophalangeal joint.
Hand Clin. 1999;15:501–527.
59. Sakellarides HT, DeWeese JW. Instability of the
metacarpophalangeal joint of the thumb. Reconstruction of the
collateral ligaments using the extensor pollicis brevis tendon. J Bone
Joint Surg Am. 1976;58:106–112.
60. Ahmad I, DePalma AF. Treatment of game-keeper’s thumb by a
new operation. Clin Orthop. 1974;103:167–169.
61. Neviaser RJ, Wilson JN, Lievano A. Rupture of the ulnar collateral
ligament of the thumb (gamekeeper’s thumb). Correction by
dynamic repair. J Bone Joint Surg Am. 1971;53:1357–1364.
62. Mitsionis GI, Varitimidis SE, Sotereanos GG. Treatment of chronic
injuries of the ulnar collateral ligament of the thumb using a free
tendon graft and bone suture anchors. J Hand Surg Br.
2000;25:208–211.
63. Bean CH, Tencer AF, Trumble TE. The effect of thumb
metacarpophalangeal ulnar collateral ligament attachment site on
joint range of motion: an in vitro study. J Hand Surg Am.
1999;24:283–287. This paper is an excellent study reviewing the precise
anatomical location to optimize motion and function following repair/
reconstruction of the MCP joint UCL.
64. Imaeda T, An KN, Cooney WP, Linscheid R. Anatomy of
trapeziometacarpal ligaments. J Hand Surg Am. 1993;18:
226–231.
65. Cooney WP, Chao EY. Biomechanical analysis of static forces in the
thumb during hand function. J Bone Joint Surg Am. 1977;59:27–36.
66. Cooney WP, Lucca MJ, Chao EY, Linscheid RL. The kinesiology of
the thumb trapeziometacarpal joint. J Bone Joint Surg Am.
1981;63:1371–1381.
67. Jakobsen CW, Elberg JJ. Isolated carpometacarpal dislocation of the
thumb. Case report. Scand J Plast Reconstr Surg Hand Surg.
1988;22:185–186.
68. Watt N, Hooper G. Dislocation of the trapezio-metacarpal joint. J
Hand Surg Br. 1987;12:242–245.
69. Eaton RG, Littler JW. Ligament reconstruction for the painful
thumb carpometacarpal joint. J Bone Joint Surg Am.
1973;55:1655–1666.
70. Simonian PT, Trumble TE. Traumatic dislocation of the thumb
carpometacarpal joint: early ligamentous reconstruction versus
closed reduction and pinning. J Hand Surg Am. 1996;21:802–806.
71. Pellegrini VD. Fractures at the base of the thumb. Hand Clin.
1988;4:87–102.
72. Foster RJ, Hastings H. Treatment of Bennett, Rolando, and vertical
intraarticular trapezial fractures. Clin Orthop. 1987;214:121–129.
73. Langhoff O, Andersen K, Kjaer-Petersen K. Rolando’s fracture. J
Hand Surg Br. 1991;16:454–459.
74. Buchler U, McCollam SM, Oppikofer C. Comminuted fractures of
the basilar joint of the thumb: combined treatment by external
fixation, limited internal fixation, and bone grafting. J Hand Surg
Am. 1991;16:556–560.
75. Schuind F, Noorbergen M, Andrianne Y, Burny F. Comminuted
fractures of the base of the first metacarpal treated by distraction-
external fixation. J Orthop Trauma. 1988;2:314–321.
76. Abzug JM, Kozin SH. Seymour fractures. J Hand Surg Am.
2013;38:2267–2270, quiz 2270.
77. Al-Qattan MM. Extra-articular transverse fractures of the base of
the distal phalanx (Seymour’s fracture) in children and adults. J
Hand Surg [Br]. 2001;26:201–206.
78. Banerjee A. Irreducible distal phalangeal epiphyseal injuries. J Hand
Surg Br. 1992;17:337–338.
79. Seymour N. Juxta-epiphysial fracture of the terminal phalanx of the
finger. J Bone Joint Surg Br. 1966;48:347–349.
80. Al-Qattan MM. Phalangeal neck fractures in children: classification
and outcome in 66 cases. J Hand Surg Br. 2001;26:112–121.
81. Al-Qattan MM. Juxta-epiphyseal fractures of the base of the
proximal phalanx of the fingers in children and adolescents. J Hand
Surg Br. 2002;27:24–30.
82. Al-Qattan MM, Hashem FK, Rasool MN, et al. A unique fracture
pattern of the proximal phalanx in children: fractures through the
phalangeal neck with an attached dorsal bony flange. Injury.
2004;35:1185–1191.
83. Botte MJ, Davis JL, Rose BA, et al. Complications of smooth pin
fixation of fractures and dislocations in the hand and wrist. Clin
Orthop Relat Res. 1992;276:194–201.
84. Freeland AE, Lindley SG. Malunions of the finger metacarpals and
phalanges. Hand Clin. 2006;22:341–355. This paper provides an
algorithm for managing malunions in the hand, including the various
different osteotomies and concomitant procedures, such as tenolysis and
capsulotomy, to improve motion.
85. Büchler U, Gupta A, Ruf S. Corrective osteotomy for post-traumatic
malunion of the phalanges in the hand. J Hand Surg Br.
1996;21:33–42.
86. Trumble T, Gilbert M. In situ osteotomy for extra-articular
malunion of the proximal phalanx. J Hand Surg Am.
1998;23:821–826.
87. Jawa A, Zucchini M, Lauri G, Jupiter J. Modified step-cut osteotomy
for metacarpal and phalangeal rotational deformity. J Hand Surg
Am. 2009;34:335–340.
88. Lucas GL. Rotational step-cut osteotomy for treatment of
metacarpal and phalangeal malunion. J Hand Surg Am. 1992;17:583.
89. Manktelow RT, Mahoney JL. Step osteotomy: a precise rotation
osteotomy to correct scissoring deformities of the fingers. Plast
Reconstr Surg. 1981;68:571–576.
90. Teoh LC, Yong FC, Chong KC. Condylar advancement osteotomy
for correcting condylar malunion of the finger. J Hand Surg [Br].
2002;27:31–35.
91. Harness NG, Chen A, Jupiter JB. Extra-articular osteotomy for
malunited unicondylar fractures of the proximal phalanx. J Hand
Surg Am. 2005;30:566–572.
92. Jupiter JB, Koniuch MP, Smith RJ. The management of delayed
union and nonunion of the metacarpals and phalanges. J Hand Surg
Am. 1985;10:457–466.

169
Future directions
32. Page SM, Stern PJ. Complications and range of motion following
plate fixation of metacarpal and phalangeal fractures. J Hand Surg
Am. 1998;23:827–832. This paper illustrates the challenges associated
with plate and screw fixation of fractures in the hand and although often
necessary due to open fractures and other conditions, complications,
including stiffness, plate prominence, infection and tendon rupture can
occur.
56. Heyman P. Injuries to the ulnar collateral ligament of the thumb
metacarpophalangeal joint. J Am Acad Orthop Surg. 1997;5:224–229.
63. Bean CH, Tencer AF, Trumble TE. The effect of thumb
metacarpophalangeal ulnar collateral ligament attachment site on
joint range of motion: an in vitro study. J Hand Surg Am.
1999;24:283–287. This paper is an excellent study reviewing the precise
anatomical location to optimize motion and function following repair/
reconstruction of the MCP joint UCL.
77. Al-Qattan MM. Extra-articular transverse fractures of the base of
the distal phalanx (Seymour’s fracture) in children and adults. J
Hand Surg [Br]. 2001;26:201–206.
83. Botte MJ, Davis JL, Rose BA, et al. Complications of smooth pin
fixation of fractures and dislocations in the hand and wrist. Clin
Orthop Relat Res. 1992;276:194–201.
84. Freeland AE, Lindley SG. Malunions of the finger metacarpals and
phalanges. Hand Clin. 2006;22:341–355. This paper provides an
algorithm for managing malunions in the hand, including the various
different osteotomies and concomitant procedures, such as tenolysis and
capsulotomy, to improve motion.
90. Teoh LC, Yong FC, Chong KC. Condylar advancement osteotomy
for correcting condylar malunion of the finger. J Hand Surg [Br].
2002;27:31–35.

SECTION II • Acquired Traumatic Disorders
8 
Fractures and dislocations of the wrist
and distal radius
Steven C. Haase and Kevin C. Chung
SYNOPSIS
■ Wrist injuries are common, and proper management relies on an
understanding of normal anatomy, alignment, and kinematics.
■ Scaphoid fractures can be subtle, and due to the precarious blood
supply to this bone, may go on to nonunion if not properly managed.
■ Indications for scapholunate ligament repair and/or reconstruction
depend on the patient’s symptoms and on the chronicity of the injury.
■ For distal radius fractures requiring stabilization, external fixation and
dorsal plating have largely been supplanted by volar fixed-angle locking
plates, which provide the necessary stability for fracture healing, even
in osteoporotic individuals.
■ Ulnar styloid fractures only require fixation in the setting of distal
radioulnar joint instability.
Introduction
The wrist is a complex articulation that connects the hand to
the forearm. Entire textbooks have been devoted to detailed
discussions of the anatomy, physiology, and pathology of this
important joint. This chapter will review some of the more
common injury patterns seen in the wrist, including fractures
of the carpal bones, ligamentous injuries of the wrist, and
fractures of the distal radius and ulna.
The epidemiology of wrist fractures has been investigated
in detail. Each year, nearly 1.5 million hand and wrist fractures
are estimated to occur in the United States, accounting for
1.5% of all emergency department visits.1 Of these, approxi­
mately 208 000 are carpal fractures.
The scaphoid is the carpal bone most commonly fractured;
it accounts for 60–80% of all carpal fractures.2,3 Incidence
estimates range from 2.9/10 000 person-years in the United
Kingdom4 to 12.1/10 000 person-years in the US military
population.5 The highest incidence is found in the 20–24-year-
old age group, and there is a clear male predominance.4,5
Distal radius fractures are the most common upper extrem­
ity fracture; the annual incidence is estimated at 643 000
fractures per year in the United States.1 When the incidence
is examined by age, there are two distinct peaks identified
(Fig. 8.1), representing the 5–14-year-old group (55.7/10 000
person-years) and the 75–84-year-old group (35.2/10 000
person-years).
Although a common injury, these fractures should never be
treated casually. There is significant potential for patient dis­
ability if these injuries are not managed with great care and
expertise. Khan and Giddins’ review of hand and wrist
surgery negligence claims in the UK from 1995–2001 revealed
that wrist fracture was the most common condition in which
negligence was alleged, comprising 48% of claims.6
Access the Historical Perspective section and Figs. 8.2
& 8.3 online at

Basic science/disease process
Anatomy
Normal anatomy of the wrist is covered in detail in Chapter
1 of this textbook. However, there are a few points that merit
emphasis in this chapter with regard to these injuries.
The vascularity of the scaphoid bone bears particular
consideration. The scaphoid bone has a single dominant
vascular pedicle that enters from the distal pole of the bone.
Therefore, the proximal pole relies wholly on the intramedul­
lary blood supply for survival. It is for this reason that proxi­
mal pole fractures typically take longer to heal and have
increased incidence of nonunion. Furthermore, in cases of
nonunion, the proximal pole is susceptible to avascular necro­
sis, which further complicates these injuries.11
Detection of ligamentous injuries of the wrist is made
easier by attention to the Gilula arcs (Fig. 8.4). Dr. Gilula, a
radiologist, described three arcs that can be noted on the
posteroanterior radiograph of the wrist, formed by the

170.e1
Historical perspective
Historical perspective
The carpus was not well described until the 1500s, when
Andreas Vesalius first identified the eight carpal bones. Before
then, drawings of the hand connected the metacarpals directly
to the distal radius, with no mention of wrist anatomy. Carpal
bones are generally named for their shapes. For example, the
scaphoid resembles a boat, whereas the lunate resembles the
crescent moon. The names of the carpal bones were not solidi­
fied until 1955 when Nomina Anatomica established the official
nomenclature for the carpal bones that we use today (Fig.
8.2).7
Historically, the carpal bones have been grouped together
in various ways, based on function and kinematics. The earli­
est classification separates the wrist joint into two rows, con­
sisting of the distal carpal row (trapezium, trapezoid, capitate,
hamate) and the proximal carpal row (scaphoid, lunate, tri­
quetrum). The carpus can also be divided into columns: a
radial column (scaphoid, trapezoid, trapezium), a central
column (lunate, capitate), and an ulnar column (triquetrum,
hamate). The pisiform bone is not involved in wrist motion,
so it is not typically included in these groupings.
Abraham Colles (1773–1843) is credited with the first clini­
cal description of fractures of the distal radius. His 1814
manuscript provides an eloquent description of closed reduc­
tion and splinting, in an era before the development of
radiographs, anesthesia, and plaster of Paris. On the results
of treatment, he proclaimed, “The cases treated on this plan
have all recovered without the smallest defect or deformity of
the limb, in the ordinary time for the cure of fractures.”8
More than 200 years later, closed reduction and immobili­
zation is still the predominant method of treatment for distal
radius fractures, though internal fixation has been steadily
gaining in popularity.9 It is now commonly believed that
restoration of anatomic alignment of the distal radius leads to
better outcomes, although the age and activity level of the
patient certainly contribute to this equation. To achieve these
ends, technology has advanced to allow for precise fracture
fixation with a variety of techniques. Over the past several
decades, pins-and-plaster and external fixation systems have
largely given way to internal fixation methods, heavily
encouraged by AO (Arbeitsgemeinschaft für Osteosynthese­
fragen). AO is a Swiss organization started in the late 1950s
for promoting more consistent fracture care, chiefly using
rigid internal fixation. Despite the development of hundreds
of fixators, plates, rods, and other devices, there is little high-
level evidence to support the use of one technique over
another. In some ways, Colles’ conservative approach was
probably correct – many patients, especially the low-demand
elderly population, achieve excellent outcomes even in the
presence of significant malunion or malalignment.10
Many textbooks discourage the use of eponyms, believing
them to be of historical interest only. However, the various
eponyms for distal radius fractures often convey precise
information regarding the fracture pattern and the type of
injury sustained. The major eponyms for distal radius frac­
tures are: Colles fracture (extra-articular fracture with dorsal
displacement of distal fragment) (Fig. 8.3A); Smith fracture
(also called reverse Colles fracture; extra-articular with volar
displacement of distal fragment) (Fig. 8.3B); Barton fracture
(intra-articular shear fracture of the radiocarpal joint, may be
dorsal or volar) (Fig. 8.3C,D); and Chauffeur fracture (intra-
articular fracture involving the radial styloid) (Fig. 8.3E). For
some cases, these eponyms may help in selecting a treatment
modality.
Fig. 8.2  Posteroanterior radiograph of the wrist, with carpal bones identified.
Triquetrum
Pisiform
Lunate
Scaphoid
Trapezoid
Hamate
Hook of hamate
Capitate
Trapezium

170.e2
SECTION II
CHAPTER 8 • Fractures and dislocations of the wrist and distal radius
A
B
C
D
E
Fig. 8.3  Examples of common distal radius fracture eponyms: (A) Colles fracture, (B) Smith fracture,
(C) dorsal Barton fracture, (D) volar Barton fracture, and (E) Chauffeur fracture.

171
Basic science/disease process
and capitate, and rupture of the lunotriquetral interosseous
ligament. If the dislocated carpus rebounds, then the capitate
will settle into the lunate fossa, and the lunate rotates volarly,
hinged on the short radiolunate ligament (Fig. 8.7).13,14
Injury patterns are also influenced by the details of bony
anatomy and structure. For example, both the diaphysis and
the articular surface of the distal radius have thicker cortical
bone than is found at the metaphysis. The thinner cortical
bone at the metaphysis is what makes it vulnerable to fracture,
especially in the osteoporotic population. Furthermore, within
the metaphysis, there is a distinct difference between the
dorsal and volar cortices. The dorsal cortex is much thinner,
resulting in extensive comminution in most cases of distal
radius fracture from falls on outstretched hands, where the
force is directed in a volar-to-dorsal direction.
The extensor pollicis longus (EPL) is the tendon most likely
to rupture after a distal radius fracture. Of note, rupture is
more common with non-displaced fractures, and has been
reported in cases of wrist injury without fracture. The etiology
of this appears to be related to interruption of the tendon’s
nutritional supply, leading to attritional rupture. This most
commonly occurs at the Lister tubercle, where there is a
natural watershed area of this tendon’s intrinsic blood supply.
If the extrinsic (diffusion-mediated) nutritional supply is also
interrupted by fracture callus, fracture displacement, or swell­
ing from edema or hematoma, rupture of the EPL can occur.15
Biomechanics
The biomechanics of the hand and wrist were reviewed in
Chapter 1, but there are a few points to revisit here.
Disruption of the normal linkages between the bones of the
wrist – whether due to ligamentous rupture or fracture – can
lead to carpal instability. The concept of carpal instability has
evolved rapidly over the past 50 years as we have learned
more about the ways in which the wrist bones move (kinemat­
ics) and transfer a load (kinetics). Specifically, a wrist is
unstable if it is unable to transfer functional loads without
sudden changes in stress on the articular cartilage, and if it is
unable to maintain motion throughout its range without
sudden alterations of intercarpal alignment.16
Carpal instability has been thoughtfully classified into four
major patterns (Table 8.1). Carpal instability dissociative
(CID) occurs when there is a disruption within or between the
proximal and distal articular surfaces of the proximal row,
and the proximal articular surface of the distal row. Increased
joint space or deviation of carpal bones from these lines is
indicative of wrist instability.12
The bones of the wrist are linked by a complex system of
intrinsic and extrinsic ligaments (Fig. 8.5). The strength of
these wrist ligaments helps determine the injury patterns
observed. For example, the very strong short radiolunate liga­
ment tends to resist lunate dislocation, retaining the lunate in
its fossa on the distal radius in all but the most severe traumas.
Instead, the surrounding carpal bones typically dislocate
away from the lunate. This perilunate pattern of injury (Fig.
8.6) involves: rupture of the scapholunate interosseous liga­
ment; capsular disruption through the space of Poirier, an area
of inherent weakness of the volar capsule between the lunate
Fig. 8.1  Age-related variation in radius/ulna fracture incidence.
(Data from Chung KC, Spilson SV. The frequency and epidemiology
of hand and forearm fractures in the United States. J Hand Surg
Am. 2001;26:908–915.)
Age (years)
Fracture incidence (per 10 000 person-years)
0
60
50
40
30
20
10
0–4
5–14
15–24
25–34
35–44
45–54
55–64
65–74
75–84
85+
Fig. 8.4  The Gilula arcs are used to detect alterations in carpal alignment and
stability. The lines are defined by (1) the proximal and (2) the distal articular
surface of the proximal row, as well as (3) the proximal articular surface of the
distal row.

172
SECTION II
CHAPTER 8 • Fractures and dislocations of the wrist and distal radius
A
Dorsal intercarpal
ligament
Dorsal radiocarpal
ligament
C
L
P
S
R
U
Tm
H
1
2
3
4
5
Td
B
Radioscaphocapitate
ligament
Ulnotriquetral
ligament
Ulnocapitate
ligament
Ulnolunate
ligament
Palmar
radioulnar
ligament
Pisohamate
ligament
Long radiolunate
ligament
Short radiolunate
ligament
C
H
Tr
L
P
S
Tm
1
2
3
4
5
Td
Fig. 8.5  (A) Dorsal extrinsic wrist ligaments. (B) Volar extrinsic wrist ligaments.
(C) Intrinsic wrist ligaments. C, Capitate; L, lunate; P, pisiform; R, radius; S, scaphoid;
Td, trapezoid; Tm, trapezium; U, ulna.
C
Capitohamate
ligament
C
H
Tr
L
P
S
Tm
1
2
3
4
5
Td
Triquetrohamate
ligament
Triquetrocapitate
ligament
Lunotriquetral
ligament
Scaphotrapezium
trapezoid ligament
Trapeziotrapezoid
ligament
Capitotrapezoid
ligament
Scapholunate
ligament
Scaphocapitate
ligament

173
Basic science/disease process
Fig. 8.6  Mayfield stages of perilunate instability: (I) scapholunate ligament rupture;
(II) volar capsule tear at the space of Poirer; (III) lunotriquetral ligament rupture; (IV)
lunate dislocation.
I
II
III
IV
Fig. 8.7  Lateral radiograph examples of (A) perilunate dislocation and (B) lunate dislocation injury patterns.
A
B
bones of the same carpal row. Carpal instability non-
dissociative (CIND) refers to a disruption between the distal
radius and the proximal carpal row, or between the proximal
and distal carpal rows. When a combination of elements of
both CID and CIND exist, it is referred to as carpal instability
complex (CIC). Finally, when the instability is an adaptive
response to a problem proximal or distal to the wrist itself, it
is called carpal instability adaptive (CIA).17
Carpal kinematics has perhaps the biggest clinical impact
on scaphoid fractures and scapholunate ligament injuries. The
proximal carpal row is “pre-tensioned”, with the scaphoid
subject to a flexion moment, and the triquetrum tending to
follow an extension moment. Any breakage of the connections
within this row, whether intracarpal (e.g., scaphoid fracture)
or intercarpal (e.g., scapholunate ligament rupture), will result
in carpal instability because the disconnected carpal bones
rotate in opposite directions. This natural tendency for the
components in this row to fall away from each other is in part
responsible for the high rate of complications after these types
of injury.
Two particular instability patterns that result from CID
within the proximal row are dorsal intercalated segment
instability (DISI) and volar intercalated segment instability
(VISI) (Fig. 8.8). DISI deformity is commonly associated
with scapholunate ligament disruption or displaced scaphoid
fractures; whereas VISI deformity is associated with lunotri­
quetral ligament disruption.

174
SECTION II
CHAPTER 8 • Fractures and dislocations of the wrist and distal radius
Table 8.1  Patterns of carpal instability
Pattern
Definition
Example(s)
Carpal instability dissociative (CID)
Disruption within or between bones of the same
carpal row
Scapholunate dissociation; Scaphoid
nonunion
Carpal instability non-dissociative
(CIND)
Disruption at the radiocarpal or midcarpal joints,
with intact proximal and distal rows
Midcarpal instability
Carpal instability complex (CIC)
Derangement both within and between carpal
rows (CID plus CIND)
Perilunate dislocation with ulnar translation
Carpal instability adaptive (CIA)
Instability due to injury proximal or distal to wrist
Distal radius malunion
(Data from International Wrist Investigators’ Workshop Terminology Committee. Wrist: terminology and definitions. J Bone Joint Surg Am. 2002;84-A(Suppl 1):1–73.)
Fig. 8.8  (A) Lunate position in DISI and VISI deformities of the wrist. X-rays of (B) DISI and (C) VISI
deformities.
A
DISI
Normal
VISI
B
C
Because of the scaphoid’s natural tendency to flex when
loaded, delayed treatment of comminuted fractures of the
scaphoid waist tend to result in the so-called “humpback
deformity” (Fig. 8.9). This term describes the shape of the
scaphoid as seen on lateral tomograms, reflecting malunion
of the bone with an abnormally acute angle between the
proximal and distal poles of the scaphoid.18
Mechanisms of injury
In elderly osteoporotic patients, wrist injuries are commonly
seen after falls from a standing height. Very often, this is
an extra-articular fracture with apex volar angulation, the
so-called “Colles fracture” (see Fig. 8.3). The younger popula­
tion typically experiences fractures caused by higher energy