What is the recommended treatment for hand fractures?

Treatment for Hand Fractures

Hand fractures should be treated with immediate active finger motion exercises following either conservative immobilization or surgical fixation, as prolonged immobilization causes more harm than benefit to functional outcomes. 1, 2

Initial Assessment and Imaging

• Obtain three-view radiographs (posteroanterior, lateral, and oblique) as the initial imaging study for all suspected hand fractures 3
• For phalangeal injuries, include an internally rotated oblique projection in addition to the standard externally rotated oblique to increase diagnostic yield 3
• Assess fracture displacement (>3mm is significant), angulation, rotation, and articular involvement to guide treatment decisions 4, 5

Non-Displaced or Minimally Displaced Fractures

Conservative management with immobilization is the preferred approach for stable, non-displaced hand fractures. 6

Immobilization Protocol

• Apply a splint that never obstructs full finger range of motion at any point during treatment 1
• Initiate immediate active finger motion exercises to prevent stiffness, as finger motion does not adversely affect adequately stabilized fractures 1
• Obtain radiographic follow-up at 3 weeks to confirm maintenance of alignment and adequate healing 1
• Repeat imaging at the time of immobilization removal 1

Key Precautions

• Monitor closely for loss of reduction, as even initially non-displaced fractures can displace during healing 1
• Watch for complications including skin irritation and muscle atrophy, which occur in approximately 14.7% of immobilization cases 1
• Do not restrict wrist motion indefinitely after the fracture is stable, as prolonged immobilization increases stiffness risk 1

Displaced or Unstable Fractures

Surgical fixation becomes indicated when post-reduction displacement exceeds 3mm or when fractures demonstrate significant angulation, malrotation, or articular involvement. 1, 5

Surgical Approach

• Perform minimally invasive open reduction and internal fixation to minimize periosteal and peritendinous dissection 2, 7
• Use rigid fixation techniques appropriate to the fracture pattern (plates, screws, or pins) 5
• Metaphyseal fractures (base and neck) heal more quickly than diaphyseal fractures (shaft), making provisional fixation more practical for metaphyseal injuries 5
• More rigid fixation is required when substantial comminution and bone loss are present 5

Postoperative Management

• Instruct patients to perform active finger motion exercises immediately following surgery to prevent stiffness 4, 2
• Implement controlled active exercise at 3 weeks postoperatively, with pain-free active traction in three positions (supination, neutral, and pronation) between 3 and 5 weeks 2
• Early wrist motion is not routinely necessary following stable fracture fixation 4
• Prescribe a home exercise program for rehabilitation 4
• Obtain radiographic follow-up at approximately 3 weeks and at the time of immobilization removal 4

Expected Outcomes and Timeline

• Significant improvements in range of motion occur between 6 and 12 weeks for both phalangeal and metacarpal fractures 2
• Most patients achieve a total range of motion exceeding 230° in the affected finger by 12 weeks 2
• Radiographic union typically occurs by 20 weeks postoperatively 2

Critical Pitfalls to Avoid

• Never allow splints to obstruct finger motion, as this is the most common preventable cause of stiffness 1
• Do not immobilize the wrist indefinitely after fracture stability is achieved, as prolonged immobilization causes more harm than the fracture itself 1
• Avoid rigid immobilization at the expense of soft tissues, as this can be as damaging as the original injury 8
• Do not delay mobilization after stable fixation, as early motion is critical for optimal functional recovery 2, 7