What is the appropriate treatment and management for a patient with a hand fracture, considering factors such as age, medical history, and fracture severity?

Management of Hand Fractures

Hand fractures should be managed primarily with conservative treatment (immobilization and rehabilitation) unless specific operative indications are met, with the key principle being restoration of function through reduction of malrotation, angulation, and articular incongruity. 1, 2

Initial Assessment and Diagnosis

Clinical Evaluation

• Assess for malrotation by examining finger cascade alignment when making a fist—any scissoring or overlap indicates rotational deformity requiring correction 2
• Evaluate for angulation patterns specific to fracture location, as metaphyseal fractures (base and neck) heal faster than diaphyseal (shaft) fractures 2
• Document hand dominance, occupation, age, and comorbidities as these significantly impact treatment decisions 3
• Examine for concomitant soft-tissue injuries including tendon, ligament, and neurovascular damage 2

Imaging

• Obtain standard radiographs with multiple views to assess fracture pattern, displacement, and articular involvement 1
• Recognize that fracture pattern determines fixation type—comminution and bone loss indicate high-energy injury with substantial soft-tissue damage requiring more rigid fixation 2

Treatment Algorithm

Conservative Management (First-Line for Most Fractures)

The majority of hand fractures are managed conservatively with immobilization followed by early mobilization. 1

• Apply appropriate splinting or casting based on fracture location and stability 1
• Immobilize metaphyseal fractures for shorter duration than diaphyseal fractures due to faster healing 2
• Initiate rehabilitation focusing on edema control, scar management, and progressive range of motion exercises 4
• Use both static and dynamic splinting techniques as healing progresses 4

Operative Indications

Surgical fixation is indicated when:

• Articular step-off >2mm is present 2
• Malrotation cannot be adequately reduced or maintained 2
• Angulation exceeds acceptable limits for the specific fracture location 2
• Substantial comminution or bone loss is present 2
• Multiple injured structures are present (though this decreases likelihood of full functional recovery) 2

Use minimally invasive techniques with immediate postoperative mobilization when surgery is required. 5

Special Considerations

Antibiotic Prophylaxis

Hand fractures do not require routine antibiotic prophylaxis unless they are open fractures. 6

• For open hand fractures with soft tissue injury, initiate broad-spectrum intravenous antibiotics after obtaining deep tissue samples 6
• Use short-course, single-agent cephalosporin regimens for fractures associated with bony injury 6
• Tailor antibiotics once organisms and sensitivities are known 6

Elderly and Frail Patients

• Recognize that hand/wrist fractures in patients over 70 years often represent fragility fractures requiring osteoporosis evaluation 6, 7
• Implement orthogeriatric co-management for frail elderly patients 7, 8
• Consider starting anti-osteoporotic treatment even without DXA scan in typical fragility fracture patterns 7, 8
• Implement secondary fracture prevention including fall risk assessment and pharmacologic therapy 6, 8

Rehabilitation Principles

Exercise Progression

• Begin active range of motion exercises as soon as fracture stability allows 4
• Progress to passive stretching only after adequate healing to avoid displacing fracture 4
• Add resistive exercises in final healing phases 4
• Address associated problems of edema, pain, and scar formation throughout rehabilitation 4

Functional Goals

The primary goal is returning patients to preinjury functional status through restoration of articular congruity and maintenance of reduction with minimal surgical intervention. 2

Common Pitfalls to Avoid

• Missing rotational deformity: Always assess finger cascade alignment—even small rotational errors cause significant functional impairment 2
• Underestimating soft-tissue injury: High-energy fractures with comminution indicate substantial soft-tissue damage requiring more aggressive management 2
• Prolonged immobilization: Metaphyseal fractures heal quickly; avoid unnecessary prolonged immobilization that causes stiffness 2
• Ignoring osteoporosis in elderly: Hand fractures in older patients warrant systematic fracture risk assessment and secondary prevention 6, 7