What is the appropriate treatment for an adult patient with no significant medical history presenting with a thumb fracture?

Treatment of Thumb Fractures in Adults

Begin with a 2-view radiographic examination (posteroanterior and lateral), though adding an oblique projection slightly increases diagnostic yield, and proceed with treatment based on fracture location, stability, and articular involvement. 1

Initial Imaging Protocol

• Obtain standard 2-view radiographs as first-line imaging for suspected thumb fractures, which captures most fractures adequately 1
• Add an oblique projection along with a PA examination of the whole hand to maximize fracture detection 1
• If initial radiographs are negative but clinical suspicion remains high, obtain CT without IV contrast to exclude occult fractures 1
• Provide multimodal analgesia with acetaminophen before diagnostic imaging, adding opioids as needed while avoiding NSAIDs if renal function is unknown 2

Treatment Algorithm by Fracture Type

Extra-Articular Fractures (Shaft and Metaphyseal)

Treat with closed reduction and cast immobilization for most cases, as angulation up to 30 degrees is well-tolerated due to compensatory motion at the thumb carpometacarpal joint. 3

• Accept up to 30 degrees of angulation without surgical intervention 3
• Immobilize in a thumb spica cast or splint 4, 3
• Begin active range-of-motion exercises of all non-immobilized fingers immediately to prevent debilitating stiffness 5
• Obtain serial radiographs at 1-2 weeks to confirm maintained reduction 2

Intra-Articular Fractures (Bennett and Rolando Fractures)

Pursue anatomic reduction with less than 1 mm articular step-off to minimize long-term posttraumatic arthritis risk, even though functional outcomes can be acceptable with some residual deformity. 3

Bennett Fractures (Two-Part Intra-Articular Base Fractures)

• Perform closed reduction with percutaneous Kirschner wire fixation for most cases 3
• Reserve open reduction and internal fixation for fractures with large Bennett fragments to achieve anatomic reduction with rigid fixation 3
• Allow early range of motion after stable fixation 2, 3

Rolando Fractures (Comminuted Intra-Articular Base Fractures)

• Apply external fixation with limited open reduction and internal fixation for severely comminuted patterns 3
• Perform bone grafting of metaphyseal defects when necessary 3
• Treat simpler three-part patterns with open reduction and internal fixation 3

Distal Phalanx Fractures

• Treat conservatively with splinting regardless of displacement 4
• These fractures heal reliably without surgical intervention 4

Critical Early Mobilization

Instruct patients to move all non-immobilized fingers through complete range of motion starting immediately, as finger stiffness is one of the most functionally disabling complications and becomes extremely difficult to treat after fracture healing. 5

• Explain that pain, swelling, and apprehension contribute to stiffness if motion is not maintained 5
• Ensure splints or casts do not obstruct movement of uninjured fingers 5
• Do not wait for pain to completely resolve before beginning motion exercises 5
• Begin active motion exercises within 3 days of injury 5

Surgical Indications

Refer to orthopedic or hand surgery for:

• Intra-articular displacement >1 mm after reduction attempt 3
• Unstable fractures that cannot maintain reduction 4, 3
• Any fracture with rotational deformity 4
• Irreducible dislocations 4
• Large Bennett fragments requiring anatomic fixation 3

Special Considerations for Patients Over 50 Years

Recognize that thumb fractures in this population may represent fragility fractures requiring comprehensive osteoporosis evaluation. 5

• Order vitamin D, calcium, and parathyroid hormone levels at the initial visit 2, 5
• Schedule outpatient DEXA scan 2
• Consider initiating calcium and vitamin D supplementation immediately 2
• Initiate bisphosphonate therapy for confirmed osteoporosis 2
• Implement orthogeriatric co-management for frail elderly patients with multiple comorbidities 2, 5
• Implement fall prevention programs including balance training 2, 5

Common Pitfalls to Avoid

• Do not ignore uninjured fingers – stiffness can develop in unfractured digits, especially with associated crush injuries 5
• Do not delay motion exercises – waiting for complete pain resolution leads to preventable stiffness requiring extensive therapy or additional surgery 5
• Do not accept >1 mm articular step-off in intra-articular fractures – this increases long-term arthritis risk despite potentially acceptable short-term function 3
• Do not fail to address underlying osteoporosis in elderly patients – this leaves them at increased risk for subsequent hip or vertebral fractures 5

Follow-Up Protocol

• Monitor for maintained reduction with radiographs at 1-2 weeks 2
• Assess for unremitting pain during follow-up, which warrants reevaluation for complications 5
• Ensure systematic follow-up for osteoporosis treatment adherence in elderly patients 5
• Provide realistic expectations that therapy duration depends on fracture type, age, comorbidities, and functional requirements 5