What is the appropriate treatment for a patient with a fractured thumb, considering their medical history and potential complications?

Treatment of Fractured Thumb

Begin with immediate 2-view radiographs (minimum) of the thumb, though adding an oblique view increases diagnostic yield, and base all subsequent treatment decisions on fracture location, stability, and articular involvement. 1

Initial Diagnostic Approach

• Obtain at minimum a 2-view radiographic examination (PA and lateral) for all suspected thumb fractures, though a 3-view series including an oblique projection provides superior diagnostic accuracy. 1
• Most thumb fractures are visible on standard 2-view imaging, but the oblique view detects additional fractures that would otherwise be missed. 1
• If initial radiographs are negative but clinical suspicion remains high, immobilize in a thumb spica splint and repeat radiographs at 10-14 days rather than delaying diagnosis. 1

Treatment Algorithm Based on Fracture Type

Distal Phalanx Fractures

• Treat conservatively with splinting of the distal interphalangeal joint for 4-6 weeks. 2
• These crush injuries have excellent outcomes with simple immobilization. 2

Metacarpal Base Fractures (Bennett and Rolando Fractures)

Extra-articular fractures:

• Treat with closed reduction and cast immobilization if angulation is ≤30 degrees, as the carpometacarpal joint compensates for this degree of deformity. 3
• Angulation beyond 30 degrees requires surgical intervention. 3

Intra-articular fractures (Bennett fractures):

• The treatment goal is anatomic reduction with <1 mm articular step-off to prevent post-traumatic arthritis, though functional outcomes remain acceptable even with some residual deformity. 3
• Most Bennett fractures respond to closed reduction with percutaneous Kirschner wire fixation. 3
• Large Bennett fragments and Rolando fractures require open reduction and internal fixation for anatomic restoration and early range of motion. 3
• Severely comminuted intra-articular fractures need external fixation with limited open reduction, internal fixation, and bone grafting of metaphyseal defects. 3

Middle and Proximal Phalanx Fractures

• Buddy splint if angulation is <10 degrees with no malrotation. 2
• Refer for reduction or surgery if angulation exceeds 10 degrees, displacement is present, or any malrotation exists. 2
• Unstable fractures or those with rotational deformity require orthopedic or hand surgery consultation. 4

Critical Indications for Immediate Surgical Referral

Refer immediately to orthopedic or hand surgery for: 4, 3

• Unstable fractures that cannot maintain reduction
• Any rotational deformity (check by having patient make a fist—all fingernails should point toward scaphoid)
• Articular step-off >1-2 mm
• Irreducible fractures
• Open fractures
• Fractures with neurovascular compromise

Common Pitfalls to Avoid

• Do not accept 2-view imaging as adequate—the oblique view detects additional pathology. 1
• Do not delay immobilization while awaiting repeat imaging; splint immediately and reimage at 10-14 days if initial films are negative. 1
• Do not underestimate acceptable angulation at the thumb metacarpal base—up to 30 degrees is tolerable due to compensatory carpometacarpal motion, unlike other metacarpals. 3
• Do not miss rotational deformity, which always requires surgical correction regardless of other fracture characteristics. 4, 2

Special Consideration for Elderly Patients

• In patients over 50 years with fragility fractures, evaluate for underlying osteoporosis and consider referral to a Fracture Liaison Service for secondary fracture prevention, though this applies more to major fractures than isolated thumb injuries. 1