Chapter 7: Hand, fingers and thumb

Anatomy

Musculoskeletal

The hand is made up of 19 bones: 5 metacarpals which form the palm and 14 phalanges

which form the digits (fingers and thumb). These bones and their respective joints are

commonly referred to by their initials (table 7.1)

Table 7.1: Hand anatomy shorthand

Code Anatomy
DP Distal phalanx

MP Middle phalanx

PP Proximal phalanx

IPJ Inter-phalangeal joint

PIPJ Proximal inter-phalangeal joint

DIPJ Distal inter-phalangeal joint

MCPJ Metacarpo-phalangeal joint

CMCJ Carpo-metacarpal joint

Each of the metacarpals is aligned with a single digit. Traditionally these were numbered 1-5

dependent upon their anatomical position. However, as clinical assessment is not always

undertaken with the hand in the true anatomical position and as a result, confusion in

descriptive terminology may arise. Consequently, current clinical etiquette is to name the

individual digit and associated metacarpal (figure 7.1a & b).

Figure 7.1a: bony anatomy of hand

Figure 7.1b: radiograph of hand

Growth and development

The metacarpals are similar to long bones in structure in that they have a base (proximal

end), shaft, neck and head (distal end). However, unlike long bones, secondary ossification

centres (epiphyses) normally only appear at one end of the metacarpal. In the thumb
metacarpal, this secondary ossification occurs at the proximal end of the bone, whilst in all

other metacarpals these occur at the distal end. However, indentations may be noted at the

opposite ends of the metacarpals. These represent pseudo-epiphyses and are present in up

to 75% of children (figure 7.2)[1]. This appearance is a common normal variant and should

not be confused with trauma. Each phalanx can also be described in terms of a base, shaft

and head. Again, a single epiphysis at the proximal end of each phalanx is visible in children

(figure 7.2).

Figure 7.2: radiograph of hand showing ossification centres and pseudo-epiphyses at the

head of the thumb metacarpal and base of index metacarpal

Sesamoid bones (accessory ossification centres) are often present on the palmar aspect of

the metacarpo-phalangeal joints, particularly in the thumb (figure 7.3).

Figure 7.3: Thumb radiograph showing sesamoid bones at IP and MCP joints

Bones and their articulations

Proximally, the metacarpals articulate with the distal row of the wrist carpus to form the carpo-

metacarpal joints (table 7.2).

Table 7.2:Carpo-metacarpal articulations

Metacarpal carpal bone associations

Thumb Trapezium

Index Trapezium, Trapezoid & Capitate

Middle Capitate

Ring Capitate & Hamate

Little Hamate

The four finger metacarpals are supported by a series of intermetacarpal and interosseous

ligaments which strengthen the palmar aspect of the hand and create the natural palmar

concavity. The movement of these metacarpals, relative to each other, is limited to promote
functional stability. In contrast, the thumb metacarpal has a greater degree of movement to

enable opposition.

The head of each metacarpal articulates with the proximal phalanx of its corresponding digit

to form the metacarpo-phalangeal joint. The fingers each have three phalanges (proximal,

middle/intermediate and distal/terminal). In contrast, the thumb has two phalanges (proximal

and distal/terminal).

The metacarpo-phalangeal and inter-phalangeal joints of the hand can all be classified as

synovial joints. Each is stabilized on the palmar aspect by a palmar ligament, commonly

referred to as the volar plate, and on the medial and lateral aspects by the collateral

ligaments.

Muscles

The muscular anatomy of the hand is complex, designed to support small precise movements

as well as facilitate a strong grip [2]. The 3 thenar muscles, opponens pollicis, flexor pollicis

brevis and abductor pollicis brevis allow opposition between the fingers and thumb and

support the wide range of thumb movements. The hypothenar muscle group are similarly

named (opponens digiti minimi, flexor digiti minimi brevis and abductor digiti minimi) but are

arranged on the medial side of the palm and allow movements of the little finger and its

associated metacarpal. Located between the metacarpals, the palmar and dorsal interosseus

muscles collectively abduct and adduct the digits as well as contribute to their flexion and

extension.

Extension and flexion of the digits are facilitated by muscles located within the forearm.

Extension is achieved through the extensor digitorum muscle with each of its 4 tendons

attaching to a separate finger. The extensor digiti minimi and extensor indicis act as

accessory extensors for the little and index fingers respectively. Flexion of the fingers is

facilitated by contraction of the flexor digitorus profundi, through its tendons which are

inserted into the distal phalanges of each finger, and the flexor digitorus superficialis whose
tendons insert into the base of the middle phalanges. Finally the flexion of the thumb is

achieved through contraction of the flexor pollocis longus.

Vascular

The blood supply to the hand is via the radial and ulnar arteries (see chapter 8). The radial

artery usually supplies blood to the thumb and the radial side of the index finger. The blood

supply to the remaining fingers and ulnar aspect of the index finger normally originates from

the ulnar artery.

Nerves

The hand is supplied by the median, ulnar and radial nerves, all three of which contribute to

both cutaneous sensation and motor function [2]. The ulnar nerve enters the hand lateral to

the pisiform where it divides into deep and superficial branches which serve the ulnar aspect

of the hand including the little finger and ulnar side of the ring finger.

The median nerve enters the hand by passing through the carpal tunnel and divides into two

branches – the recurrent and palmar digital branches. It is arguably the most important

sensory nerve in the hand as it innervates the skin of the thumb, index and middle fingers and

radial aspect of ring finger. The median nerve also innervates the thenar muscles which

control opposition movement between the thumb and fingers.

A single superficial branch of the radial nerve enters the hand by passing over the anatomical

snuffbox. This nerve innervates a variable area of skin predominantly over the dorso-radial

aspect of the hand.

The hand has multiple motor and sensory functions and loss of hand function (motor or

sensory), in particular that related to the thumb, may result in significant morbidity.

Hand Function
Movement of the hand results from a series of co-ordinated actions of individual bones and

structures as well as movement of the upper limb as a whole. Specific movements of the

fingers and thumb are described in terms of flexion, extension, abduction and adduction.

Unlike other anatomical structures where abduction and adduction are related to the

anatomical position, abduction and adduction of the fingers and thumb refers to movement

away from (abduction) and towards (adduction) the long axis of the middle finger.

Mechanism of Injury

Injuries to the hand, including those to the fingers and thumb, commonly result from direct

impact including crush injuries, forced hyper-mobility at a joint, and laceration [3].

Approximately 40% of hand injuries relate to workplace accidents [4].

Clinical Presentation and Appearance

The clinical history is important in hand injuries, not only in terms of injury mechanism but also

in relation to patient social history. In addition to demographic information, details relating to

occupation, hand dominance and previous injuries should be sought as this may influence

patient treatment and management.

As the hand has limited soft tissue, fat or muscle bulk, injuries usually present with visible soft

tissue swelling, contusion or laceration. Assessment of skin colour changes, deformity or

asymmetry with uninjured hand should be noted, particularly where the injury mechanism is

flexion or rotation of a digit. Delayed presentation to the ED is not uncommon and in those

patients with bites, wounds or abrasions, the presence of potentially disabling infection should

be considered.

Clinical Assessment
Prior to physical examination, hand jewellery should be removed and returned to the patient.

The presence of rings may prevent thorough physical assessment and cause neuro-vascular

compromise where post-traumatic swelling has occurred.

Look

Examine the hand for signs of bruising, swelling and deformity. Palmar bruising in the hand is

highly suspicious of a metacarpal fracture. Wounds should be documented along with

evidence of erythema (redness) which may relate to infection.

Feel

As with any other anatomical region, the specific site of injury should be identified and

examined last to ensure that pain is minimised and patient co-operation optimised. Following

visual assessment, physical examination should be undertaken. Dependent upon the site and

mechanism of injury, the wrist should also be examined due to its close anatomical and

functional relationship with the hand. The terms medial and lateral should be avoided when

describing location of injury due to the potential for confusion. Instead, documentation of

findings should relate to the ulna or radial aspect of fingers, hand or wrist, in common with

ligament names (e.g. ulna collateral ligament).

Physical assessment should commence at the proximal aspect of the palm of the hand.

Assessment of metacarpal bony tenderness is easier to perform on the dorsum of the hand

due to the relative lack of overlying soft tissues. Each metacarpal should be palpated from

the carpo-metacarpal joint to its head and then each digit palpated along its length. Localised

crepitus, pain or deformity can suggest an underlying bony injury.

Neuro-vascular assessment

Because of variation in the source of innervation, sensation to both the ulnar and radial

aspects of the fingers should be ascertained. Light touch is normally sufficient. However, if

decreased sensation is suspected, pin-prick sensation should be checked. Each of the digits

should be individually assessed to ensure they are pink, warm and well perfused. The neuro-
vascular status of the anatomy distal to the site of injury should be clearly documented

together with variations in capillary refill time (2 seconds).

Move

Movements of the hand are necessarily complex to permit the full range of functions.

Consequently, regardless of apparent injury severity, a full assessment of hand function

should be made. The ligaments of the hand provide stability while the tendons translate

muscle action into joint movement. Both ligaments and tendons can be sprained, torn,

ruptured or divided in isolation or in association with bony injury and may be closed in nature.

The majority of tendon injuries occur as a result of a laceration and an open exploration of the

wound should be undertaken by an appropriately trained clinician where clinical suspicion is

raised.

In young children or uncooperative adults, a brief gross assessment of all the flexor tendons

may be undertaken by observing the motion of the fingers during passive movement of the

wrist (the tenodesis test – figures 7.4 a & b). With the hand positioned palm upwards

(supination), extension at the wrist will result in finger flexion demonstrating intact long

tendons. Conversely, when the hand is positioned palm downwards (pronation), flexion at the

wrist will result in finger extension demonstrating intact extensor mechanisms [5].

Figure 7.4a: Photograph of tenodesis test palm up

Figure 7.4b: Photograph of tenodesis test palm down

Finger movement should be assessed actively by asking the patient to ‘make a fist’ which

flexes the fingers. In full flexion the fingers should all point towards the scaphoid, a

phenomenon commonly known as the digital ‘cascade’ (figure 7.5). Abnormal rotation of a

digit or overlap usually occurs as a result of metacarpal of phalangeal fracture.

Figure 7.5: Photograph hand cascade in flexion

Opposition is tested by bringing each finger to the thumb in turn. Following this, digit

movements, including extension, flexion, abduction and adduction, should be assessed

against resistance.
The collateral ligament stability of the interphalangeal joints is assessed by holding the

proximal phalanx in a fixed position while applying radial and ulnar stress to the middle

phalanx (or distal phalanx in the thumb). In the fingers this is repeated at the distal inter-

phalangeal joint.

The co-lateral stability of the metacarpo-phalangeal joint of the thumb can be assessed by

applying a force to the radial and ulnar aspects of the proximal phalanx in turn while the

thumb is held in 200 of flexion at the metacarpo-phalangeal joint. Normal thumb collateral

ligaments will stress to approximately 150. However, comparison should be made with the

uninjured limb as variation in the normal range of ligamentous laxity exists. Movement greater

than 150 is suggestive of ligamentous sprain whereas movement beyond 35 0 is consistent with

a complete ligamentous tear.

Radiographic Referral

Referral for radiographic examination is appropriate where a fracture, joint disruption or

foreign body is suspected. The site of maximal bony tenderness, deformity, joint laxity or

foreign body should be communicated on the imaging referral as the radiographic projections

undertaken may vary depending upon the clinical question posed (table 7.3)

Table 7.3: Radiographic referral

Anatomy injured Radiographic referral

Thumb – metacarpal and phalanges Thumb

Finger phalanges Named finger(s)

Finger metacarpals Hand

Radiographic examination and image review

Fingers

Radiographic examination

The standard radiographic projections for injuries to the fingers are the Dorsi-Palmar (DP) and

lateral. The DP projection is undertaken with the hand in a neutral position and fingers

outstretched. The palmar aspect of the wrist, hand and fingers remain in contact with the
image receptor. Where the finger is unable to be extended due to injury, the finger may be

imaged with the palm uppermost to optimise the anatomical information visible on the

resultant image. The radiation field is limited to the injured and adjacent finger(s).

The lateral finger projection is undertaken with the injured finger as close to the image

receptor as possible. The injured finger is held in extension and the uninjured fingers are

either flexed tightly or extended dorsally away from the injured finger to reduce

superimposition of the proximal phalanges and metacarpo-phalangeal joints. Where the

injured finger cannot be held in extension (figure 7.6a), it should not be forced into extension

by use of a radiolucent sponge or pen as this may mask important radiographic evidence of

tendon injury (figure 7.6b). Alternatively, this practice may result in hyperextension of the DIP

joint which may mimic injury.

Figure 7.6a: Photograph of lateral finger with mallet deformity

Figure 7.6b: Photograph of lateral finger with pen pushing finger into extension
Figure 7.6c: Radiograph of lateral finger with foam pad pushing finger into extension

Image review

The DP finger radiograph should demonstrate all finger anatomy from the metacarpo-

phalangeal joint distally. The tuft of the distal phalanx may appear expanded compared to the

phalangeal shaft with an indistinct or roughened cortical outline and prominent trabecular

pattern. This appearance is a common normal variant and should not be confused with

trauma (figure 7.7). The lateral borders of the inter-phalangeal joints should be similar in

appearance on the dorsi-palmar projection and the joint no more than 1-2mm in width [6].

Normal physeal fusion patterns can result in cortical indentations or beaks and these should

not be confused with fractures. In older persons, degenerative and arthritic changes can be

marked around the inter-phalangeal joints with osteophytes, erosions and joint misalignment

making radiographic interpretation difficult.

Figure 7.7: Radiograph of normal expanded finger tuft

Review of the lateral finger should demonstrate clear interphalangeal joint spaces. The base

of the proximal phalanx may be superimposed on other fingers and care should be taken
when reviewing the metacarpo-phalangeal region to ensure subtle injuries are not missed,

particularly in children.

Hand

The hand radiograph is useful for assessing injuries to the metacarpals and their associated

joints. The standard radiographic projections for injuries to the hand are the Dorsi-Palmar

(DP) and Dorsi-Palmar Oblique (DPO). A lateral projection may also be undertaken for

identification of foreign bodies (see chapter 2) or where a fracture is identified on the DP or

DPO radiograph. The lateral projection is particularly useful where a fracture involves the

base of a metacarpal to exclude dislocation or subluxation at the carpo-metacarpal joint.

Radiographic examination

The DP hand projection should be undertaken with the elbow flexed and the hand in a neutral

position with the fingers outstretched. The palmar aspect of the wrist, hand and fingers remain

in contact with the image receptor (figure 7.8a). From this position, the radial side of the hand

is raised off the detector by approximately 30 degrees to obtain the correct DPO position. If

required, the hand may be supported by a radiolucent pad to aid patient comfort and reduce

risk of movement (figure 7.8b). The DPO projection demonstrates the metacarpals in a

different orientation to the DP projection while avoiding the overlap of the metacarpal heads

that occurs on a lateral hand projection making the identification of subtle injuries difficult.

There is contention as to whether the DPO projection should be undertaken with the fingers

flexed or extended but as this projection is primarily for assessment of the metacarpals, finger

position is unlikely to alter the diagnostic quality of the image.

Figure 7.8a: Photograph of DP position for the hand

Figure 7.8b: Photograph of DPO position for the hand

Where a metacarpal fracture is observed on the DP or DPO hand projection, a lateral

projection may be useful to assess fracture angulation and any associated carpo-metacarpal
joint disruption to assist in clinical decision making. To achieve this projection, the ulna aspect

of the hand is placed in contact with the image receptor and the hand position adjusted so

that the metacarpal heads are vertically aligned (figure 7.9). The thumb is extended away

from the finger metacarpals. Once again, a radiolucent pad may be used to support the thumb

and reduce hand movement.

Figure 7.9: Photograph of lateral position for the hand

Image Review

Hand radiographs, regardless of the projection, should include the fingers, thumb,

metacarpals, carpus and the distal ends of the radius and ulna. The metacarpal cortices

should be smooth and clearly outlined (figure 7.10). The carpo-metacarpal (CMC) joints are

referred to in some texts as the ‘lazy Ms’ due to their shallow zig zag appearances on the DP

projection (figure 7.11a). However, clinicians need to be aware that DP hand radiographs

obtained with the fingers flexed may result in projectional disruption of the CMC joints due to

wrist dorsiflexion. True disturbance to the CMC articulation pattern is suggestive of injury

(7.11b) and a lateral projection, if not undertaken routinely, may be useful to confirm clinical

suspicion (7.11c).

Figure 7.10: Normal DP hand

Figure 7.11a: Normal DP hand – lazy Ms

Figure 7.11b: DP hand - Lazy M disruption base of metacarpals
Figure 7.11c: Lazy M disruption confirmed as carpo-metacarpal fracture dislocation on lateral hand

Thumb

Radiographic examination

The standard radiographic projections for injuries to the thumb are Palmi-Dorsal (PD) or DP

and lateral. The thumb may be imaged in PD or DP orientation and the choice of projection is

often dependent on patient flexibility, co-operation and co-existing injuries (figure 7.12 a & b).

While some anatomical magnification may result from DP positioning, there is little diagnostic

difference in the resultant images as long as care has been taken to minimise the amount of

soft tissue overlying the thumb metacarpal and carpo-metacarpal joint.

Figure 7.12a: Photo DP thumb position
Figure 7.12b: Photo PD thumb position

To obtain a lateral thumb projection, the hand is placed on the image receptor as for the

Dorsi-Palmar hand radiograph. The ulnar aspect of the hand is then raised to rotate the

thumb into a visibly lateral position. A radiolucent pad may be used to support the fingers and

reduce hand movement (figure 7.13) or alternatively the fingers clenched into a fist.

Figure 7.13: Photo lateral thumb position

Adapted technique

Where a patient attends the imaging department on a trolley/stretcher or is unable to rotate

the forearm to facilitate imaging the thumb in the standard positions described above,

radiographic technique must be adapted. By bending the elbow and raising the arm at the

shoulder until the hand lies palm upwards at the level of the patients head, a modified PD and

lateral thumb projection can be undertaken by varying humeral movement at the shoulder

rather than rotating the forearm (figure 7.14) This technique can also be undertaken with the

patient sitting or standing where the image receptor is placed in the erect cassette holder. As

this positioning decreases the depth of the thenar soft tissues, it may also be useful as an

alternative projection where soft tissue density prevents visualisation of the thumb metacarpo-

phalangeal area on standard PD/DP projections.

Figure 7.14: Photo modified thumb technique

Image Review

The radiographic field should extend from the distal radius to the tip of the thumb (figure 7.15

a & b). Particular care should be taken when reviewing the proximal thumb metacarpal,

scaphoid and radial styloid. These are common sites of fractures that result from similar injury

mechanisms and may be difficult to differentiate clinically due to their anatomical proximity

and associated pain and swelling. The normal appearances of the thumb phalanges are as

for the fingers. However, it must be remembered that the thumb has only two phalanges

whereas the fingers have three. This can cause confusion and the mobile thumb metacarpal

can be mistakenly referred to as the proximal phalanx

Figure 7.15a: Radiograph of PD thumb
Figure 7.15b: Radiograph of lateral thumb

Common Adult Injuries

Phalanges

The phalanges are the most commonly injured bones in the hand with fractures to the distal

phalanges accounting for more than 50% of hand fractures [6]. Multiple phalangeal fractures

often result from crush type injuries or machinery related incidents and may be grossly

abnormal in appearance both clinically and radiographically.

Distal and middle phalanges

Crush injury distal phalanx

Fractures of the phalangeal tuft caused by the finger tip being crushed, either in a door or

when hit by hammer, are relatively common and vary in appearance from simple longitudinal

or transverse fractures to gross comminution (figure 7.16). If an associated subungal (under

the nail) haematoma requires aspiration (trephine) then antibiotic cover may be necessary

where a fracture is present as the action of aspiration technically creates an open injury.

However, debate continues as to whether prophylaxis is necessary and local procedures and

protocols should be followed [7]

Figure 7.16: Radiograph comminuted phalangeal tuft fracture of thumb

Extensor tendon avulsion distal phalanx

Avulsion of the extensor tendon of the finger (partial or complete) as a result of forced

hyperflexion at the distal inter-phalangeal joint leads to an inability to straighten the finger.

Often called a ‘mallet’ deformity or ‘baseball finger’ (figure 7.6a), this injury may affect any

digit although is more common in the middle, ring and little fingers. Inability to extend a flexed

distal inter-phalangeal joint while the proximal inter-phalangeal joint is held in extension is

diagnostic of this injury. Radiographic referral is required to determine the presence of any

associated bony injury, primarily an avulsion fracture of the dorsal aspect of the base of the

distal phalanx (figure 7.17). IMPORTANT: radiographers should not forcibly extend the flexed
distal phalanx as this may mask evidence of extensor tendon injury and may lead to an

incorrect radiological interpretation (see figures 7.6b&c).

Figure 7.17 Radiograph of lateral finger with avulsion fracture distal phalanx

Flexor tendon avulsion distal phalanx

Closed rupture/avulsion of the extensor tendon (flexor digitorum profundus) may or may not

be associated with an avulsion fracture from the volar aspect of the distal phalanx. This injury

presents as an inability to flex the finger at the distal inter-phalangeal joint. If completely

ruptured, the tendon retracts towards the head of the middle phalanx. This may cause

confusion where a bony fragment has been avulsed as its location may suggest that it is

related to the middle rather than distal phalanx. Careful radiographic review of the base of the

distal phalanx is required to identify any defect.

Extensor tendon avulsion middle phalanx

Avulsion of the central slip of the extensor tendon from its insertion into the base of the middle

phalanx may result in the proximal inter-phalangeal joint becoming progressively flexed. At

the same time, the lateral slips of the extensor tendon pull the distal inter-phalangeal joint into

hyperextension. These two actions result in a ‘boutonniere’ (buttonhole) deformity (figure

7.18). Appearances on presentation may be subtle but if left untreated, the deformity will get

progressively worse. IMPORTANT: radiographers should not forcibly extend or straighten the

finger as this may mask radiographic evidence of injury and may lead to an incorrect

radiological interpretation.

Figure 7.18: Radiograph of boutonniere deformity

Flexor tendon avulsion middle phalanx

Hyperextension of the proximal inter-phalangeal joint can result in bony avulsion from the

base of the middle phalanx (figure 7.19). Often described as a volar plate injury, patients will

present with soft tissue swelling and bruising and may be unable to flex the PIP joint.

Beware! In children, this injury mechanism typically results in a buckle fracture to the dorsal

aspect of the base of the proximal phalanx.

Figure 7.19: Radiograph volar plate fractures of the ring and little fingers

Proximal phalanges

The majority of proximal phalangeal fractures involve the thumb or index finger. Fractures are

normally to the phalangeal shaft and rarely involve the articular surface (figure 7.20). A direct

blow will tend to cause transverse or comminuted fractures whereas a twisting injury

mechanism will create oblique or spiral fractures. Beware! The degree of rotation or

angulation of a proximal phalanx fracture cannot be accurately determined on a hand

radiograph and a well positioned lateral finger or thumb radiograph is required.

Figure 7.20a: Photo of fractured proximal phalanx index finger

Figure 7.20b & c: DP & lateral radiographs of fracture to proximal phalanx of index finger

The proximal thumb phalanges are susceptible to injury where excessive valgus (abduction)

force is experienced. This may result in the rupture of the ulnar collateral ligament or an

avulsion fracture at its insertion at the base of the proximal phalanx of the thumb (figure 7.21).

Traditionally this injury is referred to as “gamekeepers” or “skiers” thumb, although the use of

such eponyms is no longer recommended. In most cases, diagnosis of a collateral ligament

tear can be made following clinical assessment and radiographic referral is required only to

determine bony involvement. However, where clinical uncertainty occurs, radiographic

imaging with the thumb under stress may be useful. This injury often requires surgical

intervention.

Figure 7.21: Radiograph ulnar collateral ligament avulsion of thumb

Phalangeal dislocations

Dislocations at the interphalangeal joints (fingers and thumb) are most commonly caused by

hyperextension resulting in dorsal dislocation of the distal component. The diagnosis can

often be made clinically but radiographic referral may be required to identify any associated

fractures around the affected joint prior to reduction (figures 7.22 and 7.23).
Figure 7.22: Radiograph dislocation DIP

Figure 7.23a: Photograph hyperextension PIP joint, note flexion of DIP joint.

Figure 7.23b&c: AP and lateral radiographs demonstrating dorsal dislocation of middle

phalanx.

Metacarpal injuries

Finger metacarpals

Metacarpal injuries account for approximately 40% of hand fractures and are usually caused

by axial loading (striking an object or falling onto a clenched fist). Typical injury appearances

are a transverse (or slightly oblique) fracture at the metacarpal neck, most commonly the little

finger or ring metacarpal (figure 7.24a) with a variable degree of palmar angulation of the

distal fracture fragment. The degree of fracture angulation can only be truly appreciated on

the lateral hand projection (figure 7.24b). Opinions vary as to acceptable residual angulation

but it is generally agreed that near normal hand function can be retained with up to 30 0

residual palmer metacarpal angulation [8].

Figure 7.24a: Radiograph DP Hand with fractures of middle, ring and proximal little
metacarpals
Figure 7.24b: Radiograph Lateral Hand showing MC angulation

Fractures at the base of the ring and little metacarpals may also result from axial loading

(punch mechanisms). These injuries may be difficult to identify radiographically and care must

be taken to identify any associated dislocation or subluxation at the carpo-metacarpal joint

(see figure 7.11 b&c) or a fracture of the ulna border of the hamate (see chapter 8).

Thumb Metacarpal

Fractures at the base of the thumb metacarpal may result from axial loading, hyperextension

or forced abduction. The majority of proximal thumb metacarpal fractures are intra-articular,

the most common being an oblique fracture dislocation commonly referred to as a Bennett’s

fracture (figure 7.25). With this injury, the smaller ulnar fracture fragment remains in its correct

carpal articulation (with the trapezium) while the larger radial fragment is displaced dorsally
and radially due to the pull of the abductor pollicis tendon. This is an unstable fracture and

must be successfully reduced to prevent secondary osteoarthritis and loss of function.

Figure 7.25 a&b: AP and lateral radiograph of fracture dislocation of base of thumb
metacarpal

A similar injury is the comminuted intra-articular fracture to the base of the thumb metacarpal

(Rolando’s fracture). Typically, this fracture is “Y” or “T” shaped in orientation with a minimum

of 3 fracture fragments (figure 7.26). It is important to differentiate this injury from the

Bennett’s fracture dislocation described above as treatment options vary.

Figure 7.26 a&b: AP and lateral radiograph of comminuted intra-articular fracture of base of
thumb metacarpal

Common paediatric injuries

Phalangeal buckle fracture

Hyperextension of children’s fingers or thumb may cause the dorsal aspect of the proximal

phalanx to buckle due to compression (buckle or torus fracture). As in other skeletal areas,

these injuries can be subtle and may only be visualised on the lateral radiograph.

Epiphyseal injuries

Finger hyperextension is the most common cause of injuries involving the epiphyseal plate.

These injuries can be classified using the Salter Harris System (see chapter 5) and both the

DP and lateral finger radiographs should be carefully scrutinised for disruption to the

epiphyseal plate or adjacent structures.

Normal variants

Nutrient vessels

On a DP hand or finger radiograph, faint lucent lines may be seen travelling obliquely along

the shafts of the phalanges. The density of these lines is the same as the medulla of the bone

and they represent vascular channels for the nutrient vessels and should not be confused

with an undisplaced fracture.

Figure 7.27: Radiograph of nutrient foramen
References

1. Dreizen S, Spirakis CN & Stone RE (1965) The distribution and disposition of

anomalous notches in the non-epiphyseal ends of human metacarpal shafts. Am J

Phys Anthrop. 23, 181-188.

2. Drake RL, Vogl W, Mitchell AWM (2005) Gray’s anatomy for students. London:

Churchill Livingstone

3. Hardy M & Snaith B (2005) Beyond Red Dot…! An introduction to musculoskeletal

trauma. Bradford: Inprint & Design

4. Mackenzie K and Peters M (2000) Handedness, Hand Roles, and Hand Injuries at

Work. Journal of Safety Research 31:4; 221-7.

5. Hayton M (2002) Assessment of hand injuries. Current Orthopaedics 16: 246-254.

6. Moeller TB (2000) Normal Findings in Radiography New York: Thieme Medical

Publishers

7. Rogers LF (2002) Radiology of Skeletal Trauma. 3rd Ed. New York: Churchill Livingstone

8. Scott L & Flannery O (2004) Infection risk when trephining Subungal Haematomas

with associated closed distal phalangeal fractures. Available at

http://www.bestbets.org/cgi-bin/bets.pl?record=00603 [Accessed 28th May 2008]

9. Ali A, Hamman J, Mass DP. (1999) The Biomechanical Effects of Angulated Boxer's

Fractures. The Journal of Hand Surgery Volume 24, Issue 4, July 1999, Pages 835-

844

Further reading
Hamblen DL, Simpson H. (2007) Adams's Outline of Fractures: Including Joint Injuries 12th

Edition. Edinburgh: Churchill Livingstone

Raby N, Berman L & de Lacey G (2005) Accident & Emergency Radiology, A survival guide. 2nd

Ed. London: W B Saunders

Reif E & Moller TB (2000) Pocket Atlas of Radiographic Anatomy.Stuttgart: Thieme Medical

Publishers