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Clinical Practice Guidelines - Thumb Fractures - Emergency Department
Clinical Practice Guidelines - Thumb Fractures - Emergency Department
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1. Summary
Normal thumb function is an essential part of many activities of daily living, leisure activities and future occupational function. Careful
early detection and management of thumb injuries in the ED is important for minimising any long-term morbidity associated with the
injury
Most simple fractures can be immobilised in a thumb spica splint and followed up in an appropriate hand surgery clinic
This guideline covers types of thumb fracture that require specific management which differs from fractures of other digits. Other
fractures are managed in the same way as fractures of the other digits: please consult [insert link to finger fracture guideline here]
Hyperabduction of the thumb from either a fall or awkward contact from a ball whilst playing sports may result in a 'Skier's thumb' (UCL
injury with or without bony avulsion from the base of P1)
Axial loading of the thumb may result in intra-articular metacarpal base fracture in the adolescent patient (Bennett or Rolando)
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Bennett Fracture, usually from axial loading of the thumb in patients with closed physes.
X-ray shows a small fragment of the metacarpal base articulating with the trapezium; muscles
attaching elsewhere on the main part of the metacarpal tend to pull it into subluxation.
Examination will show bruising and tenderness at the thumb MCP joint
Definitive management by the hand surgery team requires reduction, usually involving K-wire
insertion
Fracture through an open physis, involving the same mechanism and deformation patterns as in a
Bennett fracture.
Management is as with a Bennett fracture, as it is usually subjected to the same deforming forces
from the muscle insertions.
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Examination shows bruising and swelling to MCP joint, with focal tenderness to ulnar aspect of joint
and pain there with pinch grip.
Test the ligament by applying a valgus deformity to the MCP joint with thumb in slight flexion and also
full extension: laxity of >35 degrees (or >15 degrees more than uninjured thumb) indicates UCL
injury, regardless of Xray appearance .
ED Management involves application of a thumb spica (below) and arranging early follow-up with the
Hand Surgery Team (regardless of whether avulsion present or absent)
Definitive Management is mostly not-operative with hand therapy, but some cases require surgical
repair.
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Definitive Management requires early expert reduction by specialist hand surgery team, often with K-
wire fixation. This should take place within a few days.
ED Management involves immobilisation in a thumb spica and appropriate communication with the
hand surgery team.
Follow up is with GP for most injuries, but Hand Surgery team if nailbed repair required or
significant tissue disruption
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Seymour Fracture
These are open fractures through the growth plate with associated nailbed injury and displacement
of proximal nail plate from the nail fold.
They are significantly less common in the thumb than in the other fingers.
Management requires_2
Management requires admission for washout, debridement, reduction, nailbed repair and
antibiotics.
Seymour fractures require early identification with debridement and pinning in theatre to avoid malunion, infection or nail deformities
Fractures at the base of the Metacarpal require reduction with hand surgery team involvement, and likely K-wire fixation
The number of attempts at reducing fractures across a physis anywhere should be kept to a minimum; if reduction cannot be achieved
after one or two attempts referral to the hand surgery team should occur to minimise chance of growth arrest.
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12. What are the potential complications associated with these injuries?
Arthritis, particularly in the case of intra-articular fractures or delay to diagnosis
Malunion
Stenar Lesion of UCL resulting in MCP joint instability
Delayed diagnosis of base of thumb fractures leading to long term reduction in joint function.
Information specific to RCH: Thumb injuries requiring specialist input are handled here by the Plastic Surgery team. At other centres,
this may be an orthopaedic surgical team. This guideline refers to 'hand surgery' to encompass both specialty fields.
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