FRACTURE OF THE

HAND & WRIST

DINESHWARAN NAIDU
20110066
 Contents
● Anatomy of the hand and wrist

● Types of hand and wrist fractures

● Diagnostic approaches

● Treatment and management

● Complications
 Anatomy of the hand and wrist

Skeletal system of the hand

and wrist
Anatomy of the hand joint
Anatomy of the wrist joint
 Anatomy of the hand

Palmar view of the thenar muscles.

 Anatomy of the hand

Superficial and deep layers

of the hypothenar muscles
 Anatomy of the hand

Lumbricals of the hand

 Anatomy of the hand

Lumbricals of the hand

 Anatomy of the hand
Dorsal and palmar interossei of the
hand
● Nerve supply from the deep
branch of the ulnar nerve.
● Assist in flexion of the
metacarpophalangeal joints
and extension of the
interphalangeal joints
 Anatomy of the hand

Nerve distribution
 Anatomy of the hand

Blood supply of the hand

and wrist
Carpal tunnel
Guyon’s Canal (ulnar nerve course)

● Roof: The volar carpal ligament

● Floor: The transverse carpal ligament

● Radial border: The hook of the hamate

● Medial border: The pisiform bone and pisohamate

ligament
Anatomical snuff box
Borders
● Ulnar (medial) border: Tendon of the
extensor pollicis longus.
● Radial (lateral) border: Tendons of the
extensor pollicis brevis and abductor
pollicis longus.
● Proximal border: Styloid process of the
radius.
● Floor: Carpal bones; scaphoid and
trapezium.
● Roof: Skin.
Xray of the hand (PA view)
X-ray of carpal bones(PA view)
X-ray of wrist joint (PA view)
Fractures of the
wrist
 Colles' Fracture
● This is one of the most common types of wrist fractures.

● Extraarticular distal radius fracture with dorsal displacement/angulation

● Fracture due to outstretched hand fall.

● Common in women aged 60 and older with osteoporosis.

 Colles' Fracture
● Presentation

○ Pronated forearm in wrist extension

Dinner fork deformity
○ Dorsally angulated
 Colles' Fracture
● Investigations

○ Imaging (Xray of

the wrist joint)

Lateral view
 Colles' Fracture
● Treatment (non surgical)

○ Majority of Colles fractures can be

treated with closed reduction and cast

immobilisation.

○ The Colles cast extends from below the

elbow to the metacarpal heads and

holds the wrist somewhat flexed and in

ulnar deviation
 Colles' Fracture
● Treatment (Surgical)

○ Open reduction and internal fixation if

>10 degrees dorsal angulation; >5 mm

shortening; significant comminution

■ Plates and screws

 Colles' Fracture
● Treatment (Surgical)
○ Closed reduction and percutaneous pinning (CRPP)
■ K wires can be used as a reduction tool by inserting them dorsally into the
fracture from distal to proximal (Kapandji intrafocal technique)
 Colles' Fracture
● Treatment (Surgical)

○ Closed reduction and percutaneous pinning (CRPP)

 Smith fractures
● Fracture of the distal radius featuring volar displacement or angulation.

● It typically results from a fall on the dorsum of the hand with a flexed wrist

● These fractures are extra-articular transverse fractures and can be thought of as a

reverse Colles fracture.

● Commonly seen in young males and elderly females.

 Smith fractures
● Presentation

○ Displaced or angled in the direction of the palm of the hand

Smith fractures
 Smith fractures
● Imaging (X ray of the wrist joint)
AP view Lateral view
 Smith fractures
● Treatment (non surgical)

○ Closed reduction and splint or cast

○ The reduction is carried out by reversing fracture deformity with longitudinal

traction and applying a long arm cast with the forearm in supination and wrist

in a degree of extension.
 Smith fractures
● Treatment (surgical)

○ Surgical options can include:-

■ External fixation

■ Internal fixation

■ Percutaneous pinning

■ Bone substitutes
 Scaphoid Fracture
● The most common carpal bone fracture, often occurring after a fall onto an

outstretched hand and hyperextension of the wrist.

● Tend to occur in younger, active individuals

● These injuries can be misdiagnosed initially as simple wrist sprain as fractures can be

missed during radiographic examinations

● Occasionally repeat X-rays do not show a fracture and MRI is needed

 Scaphoid Fracture
● Presentation

○ Reduced wrist extension

○ Pain and swelling at the base of the thumb in the anatomic snuffbox
○ Circumduction of the wrist is often painful
 Scaphoid Fracture
● Physical Examination

○ Tenderness usually presents in one of three locations:

■ The volar prominence at the distal wrist for distal pole fractures
■ Anatomic snuffbox for waist or mid-body fractures
■ Distal to Lister's tubercle for proximal pole fractures
 Scaphoid Fracture
● Special tests

○ Scaphoid compression test

■ Slightly pronate the patient's hand
■ The examiner places his thumb on the palmar side of the scaphoid (on the
scaphoid tubercule), his other fingers are wrapped around the back of the
wrist at the distal part of the radius
■ This will allow the examiner to put pressure on the scaphoid with his thumb.
 Scaphoid Fracture
● Special tests

○ Scaphoid compression test

 Scaphoid Fracture
● Imaging (X-ray of the wrist joint)
 Scaphoid Fracture
● Treatment (non-surgical)

○ Fractures that are non-displaced and within the distal third of the bone can be
managed non-operatively with immobilization in a cast.
○ Cast is usually needed for six weeks with repeat radiographs taken at this time to
assess for union
 Scaphoid Fracture
● Treatment (surgical)

○ Indications

■ Displacement greater than 1mm

■ Nonunion or avascular necrosis

■ Transscaphoid perilunate dislocation

■ Proximal pole fractures

■ Comminuted fractures
 Hamate Fracture
➔ Hamate fractures are rare and underreported

➔ Hamate fractures usually get subdivided into two broad groups: hook fractures and

body fractures.

◆ Hook of hamate fracture frequently occurs in sports where a firm grip is required

● Associated with ulnar artery and ulnar nerve injury

◆ Body of the hamate fractures are related to higher energy trauma

Hamate Fracture

Body of the
hamate
 Hamate Fracture
Classification of hamate fractures:
 Hamate Fracture
Physical examination

● Chronic pain along the ulnar aspect of the wrist

● Tenderness and extreme pain over the hypothenar area

● Paresthesias along the ring and small finger

● Weakened grip strength

 Hamate Fracture
Special test
● Pull test
○ Active flexion of distal interphalangeal joints of the ring and small finger may
cause pain
 Hamate Fracture
Imaging (X-ray of the wrist joint)

● Hamate fractures are often subtle and may need multiple views
 Hamate Fracture
Treatment (non-surgical)

If acute and nondisplaced

● Hook fracture

○ Immobilization, ulnar gutter cast for six weeks

● Body fracture

○ Immobilization, six-week cast

 Hamate Fracture
Treatment (surgical)
If acute and displaced
● Hook fracture
○ Excision of a bony fragment is the gold standard procedure.
○ Open reduction and internal fixation (screws or Kirschner wires)
● Body fracture
○ Open reduction and internal fixation (Kirschner wires, grid plate, or headless
compression screws)
 Barton's Fracture
● Intraarticular distal radius fracture with

dorsal displacement/angulation.

● It is similar to a Colles fracture.

● There is usually associated dorsal

subluxation of the radiocarpal joint.

● However, with Barton's fractures, the broken

bones angle up or away from the palm.

 Barton's Fracture
● Physical examination

○ Acute wrist pain, swelling, and deformity

○ Ecchymosis, tenderness, and swollen wrist joint.

○ Range of motion of the wrist joint will be limited due to pain

Barton's Fracture
Imaging
● X-ray of the wrist joint

AP view
 Barton's Fracture
● Treatment (non-surgical)
○ Undisplaced fractures can be managed with immobilization in a cast.
○ While applying the cast, the wrist is slightly volar flexed in volar barton fracture
and dorsiflexed in dorsal barton fracture.
 Barton's Fracture
● Treatment (surgical)
○ Most Barton fractures are unstable
○ Open reduction and internal fixation are recommended for Barton's fracture due
to the unstable fracture pattern and the strong pull of flexor tendons.
■ Volar Approach for Volar Barton's Fracture
● Plates are applied on the volar surface rather than the tensile/dorsal
surface due to less soft tissue irritation
■ Dorsal Approach for Dorsal Barton's Fracture
● Fixation of distal radius fracture through the 3rd dorsal compartment
 Triquetral Fracture
● Triquetral may be fractured by

means of impingement from the

ulnar styloid, shear forces, or

avulsion from strong ligamentous

attachments.

● They are the second commonest

carpal bone fracture, after the

scaphoid.
 Triquetral Fracture
Physical examination
● Pain is usually on the ulnar aspect of the wrist, exacerbated by extension/flexion
of the wrist
● Swelling over the dorsum of the hand with a tender dorsal aspect of triquetrum
 Triquetral Fracture
Imaging
● X-ray of the wrist joint
○ Dorsal avulsion fracture
○ Triquetral body fracture
○ Volar avulsion fractures
Dorsal avulsion fracture

● Pooping duck sign

Lateral view
Dorsal avulsion fracture

● Pooping duck sign

Lateral view
 Triquetral Fracture
Treatment (non-surgical)
● For the dorsal cortical or nondisplaced fracture pattern
○ Cast immobilization for 4–6 weeks
 Triquetral Fracture
Treatment (surgical)
● Surgical treatment should be considered for fractures with significant
displacement
○ Herbert bone screw and K-wires for fixation from the triquetrum into the
lunate
Complications of Wrist Fractures
Colles fracture ● Malunion resulting in dinner fork deformity
● Median nerve palsy and post-traumatic carpal tunnel syndrome
● Extensor pollicis longus tendon tear: more common in non-displaced fractures

Smith's Fracture ● Malunion

● Carpal tunnel syndrome

Scaphoid Fracture ● High risk of AVN

● Nonunion

Hamate Fracture ● Avascular necrosis in proximal pole (body fractures)

● Ulnar nerve compression (Guyon's canal)
● Nonunion

Triquetral Fracture ● Non-union

● Triangular fibrocartilage complex injury
● Pisotriquetral arthritis

Barton's Fracture ● Carpal tunnel syndrome

● Radial nerve compression
● Ulnar nerve injury
Fractures of the
hand
 Metacarpal Fractures
● Metacarpal fractures are common accounting for 10% of all fractures and 40% of all
hand fractures.
● Divided into two categories
○ Fractures of the base of the thumb (first metacarpal)
■ Bennett fracture dislocation
■ Rolando fracture
■ Epibasal thumb fracture
○ Fracture of the fifth metacarpal
■ Boxer fracture
 Metacarpal Fractures
Presentation
■ Symptoms
● Acute pain at the base of thumb or little finger with inspection
■ Physical exam
● Swelling and ecchymosis
● Tenderness to palpation at carpometacarpal (CMC) joint or proximal
interphalangeal joint (PIPJ)
● Pain with limited range of motion
 Metacarpal Fractures
● Bennett fracture dislocation
○ Fracture of the base of the thumb resulting from forced abduction of the first
metacarpal.
○ It is defined as an intra-articular two-part fracture of the base of the first metacarpal
bone.
 Metacarpal Fractures
● Bennett fracture dislocation
○ Imaging (x-ray of the hand)
Metacarpal Fractures
 Metacarpal Fractures
● Bennett fracture dislocation
○ Treatment (non-surgical)
■ Closed reduction of Bennett
fractures is obtained by
thumb traction combined
with metacarpal extension,
pronation, and abduction
 Metacarpal Fractures
● Bennett fracture dislocation
○ Treatment (non-surgical)
■ Thumb spica cast for 3-4 weeks
 Metacarpal Fractures
● Bennett fracture dislocation
○ Treatment (surgical)
■ Operative treatment is recommended for unstable fracture patterns and
intra-articular displacement of >1 mm.
■ While open reduction and internal fixation with a screw or K-wire are both
common practice, screws are often preferred as K-wires must be removed
after union.
 Metacarpal Fractures
● Rolando fracture

○ 3-part or comminuted intra-articular fracture-dislocation of the base of the

thumb (proximal first metacarpal).

○ Injury by axial blow to a partially flexed metacarpal, such as a fistfight

○ Volar fragment remains attached to the carpometacarpal joint, while the main

dorsal fragment dislocates dorsally and radially due to the unopposed pull of

the abductor pollicis longus muscle.

 Metacarpal Fractures
● Rolando fracture
 Metacarpal Fractures
● Rolando fracture
○ Imaging (x-ray of the hand)
AP view Oblique
 Metacarpal Fractures
● Rolando fracture
○ Treatment (surgical)
■ This is an unstable injury that requires surgical reduction and fixation.
● Plate and screw fixation
 Metacarpal Fractures
● Epibasal thumb fracture
○ Also called pseudo-Bennett fracture
○ Extra-articular two-piece fractures of the proximal first metacarpal bone
 Metacarpal Fractures
● Epibasal thumb fracture
○ Imaging (X-ray of the hand)
AP view Oblique
 Metacarpal Fractures
● Epibasal thumb fracture
○ Treatment (non-surgical)
■ Vast majority of epibasal fractures are considered stable and can be
treated conservatively with thumb spica immobilisation for 4-6 weeks
 Metacarpal Fractures
● Epibasal thumb fracture
○ Treatment (surgical)
■ Fractures with >30° of angulation usually require closed reduction and
Kirschner wire fixation
 Metacarpal Fractures
● Boxer fracture
○ Minimally comminuted, transverse fractures of the 5th metacarpal neck, and
are the most common type of metacarpal fracture.
○ Injury due to a direct blow with a clenched fist against a solid surface which
causes axial loading of the 5th metacarpal.
 Metacarpal Fractures
● Boxer fracture presentation
 Metacarpal Fractures
● Boxer fracture
○ Imaging (x-ray of the hand)
 Metacarpal Fractures
● Boxer fracture
○ Treatment (non-surgical)
■ Closed reduction can be
achieved by stabilising the
proximal part of the
metacarpal dorsally and
applying pressure to the
head of the metacarpal from
the palmar aspect while
flexing the proximal phalanx.
Jahss manoeuvre
 Metacarpal Fractures
● Boxer fracture
○ Treatment (non-surgical)
■ Short arm gutter-splint is
applied, with flexion of the
metacarpophalangeal joint,
typically for 2-3 weeks
 Metacarpal Fractures
● Boxer fracture
○ Treatment (surgical)
■ Surgery is not usually necessary for a boxer's fracture
■ Surgery may be indicated if the little finger is significantly rotated and is
affecting the function of the ring finger
● Open reduction and internal fixation
○ K-wire fixation
○ Headless screws and bouquet fixation
 Mallet Finger (Baseball Finger)
● Injury to the thin tendon that straightens the end joint of a finger or thumb.

● This joint is called the distal interphalangeal (DIP) joint in the fingers and the

interphalangeal (IP) joint in the thumb

● Fingertip droops and cannot be actively straightened.

Mallet Finger (Baseball Finger)
Mallet Finger (Baseball Finger)
 Mallet Finger (Baseball Finger)
Imaging

● X-ray of the hand

 Mallet Finger (Baseball Finger)
● Treatment (non-surgical)

○ Extension splinting of DIP joint for 6-8 weeks

 Mallet Finger (Baseball Finger)
● Treatment (surgical)

○ Only indicated if volar subluxation of distal phalanx

 Mallet Finger (Baseball Finger)
● Treatment (surgical)

○ Only indicated if volar subluxation of distal phalanx

■ Surgical reconstruction of terminal tendon

■ DIP arthrodesis

■ Swan neck deformity correction

Complications of Hand Fractures
● Compartment syndrome
● Deformity
Metacarpal
fractures ● Joint stiffness coexist with tendon adhesions
● Malunion / Non union
● Loss of function

● Stiffness and deformity

● Malunion
Mallet finger
● Carpal tunnel syndrome
● Swan neck deformity
● Fluid accumulation at the tendon insertion