Fractures - Hand

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide PCH ED staff in the assessment and management of fractures of the hand and fingers in children.

Background

  • Hand trauma is a common presentation in children
  • Young children tend to present with crush injuries as they explore their environment with their hands 
  • Older children tend to sustain hand fractures from sport injuries
  • At PCH, hand injuries which affect normal hand function are referred to the plastic surgery team.

Assessment

  • Thorough examination of normal hand function is important to detect underlying fracture, tendon or nerve injury.

Examination

  • Compare both hands and look for bruising, erythema, swelling and deformity
  • Rotational deformities may be more obvious when the patient makes a fist 
  • Palpate for obvious areas of tenderness
  • Assess for any neurovascular compromise
  • Passive and active range of movement of all joints in hand and wrist should be examined. Testing against resistance may identify ligamentous injury.

Investigations

X-Rays are based on clinical assessment, mechanism of injury and suspected injuries.

  • Standard PA and lateral view of the hand
  • Standard PA, oblique and lateral view (of affected finger)
  • X-Ray specific areas of focal bony tenderness

Management

  • All hand fractures distal to the carpal bones which may affect normal function are managed by the plastic surgery team at PCH
  • Compound and complicated hand fractures should be referred immediately to the plastic surgery team.
  • Initial management

    • Analgesia (consider nerve block)
    • Examination for neurovascular injury (if deficit evident manage immediately) 
    • Ice and elevation of affected limb
    • Antibiotics for compound fracture and consider tetanus
    • Keep nil by mouth if referral to hand surgeon is required.

    Further management

    Complicated hand and finger fractures

    Refer any complicated fractures immediately.

    • Compound fractures
    • Amputations
    • Associated tendon injury
    • Neurovascular compromise.

    Resting volar splint

    The resting volar splint can be used to immobilise most acute hand fractures. It is a position of safe immobilisation with minimal strain on hand ligaments.

    • Splint/plaster on volar (palmar) aspect of hand and forearm
    • Wrist in 30º extension
    • MCP joints flexed to 60º – 90º
    • IP joints at 180º (fingers fully extended)

    Phalangeal fractures

     

    Distal phalanx

    Longitudinal fracture of 3rd distal phalanx

    Distal tuft fractures
    • Simple tuft fractures are managed with buddy strapping or aluminium splint and simple analgesia.
    • If associates pulp laceration, antibiotics may be required.
    • Simple tuft fractures can be followed up by GP.
    • If associated nail bed injury, refer to plastic surgery.

    A mallet injury

    Mallet injury
    • Injury to DIP joint with extensor tendon avulsion or tear.
    • Refer immediately if >30% intra-articulation surface is involved.
    • Stax or Zimmer splint and follow up in plastic surgery clinic. Consult Mallet finger guideline.

    Salter-Harris IV fracture of middle phalanx

    Middle phalanx

    Undisplaced stable shaft fracture
    • Buddy strap and volar slab with follow up plastic surgery in 5 days
    Displaced/angulated shaft or intra-articular fracture
    • Reduce fracture under ring block +/- sedation if appropriate. Otherwise refer to plastic surgery.
    • Resting volar splint and follow up plastic surgery clinic as per plastic surgeon.

    A volar plate injury

    Volar plate injury
    • Resting volar splint and follow up with surgery clinic in 5 days

    Proximal phalanx

     

    An undisplaced fracture of proximal phalanx

    Undisplaced stable shaft fracture
    • Buddy strap and volar slab
    • Follow up plastic surgery clinic 5 days

    An intra-articular fracture of proximal phalanx

    Displaced/angulated shaft or intra-articular fracture
    • Reduced fracture under ring block +/- sedation if appropriate. Otherwise refer to plastic surgery.
    • Resting volar splint and follow up plastic surgery clinic as per plastic surgeon.

    A Salter-Harris II fracture of proximal phalanx with dorsal angulation

    Base of thumb

     

    • Undisplaced Salter-Harris II fracture - thumb spica and follow up plastic surgery clinic in 5 days.
    • Displaced Salter-Harris II fracture - reduce fracture under ring block +/- sedation if appropriate, thumb spica and follow up with plastic surgery clinic as per plastic surgeon. Otherwise refer to plastic surgery.
    • Salter-Harris III avulsion fracture of ulnar collateral ligament ("Gamekeeper's" or "Skiers" thumb), thumb spica and follow up plastic surgery clinic as per plastic surgeon.

    Finger amputations

    A partial amputation of left index finger

    All finger amputations should be referred urgently to plastic surgery
    • Stump care - irrigate with saline and cover with saline soaked gauze.
    • Care of amputated digit - irrigate with saline, wrap in saline soaked sterile gauze, place in water tight plastic bag, place in ice slurry.
    • Keep NBM, give intravenous antibiotics and tetanus booster (if required).

    Metacarpal fractures

     

    Undisplaced 4th metacarpal fracture

    Undisplaced stable fractures of neck or shaft (2nd-5th metacarpal)

    Resting volar splint and follow up plastic surgery clinic in five days.

    A fifth metacarpal fracture

    Angulated neck of metacarpal fracture
    • Most common is 5th "Boxer's Fracture"
    • Reduce fracture under nerve block +/- sedation if appropriate. Otherwise refer to plastic surgery.
    • Resting volar splint and follow up plastic surgery clinic as per plastic surgeon.

    A fracture at the base of the first metacarpal

    Thumb metacarpal fractures
    • Undisplaced fracture – thumb spica and follow up plastic surgery clinic in 5 days
    • Refer immediately if significant angulation or displacement.
    Displaced intra-articular, unstable, comminuted or irreducible fractures
    • Refer to plastic surgery team

    Referrals and follow-up

    • Plaster check within 24 hours
    • Follow up in Plastic Surgical Clinic as required
    • Advise parents of signs and symptoms of compartment syndrome.

    Nursing

    • Routine nursing care.

    Bibliography

    1. Yeh PC, Dodds SD. Pediatric Hand Fractures. Techniques in Orthopedics. 2009; 24(3): 150-162
    2. Andrade A, Hern HG. Traumatic Hand Injuries: The Emergency Clinician’s Evidence Based Approach. Emergency Medicine Practice. 2011; 13(6)  

    Endorsed by:  Director, Emergency Department   Date:  Jun 2017


     Review date:   Jun 2020


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