Thumb Fracture, Emergency Medicine

Basics

Distal phalangeal fractures:Blunt trauma, hyperextension of the thumb, axial loading of the thumb, and crush injuries.Tuft fracture is a similar fracture in other digits, in which the distal phalanx is crushed and/or fragmented.It may be open or closed and associated with nail bed injury.Severe nail bed injury, intra-articular, displaced/angulated fractures, or tendon injuries warrant orthopedics ' consultation.Noncomplex tuft fractures can be splinted and treated as soft tissue injuries.
Proximal phalangeal fractures and thumb metacarpal fractures:Blunt trauma to the thumb:Axial loading of the thumb with the metacarpophalangeal (MP) joint partially flexed, the hand closed or the thumb MP joint otherwise stabilizedBennett fracture (type I):Intra-articular fracture/dislocation at the base of the metacarpal where the ulnar aspect of the metacarpal maintains its attachment.Rolando fracture (type II):Comminuted Y- or T-shaped intra-articular fracture of the base of the 1st metacarpal.Similar to a comminuted Bennett, these can be much more complex with multiple comminuted fractures.Type III fracturesExtra-articular metacarpal fractures. Tend to be transverse or less commonly oblique.

Pain, swelling, and deformity of the thumb
Exam should include the thenar eminence for pain or deformity.
The thumb may be rotated distal to the fracture site.
The base of the thumb may appear radially deviated relative to the rest of the hand in the resting position.
Occasionally, there may be damage to the thumb digital nerves.

Physical Exam

Radiography as noted below

Imaging

Plain radiography of affected areas
Avoid testing stress of thumb MP joint, as in testing for gamekeeper thumb, until all plain radiography is complete.

Immobilize thumb pending definitive evaluation.

Thumb spica splint with the thumb in neutral position, as if holding a beverage can
Splint instructions should be provided to patient.
Angulated extra-articular fractures of the 1st metacarpal require reduction. Can tolerate up to 30 ° of angulation. Angulation >30 ° requires another attempt at reduction or orthopedics ' consultation.
Distal phalangeal fractures require DIP splint in extension for 3 " 4 wk.

Pain control with oral analgesic preparations

Admission Criteria

Open fracture, presence of multiple trauma, or other more serious injuries

Discharge Criteria

Counsel the patient that there is a strong likelihood of the need for operative repair for 1st metacarpal injuries.
Closed injuries: Referral, splinting, and explain frequent need for operative fixation

Issues for Referral

72-hr orthopedic referral

Due to tendon insertions, fractures at the base of thumb are often unstable and frequently require operative fixation

Brownlie C, Anderson D. Bennett fracture dislocation " review and management. Aust Fam Physician. 2011;40(6):394 " 396.
Capo JT, Hall M, Nourbakhsh A, et al. Initial management of open hand fractures in an emergency department. Am J Orthop (Belle Mead NJ). 2011;40(12):E243 " E248.
Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. J Hand Surg Am. 2009;34(5):945 " 952.
Haughton D, Jordan D, Malahias M, et al. Principles of hand fracture management. Open Orthop J. 2012;6:43 " 53.
Leggit JC, Meko CJ. Acute finger injuries: Part II. Fractures, dislocations, and thumb injuries. Am Fam Physician. 2006;73(5):827 " 834.
Lyn E, Mailhot T. Hand. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. John A. Marx. Philadelphia, PA: Mosby-Elsevier; 2010:489 " 524.

274160002 Fracture of phalanx of thumb (disorder)
208439004 Closed fracture thumb distal phalanx (disorder)
208442005 Closed fracture thumb distal phalanx, tuft (disorder)
208434009 Closed fracture thumb proximal phalanx (disorder)
208404004 Closed fracture thumb metacarpal base, intra-articular, Rolando (disorder)
61653009 Bennetts fracture (disorder)