Basics
Description
- 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 stabilized
- Bennett 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 fractures
- Extra-articular metacarpal fractures. Tend to be transverse or less commonly oblique.
Etiology
- Falls, hyperflexion, hyperextension
- Motor vehicle accidents
- Sports, especially downhill or alpine skiing
- Basketball
- Baseball
- Football
- Rugby
Diagnosis
Signs and Symptoms
- 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.
- Fractures to the thumb sometimes occur in children.
- Consider nonaccidental trauma.
- Do not neglect appropriate pain management in children.
Physical Exam
- Immobilize the thumb pending definitive evaluation.
- Neurovascular exam with 2-point discrimination.
Essential Workup
Radiography as noted below
Diagnosis Tests & Interpretation
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.
Differential Diagnosis
- Extra-articular fracture of the base of the thumb metacarpal
- Scaphoid fracture
- Gamekeeper thumb: Ulnar collateral ligamentous injury
Treatment
Pre-Hospital
- Dress open wounds.
- Immobilize hand and wrist with thumb in neutral position.
- Elevate and apply cold to reduce swelling.
- Age-appropriate social management
Initial Stabilization/Therapy
Immobilize thumb pending definitive evaluation.
Ed Treatment/Procedures
- 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.
Medication
Pain control with oral analgesic preparations
Follow-Up
Disposition
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
Pearls and Pitfalls
Due to tendon insertions, fractures at the base of thumb are often unstable and frequently require operative fixation
Additional Reading
- 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.
Codes
ICD9
- 816.00 Closed fracture of phalanx or phalanges of hand, unspecified
- 816.01 Closed fracture of middle or proximal phalanx or phalanges of hand
- 816.02 Closed fracture of distal phalanx or phalanges of hand
- 816.03 Closed fracture of multiple sites of phalanx or phalanges of hand
- 815.01 Closed fracture of base of thumb [first] metacarpal
- 816.0 Closed fracture of one or more phalanges of hand
ICD10
- S62.509A Fracture of unsp phalanx of unsp thumb, init for clos fx
- S62.516A Nondisp fx of proximal phalanx of unsp thumb, init
- S62.523A Disp fx of distal phalanx of unsp thumb, init for clos fx
- S62.526A Nondisp fx of distal phalanx of unsp thumb, init for clos fx
- S62.211A Bennetts fracture, right hand, init for clos fx
- S62.212A Bennett's fracture, left hand, init for clos fx
- S62.213A Bennett's fracture, unsp hand, init for clos fx
- S62.221A Displaced Rolando's fracture, right hand, init for clos fx
- S62.222A Displaced Rolando's fracture, left hand, init for clos fx
- S62.223A Displaced Rolando's fracture, unsp hand, init for clos fx
- S62.224A Nondisplaced Rolando's fracture, right hand, init
- S62.225A Nondisplaced Rolando's fracture, left hand, init for clos fx
- S62.226A Nondisplaced Rolando's fracture, unsp hand, init for clos fx
- S62.501A Fracture of unsp phalanx of right thumb, init for clos fx
- S62.502A Fracture of unsp phalanx of left thumb, init for clos fx
- S62.521A Disp fx of distal phalanx of right thumb, init for clos fx
- S62.522A Disp fx of distal phalanx of left thumb, init for clos fx
- S62.524A Nondisp fx of distal phalanx of right thumb, init
- S62.525A Nondisp fx of distal phalanx of left thumb, init for clos fx
SNOMED
- 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)