Injuries and Fractures

The wrist is comprised of two bones in the forearm, the radius and ulna, and eight tiny carpal bones in the palm. The bones meet to form multiple large and small joints. A wrist fracture refers to a break in one or more of these bones.

Types of wrist fracture include:

• Simple wrist fractures in which the fractured pieces of bone are well aligned and stable.
• Unstable fractures are those in which fragments of the broken bone are misaligned and displaced.
• Open (compound) wrist fractures are severe fractures in which the broken bones cut through the skin. This type of fracture is more prone to infection and requires immediate medical attention.

Causes

Wrist fractures may be caused due to fall on an outstretched arm, vehicular accidents or workplace injuries. Certain sports such as football, snowboarding, or soccer may also be a cause of wrist fractures. Wrist fractures are more common in people with osteoporosis, a condition marked by brittleness of the bones.

Signs and Symptoms

Common symptoms of a wrist fracture include severe pain, swelling, and limited movement of the hand and wrist. Other symptoms include:

• Deformed or crooked wrist
• Bruising
• Numbness
• Stiffness

Diagnosis

Your doctor performs a preliminary physical examination followed by imaging tests such as an X-ray of the wrist to diagnose a fracture and check alignment of the bones. Sometimes a CT scan may be ordered to gather more detail of the fracture, such as soft tissue, nerves or blood vessel injury. MRI may be performed to identify tiny fractures and ligament injuries.

Your doctor will order a bone scan to identify stress fractures due to repeated trauma. The radioactive substance injected into the blood gets collected in areas where the bone is healing and is detected with a scanner.

Treatment

Your doctor may prescribe analgesics and anti-inflammatory medications to relieve pain and inflammation.

Fractures that are not displaced are treated with either a splint or a cast to hold the wrist in place.

If the wrist bones are displaced, your surgeon may perform fracture reduction to align the bones. This is performed under local anesthesia. A splint or a cast is then placed to support the wrist and allow healing.

Surgery

Surgery is recommended to treat severely displaced wrist fractures and is carried out under the effect of general anesthesia.

External fixation, such as pins may be used to treat the fracture from the outside. These pins are fixed above and below the fracture site and are held in place by an external frame outside the wrist.

Internal fixation may be recommended to maintain the bones in proper position while they heal. Devices such as rods, plates and screws may be implanted at the fracture site.

Crushed or missing bone may be treated by using bone grafts taken from another part of your body, bone bank or using a bone graft substitute.

During the healing period, you may be asked to perform some motion exercises to keep your wrist flexible. Your doctor may recommend hand rehabilitation therapy or physical therapy to improve function, strength and reduce stiffness.

Risks and Complications

As with any procedure, wrist fracture surgery involves certain risks and complications. They include:

• Infection
• Residual joint stiffness
• Arthritis

The hand is one of the most flexible and useful parts of our body. Because of overuse in various activities, the hands are more prone to injuries, such as sprains and strains, fractures and dislocations, lacerations and amputations while operating machinery, bracing against a fall and sports-related injuries.

Fractures

A fracture is a break in the bone, which occurs when force greater than the bearable limit is applied against a bone. The most common symptoms of any fracture include severe pain, swelling, bruising or bleeding, deformity, discoloration of the skin and limited mobility of the hand.

Finger fracture

Fingers are fine structures of the human body that assist in daily routine activities through coordinated movements. Any abnormality affecting the fingers can have a huge impact on the quality of life. A finger fracture is not a minor injury, and if left untreated can lead to stiffness, pain, disruption of the alignment of the whole hand and interference with specialized functions such as grasping or manipulating objects. Finger fractures commonly occur during sports activities, when you break a fall or while operating machinery.

Diagnosis

The diagnosis of a hand or finger fracture is based on history, physical examinations and X-ray imaging to determine the type and severity of the fracture. X-rays are the most widely used diagnostic tools for the evaluation of fractures.

Treatment

The objective of early fracture management is to control bleeding, provide pain relief, prevent ischemic injury (bone death) and remove sources of infection such as foreign bodies and dead tissues. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after the fracture heals. To achieve this, maintenance of fracture reduction with immobilization technique is done by either non-operative or surgical methods.

Non-operative Therapy

The bones can be realigned by manipulating them into place. Following this, splints, casts or braces made up of fiberglass or plaster of Paris material are used to immobilize the bones until they heal. The cast is worn for 3 to 6 weeks.

Surgical Therapy

During surgery, the fracture site is adequately exposed, the bones realigned and reduction of the fracture is done internally using wires, plates and screws and intramedullary nails.

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of the cast or brace so that the bone becomes solid enough to bear stress. Rehabilitation program involves exercises and gradual increase in activity levels to strengthen the muscles and improve range of motion.

Injuries caused due to stretching or tearing of the ligaments in the wrist are called wrist sprains. These injuries are usually caused by a fall during daily activities or sports activities. Sprains can range from mild to severe based on the extent of injury to the ligament. Some of the main symptoms of wrist sprains include:

• Swelling and pain in the wrist
• Difficulty in moving your wrist
• Bruising around the wrist
• Popping sensation inside the wrist
• A feeling of warmth or feverishness in the wrist

Your doctor diagnoses this condition with the help of your medical history and physical examination of your wrist. Your doctor may also use imaging tests such as X-rays, CT scans and MRI to diagnose partial ligament tears.

Treatment for wrist sprains includes surgical and non-surgical treatments. Non-surgical treatment involves immobilization of the wrist and performing strengthening exercises once the pain has reduced. Surgical treatment is used to repair the ligament if it is completely torn.

Tendons are the bands of fibrous connective tissue that connect muscles to bone. Tendons aid in movement of the fingers, hand and all other body parts.

There are two types of tendons present in the hand- extensor tendons and flexor tendons. Extensor tendons present on top of the hand help with straightening the fingers. Whereas, flexor tendons that lie on the palm side of the hand help in bending the fingers. The flexor tendons are smooth, flexible, thick tissue strands which bend the fingers.

Deep cuts on the under surface of the wrist, hand, or fingers can cut and injure the tendon and make it unable to bend one or more joints in a finger. When a tendon is cut, it acts like a rubber band, where the cut ends are pulled away from each other.

Flexor tendon tears may be partial or complete. If tendons are completely cut through, the finger joints cannot bend on their own at all.

Causes

Any cut or laceration to the arm, hand, or fingers can cause a flexor tendon injury. Other possible causes include:

• Damage to the tendon from -a sports injury, often associated with football, rugby, and wrestling
• Stretching of the tendon where the tendon is pulled off the bone
• Jersey finger: When a player finger catches on another player’s jersey or clothing
• Rheumatoid arthritis
• Adventurous activities such as rock climbing

Symptoms

Inform your doctor if you have any of the following symptoms:

• Recent cut to hand or fingers
• Pain
• Swelling
• Loss of ability to bend the finger
• Numbness (loss of sensation)

Diagnosis

Make sure to see a doctor when you sustain a finger injury that is affecting the flexion and extension of your fingers.

First Aid: Apply ice immediately to the injured finger. Wrap a sterile cloth or bandage around the injury and keep your finger elevated above your heart level to reduce bleeding if present. A tetanus injection may need to be administered if not current.

Your doctor will review your symptoms and medical history. A physical examination will be done, which includes a complete examination of both hands. During the exam, you will be asked to bend and straighten your fingers. Your fingers will also be checked for sensation, blood flow, and strength. An X-ray may be ordered to check for any damage to the surrounding bone.

Treatment

A ruptured tendon cannot heal without surgery because the cut ends usually pull away after an injury.

There are many options to repair a cut tendon; the type of repair depends on the type of cut. The aim of the procedure is to restore normal function of the joints and surrounding tissues following a tendon laceration.

The flexor tendon repair is usually an outpatient procedure and can be performed under local or general anesthesia. The surgeon makes an incision on the skin over the injured tendon. The damaged ends of the tendon are brought together with sutures to achieve a secure repair. If the tendon injury is severe, a graft may be required. A graft is a piece of tendon that is derived from other parts of the body such as a foot or toe. After the repositioning of the tendon, the incisions are closed with sutures and a dressing pad is placed over the surgical site. Your surgeon will place your hand in a protective splint to restrict movements.

Depending on the injury, you will be advised to start hand therapy for a few weeks following surgery. This is to improve the movement of the finger. Follow your surgeon’s specific instructions for a successful recovery.

Possible complications of surgery include pain, bleeding, infection, stiffness, rupture of the repair, and damage to the surrounding nerves or blood vessels. A second surgery may be needed to release any excess scar tissue that interferes with finger movement.

Introduction

The hand is made up of 27 bones that form the wrist, palm, and fingers. Fingers can easily injure from daily activities, and fractures are common injuries that can occur. Injury to the metacarpal bone that connects to the little finger are the most common fractures, accounting for about one-third of all hand fractures. The fracture may be simple or involve a shift in the position of the bone or joint. There are also more severe fractures where the bone is crushed into many pieces.

Causes

Finger fractures occur most often from high impact trauma to the hand  such as with  a fall, motor vehicle accident, sports activities, or a fist fight.

Signs and Symptoms

The common signs of a finger fracture include

• Swelling and bruising around the fracture site
• Pain and tenderness
• Difficulty with finger movement
• Deformity of the finger

Diagnosis

Finger fractures can be  difficult to diagnose as the symptoms are similar to those of bone dislocation or sprain. Your physician diagnoses finger fracture after examining both the injured and uninjured fingers of the hand to see if they are of the same length. A fracture can also be detected when the injured finger overlaps with the others when you make a fist. An X-ray will be ordered to locate the injured area and confirm the diagnosis of a fracture.

Treatment

The treatment of a finger fracture begins with realigning the finger bone into the correct position usually under local anesthesia without cutting the skin. This is referred to as a closed reduction. 

A splint or plaster cast is then wrapped around the finger to support and protect it and keep it in the correct position while it heals. Your doctor may include the adjacent finger within the splint for additional support, a technique called buddy taping.

Surgery

If the fracture is severe, your surgeon will recommend surgery to repair the finger bones. An incision is made over the site of the fracture. Your surgeon will set the bones in correct alignment with instrumentation such as plates, pins or screws to hold the bones in place. Sometimes the bones may be severely shattered beyond repair. In such cases, your surgeon will use a bone graft to place new bone or bone substitutes into the spaces around the fracture. Once the repair is complete, the incision is closed and the finger is placed in a cast.

Post-op care

You will be instructed on how to care for your cast.  For the first 2-3 days you should elevate the hand to decrease swelling and apply ice over the cast for 20 minutes at a time.

Do not smoke as smoking slows down or prevents bone healing.  If a bone graft was inserted, smoking can cause the graft to fail.

Once the cast is removed, your physical therapist will instruct you on rehabilitation exercises to reduce the stiffness and restore range of motion to the finger.

Risks and complications

The possible risks and complication associated with finger fracture surgery include:

• Pain
• Bleeding
• Infection
• Stiffness
• Nonunion (bone fails to unite)
• Malunion (Deformed union of the fractured bone)
• Damage of the surrounding nerves or blood vessels

Mallet finger is a condition where the end of the finger is bent and does not straighten. It occurs when the extensor tendon on the back of the finger is damaged. The finger joint is a hinge-joint that allows bending and straightening of the fingers. Each finger is composed of 3 phalanges bones, joined by 2 interphalangeal joints (IP joints). The joint near the base of the finger is called the proximal IP joint or PIP joint, and the joint near the tip of the finger is called the distal IP joint or DIP joint.

Mallet finger occurs from sports activities causing a “jammed” finger or from excessive stress on the finger such as with a crushing injury. The injury causes either rupture of the extensor tendon without a bone fracture or rupture with a small or large bone fracture.

Generally, mallet finger can be treated non-surgically using specially designed splints that immobilize the finger and promote natural healing. In cases of fracture, complete bone healing may take 6-8 weeks, followed by physical therapy for strengthening. In severe cases that don’t respond to conservative treatment, surgery is recommended.

If left untreated, mallet finger can develop into a finger joint deformity referred to as a swan neck deformity.

Causes

Mallet finger occurs due to sports activities (such as baseball) or other activities that cause a direct and forceful impact on the fingers. 

Signs and Symptoms

The main symptoms of mallet finger are drooping of the finger at the distal joint, pain and swelling around the area and limited range of motion at the joint.

Diagnosis

The diagnosis of mallet finger involves a physical examination and obtaining an X-ray of the injured finger. In some cases, other imaging techniques such as MRI scan may be recommended.

Treatment

Mallet finger can be treated non-surgically by applying a specially designed splint for 6-8 weeks. Immobilizing the finger with a splint helps promote natural healing of the torn tendon or bones. 

For patients who require use of their fingers to perform occupational tasks, internal splints can be used; this involves surgical placement of metal pins in the affected bones. The pins can be removed after 6 weeks of healing.

Patients who fail to achieve adequate relief are recommended for surgery which involves repairing the torn tendon. If the mallet finger involves a fracture of the bone fragment, then it can be stabilized and fixed using pins and a special K-wire. 

Post-operative care

After mallet finger surgery, the patient is recommended for physical therapy or occupational therapy for flexibility and strengthening exercises.

Risks and complications

The common risks and complications associated with mallet finger surgery, include:

• Avascular necrosis (bone death from lack of blood supply)
• Infection
• Stiffness
• Nail-bed damage
• Chronic tenderness

Injuries that involve tearing or stretching of the ligaments of your fingers are termed as sprains. Sprains in the fingers are most often caused from a fall when you extend your arms to reduce the impact of the fall, or from overuse or repetitive activity of the thumb such as with texting.

Some of the symptoms of finger sprains include:

• Reduction in your ability to grasp items
• Pain immediately after the injury
• Swelling and bruising of the fingers
• Redness and tenderness

Finger sprains are diagnosed with the help of a physical examination of the hand to check for any abnormalities by moving your fingers in different positions. Your doctor may also suggest imaging tests such as X-rays to find the exact location of the injury.

Finger sprains can be treated with the help of applying ice packs and immobilizing your finger to allow it to heal. You may also be given pain medications to reduce discomfort. Once your fingers heal, you will be advised to perform strengthening exercises to strengthen your fingers. Surgical treatment is very rare and may be required only in complex cases where the ligament is completely torn.

A break or a crack in the bones of the thumb is known as a thumb fracture. Thumb fractures can occur from a direct blow, a fall, and muscle contractions or twisting during sports such as football, hockey, skiing and wrestling. Fractures may occur anywhere on the thumb, but a fracture at the base of the thumb, near the wrist, is considered the most serious. A fractured thumb is associated with severe pain, tenderness and swelling at the fracture site, little or no thumb movement, deformed appearance or coldness or numbness in the thumb.

A diagnosis of a fracture in the thumb is done by reviewing your medical history and performing a detailed examination of your thumb. X-rays are usually ordered to confirm the diagnosis.

Treatment involves the use of splints or casts to immobilize the bones until they heal. Surgery is usually considered if nonsurgical treatment fails to provide relief. External fixation is a surgery that fixes pins above and below the fracture site to treat the fracture from the outside. These pins are held in place by an external fixation device. Internal fixation involves the implantation of wires, pins, screws and plates from the inside to maintain the bones in proper position while they heal.

The scaphoid bone is a small, boat-shaped bone in the wrist, which, along with 7 other bones, forms the wrist joint.   It is present on the thumb side of the wrist causing it to be at a high risk for fractures. A scaphoid fracture is usually seen in young men aged 20 to 30 years. They can occur at two places: near the thumb or near the forearm.

Causes

Scaphoid fracture occurs due to a fall on an outstretched hand with complete weight falling on the palm. This fracture usually occurs during motor accidents or sports activities.

Symptoms

Symptoms of a scaphoid fracture include pain and swelling at the site of injury (base of the thumb and forearm). There is usually no deformity at the site of fracture, hence it may be mistaken for just a sprain. Bruising is also a very rare symptom of the fracture. There are chances that the patient might not be aware of the fracture for months or even years after the fall as the pain generally improves in a few days.

Diagnosis

Scaphoid fractures are diagnosed by X-rays; however, a non-displaced fracture does not show up on an X-ray when it is taken as early as the first week. Hence, your doctor will test for tenderness at the site of the scaphoid bone to detect the fracture. Your doctor will also advise you to use a splint and avoid lifting anything heavy for a few weeks and then order another X-ray to check for visibility of the fracture. Sometimes, an MRI scan, CT scan or bone scan can also be ordered to confirm the diagnosis of the scaphoid fracture.

Treatment

Treatment for scaphoid fracture is based on the site of the fracture i.e. the fracture near the thumb or near the forearm.

Non-surgical Treatment: Your doctor will suggest non-surgical treatment when the scaphoid fracture is not displaced. Non-surgical treatment involves immobilization of the forearm, hand and/or thumb in a cast. It might also include the elbow in case of fractures near the forearm. The time taken for the fracture to heal ranges from 6 – 10 weeks. Fractures near the thumb take relatively less time to heal when compared to fractures near the forearm as the blood supply necessary for healing is better near the thumb.

Surgical Treatment: Surgical treatment may be suggested when the fracture is displaced or is present closer to the forearm. In surgical treatment, an incision is made either in the front or back of the wrist. Your surgeon will use screws and wires to hold the scaphoid bone in place as it heals. If the bone is broken into more than 2 pieces, bone graft (graft usually taken from the forearm or hip) may be used to help in the healing process.

Following surgery, your hand will be placed in a splint or cast until it completely heals. Until then, you will be advised by your doctor to avoid contact sports and not to lift, throw, push or pull heavy weights with the injured arm. During recovery, you will be given physical therapy and taught certain exercises to help you regain strength and range of motion in your wrist.

Complications

The complications involved in the treatment of scaphoid fracture include:

• Non-union: when a bone fails to heal after treatment. This is caused due to limited blood supply in the scaphoid region. A special kind of bone graft called a vascularized graft, in which the bone has its own blood vessels, can be used to overcome this complication.
• Avascular necrosis: This is a complication in which cells of the scaphoid bone die due to lack of blood supply, causing bone collapse and arthritis. This usually happens in case of displaced fractures, as the displaced bone fails to get proper nutrients. Treatment with a vascularized graft will be suggested by your doctor to treat this complication.
• Post-traumatic arthritis: Persistent non-union and avascular necrosis of the scaphoid can cause arthritis of the wrist. This can be treated with splits, anti-inflammatory medications, steroid injections or surgery.

Conclusion

Scaphoid fractures can prove to be a permanent disability if not treated appropriately and with full care. The patient must take proper care to wear the cast until complete recovery of the fracture has occurred. It is also very important to maintain complete motion of the fingers and avoid lifting or pushing heavy weights during the recovery period. Exercise programs and physical therapy prescribed by the doctor should be strictly followed until the same motion and strength in the wrist is restored.