M e t a c a r p a l a n d Ph a l a n g e a l F r a c t u re s i n A t h l e t e s Ilvy H. Cotterell,

MD

a,

*, Marc J. Richard,

MD

b

KEYWORDS  Athlete  Hand injuries  Metacarpal fractures  Phalangeal fractures KEY POINTS  Most metacarpal and phalangeal fractures resulting from athletic injuries occur by a low-energy mechanism and are usually extra-articular and minimally displaced.  Football injuries account for most metacarpal and phalanx fractures.  Sport, player position, time of season, and level of play should be taken into consideration when determining treatment options.  Early range of motion is a key aspect in the recovery process.

EPIDEMIOLOGY

Metacarpal and phalangeal fractures are among the most common skeletal injuries in the general population, accounting for 10% of all fractures and 1% of emergency department visits in the United States.1–3 Nearly half (41%) of all injuries to the hand warranting an emergency room or urgent care facility visit involve a fracture to the metacarpal or phalanx. These injuries occur most commonly in young adult men and nearly a quarter (22.4%) are sustained during athletic events.3–5 Organized sporting events are becoming increasingly popular among children and adolescents, with 45 million active participants in the United States.6 High school participation has also been growing annually for the past 20 years to more than 7 million athletes.7 With this increase in participation, both acute and chronic overuse injuries are increasing as well.8,9 Metacarpal fractures sustained from a direct blow are the most commonly occurring fracture (2 in 3) in the young male athlete population, especially those participating in contact sports such as football, lacrosse, or hockey.10–13 Fifty percent of all hand fractures occur during football events.14

Disclosures: M.J. Richard is a consultant for Acumed, DePuy Synthes, and Extremity Medical. a Department of Orthopaedic Surgery, Virginia Commonwealth University, 1200 East Broad Street, West Hospital 9th Floor, Richmond, VA 23298, USA; b Department of Orthopaedic Surgery, Duke University, 4709 Creekstone Drive, Durham, NC 27703, USA * Corresponding author. E-mail address: [email protected] Clin Sports Med 34 (2015) 69–98 http://dx.doi.org/10.1016/j.csm.2014.09.009 sportsmed.theclinics.com 0278-5919/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.

70

Cotterell & Richard

Although the number of injuries sustained is higher during practice, the injury rate is higher during competitive games. The reason for this is that more time is spent at practice as opposed to games, but competition typically increases the intensity level.14–17 Because women’s sporting events typically do not involve forced contact, lower extremity injuries in general are more common in young female athletes.18,19 MECHANISM OF INJURY

Most hand fractures result from a direct blow, fall, or crush. In athletic events, these are most commonly caused by low-energy forces and therefore result in minimal soft tissue injury. Common fracture patterns exist secondary to the relative anatomy and deforming forces on susceptible areas of the bone. Torsion, compression, shear, bending, and tension can all result in specific fracture patterns. These patterns are discussed in greater detail later in the article. Sport-specific injuries occur and the specific protective gear may uniquely protect from or predispose to particular injuries.5,12,18,20,21 It is incumbent on the physician caring for the athlete to understand these patterns and to assist in both the prevention and treatment of these injuries. Stress fractures in the upper extremity, specifically in metacarpals or phalanges, are rare compared with lower extremity stress fractures.18,22 There have been reports of metacarpal stress fractures in the dominant hand of racquet-playing athletes, such as golfers, batters, or tennis players.22 These injuries are managed similarly to lower extremity stress fractures and are primarily treated by rest, activity modification, and immobilization. Fractures of the metacarpals or phalanges can significantly affect an athlete’s training program, season, or career, depending on the timing and severity of injury. Regardless of the type of injury, the well-established principles of stable anatomic reduction and early functional motion are the keystones of treatment. ANATOMY AND CLASSIFICATION

The anatomy of the metacarpals is unique in that all 4 nonthumb metacarpal bones are connected via strong interosseous ligaments and distally by the deep transverse metacarpal ligament, which maintains the stability of the metacarpal arch.23–25 Therefore, isolated metacarpal shaft fractures, especially those in the central 2 digits, tend to be stable (Fig. 1). The index metacarpal is typically the longest metacarpal bone with the broadest base, whereas the ring finger metacarpal is usually the narrowest in diameter, with the small finger metacarpal being the shortest.24 These subtle changes in bony anatomy can be important for evaluation of imaging studies as well as for implant selection, such as intramedullary devices or plates. The carpometacarpal (CMC) joints of the index and long fingers have an inherent stability because of their bony morphology and soft tissue support, thereby permitting only minimal range of motion. In comparison, the articulations of the ring and small finger metacarpal bases with the hamate allow a larger degree of motion, especially in flexion, to enable a powerful grip. For this reason, more displacement can be permitted in fractures of the ulnar metacarpals because the deformity can more easily be compensated. Because of the anatomy, border metacarpals are more susceptible to shortening, because they have less soft tissue support (see Fig. 1); however, they can tolerate more angulation in the coronal plane away from the center, because a slight malrotation deformity does not lead to impingement on the other digits.

Metacarpal and Phalangeal Fractures in Athletes

Fig. 1. Spiral fractures tend to be most unstable in the border digits, where only 1 side of the metacarpal is supported by a deep transverse intermetacarpal ligament. (Reprinted from Capo JT, Hastings H II. Metacarpal and phalangeal fractures in athletes. Clin Sports Med 1998;17(3):497. Figure 3; with permission from Elsevier.)

The metacarpal heads distally have a cam shape, with the head positioned more volar than the axis of the shaft. As a result, the collateral ligaments change length with range of motion of the metacarpophalangeal (MCP) joint, and are at maximum length and tension in flexion and lax in extension. This feature is clinically important, because the MCP joint is therefore more stable in flexion, which is also significant when determining the position of joint immobilization for a prolonged time course, because contractures of the collateral ligaments can occur with the MCP immobilized in an extended position. These contractures can be prevented with the MCP joint immobilized in 70 to 90 of flexion, although ultimately fracture reduction and stability dictate the position of immobilization. Proximal phalanx fractures typically have an apex volar angulation deformity (Figs. 2 and 3), because of the contributions from the lumbricals and interossei flexing the proximal base segment and the central slip attachment at the dorsal base of the middle phalanx pulling the distal fragment into extension. In contrast, middle phalanx fractures have a less predictable deformity, because the 2 terminal slips of the flexor digitorum superficialis (FDS) inserting at the volar base act as equalizers to the central slip (Fig. 4). The heads of the proximal and middle phalanges include 2 condyles separated by an intercondylar notch, which provides some inherent joint stability through its articulation with the median ridge at the base of the middle and distal phalanx, respectively. At the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, the collateral ligaments are taut throughout the range of motion, and therefore can be immobilized in extension without causing contractures of the collateral ligaments. The distal phalanx is protected by the nail plate, which acts as an external splint in the setting of a fracture, thereby limiting deformity. In addition, no significant deforming forces exist, because the terminal extensor tendon inserts at the base of the distal phalanx dorsally, and the flexor digitorum profundus inserts volarly.

71

72

Cotterell & Richard

Fig. 2. (A) Anteroposterior (AP) and (B) lateral radiographs of small finger proximal phalanx fracture resulting in the typical apex volar deforming forces.

Fig. 3. Deforming forces acting on proximal phalanx fractures. The central slip pulls the distal fracture fragment into extension.

Metacarpal and Phalangeal Fractures in Athletes

Fig. 4. Deforming forces acting on middle phalanx fractures. (A) Transverse fractures proximal to the FDS insertion angulate dorsally. (B) Those distal to the FDS insertion angulate volarly. (Reprinted from Capo JT, Hastings H II. Metacarpal and phalangeal fractures in athletes. Clin Sports Med 1998;17(3):508. Figure 15; with permission from Elsevier.)

The thumb is unique in that it has a great range of motion because of the lack of bony constraints at the CMC joint and the lack of ligamentous attachments to the other metacarpals, permitting precise fine motor skills such as pinch and opposition. The thumb metacarpal is pronated compared with the rest of the hand. Similar to other joints with a large range of motion, there is little bony stability inherent to the thumb CMC joint and a reciprocal dependence on ligamentous support to remain stable. One of the benefits of this sizable range of motion is the ability to accommodate for a larger amount of deformity.26 The classification of metacarpal and phalangeal fractures is most accurately explained with descriptive terminology, beginning with the name of the fractured bone, the location within the bone, specific fracture characteristics, and the resultant displacement that occurs (Table 1). In addition, several fracture types have commonly used eponyms, which are further described later. EVALUATION AND INITIAL MANAGEMENT

The mechanism of injury can give clues to the injury pattern. Careful examination of the soft tissue envelope should be performed to rule out open fractures, which need to be treated more promptly and differently than a closed injury. Not all fractures lead to obvious deformities in the hand and digits, and careful evaluation for rotational deformities is paramount in assessing and treating hand fractures. Before a definitive diagnosis can be established, temporary immobilization with splints can provide comfort. Although some investigators have cautioned the use of ice packs distal to the metacarpal,27 we have found the judicious use of ice beneficial

73

74

Cotterell & Richard

Table 1 Metacarpal and phalangeal fracture description Bone

Location

Pattern

Intra-articular (CMC joint)

Transverse

Extra-articular base

Oblique

Shaft

Spiral

Metacarpal

Displacement

Long Short

Angulated

Neck Head Base Proximal phalanx

Intra Extra

Shaft

Articular Comminuted

Translated

Neck Middle phalanx

Uni Bi Base

Distal phalanx Tuft

Condylar

Rotated Dorsal Volar

Lip avulsion

Transverse

Shortened

Comminuted

in reducing pain and limiting swelling without compromising the vascular supply distally. Reduction of an obviously deformed finger should not be attempted before radiographic evaluation, because the reduction maneuver should be tailored to the individual fracture or dislocation pattern. Training rooms, especially in the college and professional setting, are becoming increasingly well equipped for the treatment of orthopedic injuries. Mini–fluoroscopy units are sometimes available to facilitate the rapid evaluation and diagnosis of these injuries in the field. Once in the emergency department or office setting, a careful focused examination of the hand should focus on the soft tissue envelope, neurovascular status, and rotational or angular deformity of the injured digit. To better assess this, a hematoma or digital block with local anesthetic can be helpful (after confirming neurologic status). Rotational deformity is best evaluated while observing active flexion and extension of the fingers, and cannot be substituted for by any imaging. When full flexion is possible, all fingers should point toward the scaphoid tubercle. When a patient is not able to fully flex the fingers because of pain or swelling, a nonfractured digit can appear malrotated when evaluated during midrange because of the normal finger cascade. This condition can be confirmed by the examiner comparing the rotation with the uninvolved contralateral side placed at the same degree of limited flexion. Malrotation may be seen as digital malalignment such as overlap or scissoring. It may also be seen as a difference in distal tip rotation compared with the other side. Passive flexion may falsely underestimate the amount of malrotation because the examiner can unknowingly rotate the finger through the fracture into a more normal posture. In addition, tenodesis may help show abnormal rotation, especially with more proximal fractures. IMAGING MODALITIES

Radiographs are routinely used in the evaluation, diagnosis, and management of hand injuries. Anteroposterior, oblique, and lateral radiographs are standard, and additional

Metacarpal and Phalangeal Fractures in Athletes

views can be helpful when certain fractures or dislocations are suspected based on clinical examination. The hand can be pronated or supinated depending on which finger or joint is being evaluated (Fig. 5). Imaging of the contralateral hand for comparison can also be useful in the setting of abnormal anatomy or in skeletally immature patients. Mini–fluoroscopy units are becoming increasingly abundant in the office setting, and sometimes even in training rooms. They are beneficial because a dynamic examination can pinpoint the exact view desired. Furthermore, they limit radiation exposure to the patient and the examiner, and are portable and cost-effective. Fluoroscopy has been shown to be reliable and equal to standard radiographs in assessing large bones; for example, in the reduction of pediatric both-bone forearm fractures.28 However, the quality of images generated by fluoroscopy compared with standard radiographs, especially when evaluating small intra-articular step-offs, such as in the metacarpals or phalanges, has been challenged.29 A study evaluating thumb metacarpal base fractures in a cadaver model found that fluoroscopy was inferior to radiographs in accurately assessing intra-articular joint deformity, although the investigators did not disclose the type and resolution of the fluoroscopy unit used.29

Fig. 5. Axial relationships of metacarpals, showing that a lateral radiograph of the hand (A) requires slight pronation (B) and slight supination (C) for independent visualization of index and small metacarpals. (Reprinted from Capo JT, Hastings H II. Metacarpal and phalangeal fractures in athletes. Clin Sports Med 1998;17(3):494. Figure 1; with permission from Elsevier.)

75

76

Cotterell & Richard

However, a more recent study that was similar in design set out to challenge this concept, and ultimately found no difference between fluoroscopy and traditional radiographs.30 With newer high-resolution designs rapidly evolving, the imaging quality is progressing to a level near that of traditional radiographs. Regardless of image quality, live fluoroscopy, when available, is a useful adjunct in obtaining a specific view, as well as for obtaining dynamic stress views to provide additional information on the ligamentous or bony stability. Ultrasonography is rapidly evolving in the treatment and management of musculoskeletal conditions and, in the upper extremity, high-frequency probes (>10 MHz) have proved useful in evaluating ligament tears, radiolucent foreign bodies, tendon disorders,31–33 and even in the diagnosis of a clinically suspected scaphoid fracture.34 A recent study even showed ultrasonography assistance to be equal to fluoroscopy in aiding reduction of distal radius fractures,35 but its use in evaluation and management of fractures of the metacarpals and phalanges is still limited. Although radiographs remain the main tool for assessing fracture characteristics, three-dimensional imaging, such as computed tomography (CT), can be helpful, particularly when assessing intra-articular fractures (Fig. 6). However, MRI is rarely indicated in the acute setting of these fractures. When evaluating fracture healing in the hand, radiographic assessment, whether with traditional radiographs or fluoroscopy, generally lags several weeks behind clinical union. A clinical examination showing improved pain, minimal tenderness to

Fig. 6. Lateral radiograph (A) and sagittal CT scan cut (B) of ring finger proximal phalanx intra-articular base fracture.

Metacarpal and Phalangeal Fractures in Athletes

palpation at the fracture site, progressing range of motion, and sometimes even a palpable callus can sometimes be more helpful than radiographs in confirming early fracture union. GENERAL TREATMENT PRINCIPLES

Many fractures of the hand and digits can be treated nonoperatively. However, with growing patient demands, advances in anesthesia, and improved orthopedic implants and techniques, operative management is becoming increasingly popular.36–40 Regardless of the treatment method chosen, the treatment goals remain the same: restoration of anatomic bony alignment, range of motion, and function. The management of metacarpal and phalangeal fractures in elite athletes is often determined on a per case basis. The influences on management decisions in this subgroup of patients are multifactorial. Depending on factors such as the level of play, time of season, and position, a fracture that otherwise would be amenable to nonoperative treatment may be managed operatively if an earlier return to play can safely be permitted. Immobilization of phalangeal and metacarpal fractures differs based on the fracture pattern, but generally should not exceed 3 to 4 weeks respectively. During recovery, patients are encouraged to mobilize the noninjured digits and joints, including the elbow and shoulder. Slings are frequently given out by urgent care facilities but serve no functional purpose in hand injuries. Furthermore, they prevent mobilization of the healthy, uninjured joints and keep the hand in a dependent position, and therefore are not recommended for isolated hand fractures. Whether an athlete is allowed to play with an orthosis or cast depends on the sport, position, and the level of play, and ultimately the umpire or referee. More information can be found in specific association guidebooks, such as the National Federation of State High School Associations, the National Collegiate Athletic Association, and the individual professional organizations’ rulebooks, which are accessible online. METACARPAL FRACTURES

Metacarpal fractures can be divided into base, shaft, head, and neck fractures (see Table 1). Owing to the varying anatomy of the CMC joint at the radial and ulnar aspect of the hand, as discussed earlier, injuries of the nonthumb metacarpals are each treated differently based on their location. Because the CMC joint becomes more mobile and forgiving from radial to ulnar, more angulation and displacement can be permitted at the fourth and fifth metacarpals. In general, most metacarpal fractures resulting from low-energy mechanism are minimally displaced and stable, and are treated successfully with immobilization. Manipulation and Splinting

In the past, when splinting common fractures of the hand, the MCP joints were immobilized in flexion and interphalangeal joints in extension to prevent collateral ligament contracture. This method has been disputed by multiple recent studies that have evaluated clinical outcomes after different types of immobilization.41–43 A retrospective review of 3 different cast immobilization methods of metacarpal fractures found no difference between the types of immobilization on the maintenance of fracture reduction, finger range of motion, or grip strength if immobilization was discontinued at 5 weeks.41 A prospective randomized study similarly showed no difference in overall outcomes at 3 months between fifth metacarpal neck fractures immobilized with the MCP joint in flexion versus in a neutral position for 4 weeks.42 Furthermore, a

77

78

Cotterell & Richard

Cochrane Database Review compared 5 randomized studies of different types of immobilization for fifth metacarpal neck fractures, and found that outcomes generally were excellent, regardless of the types of immobilization, which included cast immobilization with and without the wrist included, buddy taping, and dynamic splinting.43 Metacarpal Base Fractures

Metacarpal base fractures occur from an axial load to the hand with the wrist in flexion and elbow in extension, and can sometimes be associated with CMC joint dislocations. CMC dislocations are easily missed on initial presentation on standard radiographs. A 30 pronated lateral view yields good visualization of the small and ring finger CMC joints (Fig. 7). The eponyms Baby Bennett fractures or reverse Bennett fractures are sometimes used to describe intra-articular base of the small finger metacarpal fractures, because analogous deforming forces act on the fracture fragments as in the thumb metacarpal base fracture, or Bennett fracture. The radial aspect of the fifth metacarpal base is the stable fragment, or Bennett fragment, and is stabilized by the intermetacarpal ligament, which connects it to the ring finger metacarpal base. The hypothenar muscles cause the shaft to deviate radially and the extensor carpi ulnaris leads to proximal and

Fig. 7. Injury radiographs. AP (A) and pronated oblique (B) views of a fifth metacarpal base fracture dislocation (reverse Bennett fracture). The 30 pronated view allows better visualization of the dorsally subluxated fifth CMC joint. AP (C), oblique (D), and lateral views (E) views after percutaneous K-wire fixation. The pins were removed at 6 weeks.

Metacarpal and Phalangeal Fractures in Athletes

ulnar displacement of the remainder of the metacarpal base. Because this is an intraarticular fracture, surgical fixation to restore the articular surface is recommended to prevent posttraumatic arthritis.44 Although it can be difficult to assess joint congruency on radiographs, suggested parameters of a step-off or gap of more than 1 mm or greater than 25% of articular involvement should be treated operatively.39 Successful stabilization can usually be achieved with 1.14-mm (0.045 inch) Kirschner wire (K-wire) fixation to either the adjacent metacarpal and/or the hamate. Metacarpal Shaft Fractures

Metacarpal shaft fractures, when occurring in isolation, are usually stable, especially in the central digits, owing to the intermetacarpal ligaments, and therefore can often be managed conservatively. The intrinsic insertions and extrinsic flexor tendons constitute the main deforming forces, and act to flex the distal fragment, resulting in the classic apex dorsal angulation. Angulation of the metacarpal shaft of 10 is tolerated in the index metacarpal, whereas in the ulnarmost fifth metacarpal 30 of angulation can have little clinical impact. However, malrotation is not well tolerated, because as little as 10 of malrotation can lead to 2 cm of fingertip overlap.45 Because this can be difficult to evaluate radiographically, a careful clinical examination of the finger cascade is warranted for all metacarpal fractures, as described previously. Shortening is also not well tolerated, because as little as 2 mm of shortening can lead to a 7 extensor lag.46 Thus, more than 6 mm of shortening is generally not accepted, because this results in a 21 extensor lag, which can no longer be compensated for by the 20 natural hyperextension capability at the MCP joint. Furthermore, significant shortening can result in loss of knuckle contour, pseudoclawing, and muscle fatigue.47 Stable fixation should be considered with any significant shortening or clinically evident rotation, with unstable fracture types (eg, a long oblique fracture that shortens along the obliquity) or in the setting of multiple metacarpal fractures, although much debate exists regarding acceptable parameters.48,49 Closed reduction followed by percutaneous intramedullary fixation offers the potential benefit of not violating the fracture hematoma along with its positive effects on fracture healing, and avoidance of excessive soft tissue dissection decreases scar formation and tendon adhesions. Pinning to adjacent metacarpals is less useful in athletes, because tendon irritation is quick to occur with any hand movement. Intramedullary pinning is a good option, to preserve the soft tissues but increase stability, and can be done either in an antegrade fashion with bouquet-style pinning or in a retrograde fashion through the collateral recesses (Fig. 8). When using this technique, especially if anatomic reduction is not possible because of comminution, it is important to evaluate rotational alignment clinically while in the operating room. Although 1 study found no difference in clinical outcomes between percutaneous pinning and open reduction followed by plating of metacarpal fractures in the general population, operative complications were higher in the intramedullary nail group, and included joint penetration, tendon irritation, loss of reduction, and need for secondary surgeries.50 When considering percutaneous fixation versus plating, clinicians should keep in mind that continued participation in athletics or even conditioning will be compromised with pins protruding out of the skin. Lag screw fixation is a middle ground between percutaneous and open treatment. The advantage of lag screws is that they typically do not lead to tendon irritation, but they require open reduction, as with a plate. A lag screw construct is stable when the length of fracture is greater than twice the diameter of bone (Fig. 9). However, it does not protect from torsional forces.

79

80

Cotterell & Richard

Fig. 8. Methods of internal fixation of unstable metacarpal shaft fractures. Bouquet-style pinning (A, B) and collateral recess pinning (C, D).

When more stable fixation is desired, especially with contact athletes or in the setting of multiple metacarpal fractures, open reduction and plate fixation is the recommended method of choice. After rigid fixation, there is usually no need for a protective splint or orthosis, and early range of motion is permitted. Tension band construct fixation or intraosseous wiring are alternative fixation options, but, with advances in implant technology, these techniques are falling out of favor.

Metacarpal and Phalangeal Fractures in Athletes

Fig. 9. AP and lateral injury radiographs (A, B) of second and third oblique metacarpal shaft fractures in a 20 year-old man who sustained a left hand injury while playing basketball. The length of the second metacarpal fracture is more than twice the diameter of the metacarpal shaft, whereas the third metacarpal fracture length is shorter than twice the diameter (C). The second metacarpal was stabilized with lag screw fixation and the third metacarpal with a plate (D).

Metacarpal shaft fractures are routinely approached with a dorsal exposure and retraction of the common extensor tendon. It is important to ensure that the bend of the plate is similar to the bend of the metacarpal shaft, otherwise the fracture will gap volarly. Traditional plating techniques using standard AO principles includes a straight mini–fragmentary plate with 3 screws in the proximal and distal fragments each, with bicortical purchase. Locking technology is generally reserved for unstable periarticular fractures, fractures with metaphyseal comminution, and those with segmental bone loss.51 Limitations of locking plates, especially in the setting of metacarpal fractures, are that they are too stiff and provide no compression across the fracture fragments. A biomechanical study using a comminuted metacarpal sawbone fracture model found that fixation using a standard plate and 6 bicortical screws compared with a locking plate with 4 bicortical screws had equivalent bending and torsional stiffness, bending load, and maximum torque.52 Newer plate designs are emerging, and include shorter and thinner plate options that enable an equally stable reduction compared with conventional plates, but with a smaller exposure and minimal soft tissue dissection.53,54 These plates allow placement of more screws in a given bone segment by a double row or ladder design (Fig. 10). In a biomechanical study using a transverse metacarpal fracture sawbone

81

82

Cotterell & Richard

Fig. 10. AP and lateral radiographs (A, B) after plate fixation of a fifth metacarpal shaft fracture. Newer plate design allowing more screws to be placed per bone segment because of the staggered design of the screw holes in the plate.

model, 3 nonlocking plates with different lengths and screw configurations were evaluated for their load to bending failure. Although 1 plate outperformed the others, showing a higher load to failure, all constructs broke through the bone adjacent to the plate or at the last screw hole.55 After surgery, when stable fixation has been achieved, early range of motion can be initiated to promote tendon gliding to prevent tendon adhesions and stiffness. Depending on fracture morphology and the fixation method chosen, return to play with a protective brace can usually be achieved by 1 to 3 weeks postoperatively.49,56 Metacarpal Neck Fractures

Metacarpal neck fractures are the most common among metacarpal fractures, because this region comprises the weakest area of the bone. The mechanism of injury is usually punching a firm object, which results in the commonly termed boxer’s fracture or fifth metacarpal neck fracture. However, this is a misnomer, because boxers, who are formally trained to punch, load the more rigid index finger, and the resultant fracture involves the index metacarpal base, not the fifth metacarpal neck. Thus, the fifth metacarpal neck fracture is also coined a fighters fracture or the untrained pugilist fracture. Closed reduction and splinting should be the first treatment choice. Immobilization methods, regardless of the type chosen (ie, with or without inclusion of the PIP or DIP joints; position of the MCP joint in flexion or extension) do not alter the outcome. A study of fifth metacarpal neck fractures in young active-duty military patients showed no difference between a volar short-arm cast with outrigger compared with a shortarm cast to include the PIP of the small finger in extension.42 We buddy tape the injured finger to the adjacent one in the splint or cast and prefer immobilization to incorporate the PIP joint for at least the first 2 weeks. After this, the patient is

Metacarpal and Phalangeal Fractures in Athletes

transitioned to a removable splint and permitted to initiate controlled range of motion with buddy taping. Close radiographic follow-up is necessary, because some loss of reduction is common. As a general rule, the more distal the fracture location is in the neck, the less prominent the metacarpal head is in the palm, and these types of fractures are mostly amenable to conservative treatment with immobilization alone. When assessing the angulation of displacement, clinicians must bear in mind that the anatomy of a metacarpal neck has a slight natural flexion (ie, a noninjured fifth metacarpal neck has an approximately 15 volar angulation). However, it is important to differentiate true neck fractures from fractures in the meta-diaphyseal region. Because of their more proximal location, these fractures are inherently more unstable; the effect of angulation at the fracture site is further exaggerated (Fig. 11); and, as holds true for metadiaphyseal fractures in general, they anecdotally have a longer time to union. For these fractures, we recommend considering surgical fixation to facilitate stability, enable fracture union, and to prevent prominence of the metacarpal head in the palm as well as loss of dorsal knuckle contour (Fig. 12). Metacarpal Head Fractures

Metacarpal head fractures are intra-articular fractures and, similar to metacarpal base fractures, should generally be treated operatively to prevent posttraumatic arthritis.39 Surgical options include interfragmentary K-wires or headless compression screws, or, in the case of diaphyseal extension, a plate and screw construct (Fig. 13).57 PHALANGEAL FRACTURES

Phalangeal fractures can be divided into base, shaft, and condylar types (see Table 1). Similar to metacarpal fractures, those with minimal displacement and no intra-articular involvement can be managed conservatively with closed reduction and immobilization. They rarely require more than 3 weeks of immobilization because osteocutaneous ligaments and the fibro-osseus tendon sheath along with the annular pulleys provide additional internal stability. Buddy taping can be a helpful adjunct when protecting an isolated digit injury, especially in the border digits, because the adjacent finger can act as a protective splint. Depending on the fracture type and location, fractures of the proximal and middle phalanx can be unstable (see Fig. 3) and require operative fixation.58–63 When a phalangeal facture assumes the typical apex volar angulation (see Fig. 2), a lack of reduction can lead to pseudoclawing and extensor lag. The mechanism of injury

Fig. 11. The effect of fracture level on metacarpal head displacement. The more proximal the fracture, the greater the palmar prominence. (Reprinted from Capo JT, Hastings H II. Metacarpal and phalangeal fractures in athletes. Clin Sports Med 1998;17(3):498. Figure 4; with permission from Elsevier.)

83

84

Cotterell & Richard

Fig. 12. Unstable fifth metacarpal neck fracture with 90 volar angulation of the head fragment (A) after fixation with percutaneous pins (B).

Fig. 13. Second metacarpal head fracture with diaphyseal extension (A, B) after fixation with laterally placed plate (C).

Metacarpal and Phalangeal Fractures in Athletes

can predictably determine fracture characteristics. Transverse fractures tend to occur from a fall onto a clenched fist, whereas torsion or angular deformities such can occur during a twisting injury result in oblique or spiral fractures. Surgical indications include intra-articular fractures, any rotational malalignment, angulation of more than 15 , and greater than 6 mm of shortening.58 Fixation methods are based on fracture characteristics, and, especially in the phalanges, are heavily surgeon dependent. They can vary from closed manipulation and K-wire fixation to open reduction and internal fixation using a combination of plates and screws. When using K-wires, a 16-gauge needle can be helpful as a guide and to protect the soft tissues during insertion of a 1.14-mm (0.045 inch) K-wire. Proximal and Middle Phalanx Shaft Fractures

Stable, extra-articular fractures with minimal displacement can safely be treated conservatively, and protective splints can be applied to enable early return to play. Unstable or displaced fractures requiring operative intervention can be managed with closed reduction and percutaneous fixation, open reduction, or cerclage wiring.64 A retrospective review of 50 proximal phalangeal base and shaft fractures treated with periarticular pinning found that most fractures were healed within 4 weeks, and 80% of patients had good or excellent results, lacking less than 20 range of motion at final follow-up.65 Joint-sparing techniques have recently been described yielding equally good results for transverse fractures of the middle phalanx. One article describes a technique in which the K-wire is inserted through the proximal dorsal cortex of the middle phalanx, thereby sparing the intra-articular penetration of conventional antegrade pinning, although this does not pose any clinical deficit in our experience.66 Closed reduction can be facilitated using a pointed reduction clamp to control the distal segment, and K-wires can be placed intramedullary in a converging or crossed fashion (Fig. 14). Purchase in the distal subchondral bone can be helpful for additional fixation stability. A prospective randomized study of 15 patients with isolated, long oblique, or spiral fractures of the proximal phalanx compared K-wire with lag screw fixation and found that the incidence of tendon adhesions was higher in the K-wire group, whereas malunion was more common in the lag screw group. Given the small numbers, no meaningful conclusion was observed.67 As discussed for metacarpal fractures, open reduction with stable internal fixation is the preferred method of choice in elite athletes to enable early range of motion and return to play. These fractures are typically approached through a dorsal or midaxial approach and tendon adhesions are a common complication following fixation with either. Intra-articular Fractures: Base (Pilon) and Condylar Types

Most articular fractures involving the PIP and DIP joints should be treated operatively to prevent posttraumatic arthritis. Surgical fixation should focus on near-anatomic reduction of the articular surface, restoration of joint congruency, and permitting early postoperative range of motion.61 When reduction can be achieved in a closed manner, simple articular fractures can be treated with percutaneous pin or screw fixation (Fig. 15), although sometimes a small incision at the fracture is required to facilitate a better reduction with use of a dental pick (Fig. 16). When open reduction is necessary for condylar fractures, is important to preserve the collateral ligament attachments, to preserve the vascular supply to the condyles and prevent avascular necrosis. Stable internal fixation can be achieved with a combination of low-profile plates and screws (Fig. 17). In their series of 38 distal unicondylar fractures of the proximal phalanx, Weiss and Hastings68 found that fixation

85

86

Cotterell & Richard

Fig. 14. Comminuted extra-articular proximal phalanx fracture with typical apex volar displacement (A, B) after fixation with 2 crossed antegrade K-wires (D, E). A towel clamp was used to hold the reduction while K-wires were being placed (C).

Metacarpal and Phalangeal Fractures in Athletes

Fig. 15. Condylar fracture of proximal phalanx without intra-articular extension (A) after fixation with percutaneous pins (B, C). An intramedullary pin was used for additional longitudinal stability.

using multiple K-wires or screws for fixation achieved the most predictable functional outcome for joint range of motion and fracture healing. Articular fractures at the phalangeal base are best approached with a volar shotgun approach, exposing the articular surface after opening the flexor tendon sheath between the A2 and A4 pulleys and release of the volar plate distally (Fig. 18).69 In significantly comminuted articular fractures, or Pilon-type fractures, anatomic articular restoration may not be feasible. Therefore, distraction osteosynthesis with a dynamic traction external fixation device, such as a Suzuki fame, may be required to maintain

Fig. 16. Unicondylar fracture of proximal phalanx (A) after percutaneous screw fixation (B, C). A small incision was made to facilitate reduction.

87

88

Cotterell & Richard

Fig. 17. A 20-year-old male offensive guard collegiate football player with comminuted condylar fracture of proximal phalanx (A, B) stabilized with fixed-angle locking plate construct (C, D). He underwent plate removal and tenolysis 8 months later (E, F) and returned to play with no pain and a range of motion from 7 to 90 .

Metacarpal and Phalangeal Fractures in Athletes

Fig. 18. A 17-year-old male lacrosse player with intra-articular base fracture of the middle phalanx after dorsal dislocation (A, B). Fixation was achieved using a volar shotgun approach (C) with 1.5-mm mini–fragment plate placed around the volar lip as a belt (D). Two months postoperatively (E) the patient returned to play at with a 10 to 95 range of motion.

the articular reduction through ligamentotaxis (Fig. 19).70–72 Similar to percutaneous K-wires, the disadvantage of skeletal traction includes potential soft tissue irritation, pin tract infections, and the inability to return to play with the device. Hemi-hamate autograft is a salvage option generally reserved for nonreconstructable or missed volar lip fractures. As with most periarticular injuries, these have a propensity for stiffness, but in our experience this has little clinical impact. Distal Phalanx Fractures: Tuft/Shaft

Fractures of the distal phalanx are generally stable, owing to the support of the surrounding soft tissue envelope and overlying nail plate, and therefore rarely require operative fixation. Tuft fractures occur from a crush mechanism and frequently have an associated subungual hematoma. When the germinal matrix is involved, the nail should be removed and a repair should be performed to prevent a nail deformity. Mallet fractures are dorsal avulsions of the terminal tendon insertion. Relative operative indications are intra-articular involvement of greater than 40% or volar subluxation resulting in joint incongruency. Operative techniques include K-wire fixation with dorsal block pinning, joystick pinning (Fig. 20), screw fixation, or suture-button fixation, and no single technique was superior in a multicenter comparison.73 When using a K-wire method, it is important to keep the K-wire prominent at both the insertion and exit sites, so that it can easily be retrieved in the case of it breaking.

89

90

Cotterell & Richard

Fig. 19. A 21-year-old tight end collegiate football player with middle phalanx comminuted articular base fracture (A, B) after stabilization with Suzuki frame (C, D). The frame was removed at 6 weeks, and at 2 months after fixation (E) the patient returned to play with a 0 to 95 range of motion.

THE THUMB

Because of the large range of motion of the thumb, especially at the basilar (CMC) joint, significant angulation can have little functional impact, and is generally well tolerated. Bennett and Rolando Fractures

Partial articular fractures at the base of the thumb metacarpal are referred to as Bennett fractures, and more comminuted complete articular fractures are called Rolando fractures. The Bennett fracture is the most common fracture affecting the CMC joints.74 The stable piece is the volar-ulnar fragment, which is held in place by the volar beak ligament/anterior oblique ligament. The metacarpal shaft is pulled proximally, dorsally, and radially by the abductor pollicis longus. Because this is an intraarticular fracture, operative fixation is generally recommended.75,76 The reduction can be achieved by applying pressure on the metacarpal base while exerting traction,

Metacarpal and Phalangeal Fractures in Athletes

Fig. 20. A 23-year-old man with intra-articular base fracture of distal phalanx from a basketball injury (A) after percutaneous joystick reduction and K-wire fixation (B–E). The wire was removed at 4 weeks (F) and articular congruency was maintained at 8 weeks (G, H).

extension, and pronation to the shaft. Stable reduction can usually be maintained with percutaneous K-wire fixation into the trapezium, index metacarpal base, or a combination of the two (Fig. 21). Rolando fractures can be treated in a similar fashion, although, as with any other periarticular fracture, outcomes are generally less favorable because the risk of posttraumatic arthritis increases with the severity of the articular comminution.

91

92

Cotterell & Richard

Fig. 21. A 16-year-old male football player with thumb partial articular metacarpal base fracture (Bennett fracture) (A, B) after percutaneous stabilization with K-wires. Two months later the fracture has healed with anatomic joint congruency.

Metacarpal and Phalangeal Fractures in Athletes

Thumb Metacarpal Shaft Fractures

Unlike fractures in the nonthumb metacarpals, thumb metacarpal fractures lack the surrounding soft tissue structures supporting fracture stability, and therefore are inherently more unstable, but in contrast they can tolerate more deformity because of the large range of motion of the thumb. Unstable fractures can therefore be treated similarly to other metacarpal fractures, with percutaneous K-wire fixation and sometimes open reduction. COMPLICATIONS

Complications can develop after either conservative or surgical treatment of metacarpal and phalangeal fractures. However, outcomes in athletes are usually better than those in the general population. This difference has several reasons: on average, they are younger and overall healthier; they are dedicated to rehabilitation protocols and motivated to recover quickly; they have resources, including rehabilitation facilities and athletic trainers to facilitate in the recovery process.58 Stiffness, malunion, nonunion, and arthrosis are common complications arising after any treatment of fractures of the metacarpals and phalanges, whereas hardware irritation, infection, and wound problems are unique to operative treatments.77–80 The best way to prevent stiffness is by enabling early range of motion, even in the setting of a delayed union or nonunion. There is rarely an indication to prolong immobilization past 4 weeks. In the hand, most nonunions are atrophic, and are typically associated with concomitant soft tissue injury, bone loss, and infection.79 Radiographic lucencies can persist for many months after a hand fracture. Pain at the fracture site similarly may be present for up to a year in a routinely healing fracture. Jupiter and colleagues81 have therefore defined a nonunion as when there is no evidence of radiographic or clinical healing present at 4 months. Malunions can be functionally limiting as well as cosmetically displeasing. Most malunions in the phalanges and metacarpals result from angular or rotational deformities. Proximal deformities are less well tolerated than distal deformities because the resulting segment distal to the malunion is longer. This longer segment has more opportunity to cause disruption of function and to interfere with normal use patterns. These deformities are best treated with corrective osteotomies. Page and Stern77 reviewed 82 patients with 105 hand fractures and found that open fractures and phalangeal fractures had an overall higher complication rate (36%). Stiffness, nonunion, hardware prominence, infection, and tendon rupture were the most common complications reported. Two-thirds of closed fractures and 75% of metacarpal fractures had an excellent final total active motion (220 ), whereas only 11% of phalanx and 24% of open fractures had similar results.77 This conclusion was challenged by a more recent review of 365 patients treated with open reduction and internal fixation. The overall union rate was 91%, and 85% had acceptable to excellent function. Those with unsatisfactory results were noted to have concomitant soft tissue injuries. The investigators found no significant difference in infection or union rates between open and closed injuries.82 Percutaneous K-wire fixation of metacarpal and phalangeal fractures is a widely used technique because of its technical ease, minimal need for dissection, and cost-effectiveness, but complications are also common. Complication rates as high as 44% have been reported, and include, but are not limited to, pin migration and breakage, loss of reduction and malunion, pin tract infections, osteomyelitis, and injury to nerve and vessels.80,83–86 Overall, most complications are minor with superficial pin tract infections being most common, and typically are easily treatable with pin removal

93

94

Cotterell & Richard

and oral antibiotics. These complications need to be taken into consideration when determining the best treatment option for athletes, because an exposed or superficially buried K-wire may have a higher chance of infection in this patient population. SUMMARY

Metacarpal and phalangeal fractures are common athletic injuries. Although many of these injuries can be treated conservatively with immobilization, sport-specific and player-specific circumstances can sometimes dictate the need for surgical treatment. Surgical implant designs are evolving to facilitate stable reduction with minimal soft tissue dissection. Regardless of the treatment method chosen, early range of motion is a key aspect in the recovery process and can minimize common complications from stiffness. A tailored treatment plan should be established for each individual athlete and injury. REFERENCES

1. Centers for Disease Control and Prevention. Sports-related injuries among high school athletes: United States, 2005–06 school year. MMWR Morb Mortal Wkly Rep 2006;55(38):1037–40. 2. Bernstein ML, Chung KC. Hand fractures and their management: an international view. Injury 2006;37(11):1043–8. 3. Immerman I, Livermore MS, Szabo RM. Use of emergency department services for hand, wrist, and forearm fractures in the United States in 2008. J Surg Orthop Adv 2014;23(2):98–104. 4. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26(5):908–15. 5. Court-Brown CM, Wood AM, Aitken S. The epidemiology of acute sports-related fractures in adults. Injury 2008;39(12):1365–72. 6. Merkel DL. Youth sport: positive and negative impact on young athletes. Open Access J Sports Med 2013;4:151–60. 7. Gillis J. High School sports participation increases again. National Federation of State High School Associations. Available at: http://www.nfhs.org/articles/highschool-sports-participation-increases-again. Accessed July 20, 2014. 8. Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Med 2003; 33(1):75–81. 9. Darrow CJ, Collins CL, Yard EE, et al. Epidemiology of severe injuries among United States high school athletes: 2005–2007. Am J Sports Med 2009;37(9): 1798–805. 10. Nakashian MN, Pointer L, Owens BD, et al. Incidence of metacarpal fractures in the US population. Hand (N Y) 2012;7(4):426–30. 11. Rettig AC, Ryan R, Shelbourne KD, et al. Metacarpal fractures in the athlete. Am J Sports Med 1989;17(4):567–72. 12. Amadio PC. Epidemiology of hand and wrist injuries in sports. Hand Clin 1990;6: 379–81. 13. Swenson DM, Yard EE, Collins CL, et al. Epidemiology of US high school sportsrelated fractures, 2005–2009. Clin J Sport Med 2010;20(4):293–9. 14. Singletary S, Freeland AE, Jarrett CA. Metacarpal fractures in athletes: treatment, rehabilitation, and safe early return to play. J Hand Ther 2003;16(2):171–9. 15. Whiteside JA, Fleagle SB, Kalenak A. Fractures and refractures in intercollegiate athletes. Am J Sports Med 1981;9:369–77.

Metacarpal and Phalangeal Fractures in Athletes

16. Mall NA, Carlisle JC, Matava MJ, et al. Upper extremity injuries in the National Football League: part I: hand and digital injuries. Am J Sports Med 2008; 36(10):1938–44. 17. Borowski LA, Yard EE, Fields SK, et al. The epidemiology of US high school basketball injuries, 2005–2007. Am J Sports Med 2008;36(12):2328–35. 18. Hickey GJ, Fricker PA, McDonald WA. Injuries of young elite female basketball players over a six-year period. Clin J Sport Med 1997;7:252–6. 19. Murtaugh K. Injury patterns among female field hockey players. Med Sci Sports Exerc 2001;33:201–7. 20. Matsumoto K, Miyamoto K, Sumi H, et al. Upper extremity injuries in snowboarding and skiing: a comparative study. Clin J Sport Med 2002;12:354–9. 21. Carr D, Johnson RJ, Pope M. Upper extremity injuries in skiing. Am J Sports Med 1981;9:378–83. 22. Waninger KN, Lombardo J. Stress fracture of index metacarpal in an adolescent tennis player. Clin J Sport Med 1995;5:63–6. 23. Day CS, Stern PJ. Fractures of the metacarpals and phalanges. In: Wolfe S, editor. Green’s operative hand surgery. 6th edition. Philadelphia: Elsevier Churchill Livingstone; 2011. p. 245. 24. al-Quattan MM, Robertson GA. An anatomic study of the deep transverse metacarpal ligament. J Anat 1993;182:443–6. 25. Panchal-Kildare S, Malone K. Skeletal anatomy of the hand. Hand Clin 2013; 29(4):459–71. 26. Leversedge FJ. Anatomy and pathomechanics of the thumb. Hand Clin 2008; 24(3):219–29. 27. Capo JT, Hastings H. Metacarpal and phalangeal fractures in athletes. Clin Sports Med 1998;17(3):491–511. 28. Sharieff GQ, Kanegaye J, Wallace CD, et al. Can portable bedside fluoroscopy replace standard, postreduction radiographs in the management of pediatric fractures? Pediatr Emerg Care 1999;15(4):249–51. 29. Capo JT, Kinchelow T, Orillaza NS, et al. Accuracy of fluoroscopy in closed reduction and percutaneous fixation of simulated Bennett’s fracture. J Hand Surg Am 2009;34:637–41. 30. Greeven AP, Hammer S, Deruiter MC, et al. Accuracy of fluoroscopy in the treatment of intra-articular thumb metacarpal fractures. J Hand Surg Eur Vol 2013; 38(9):979–83. 31. Seidenberg PH, Howe AH. Musculoskeletal imaging: types and indications. Med Clin North Am 2014;98(4):895–914. 32. Bianchi S, Martinoli C, Sureda D, et al. Ultrasound of the hand. Eur J Ultrasound 2001;14(1):29–34. 33. Furrer M, Schweizer A, Rufibach K, et al. The value of ultrasonography in hand surgery. Hand (N Y) 2009;4(4):385–90. 34. Senall JA, Failla JM, Bouffard A, et al. Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. J Hand Surg Am 2004;29(3):400–5. 35. Kodama N, Takemura Y, Ueba H, et al. Ultrasound-assisted closed reduction of distal radius fractures. J Hand Surg Am 2014;39(7):1287–94. 36. Stern PJ. Management of fractures of the hand over the last 25 years. J Hand Surg Am 2000;25(5):817–23. 37. Kodama N, Takemura Y, Ueba H, et al. Operative treatment of metacarpal and phalangeal fractures in athletes: early return to play. J Orthop Sci 2014;19(5):729–36. 38. Meals C, Meals RJ. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38(5):1021–31.

95

96

Cotterell & Richard

39. Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat Res 2006;445:133–45. 40. Jones NF, Jupiter JB, Lalonde DH. Common fractures and dislocations of the hand. Plast Reconstr Surg 2012;130(5):722e–36e. 41. Tavassoli J, Ruland RT, Hogan CJ, et al. Three cast techniques for the treatment of extra-articular metacarpal fractures. Comparison of short-term outcomes and final fracture alignments. J Bone Joint Surg Am 2005;87(10):2196–201. 42. Hofmeister EP, Kim J, Shin AY. Comparison of 2 methods of immobilization of fifth metacarpal neck fractures: a prospective randomized study. J Hand Surg Am 2008;33(8):1362–8. 43. Poolman RW, Goslings JC, Lee JB, et al. Conservative treatment for closed fifth (small finger) metacarpal neck fractures. Cochrane Database Syst Rev 2005;(3):CD003210. 44. Bushnell BD, Draeger RW, Crosby CG, et al. Management of intra-articular metacarpal base fractures of the second through fifth metacarpals. J Hand Surg Am 2008;33(4):573–83. 45. Royle SG. Rotational deformity following metacarpal fracture. J Hand Surg Br 1990;15(1):124–5. 46. Strauch RJ, Rosenwasser MP, Lunt JG. Metacarpal shaft fractures: the effect of shortening on the extensor tendon mechanism. J Hand Surg Am 1998;23:519–23. 47. Meunier MJ, Hentzen E, Ryan M, et al. Predicted effects of metacarpal shortening on interosseous muscle function. J Hand Surg Am 2004;29(4):689–93. 48. Bloom JM, Hammert WC. Evidence-based medicine: metacarpal fractures. Plast Reconstr Surg 2014;133(5):1252–60. 49. Geissler WB. Operative fixation of metacarpal and phalangeal fractures in athletes. Hand Clin 2009;25(3):409–21. 50. Ozer K, Gillani S, Williams A, et al. Comparison of intramedullary nailing versus plate-screw fixation of extra-articular metacarpal fractures. J Hand Surg Am 2008;33(10):1724–31. 51. Ruchelsman DE, Mudgal CS, Jupiter JB. The role of locking technology in the hand. Hand Clin 2010;26(3):307–19. 52. Barr C, Behn AW, Yao J. Plating of metacarpal fractures with locked or nonlocked screws, a biomechanical study: how many cortices are really necessary? Hand (N Y) 2013;8(4):454–9. 53. Yaffe MA, Saucedo JM, Kalainov DM. Non-locked and locked plating technology for hand fractures. J Hand Surg Am 2011;36(12):2052–5. 54. Gajendran VK, Szabo RM, Myo GK, et al. Biomechanical comparison of double-row locking plates versus single- and double-row non-locking plates in a comminuted metacarpal fracture model. J Hand Surg Am 2009;34:1851–8. 55. Sohn RC, Jahng KH, Curtiss SB, et al. Comparison of metacarpal plating methods. J Hand Surg Am 2008;33(3):316–21. 56. Fufa DT, Goldfarb CA. Fractures of the thumb and finger metacarpals in athletes. Hand Clin 2012;28(3):379–88. 57. Tan JS, Foo AT, Chew WC, et al. Articularly placed interfragmentary screw fixation of difficult condylar fractures of the hand. J Hand Surg Am 2011;36:604–9. 58. Gaston RG, Chadderdon C. Phalangeal fractures: displaced/nondisplaced. Hand Clin 2012;28(3):395–401. 59. Kawamura K, Chung KC. Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures. Hand Clin 2006;22(3):287–95. 60. Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal phalangeal fractures. J Hand Surg 1984;9A:725–9.

Metacarpal and Phalangeal Fractures in Athletes

61. Kiefhaber T, Stern P. Fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am 1998;23(3):369–80. 62. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8(2):111–21. 63. Gregory S, Lalonde DH, Fung Leung LT. Minimally invasive finger fracture management: wide-awake closed reduction, K-wire fixation, and early protected movement. Hand Clin 2014;30(1):7–15. 64. Shim WC, Yang JW, Roh SY, et al. Percutaneous cerclage wiring technique for phalangeal fractures. Tech Hand Up Extrem Surg 2014;18(1):36–40. 65. Eberlin KR, Babushkina A, Neira JR, et al. Outcomes of closed reduction and periarticular pinning of base and shaft fractures of the proximal phalanx. J Hand Surg Am 2014;39(8):1524–8. 66. Dhamangaonkar AC, Patankar HS. Antegrade joint-sparing intramedullary wiring for middle phalanx shaft fractures. J Hand Surg Am 2014;39(8):1517–23. 67. Horton TC, Hatton M, Davis TR. A prospective randomized controlled study of fixation of long oblique and spiral shaft fractures of the proximal phalanx: closed reduction and percutaneous Kirschner wiring versus open reduction and lag screw fixation. J Hand Surg Br 2003;28:5–9. 68. Weiss AP, Hastings H 2nd. Distal unicondylar fractures of the proximal phalanx. J Hand Surg Am 1993;18(4):594–9. 69. Bindra RR, Foster BJ. Management of proximal interphalangeal joint dislocations in athletes. Hand Clin 2009;25(3):423–35. 70. Finsen V. Suzuki’s pins and rubber traction for fractures of the base of the middle phalanx. J Plast Surg Hand Surg 2010;44(4–5):209–13. 71. Figl M, Weninger P, Hofbauer M, et al. Results of dynamic treatment of fractures of the proximal phalanx of the hand. J Trauma 2011;70(4):852–6. 72. Nilsson JA, Rosberg HE. Treatment of proximal interphalangeal joint fractures by the pins and rubbers traction system: a follow-up. J Plast Surg Hand Surg 2014; 48(4):259–64. 73. Lucchina S, Badia A, Dornean V, et al. Unstable mallet fractures: a comparison between three different techniques in a multicenter study. Chin J Traumatol 2010;13(4):195–200. 74. Cullen JP, Parentis MA, Chinchill VM, et al. Simulated Bennett fracture treated with closed reduction and percutaneous pinning. J Bone Joint Surg Am 1997; 79:413–20. 75. Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures and ulnar collateral ligament injuries. J Hand Surg 2009;34:945–52. 76. Foster RJ, Hastings H. Treatment of Bennett, Rolando and vertical intraarticular trapezial fractures. Clin Orthop Relat Res 1987;(214):121–9. 77. Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg 1998;23:827–32. 78. Kollitz KM, Hammert WC, Vedder NB, et al. Metacarpal fractures: treatment and complications. Hand (N Y) 2014;9(1):16–23. 79. Ring D. Malunion and nonunion of the metacarpals and phalanges. J Bone Joint Surg 2005;87(6):1380–8. 80. Balaram AK, Bednar MS. Complications after the fractures of metacarpal and phalanges. Hand Clin 2010;26:169–77. 81. Jupiter JB, Koniuch MP, Smith RJ. The management of delayed union and non-union of the metacarpals and phalanges. J Hand Surg 1985;4:457–66. 82. Bannasch H, Heermann A, Iblher N, et al. Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and outcome analysis

97

98

Cotterell & Richard

83. 84. 85. 86.

show no increase of complications in the treatment of open compared with closed fractures. J Trauma 2010;68(3):624–8. Hsu LP, Schwartz EG, Kalainov DM, et al. Complications of K-Wire fixation in procedures involving the hand and wrist. J Hand Surg Am 2011;36(4):610–6. Stahl S, Schwartz O. Complications of K-wire fixation of fractures and dislocations in the hand and wrist. Arch Orthop Trauma Surg 2001;121(9):527–30. Freeland AE, Lindley SG. Malunions of the finger metacarpals and phalanges. Hand Clin 2006;22:341–55. Blazar PE, Steinberg DR. Fractures of the proximal interphalangeal joint. J Am Acad Orthop Surg 2000;8(6):383–90.