Fractures of the Proximal

Phalanx and Metacarpals in

the Hand: Preferred
Methods of Stabilization

Mark H. Henry, MD

Dr. Henry is in private practice, Hand

and Wrist Center of Houston, Houston,
TX.
Neither Dr. Henry nor a member of his
immediate family has received anything
of value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
Reprint requests: Dr. Henry, Hand and
Wrist Center of Houston, 1200 Binz,
13th Floor, Houston, TX 77004.
J Am Acad Orthop Surg 2008;16:586595
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.

586

Abstract
Treatment of fractures of the proximal phalanx and metacarpals is
based on the presentation of the fracture, degree of displacement,
and difficulty in maintaining fracture reduction. A wide array of
treatment options exists for the variation in fracture patterns observed. Inherently stable fractures do not require surgical treatment; all other fractures should be considered for additional stabilization. In general, of the many combinations of internal fixation
possible, Kirschner wires and screw-and-plate fixation predominate. Early closed reduction typically is successful for unicondylar
fractures of the head of the proximal phalanx. Bicondylar proximal
phalanx fractures usually are treated with plate fixation. Transverse
and short oblique proximal phalanx fractures generally are treated
with Kirschner wires, although a stable short oblique transverse
shaft fracture can be managed with an intrinsic plus splint. Plate
fixation is used in comminuted proximal phalanx as well as comminuted metacarpal fractures, and lag screws in spiral long oblique
phalanx shaft fractures and metacarpal head fractures. Kirschner
wire fixation is successful in metacarpal neck fractures as well as
both short and long transverse oblique shaft fractures.

ractures of the metacarpals account for 18% and the phalanges

for 23% of all below-elbow fractures
in the United States, peaking in the
third decade for men and second
decade for women.1 The two most
typical mechanisms of injury are accidental fall and direct blow; directblow injuries often result from one
person against another person or object.1 Phalangeal fractures are nearly
twice as common as metacarpal fractures. Most phalangeal fractures occur in the proximal phalanx, followed
by the distal phalanx, then the middle phalanx.2 The small finger ray ac-

counts for 38% of all hand fractures,

with a relatively even distribution
across the remaining four rays.2
Despite the high number of patients undergoing treatment of hand
fractures, the literature remains unclear with respect to providing guidance to the clinician for specific phalangeal and metacarpal fractures.
There are no well-performed, published studies providing level I or II
evidence. Randomized controlled
trials are prevented from being performed because of the broad spectrum of variation in fracture patterns
and the many associated variables

Journal of the American Academy of Orthopaedic Surgeons

Mark H. Henry, MD

that are thought to affect treatment

and outcome.
The forms of treatment discussed
below for common fracture patterns
in the hand are based on experience
gained in a high-volume hand trauma specialty practice. This does not
imply that all fractures of a certain
pattern must be fixed according to
that method of treatment. Details
related to more comprehensive
treatment of all phalangeal and
metacarpal fractures are discussed
by the author elsewhere.3,4

Review of the Literature

In a series of 924 hand fractures
managed over a period of 10 years,
overall results were excellent or
good in >90% of thumbs but in only
59% to 76% of fingers. Reasons cited for poor results were comminution and open or multiple fractures.5 High-energy fractures with
comminution predispose to stiffness
of the proximal interphalangeal (PIP)
joint, in particular; Gonzalez et al6
reported an average postoperative
range of motion (ROM) of 66 in 27
patients (28 PIP fractures). Intraarticular extension was another variable that conferred a worse prognosis, with total active motion (TAM)
of 169 compared with TAM of 213
in those without intra-articular extension.6 In another series of intraarticular fractures in patients following open reduction and internal
fixation in the fingers, there were 9
excellent, 8 good, and 6 poor results.
This study identified comminution
and initial open fracture as the variables leading to the poorest results.7
Generally, the severity of the injury, in terms of energy imparted into
the tissues and the associated softtissue lesions, serves as the primary
determinant of outcome. Nevertheless, when a fracture is too unstable
for nonsurgical management, a decision must be made regarding the
method of fracture stabilization. Of
the many combinations of internal
fixation possible, Kirschner wires
Volume 16, Number 10, October 2008

(K-wires) and screw-and-plate fixation

predominate. Because of uncertainty
regarding which method produces a
superior outcome, decisions are often
made with a goal of minimizing complications. The general concerns with
smooth-sided, stainless steel K-wires
are loss of reduction; tethering of soft
tissues (primarily the extensor mechanism); and pin tract infection, potentially leading to osteomyelitis. Botte
et al8 reported a smooth-pin fixation
complication rate of 18%, including
infection (7%), pin loosening (5%),
and nonunion (4%).
Plate fixation has been noted to
cause substantial loss of motion because of tendon adherence at the
plates surface as well as the added
surgical dissection needed to reduce
the fracture and apply the plate. Following plate fixation of phalangeal
fractures, Kurzen et al9 reported a
complication rate of 52%. These authors included TAM of <180 as a
complication (24/64 fractures). The
negative impact of tendon adhesions
was not as great at the metacarpal
level as at the proximal phalangeal
level. Page and Stern10 reported that
plate fixation yielded TAM of >220
in 76% of metacarpal fractures but
in only 11% of phalangeal fractures.
In another study, plate fixation produced a complication rate of 31% at
the metacarpal level and of 82% at
the phalangeal level.11
A specific concern with plate fixation in metacarpal fractures is delayed or nonunion that was found to
be higher (30%) in transverse fracture
patterns than in those with a broader
interface (7%).12 Fixation by lag screw
only, without a plate, represents
something of a middle ground between K-wires and plates. It requires
the added surgical dissection of the
open approach but left a far lower
hardware profile and, thus, less tendon irritation.
To date, there has been one attempt at a prospective, randomized,
controlled study of long oblique and
spiral isolated proximal phalanx (P1)
fractures comparing percutaneous

pinning and lag screws. However,

the numbers are too small to provide
meaningful conclusions.13 Notably,
in 3 of 17 patients, fractures treated
by K-wire required formal extensor
tenolysis for tethering; this was not
the case in any of the 15 patients
whose fractures were treated by lag
screw. There were, however, 8
malunions of the 15 resulting from
lag screw fixation, a high number
considering the opportunity for precise reduction and rigid fixation possible with this method.13

Nonsurgical Treatment
Fractures that are inherently stable
(ie, limited initial displacement, lowenergy mechanism of injury) do not
need surgical treatment; all other fractures should be considered for some
form of additional stabilization. Ebinger et al14 reported that the intrinsic
plus splinting position, with active
PIP motion, achieved full active motion and complete fracture healing by
6 weeks in 44 of 48 displaced proximal phalanx fractures. The standard
intrinsic plus splint is dorsally based
from the level of the PIP joint to the
base of the metacarpals, with the
metacarpophalangeal (MCP) joints in
full flexion. Immediate PIP joint motion exerts a dynamic tension-band
effect with the extrinsic extensor that
actually aids in the reduction of P1
fractures.
The general principles of hand fracture rehabilitation include early active joint ROM and tendon gliding using synergistic wrist positions and
blocking techniques, including blocking splints.15 Hard splints may be discontinued in favor of side strapping
(ie, buddy taping) protection by 3
weeks in P1 and metaphyseal metacarpal fractures and by 4 weeks in diaphyseal metacarpal fractures. At this
time, the fracture line is routinely
still visible on plain radiographs without evidence yet of periosteal callus.
Even at approximately 6 weeks, when
the fracture is considered clinically to
be fully healed (ie, nontender to pres587

Fractures of the Proximal Phalanx and Metacarpals in the Hand: Preferred Methods of Stabilization

Figure 1

A, Oblique radiograph. Unicondylar fractures typically angulate at the PIP joint as the unstable condyle migrates axially while
translating away from, but rotating toward, the intact condyle at the articular surface. B, Oblique radiograph. Interfragmentary lag
screws are particularly effective when there is an extended diaphyseal spike proximal to the collateral origin. C, Anteroposterior
radiograph. As long as an early anatomic closed reduction can be achieved, diverging smooth-sided K-wires can maintain
reduction as well as lag screws.

sure on examination), the radiograph

usually still reveals the original fracture line.
Preload-and-release tendon acceleration exercises have been described as a method to take advantage of the viscoelastic properties of
both tendon and scar tissue in order
to achieve differential gliding between the two.16 Motion is restrained by the ipsilateral thumb,
while the extensor tendon is brought
to maximum isometric tension followed by a rapid release of the joint
block. This causes a sudden excursion of that segment of tendon directly overlying the fracture.

Surgical Treatment
Less Frequently Used
Treatment Methods
Virtually any method of providing
additional stability to a fracture is a
588

potentially valid strategy. Bone grafting alone into the site of impacted P1
base fractures provided rigid internal fixation, with reported good results and early return to work for 10
patients (13 fractures).17 Twenty-five
patients with avulsion fractures of the
base of the proximal phalanx were
treated with a single lag screw via a
palmar approach; excellent results
were reported in all cases, with full
ROM achieved by 3 weeks.18 Multiple intramedullary K-wires can be
used at both the metacarpal and proximal phalangeal levels.19 Tensionband wiring was reported to achieve
an average TAM of 188 in 16 P1 and
10 P2 fractures, with no complications.20 Of 36 metacarpal shaft fractures fixed with interosseous loop
wire, 34 achieved full motion with no
complications.21 External fixation of
closed fractures has been reported to

produce TAM of 230 or better in all

metacarpal fractures and in 76% of
phalangeal fractures.22
Unicondylar Proximal
Phalanx Fractures
Unicondylar fracture of the head
of the proximal phalanx typically occurs as the result of axial loading
with angulation directed toward the
side of the small fragment, producing an oblique fracture line through
the metaphysis that originates in the
intercondylar groove (Figure 1, A).
Some fractures involve less than the
whole condyle; others take part of
the second condyle with the smaller
fragment. A variable degree of extension into the diaphysis occurs proximal to the origin of the collateral
ligament. The primary treatment
goal is achievement of a congruent
articular surface that restores coro-

Journal of the American Academy of Orthopaedic Surgeons

Mark H. Henry, MD

nal plane alignment of the digit and

which should mitigate posttraumatic arthritis, necessitating stable fixation to resist axial shear forces.
Early Presentation and Easy
Reduction

If the patient presents early,

closed reduction often may achieve
the goal of a congruent articular surface. If fixation is to be with smoothsided K-wires only, two wires that
diverge are required to prevent slippage of the smaller fragment along
the surface of one wire alone (Figure 1, C). The standard configuration
is with the first wire placed transverse and subchondral, in order to
level the articular surface; the second wire is placed obliquely from
the condylar fragment into the opposite diaphyseal cortex to buttress the
fragment against the opposite
condyle.
Late Presentation or Difficult
Reduction

With late presentation or a difficult reduction, open treatment may

be required. Caution is required to
avoid excessive soft-tissue dissection of the smaller fragment, especially the collateral ligament origin,
which covers most of the fragments
cortex, to avoid osteonecrosis. Excessive dissection risks devascularization of the fragment, whose blood
supply is contained in the collateral
ligament. Fixation may be with either K-wires, as described, or with
1.3-mm lag screws. With smaller
fragments, the collateral ligament
origin interferes with the normal
process of countersinking a lag
screw. With an extended diaphyseal
spike on the smaller fragment, lag
screw fixation becomes an increasingly attractive option (Figure 1, B).
An alternative method involves
cannulated, percutaneous, variable
pitch, headless screw fixation.
Geissler23 reported that such fixation
achieved PIP joint ROM of 5 to 85
in 18 patients.
Volume 16, Number 10, October 2008

Bicondylar Proximal
Phalanx Fractures
Although a series of K-wires may
be used in treating a bicondylar proximal phalanx fracture (usually one
transverse between the two condyles
and an oblique wire from each
condyle to the opposite proximal
cortex), more commonly, plate fixation serves to permit immediate mobilization of the PIP joint. When
there are three large fragments (ie,
two condyles and the shaft) without
comminution, a 1.5-mm straight
plate applied laterally will function
as a load-sharing device, along with
inherent fracture geometry.
With substantial comminution,
the plate must be a load-bearing device; here the 1.5-mm condylar blade
plate is preferred (Figure 2). Meticulous precontouring of the plate is required before implanting the blade because the surface of the shaft does not
naturally match the plate as it comes
from the manufacturer. However, repeated removal and reinsertion of the
blade into the condylar fragments can
create further comminution of the
fracture to the point of rendering the
fracture irreducible or not acceptable
to plate fixation. Dorsal placement of
a plate at this distal location under
the extensor zone IV to zone III junction (Figure 3), right at the margin of
the PIP joint, is even more functionally damaging than is a dorsal plate
on the midshaft. This placement
should be avoided if at all possible.
A rare bicondylar fracture pattern
is the triplane fracture, which is difficult to recognize and technically
challenging to treat. However, by
virtue of the pattern, the triplane
fracture can be stabilized with 1.5mm lag screws only rather than a
plate.24
Transverse Proximal
Phalanx Neck Fractures
In treating a transverse proximal
phalanx neck fracture, retrograde
pinning through the small fragment
and down the shaft can provide appropriate early fixation and fracture

Figure 2

Anteroposterior radiograph. The

condylar blade plate is an implant
specifically designed for lateral
placement in the fixation of
comminuted bicondylar proximal
phalanx fractures.

stability. Long-term PIP motion of

90 or better has been reported.25
Passage of a 0.045-inch K-wire retrograde through the PIP has risks, including pin tract infection that can
lead directly to septic arthritis. Such
pin positioning demands either more
meticulous pin care than normal or
cutting of the pin below the surface
of the skin (Figure 4). PIP joint motion rehabilitation while the pin is
in place creates a small longitudinal
rent in the extensor mechanism, but
this does not pose any short-term or
long-term functional detriment. Far
more detrimental would be failure to
initiate early rehabilitation. In most
patients, the pin should be removed
by 3 weeks, and not later than 4
weeks, unless there are extenuating
circumstances.
589

Fractures of the Proximal Phalanx and Metacarpals in the Hand: Preferred Methods of Stabilization

Figure 3

The extensor tendon zones are

numbered I through IX, with odd
numbers overlying joints. (Reproduced
with permission from Newport ML:
Early repair of extensor tendon injuries,
in Berger RA, Weiss PC [eds]: Hand
Surgery. Philadelphia, PA: Lippincott
Williams & Wilkins, 2004, vol 1, p 739.)

Transverse (Short Oblique)

Proximal Phalanx Shaft
Fractures
A transverse shaft fracture displaces into an apex palmar angulated position under the pull of the central slip on the distal fragment and
the interossei insertions at the base
of P1 (Figure 5, A). If allowed to heal
in apex palmar malunion, the predicted corresponding extensor lags
are for a 10 lag at 16 of angular deformity, a 24 lag at 27 of deformity, and a 66 lag at 46 of deformity.26 When the PIP joint is flexed, the
extensor mechanism as a whole
functions as a tension band to help
reduce the fracture if the hand is positioned in an intrinsic plus splint.
Collateral ligament, capsule, and intrinsic muscle attachments render
590

taneous pins removed at 3 weeks and

immediate PIP rehabilitation, avoiding PIP extensor lag can be difficult.
In a series of 35 transmetacarpal longitudinal pinnings of unstable proximal phalangeal fractures, 32% developed a PIP joint flexion contracture
averaging 18, and 4 resulted in rotational deformity.29

Figure 4

Lateral radiograph. Proximal phalanx

neck fractures tend to rotate into
extreme extension (even 180) but can
still be reduced closed and pinned
retrograde through the PIP joint with
either a single wire or a supplementary
wire to resist axial rotation of the distal
fragment.

transverse fractures in the proximal

6 to 9 mm of the P1 base more stable
than fractures located distally.27
These fractures often can be well
maintained in an intrinsic plus
splint alone. At the least, these fractures reduce the pin requirements
from two K-wires for rotational control to one K-wire.
Most transverse or short oblique
P1 fractures without comminution
are best stabilized by two 0.045-inch
K-wires placed longitudinally through
the fully flexed MCP joint (Figure 5,
B and C). A single wire alone risks rotational malunion, but some fracture
patterns may provide inherent rotational stability that would allow use
of one wire for angular control. In a
series of 12 transarticular intramedullary pinnings of extra-articular P1
fractures, the average TAM was 265,
with only one flexion contracture and
one rotational deformity.28 Even with
the minimal tissue trauma of percu-

Spiral (Long Oblique)

Proximal Phalanx Shaft
Fractures
Extensor lag at the PIP joint is the
result of zone IV tendon adherence
at the fracture site and may be worsened by apex palmar malunion as
well as by the effects of shortening at
the fracture site, which creates slack
in the extensor mechanism. Extensor lag is predicted to be 12 for each
millimeter of shortening, with the
concept of an extensor tendon reserve of 2 to 6 mm.26 Spiral and long
oblique P1 fractures tend to angulate
less than do transverse and short oblique patterns. Also, spiral and long
oblique P1 fractures more often
shorten along the slope of the fracture, with varying degrees of axial
rotational deformity. As long as the
angular deformity is corrected and
maintained in a transverse fracture,
there is considerable inherent stability provided by the fracture fragment
contact to resist the forces of rehabilitation.
This is not the case with long
sloping fractures that offer very little
help from fracture fragment contact
unless significant interfragmentary
compression can be achieved. Lag
screws (1.3 mm is preferred to 1.5
mm) can achieve stability through
interfragmentary compression in a
two-part spiral or long oblique fracture that rivals the stability of an intact bone (Figure 6). This capability,
combined with the need to achieve
precise correction of rotation in spiral fractures, makes open reduction
and lag screw fixation the treatment
of choice for the spiral P1 shaft fracture. Although rotation is not as
much of an issue in long oblique

Journal of the American Academy of Orthopaedic Surgeons

Mark H. Henry, MD

Figure 5

A, Anteroposterior radiograph. Transverse fractures of the proximal phalanx typically displace with apex volar angulation.
B, Anteroposterior radiograph. Double axial K-wires control both angulation and axial rotation. C, Lateral radiograph. The wires
are placed transarticular through the MCP joint in a flexed (intrinsic plus) posture.

fractures, the benefits of open lag

screw fixation still hold true for this
pattern. An alternative approach is
to attempt to place the lag screws
percutaneously; however, there is a
low likelihood of achieving excellent interfragmentary compression,
which then causes the screws to
function in a load-bearing rather
than a load-sharing capacity.
The surgical approach is midlateral without dissecting between tissue
planes. A single sleeve of tissue, including periosteum, the extensor
tendon mechanism, and skin, is
raised to expose the fracture site.
Clot and early callus are removed
from the fracture edges with a finetipped curet to facilitate precise interdigitation along the fracture line.
Firm compression must be held between the fragments while placing
the lag screws. Screws should be
spaced apart from each other and the
fracture edges by at least a full screw
head diameter, with careful counterVolume 16, Number 10, October 2008

sinking done to distribute the stress

of the screws head over as broad an
area as possible. In addition to a precision fit of the fracture line, the surgeon must clinically check the rotation of the finger (ie, fracture). A
standard intrinsic plus splint, as described above, can be used between
exercise sessions that include
preload-and-release rapid extensor
tendon activation.
Comminuted Proximal
Phalanx Fractures
Interfragmentary lag screws and
percutaneous K-wire fixation both
depend on the inherent stability offered by fracture fragment contact.
In the presence of substantial comminution, this inherent stability is
lost, and the fixation materials need
to function in a load-bearing capacity. This usually requires the use of a
plate (Figure 7). At the P1 level, the
concern with plates is the added potential for extensor tendon adher-

ence to hardware exposed on the surface of the bone. For this reason,
dorsal plates are avoided at all costs,
which is consistent with the inferior biomechanical stability associated with the dorsal plate position.
Biomechanical studies demonstrate
that the optimal plate position is
midlateral.30-32
The single-tissue sleeve approach
described above should be used. Alternatively, the unilateral resection
of the intrinsic tendon may mitigate
subsequent interference with extensor tendon rehabilitation and PIP
joint motion because of plate contact.33 Meticulous plate contouring is
critically important, as is the need for
clinical assessment of rotational angular alignment during the stages of
plate application. High-energy comminuted fractures requiring plate fixation cannot be expected to achieve
functional results equivalent to simpler P1 fracture patterns. Only 6 of 16
patients with comminuted pha591

Fractures of the Proximal Phalanx and Metacarpals in the Hand: Preferred Methods of Stabilization

Figure 6

Anteroposterior radiograph. Spiral

fractures of the proximal phalanx, with
lag screws placed primarily in the
coronal plane, may undergo immediate
active ROM of the PIP joint, with
minimal interference of the zone IV
extensor tendon.

langeal fractures and associated softtissue injuries achieved >180 of

TAM.34
Metacarpal Head Fractures
Metacarpal head fractures are
rare. They are best treated by lag
screws with deep countersinking of
the screw head, especially when it
must pass through hyaline cartilage
(Figure 8). Careful handling is required to achieve fracture healing
and prevent osteonecrosis.
Metacarpal Neck and
Transverse (Short Oblique)
Metacarpal Shaft Fractures
Metacarpal neck fractures typically angulate apex dorsal; the small
finger also usually supinates. The tolerable limit of angulation that does
not alter function continues to be de592

Figure 7

Figure 8

Anteroposterior radiograph. Deep

countersinking is required when using
lag screws to fix complex fractures of
the metacarpal head.

Anteroposterior radiograph. Plates

used for comminuted unstable proximal
phalanx fractures are placed laterally
away from the overlying zone IV
extensor tendon and are contoured to
match the surface geometry.

bated, although safe angulation from

the index through the small finger
are 10, 10, 20, and 30, respectively. Beyond 30 of apex dorsal angulation in small-finger metacarpal
neck fractures, there was a rapid decay in efficiency of the flexor tendon
system, including tendon excursion,
load, and work requirements.35 In the
absence of an originally open fracture, substantial comminution, or
multiple adjacent unstable fractures,
the need for open treatment of metacarpal neck fractures is rare. Wong et
al36 detected no radiographic, functional, or complication differences
between transverse pins or intramedullary K-wires for fixation of small-

finger metacarpal neck fractures in

59 patients.
The surgeon must be able to control the metacarpal neck deformity
primarily in sagittal plane angulation and less so in coronal angulation (more often seen as lateral
translation at the fracture site) and
axial rotation (primarily with the
small finger and sometimes the index finger, and infrequently in the
long and ring fingers). A method of
precise control over all three planes
is transverse pinning of the fractured
ray to its adjacent ray (Figure 9). The
biomechanics of external fixation
apply, with the intact adjacent metacarpal serving as the fixator bar.
Three 0.045-inch K-wires are needed; the carpometacarpal ligaments
function as the fourth point of fixation. Wires are left through the skin
for removal at 3 weeks or are cut beneath the skin, at the surgeons discretion. Intrinsic plus splinting is
important to prevent extension contracture of the MCP joint, particular-

Journal of the American Academy of Orthopaedic Surgeons

Mark H. Henry, MD

ly in the small finger, where a splint

at 90 formed to the radial three fingers will allow the small finger to sit
at 60 of MCP flexion. As long as the
PIP joints are moved from the outset, there is no long-term difference
in motion between either splinting
for 3 weeks and then initiating active MCP exercises or beginning
MCP motion immediately and returning to the splint in between sessions.
Metacarpal shaft fractures tend to
angulate apex dorsal, just as metacarpal neck fractures do, but the tolerable angular deformity is less owing
to the greater distance from the joint.
Compared with neck fractures, there
is more lateral translation between
the fracture fragments at the fracture
site, with coronal angulation of the
distal fragment. The deep transverse
intermetacarpal ligaments limit the
amount of proximal translation of the
central two rays more effectively than
of the border rays. The biomechanics
of transverse shaft fractures allow the
principles of external fixation to be
even more effective because of the
longer distal segment.
Galanakis et al37 treated 25 transverse small-finger metacarpal fractures by three K-wires (one proximal
to the fracture site, two distal), resulting in no shortening, appreciable angulation, or complications and producing excellent functional results.
Optimal placement of the first and
second wires is as close to the metacarpal shaft fracture site as possible.
The third wire optimizes its biomechanical effect when it is placed as far
distally as possible in the metacarpal
head, but functionally it is better for
the patient if the third wire is placed
proximal to the sagittal bands and
MCP collateral ligaments. The flare
of the metacarpal head at the proximal extent of the collateral origin recess is an obvious radiographic feature
that easily allows correct placement
of the most distal wire. The cortical
fracture interface of the metacarpal
shaft, which is small in cross-section,
heals slightly slower than does the
Volume 16, Number 10, October 2008

broad cancellous contact of a neck

fracture, and pins should be retained
for 4 rather than 3 weeks.37
Spiral (Long Oblique)
Metacarpal Shaft Fractures
As with phalangeal fractures, the
predominate concern with spiral and
long oblique fractures is less angulation than it is shortening and axial rotation. As the metacarpal shortens
through the fracture interface, laboratory analysis predicts 7 of MP joint
extensor lag for every 2 mm of shortening.38 Closed reduction is less able
to restore length than it is angulation,
and percutaneous pinning (transverse
or intramedullary) is less able to
maintain reduction with this pattern
compared with transverse fractures.
Transverse pinning still can be a good
option for these fractures, but the
treatment required to ensure maintenance of a precise reduction and provide a solid foundation for immediate rehabilitation is interfragmentary
1.5-mm compression lag screws. (Although 2.0-mm plates are indicated
for metacarpal fractures, 2.0 mm is
too large when used as a lag screw).
Patients can start immediate rehabilitation exercises, and office workers
can remove the splint and type at a
keyboard normally immediately after surgery. With a two-part fracture,
the lag screws are functioning in a
load-sharing relationship with the
fracture interface (Figure 10). An intrinsic plus splint should be worn in
the first 3 to 4 weeks during at-risk
situations when the hand is likely to
have unwanted contact, such as in
crowds.
Comminuted Metacarpal
Fractures
Without any inherent stability
from the fracture interface in comminuted fractures, the fixation hardware bears the entire load of rehabilitation forces until early healing
takes over. Plate-and-screw fixation
is the standard in this situation. Just
as in the proximal phalanx, lateral
positioning of the plate is ideal in or-

Figure 9

Anteroposterior radiograph. Four-point

fixation is achieved using the
intermetacarpal ligaments at the
carpometacarpal level as the first point
of fixation. The second point is the
transverse wire linking to the intact
adjacent metacarpal and should be as
close to the fracture site as possible
proximally. The next wire should be as
close to the fracture site as possible
distally. The last wire should be as
distal as possible without violating the
sagittal bands.

der to keep it away from the extensor tendon (Figure 11). But, unlike
the proximal phalanx, which has an
oval (actually, a kidney beanshaped)
cross section, the midshaft of the
metacarpal has a more triangular
cross section on its external surface.
Distally, there is a true lateral surface just proximal to the collateral
recess, but that quickly spirals
around to a dorsolateral plane at the
shaft level. Careful axial contouring
of the plate ahead of time to recognize this anatomy is important in order to avoid an iatrogenic rotational
malunion. Fortunately, the zone VI
593

Fractures of the Proximal Phalanx and Metacarpals in the Hand: Preferred Methods of Stabilization

Figure 10

Figure 11

Anteroposterior radiographs. A, Spiral fractures tend to shorten and rotate more

than angulate. What appears to be a two-part fracture at first glance may well have
additional fracture lines in one of the two fragments, as can just be seen proximally.
B, Interfragmentary lag screw fixation needs to secure not only the primary fracture
plane but also any extensions into the main fragments to allow immediate active
ROM rehabilitation.

extensor (Figure 3) does not have as

intimate a relationship with the
bone as does the zone IV extensor.
Also, the zone VI extensor is much
more forgiving of the presence of
hardware.
The method that applies in this
situation is setting preliminary relationships between major fragments
with individual lag screws, then placing the plate in neutralization mode,
as with fixation of the long tubular
bones. The added soft-tissue crush
trauma associated with fracture comminution causes the intrinsic muscles to fibrose and initiates an intrinsic minus contracture, placing added
emphasis on the importance of intrinsic plus splinting between ROM sessions as well as at night.

Summary
Nondisplaced and inherently stable
isolated fractures in the hand do not
594

require surgery. Fractures that require formal stabilization may be

treated by several possible methods.
No one strategy is universally the
best, and the literature lacks any
strong level I or II evidence to lend
direction. The orthopaedic surgeon
should be clinically comfortable
with the chosen method of stabilization as long as the strategy accommodates early active motion, especially of the PIP joint.

References

Anteroposterior radiograph. Plate

placement in the metacarpal also
should be lateral when possible, with
careful contouring to the surface.
Independent lag screws outside the
plate can control individual fragment
relationships.

within the past 5 years.

1.

2.

3.

Evidence-based Medicine: There are

two level I/II limited prospective
randomized studies reported (references 13 and 22). Most of the references presented are case-control cohort studies or case reports (level III/
IV) or are level V expert opinion
studies.
Citation numbers printed in bold
type indicate references published

4.

5.

Chung KC, Spilson SV: The frequency

and epidemiology of hand and forearm fractures in the United States.
J Hand Surg Am 2001;26:908-915.
van Onselen EB, Karim RB, Hage JJ,
Ritt MJ: Prevalence and distribution
of hand fractures. J Hand Surg Br
2003;28:491-495.
Henry MH: Fractures and dislocations
of the hand, in Heckman JD (ed):
Rockwood and Greens Fractures in
Adults, ed 6. Philadelphia, PA: Lippincott Williams & Wilkins, 2006, vol 1,
pp 771-856.
Henry MH: Fractures and dislocations
of the hand, in Heckman JD (ed):
Rockwood and Greens Fractures in
Adults, ed 5. Philadelphia, PA: Lippincott Williams & Wilkins, 2002, vol 1,
pp 655-744.
Ip WY, Ng KH, Chow SP: A prospective study of 924 digital fractures of

Journal of the American Academy of Orthopaedic Surgeons

Mark H. Henry, MD

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

the hand. Injury 1996;27:279-285.

Gonzalez MH, Hall M, Hall RF Jr:
Low-velocity gunshot wounds of the
proximal phalanx: Treatment by early
stable fixation. J Hand Surg Am
1998;23:150-155.
Tan V, Beredjiklian PK, Weiland AJ:
Intra-articular fractures of the hand:
Treatment by open reduction and internal fixation. J Orthop Trauma
2005;19:518-523.
Botte MJ, Davis JLW, Rose BA, et al:
Complication of smooth pin fixation
of fracture and dislocation in the hand
and wrist. Clin Orthop Relat Res
1992;276:194-201.
Kurzen P, Fusetti C, Bonaccio M,
Nagy L: Complications after plate
fixation of phalangeal fractures.
J Trauma 2006;60:841-843.
Page SM, Stern PJ: Complications and
range of motion following plate fixation of metacarpal and phalangeal
fractures. J Hand Surg Am 1998;23:
827-832.
Trevisan C, Morganti A, Casiraghi A,
Marinoni EC: Low-severity metacarpal and phalangeal fractures treated
with miniature plates and screws.
Arch Orthop Trauma Surg 2004;124:
675-680.
Fusetti C, Della Santa DR: Influence
of fracture pattern on consolidation
after metacarpal plate fixation. Chir
Main 2004;23:32-36.
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.
Ebinger T, Erhard N, Kinzl L, Mentzel
M: Dynamic treatment of displaced
proximal phalangeal fractures. J
Hand Surg Am 1999;24:1254-1262.
Freeland AE, Hardy MA, Singletary S:
Rehabilitation for proximal phalangeal fractures. J Hand Ther 2003;
16:129-142.
Brown H, Stutz C, Henry M: Technique for extensor tendon acceleration. J Hand Ther 2006;19:421-424.

Volume 16, Number 10, October 2008

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

Strickler M, Nagy L, Buchler U: Rigid

internal fixation of basilar fractures of
the proximal phalanges by cancellous
bone grafting only. J Hand Surg Br
2001;26:455-458.
Shewring DJ, Thomas RH: Avulsion
fractures from the base of the proximal phalanges of the fingers. J Hand
Surg Br 2003;28:10-14.
Liew KH, Chan BK, Low CO: Metacarpal and proximal phalangeal
fractures-fixation with multiple intramedullary Kirschner wires. Hand
Surg 2000;5:125-130.
Safoury Y: Treatment of phalangeal
fractures by tension band wiring.
J Hand Surg Br 2001;26:50-52.
Al-Qattan MM: Metacarpal shaft fractures of the fingers: Treatment with
interosseous loop wire fixation and
immediate postoperative finger mobilisation in a wrist splint. J Hand
Surg Br 2006;31:377-382.
Margic K: External fixation of closed
metacarpal and phalangeal fractures
of digits: A prospective study of one
hundred consecutive patients. J
Hand Surg Br 2006;31:30-40.
Geissler WB: Cannulated percutaneous fixation of intra-articular hand
fractures. Hand Clin 2006;22:297305.
Chin KR, Jupiter JB: Treatment of
triplane fractures of the head of the
proximal phalanx. J Hand Surg Am
1999;24:1263-1268.
Crofoot CD, Saing M, Raphael J: Intrafocal pinning for juxtaarticular
phalanx fractures. Tech Hand Up
Extrem Surg 2005;9:164-168.
Vahey JW, Wegner DA, Hastings H III:
Effect of proximal phalangeal fracture
deformity on extensor tendon function. J Hand Surg Am 1998;23:673681.
Widgerow AD, Ladas CS: Anatomical
attachments to the proximal phalangeal base: A case for stability.
Scand J Plast Reconstr Surg Hand
Surg 2001;35:85-90.
Hornbach EE, Cohen MS: Closed reduction and percutaneous pinning of
fractures of the proximal phalanx.
J Hand Surg Br 2001;26:45-49.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

Elmaraghy MW, Elmaraghy AW,

Richards RS, Chinchalkar SJ, Turner
R, Roth JH: Transmetacarpal intramedullary K-wire fixation of proximal phalangeal fractures. Ann Plast
Surg 1998;41:125-130.
Lins RE, Myers BS, Spinner RJ, Levin
LS: A comparative mechanical analysis of plate fixation in a proximal phalanx fracture model. J Hand Surg Am
1996;21:1059-1064.
Lu WW, Furumachi K, Ip WY, Chow
SP: Fixation for comminuted phalangeal fractures: A biomechanical
study of five methods. J Hand Surg
Br 1996;21:765-767.
Ouellette EA, Dennis JJ, Latta LL,
Milne EL, Makowski AL: The role of
soft tissues in plate fixation of proximal phalanx fractures. Clin Orthop
Relat Res 2004;418:213-218.
Freeland AE, Sud V, Lindley SG: Unilateral intrinsic resection of the lateral band and oblique fibers of the
metacarpophalangeal joint for proximal phalanx fractures. Tech Hand
Up Extrem Surg 2001;5:85-90.
Curtin CM, Chung KC: Use of eighthole titanium miniplates for unstable
phalangeal fractures. Ann Plast Surg
2002;49:580-586.
Birndorf MS, Daley R, Greenwald DP:
Metacarpal fracture angulation decreases flexor mechanical efficiency
in human hands. Plast Reconstr Surg
1997;99:1079-1083.
Wong TC, Ip FK, Yeung SH: Comparison between percutaneous transverse fixation and intramedullary
K-wires in treating closed fractures of
the metacarpal neck of the little finger. J Hand Surg Br 2006;31:61-65.
Galanakis I, Aliquizakis A, Katonis P,
Papadokostakis G, Sterqiopoulos K,
Hadjipavlou A: Treatment of closed
unstable metacarpal fractures using
percutaneous transverse fixation with
Kirschner wires. J Trauma 2003;55:
509-513.
Strauch RJ, Rosenwasser MP, Lunt
JG: Metacarpal shaft fractures: The effect of shortening on the extensor tendon mechanism. J Hand Surg Am
1998;23:519-523.

595