Hand & Carpal Fractures

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Hand & Carpal Fractures Kim Kraft PT, DPT, CHT

1 Hand & Carpal Fractures Kim Kraft PT, DPT, CHT Accessed 2/28/15 Accessed 2/28/15 /dollar-sign-on-the-muscle-out-for-theseason-broken-knuckles/ 1

2 Topics 1. Hand Fracture Reduction Methods 2. Fracture Healing Essentials 3. Therapy Basics 4. Characteristics of Specific Fractures 5. Special Cases Retrieved 4/2/15 Handsurgery.sp Hand Fracture Reduction Methods Open reduction with plate and screws Open reduction with screws 2

$Closed Reduction Cast vs Splint Splint = Orthosis Prevents displacement of a fracture with good$ $support of the fracture in all directions ORIF Open Reduction Internal Fixation Unstable fracture$ Surgical Fixation Requires 1. Good soft tissue skills & knowledge of anatomy 2.

Surgical Fixation Requires 1. Good soft tissue skills & knowledge of anatomy 2.

3 Closed Reduction Cast vs Splint Splint = Orthosis Prevents displacement of a fracture with good alignment Protects tendon and soft tissue injuries Works by compression of soft tissues Three point support of the fracture in all directions ORIF Open Reduction Internal Fixation Unstable fracture Displaced fracture Soft tissue injury Fractures with bone loss Rotational deformity Angulation Surgical Fixation Requires 1. Good soft tissue skills & knowledge of anatomy 2. Understanding of hand incisions 3. Rehabilitation 4. Motion within 2-3 days after surgery 5. Protection 6. Edema management and wound care 3

$fracture ends Has some wiggle K Wires, Pins, External Fixation Splinting/casting$ Immobilization Position MP ligaments are taut in flexion IPs are tight in extension

Immobilization Position MP ligaments are taut in flexion IPs are tight in extension

RE, Moran CG, eds. (2007) AO Principles of Fracture Management.

4 Closed Reduction Internal Fixation Closed Reduction External Fixation Approximates fracture ends Has some wiggle K Wires, Pins, External Fixation Splinting/casting Immobilization Position MP ligaments are taut in flexion IPs are tight in extension Safe position prevents contractures is MP flexion, IP extension Ruedi TP, Buckley RE, Moran CG, eds. (2007) AO Principles of Fracture Management. AO Publishing, Switzerland. Copyright by AO Publishing, Switzerland Video: Abduction with and without MP Flexion 4

$com/books/gene-therapyapplications/gene-therapy-applications-for-fracture-repair How Fractures$ $motion at the fracture Stressstrain at fracture site Fracture ends in contact Plastic Cutting$

5 FRACTURE HEALING ESSENTIALS Retrieved 3/4/15 How Fractures Heal No callus Callus Primary Open reduction Secondary Casting, Splinting, Wires/Pins No motion at the fracture Stressstrain at fracture site Fracture ends in contact Plastic Cutting cones Soft callus ossification 5

Primary Bone Healing Cutting Cone = Zamboni

6 Primary Bone Healing Cutting Cone = Zamboni of the Haversian Canal System Retrieved 3/7/15 nid=64953d049904ce14641f958dfdab08f2?_36_viewmode=print Accessed 2/28/

Secondary Bone Healing PAIN & SWELLING before callus

(cartilage) HARD CALLUS (cartilage turns to bone)

Results From Stress & Strain Retrieved 3/4/15 http://www.

7 Secondary Bone Healing PAIN & SWELLING before callus formation Less painful after SOFT CALLUS forms (cartilage) HARD CALLUS (cartilage turns to bone) Calcification & remodeling Wolff s Law of Bone Remodeling Results From Stress & Strain Retrieved 3/4/15 /nrrheum _f1.html Therapy Basics 7

Edema Control Prevents throbbing Improves active motion Ultimately less scar tissue Physiological Goals: Increase tissue hydrostatic pressure Reduce the intravascular pressure Support lymphatic

Compression Very effective with early low-protein edema PRECAUTION: VASCULAR COMPROMISE, LACK OF SENSATION, GRAFTS AND WOUNDS, CIRCUMFERENTIAL OR TOO TIGHT BANDAGES CAUSE TOURNIQUET, NEED TO WAIT

8 Edema Control Prevents throbbing Improves active motion Ultimately less scar tissue Physiological Goals: Increase tissue hydrostatic pressure Reduce the intravascular pressure Support lymphatic return Edema Control 1. Compression Very effective with early low-protein edema PRECAUTION: VASCULAR COMPROMISE, LACK OF SENSATION, GRAFTS AND WOUNDS, CIRCUMFERENTIAL OR TOO TIGHT BANDAGES CAUSE TOURNIQUET, NEED TO WAIT UNTIL AROM PERMITTED TO DON GLOVE Edema Control 2. Elevation On the shoulder, the sofa, the pillow Increases intravascular pressure, reduces capillary filtration pressure because peripheral arterial and venous pressures are affected by gravity. 3. Light cardiovascular exercise Increased diaphragm activity & compression of interstitial spaces, veins, lymphatic vessels, create increased lymphatic activity. 4. Active motion when permitted Soft tissue motion, compression of interstitial spaces, counter pressure of compressive dressing or glove/stocking, increase lymphatic return. 8

$the hand (metacarpal fractures) Creates motion between tissue layers$ PRECAUTION: MAY OPEN INCISIONS IF NOT COMPLETELY HEALED, CAN TEAR or

org/cases/flexor-andextensor-insertions-at-the-hand-and-wrist Active Motion

prevent deformity TENDON MOBILITY prevent adhesion between tissue layers

9 Kinesiotape Lifts epidermis Opens lymph channels Effective on the back of the hand (metacarpal fractures) Creates motion between tissue layers PRECAUTION: MAY OPEN INCISIONS IF NOT COMPLETELY HEALED, CAN TEAR or CONTUSE Making Motion: AROM & PROM Retrieved 3/16/15 Active Motion 3-4 days after ORIF 2-4 weeks for closed reduction Balance tendon forces to prevent deformity TENDON MOBILITY prevent adhesion between tissue layers Retrieved 3/16/15http://radiopaedia.org/cases/flexorand-extensor-insertions-at-the-hand-and-wrist 9

Active Motion Blocking Flexor Digitorum Profundus Flexor Digitorum Superficialis Flexor Pollicis Longus Tendon Gliding Fist Hook Fist Straight Fist Reverse Blocking Retrieved 3/28/15

10 Active Motion Blocking Flexor Digitorum Profundus Flexor Digitorum Superficialis Flexor Pollicis Longus Tendon Gliding Fist Hook Fist Straight Fist Reverse Blocking Retrieved 3/28/15 Video: AROM Passive Motion Fracture stability first, in 4-6 weeks with Xray evidence of bone healing Low-Load Prolonged Stress Heat Joint mobility 1. Elastic loops:10 minutes 4x/day 2. Tape: Can be used with heat 3. LMB: minutes 4x/day 4. SPLINTING 10

$Rehabilitation approaches for distal and middle phalanx fractures of the hand.$

11 Passive Motion Splinting 30 minutes 4 times per day 1. Static 2. Dynamic 3. Static Progressive Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: Video: PROM Strengthening Putty & light resistive exercise Begin after 6-8 weeks if healing 1.Grip 2.Pinch 3.Opposition 4.Finger & thumb extension 5.Abduction/Adduction 11

12 Video: Strengthening Phalanx Fractures P1, P2, P3 Retrieved 4/2/15 6/10/586/F2.expansion Distal Phalanx Fractures Tuft Nailbed injury Sensitivity Shaft Base FDP Avulsion Bony Mallet 12

Distal Phalanx Insertion of FDP palmar base Insertion of extensors by terminal tendon

blogsp ot.com/2012/05/fingernailzhijia.ht ml Retrieved 3/16/15 http://eorif.

html Immobilize IP joints straight mallet splint that includes the DIP but not the

$Principles of metacarpal and phalangeal fracture management: a review of$ $Rehabilitation approaches for distal and middle phalanx fractures of the hand.$ Distal Phalanx Shaft & Tuft Fractures AROM FDP Blocking FDP Gliding DESENSITIZATION

Distal Phalanx Shaft & Tuft Fractures AROM FDP Blocking FDP Gliding DESENSITIZATION

13 Distal Phalanx Insertion of FDP palmar base Insertion of extensors by terminal tendon dorsal base Germinal matrix & nail bed Retrieved 3/16/15 ot.com/2012/05/fingernailzhijia.ht ml Retrieved 3/16/15 istal%20class.html Immobilize IP joints straight mallet splint that includes the DIP but not the PIP 2-3 weeks before active motion Distal Phalanx Shaft & Tuft Fractures Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12): Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: Distal Phalanx Shaft & Tuft Fractures AROM FDP Blocking FDP Gliding DESENSITIZATION Vibration Rice bucket Massage 10 minutes 2-4x/day Works within 2 weeks Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):

$Baseball fracture Immobilized 6 weeks, then at night and heavy activity Active fisting ex program No DIP$ $Rehabilitation approaches for distal and middle phalanx fracture the hand. J Hand Ther 2003; 16: 105-116.$

14 FDP AVULSION Distal Phalanx Base Fractures Are TENDON INJURIES Jersey finger Wire to stabilize & dorsal button Zone 1 Flexor Tendon Repair: follow Modified Duran flexor tendon repair program BONY MALLET Baseball fracture Immobilized 6 weeks, then at night and heavy activity Active fisting ex program No DIP BLOCKING (causes extension lag) Cannon NM. Rehabilitation approaches for distal and middle phalanx fracture the hand. J Hand Ther 2003; 16: Distal Phalanx Fracture Middle Phalanx Fractures Condyles and lateral ligaments for stability with DIP joint Special Considerations Volar plate injury Insertion of FDS at the base 14

$shaft fracture Slight flexion of PIP for 6 weeks if a dorsal dislocation with$ $volar plate injury or articular fracture ORIF Cannon NM.$ $Principles of metacarpal and phalangeal fracture management: a review of$ rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.

rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.

Tendon gliding Fist Hook Straight fist Hardy MA. Middle Phalanx Fracture 15

15 Middle Phalanx Fractures P2 IP Gutter Extension gutter or buddy tapes if shaft fracture Slight flexion of PIP for 6 weeks if a dorsal dislocation with volar plate injury or articular fracture ORIF Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12): Active Motion Middle Phalanx Fractures 1. FDS blocking 2. Reverse blocking 3. Tendon gliding Fist Hook Straight fist Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12): Middle Phalanx Fracture 15

Proximal Phalanx Fractures Base, Shaft, Head NO

flexion where collateral ligaments are elongated

piece Splinting Proximal Phalanx Fractures P1 Forearm

digit for stability SAFE Position MP Flexion IP

$Principles of metacarpal and phalangeal fracture$

16 Proximal Phalanx Fractures Base, Shaft, Head NO complicating tendon insertions Immobilization in MP flexion where collateral ligaments are elongated Intrinsics flex proximal piece; extensors extend distal piece Splinting Proximal Phalanx Fractures P1 Forearm based radial gutter / ulnar gutter Include neighboring digit for stability SAFE Position MP Flexion IP Extension Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12): Proximal Phalanx Fracture 16

17 Thumb Fractures Proximal and distal phalanx (P1, P2) Tendon insertions: EPB, APB, EPL, FPL Fractures displaced by tendon pull, pinch/grip Metacarpal Fractures Retrieved 4/2/15 Metacarpal Fractures Special problems 1. angulation 2. malrotation 3. shortening 17

⁰ ring⁰ 2. Shortening Relative lengthening of the common finger extensors.

18 Metacarpal Malunion 1. Angulation Apex dorsal because of pull of interossei 30⁰ tolerated in small finger, 20 ⁰ ring⁰ 2. Shortening Relative lengthening of the common finger extensors. 2mm of metacarpal shortening = 7⁰ extensor lag at the MP joint 3. Malrotation 5⁰ at the shaft creates 1.5 cm of overlap of the digit during fisting Buddy tape while immobilized to prevent malrotation Boxer s Fracture Special fracture of the 5 th metacarpal Usual mechanism of injury: hitting a wall or other hard object Boxer s Fracture 18

19 Thumb Metacarpal Fractures Thumb Fractures Special Problems Tendon adherence FPL/EPL Loss of web space Loss of pinch strength Rolyan Wrist and Thumb Immobilizer Metacarpal Neck Fracture 19

$Bennett s First Metacarpal Fracture Partial articular fracture dislocation at the base of the$ $1/6/15 /lifeinthefastlane.com/education/who-was/eponymous-fractures/ Bennett s Fracture.$ $"Open reduction and osteosynthesis of the so-called Bennett's fracture in the carpo-metacarpal$

20 Bennett s First Metacarpal Fracture Partial articular fracture dislocation at the base of the first metacarpal Mechanism: Axial load on a flexed first CMC joint, FOOSH Causes OA Retrieved 1/6/15 /lifeinthefastlane.com/education/who-was/eponymous-fractures/ Bennett s Fracture. Palmar oblique ligament 4 Adductor pollicis Thumb extensors Abductor pollicis longus Gedda, K-O., and Eric Moberg. "Open reduction and osteosynthesis of the so-called Bennett's fracture in the carpo-metacarpal joint of the thumb." Acta Orthopaedica (1952): Bennett s Fracture Before 20

$piece intra-articular fracture at$ $fracture Retrieved 1/6/15$ /lifeinthefastlane.

21 Bennett s Fracture Rolando s First Metacarpal Fractures 3 piece intra-articular fracture at the base of the first metacarpal T or Y shaped Complete articular fracture Retrieved 1/6/15 /lifeinthefastlane.com/education/who-was/eponymous-fractures/ Rolando s Fracture 21

$"Thumb trauma: Bennett fractures, Rolando fractures, and ulnar$ collateral ligament injuries." The Journal of hand surgery 34.

$"Rolando's fracture of the first metacarpal.$ " Journal of Bone & Joint Surgery, British Volume 74.

22 Rolando Fracture Carlsen BT, Moran SL. "Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries." The Journal of hand surgery 34.5 (2009): Proubasta IR. "Rolando's fracture of the first metacarpal. Treatment by external fixation." Journal of Bone & Joint Surgery, British Volume 74.3 (1992): Carpal Fractures Retrieved 4/2/15 RETRIEVED 3/31/15 TRULIFE.COM 22

$Scaphoid Fracture Men 15-29 years old Most common carpal fracture in kids$ to radial wrist Retrieved 3/25/15orthopedicsone.com https://sites.google.

to radial wrist Retrieved 3/25/15orthopedicsone.com https://sites.google.

Blood flow from distal to proximal Healing 8-24 weeks Return to

Palpation in the anatomic snuffbox with ulnar deviation, or 2.

23 Scaphoid Fracture Men years old Most common carpal fracture in kids 80% of the scaphoid are articular surfaces Onset: FOOSH, MVA, direct blow to radial wrist Retrieved 3/25/15orthopedicsone.com hysiotherapyclinic/scaphoid-injury Scaphoid Fracture Blood flow from distal to proximal Healing 8-24 weeks Return to sport/activity weeks after cast removed 1. Palpation in the anatomic snuffbox with ulnar deviation, or 2. Transverse wrist crease 3. 2% don t appear on initial X-ray Scaphoid Fracture 23

$Trapezium Fracture 1-5 % of carpal fractures Chip fractures are not treated Axial force of the 1 st MC$ Retrieved 3/25/15orthopedicsone.

$An update on the management of carpal fractures. J Hand Ther 2003; 16: 152 160.$ $com Capitate Fracture 6 weeks casted before beginning AROM 1% carpal fractures ORIF: Mobilize scar,$

24 Trapezium Fracture 1-5 % of carpal fractures Chip fractures are not treated Axial force of the 1 st MC causes splaying of waist fractures Palpation: base of the 1 st metacarpal in small finger opposition Retrieved 3/25/15orthopedicsone.com Hamate Fracture Injury by compression (bat swing is classic), treated with wire, excision, or cast Fracture becomes displaced by ligaments Ulnar nerve sensitivity Brach P, Goitz R. An update on the management of carpal fractures. J Hand Ther 2003; 16: Retrieved 3/25/15orthopedicsone.com Capitate Fracture 6 weeks casted before beginning AROM 1% carpal fractures ORIF: Mobilize scar, Continuous US with steroid Retrieved 3/25/15orthopedicsone.com Retreieved 4/2/14 Treatment.html Retrieved 3/25/15orthopedicsone.com 24

Pisiform Fracture Caused by a direct blow, maybe repetitive stress Excision common

$com Triquetrum Fracture Second most common carpal fracture 4 weeks in cast$ Complaints of ulnar wrist pain, local tenderness Pisiform lies on top Lunate

Complaints of ulnar wrist pain, local tenderness Pisiform lies on top Lunate

25 Pisiform Fracture Caused by a direct blow, maybe repetitive stress Excision common (nonunion) Scar sensitivity & grip weakness Pisiform Retrieved 3/25/15orthopedicsone.com Triquetrum Fracture Second most common carpal fracture 4 weeks in cast Complaints of ulnar wrist pain, local tenderness Pisiform lies on top Lunate Fracture Caused by impact with wrist extension Casted 6-8 weeks Associated with ligament injuries It s Complicated Keinbock s = avascular necrosis of the lunate May lose wrist ROM 25

$fracture site Physeal arrest from mishandling Middle and Distal Phalanges 14-16 years Thumb Metacarpal 14-16 years Proximal Phalanges 14-16 years$ Metacarpal Head 14-16 years Lightdale-Miric N, Kozin SH. Fractures and dislocations of the hand and carpal bones in children.

Metacarpal Head 14-16 years Lightdale-Miric N, Kozin SH. Fractures and dislocations of the hand and carpal bones in children.

26 Hand Physeal Closure Ages Open physis is weaker than surrounding bone Differential growth of the physis can correct for some malalignment of the fracture site Physeal arrest from mishandling Middle and Distal Phalanges years Thumb Metacarpal years Proximal Phalanges years Metacarpal Head years Lightdale-Miric N, Kozin SH. Fractures and dislocations of the hand and carpal bones in children. In :Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkin Fractures in Children 2015, Walters Kluwer Health Philadelphia. P265. Salter-Harris Retrieved 4/3/15 Studyblue.com HAND PHYSES 26

27 Special Pediatric Fractures 1. Seymour fracture Fracture of the physis of the distal phalanx Results in infection, growth arrest, mallet deformity 2. Tuft fracture 2-3 year olds Very painful-needs cushioning and protection (tip protector) Osteoporotic Fractures 1. Age 2. Post-menopausal female 3. Glucocorticoids 4. Smoking 5. Alcoholism 6. High protein diet 7. Balance deficit 8. Failure of fixation Biophosphonates- Treatment for osteoporosis, slows osteoclast activity; also slows fracture healing; half life in bone is years, shows a higher rate of non-union Fracture Complications Nonunion, delayed union, malunion, avascular necrosis, osteomyelitis, amputation, stiffness/motion loss, instability, laxity, poor durability, lack of coverage, contracture, tendon adhesions, motion lag, numbness, hypersensitivity, pain, CRPS, ischemia, venous congestion, sensitivity, joint laxity 27

$Baldwin PC, Wolf JM. Outcomes of hand fracture treatments. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; 621-630. 2. Brach P, Goitz R.$ $An update on the management of carpal fractures. J Hand Ther 2003; 16: 152 160. 3. Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand.$ Fractures of he metacarpals and phalanges. In: Wolfe SW, Hotchkiss RN, Pederson WC, e al,editors. Green's operative hand surgery. 6th edition.

Fractures of he metacarpals and phalanges. In: Wolfe SW, Hotchkiss RN, Pederson WC, e al,editors. Green's operative hand surgery. 6th edition.

28 Hand Compartment Syndrome Pressure in enclosed space Soft tissue injury from crush, burn, tight bandaging Retrieved 3/29/15 Scienceopen.com Retrieved 3/29/15 Galleryhip.com References 1. Baldwin PC, Wolf JM. Outcomes of hand fracture treatments. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; Brach P, Goitz R. An update on the management of carpal fractures. J Hand Ther 2003; 16: Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. J Hand Surg 2009; 34: Day CS, Stern PJ. Fractures of he metacarpals and phalanges. In: Wolfe SW, Hotchkiss RN, Pederson WC, e al,editors. Green's operative hand surgery. 6th edition. Philadelphia: Elsevier Churchill Livingstone; 2011; Flowers K, LeStayo P. Effect of total end range time on improving passive range of motion. J Hand Ther 1994; 7: Foster RJ, Hastings H II. Treatment of Bennett, Rolando, and vertical intraarticular trapezialfractures. Clin Orth Rel Res 1987; 21: Gedda KO, Moberg E. Open reduction and osteosynthesis of the so-called Bennett's fracture in the carpo-metacarpal joint of the thumb. Acta Orth 1952; 1-4: Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J Orthop Sports Phys Ther 2004; 34(12): Hardy MA, Freeland AE. Hand fracture fixation and healing : skeletal stability and digital mobility. In: Skirven TM, Osterman AL, Fedorczyk, et al, editors. Rehabilitation of the hand and upper extremity. 6 th edition. Philadelphia: Elsevier Mosby; 2011; Hays PL, Rozental TD. Rehabilitative strategies following Hand Fractures. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; Lightdale-Miric N, Kozin SH. Fractures and dislocations of the hand and carpal bones in children. In :Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkin Fractures in Children 2015, Walters Kluwer Health Philadelphia; 2015; Markiewitz AD. Complications of hand fractures and their prevention. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; McNemar TB, Howell JW, Chang E. Management of Metacarpal Fractures. J Hand Ther;2003:16: Michlovitz SL. Is there a role for ultrasound and electrical stimulation following injury to tendon and bone? J Hand Ther 2005; 18: Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving joint range of motion: a systematic review. J Hand Ther 2004; 17: O'Brien L. The evidence on ways to improve patient's adherence in hand therapy. J Hand Ther 2012; 25: Proubasta IR. Rolando's fracture of the first metacarpal. Treatment by external fixation. J Bone Joint Surg, Br 1992; 74.3: Ruedi TP, Buckley RE, Moran CG, eds. AO Principles of Fracture Management. AO Publishing, Switzerland Sarmiento A, Latta L. The Nonsurgical Treatment of Fractures in Contemporary Orthopedics. Joyce Brothers, New Delhi Shin AY, Amadio PC. The stiff finger. In: Wolfe SW, Hotchkiss RN, Pederson WC, e al,editors. Green's operative hand surgery. 6th edition. Philadelphia: Elsevier Churchill Livingstone; 2011; Villeco JP. Edema: A silent but important factor. J Hand Ther 2012; 25: Watson HK, Weinzweig, eds. The Wrist. 2001, Lippincot Williams & Wilkins, Philadelphia PA. Questions? Answers? Pearls? 28

Hand injuries. The metacarpal bones may fracture through the base, shaft or the neck.

$Hand injuries. The metacarpal bones may fracture through the base, shaft or the neck.$ Hand injuries Metacarpal injuries The metacarpal bones may fracture through the base, shaft or the neck. Shaft fractures; these are caused by direct trauma which may cause transverse # of one or more metacarpal