Hand Injuries - An Overview

Hand injuries are among the most frequent musculoskeletal injuries encountered in emergency departments, fracture clinics, sports medicine and orthopaedic practice. Although many appear minor on initial examination, the hand has little tolerance for malrotation, articular incongruity, tendon imbalance or prolonged immobilisation. A fracture that heals reliably but heals in the wrong position may produce a much greater functional disability than a seemingly more severe fracture elsewhere in the skeleton. The primary goals of treatment are therefore not simply fracture union, but restoration of alignment, joint congruity, tendon excursion, stability, sensation and early functional movement.

• The fundamental principle of hand trauma is: restore LENGTH, ALIGNMENT and ROTATION while preserving SOFT-TISSUE GLIDING and allowing EARLY MOTION.
• Metacarpal and phalangeal fractures constitute the majority of fractures of the hand. Fifth metacarpal neck fractures are particularly common, while fractures involving the thumb demand special attention because thumb function contributes disproportionately to pinch, opposition and overall hand function.
• Never assess the X-ray alone. A relatively innocent-looking spiral fracture may have clinically unacceptable rotation, while considerable radiographic angulation of a fifth metacarpal neck fracture may remain functionally acceptable.
• Hand trauma should always be considered a combined injury to bone, joint, tendon, ligament, skin, nail bed, nerve and vascular structures until these components have been individually assessed.
• Open wounds, contamination, human bites, vascular compromise, tendon injury, compartment syndrome, irreducible dislocation and unstable open fractures require urgent recognition and appropriate surgical referral.

• Examine the hand BEFORE anaesthesia or reduction whenever possible. Document skin integrity, capillary refill, sensation, active tendon function and rotational alignment before manipulating the injury.
• History: determine mechanism, direction and magnitude of force; hand dominance; occupation; sporting requirements; time since injury; contamination; bite mechanism; tetanus status; smoking; diabetes; previous hand injuries and baseline function.
• Inspection: assess swelling, bruising, wounds, nail plate position, subungual haematoma, loss of knuckle prominence, abnormal finger cascade, shortening, angular deformity and obvious dislocation.
• Rotation: rotational deformity is one of the least tolerated deformities in the hand. Ask the patient to flex the fingers toward the palm. The digits should form a harmonious cascade without crossing or scissoring. Compare nail plate orientation with neighbouring digits and the opposite hand.
• There is essentially NO acceptable clinically significant rotational deformity in a metacarpal or phalangeal fracture. Rotation that produces finger overlap during flexion should be corrected.
• Tendon examination: test FDP by holding the PIP joint extended and asking the patient to flex the DIP joint; test FDS by holding the other fingers extended and asking for isolated PIP flexion; test extensor function at MCP, PIP and DIP levels; examine EPL and FPL independently in thumb injuries.
• Neurovascular assessment: capillary refill, skin colour and temperature should be recorded. Test median, ulnar and radial sensory territories and, where appropriate, two-point discrimination on the involved digit.
• Any dorsal MCP wound following a punch should be regarded as a possible human fight bite until proven otherwise.

• Standard radiographs generally include PA, oblique and lateral views. A true lateral of the affected digit may be more useful than a lateral of the entire hand when assessing phalangeal or articular injuries.
• Always identify whether a fracture is extra-articular or intra-articular and assess displacement, angulation, shortening, comminution and associated subluxation or dislocation.
• Thumb: dedicated thumb views should be obtained. A Robert view provides a true AP-type projection of the thumb CMC joint and is particularly useful for first metacarpal base fractures.
• Brewerton view: may help demonstrate metacarpal head fractures that are difficult to appreciate on standard views.
• CT is especially valuable for complex intra-articular fractures, metacarpal head fractures, CMC fracture-dislocations, hamate-associated injuries, Rolando fractures and injuries where the true extent of articular comminution is unclear on plain radiographs.

When immobilisation is required, the position of the hand matters almost as much as the duration of immobilisation. The intrinsic-plus or Edinburgh position places the important capsuloligamentous structures near their maximum functional length and reduces the risk of disabling contracture.

Hand stiffness is often more disabling than the original fracture. Immobilise only what needs to be immobilised and begin controlled motion as soon as fracture and soft-tissue stability permit.

• The metacarpals may be fractured at the head, neck, shaft or base. Treatment depends more on location, rotation, stability and articular involvement than simply on the presence of a fracture.
• The second and third CMC joints are relatively rigid, whereas the fourth and especially fifth CMC joints are progressively more mobile. Consequently, the ulnar metacarpals can compensate for greater sagittal-plane angulation.
• Rotation is poorly tolerated at EVERY metacarpal. Increasing CMC mobility allows progressively more ANGULATION from index to little finger, but it does not compensate for ROTATION.
• Shortening may alter the extensor mechanism and reduce MCP extension. Significant shortening is particularly problematic in multiple metacarpal fractures where neighbouring intact metacarpals can no longer act as internal splints.
• Operative indications vary with fracture pattern but commonly include open fracture, unacceptable rotation, substantial shortening, unstable displacement, irreducible fracture, multiple unstable metacarpal fractures and displaced intra-articular fractures.

• Metacarpal head fractures are relatively uncommon but important because they directly involve the MCP articular surface.
• Patterns include osteochondral fractures, collateral ligament avulsion fractures, sagittal fractures, coronal fractures, comminuted fractures and fractures associated with MCP dislocation.
• Mechanisms include direct impact, axial compression and shearing forces across a flexed MCP joint.
• Because the metacarpal head is articular, displacement is tolerated much less readily than in extra-articular neck fractures. Restoration of joint congruity is the principal treatment goal.
• CT may be helpful when the fracture pattern or amount of articular involvement is unclear.
• Small, stable and essentially undisplaced osteochondral injuries may be managed non-operatively with short immobilisation followed by early motion.
• Displaced articular fractures generally require anatomical or near-anatomical reduction. Fixation options include mini-fragment screws, headless compression screws, K-wires or other low-profile fixation depending on fragment size.
• Complications include MCP stiffness, avascular necrosis of fragments, extensor adhesions and post-traumatic arthritis.

• The fifth metacarpal neck is the classic site of a boxer’s fracture, usually caused by striking a solid object with a clenched fist.
• The distal fragment typically displaces volarly, producing apex dorsal angulation and loss of the normal knuckle prominence.
• Examine specifically for rotational deformity and for wounds over the MCP joint that could represent tooth penetration.
• Angulation is better tolerated in the fourth and fifth metacarpals than the second and third because of increasing ulnar CMC mobility.

• Jahss manoeuvre: classically used for reduction of a metacarpal neck fracture. Flex the MCP and PIP joints and use the proximal phalanx as a lever to elevate the depressed metacarpal head while counter-pressure corrects the apex dorsal deformity.
• A fifth metacarpal neck fracture with substantial radiographic angulation may still function well if there is no rotation, significant pseudoclawing or unacceptable functional deformity. Treat the patient, not simply the angle on the X-ray.
• Stable fractures can often be treated with protected mobilisation, buddy support or an ulnar gutter splint depending on pain and stability.
• Unstable fractures, rotational deformity, open fractures and fractures with unacceptable functional deformity may be treated with K-wires, intramedullary fixation, transverse pinning or plate fixation.

• Metacarpal shaft fractures may be transverse, short oblique, long oblique, spiral or comminuted.
• Transverse fractures commonly develop apex dorsal angulation. Spiral fractures are particularly important because they may produce significant rotational malalignment despite modest angulation on X-ray.
• A spiral metacarpal fracture + finger scissoring = rotational instability until proven otherwise.
• Index and middle metacarpal shaft fractures tolerate relatively little angulation because their CMC articulations are rigid. Greater sagittal angulation can be accepted toward the ring and little metacarpals.
• Stable fractures without clinically significant rotation can often be treated non-operatively with short protective immobilisation and early controlled motion.
• Lag screws: long oblique and spiral fractures with sufficient fracture length may be ideal for interfragmentary screw fixation.
• Plate fixation: provides rigid fixation and permits early motion but requires soft-tissue dissection and may cause extensor tendon adhesions or hardware irritation.
• Intramedullary fixation: increasingly used for selected transverse and short-oblique fractures because it can provide stable fixation with limited soft-tissue disruption.

• Metacarpal base injuries may be isolated fractures or part of a CMC fracture-dislocation. They are particularly important on the ulnar side of the hand.
• Fourth and fifth CMC fracture-dislocations may be associated with hamate fractures and are frequently missed on routine radiographs because of overlapping bones.
• Look for loss of normal CMC joint congruity, altered metacarpal cascade and dorsal displacement on the lateral view.
• Persistent swelling and tenderness over the CMC region after high-energy trauma with apparently inconclusive X-rays should prompt CT evaluation.
• Stable undisplaced base fractures may be treated with immobilisation. Displaced or unstable CMC fracture-dislocations generally require reduction and temporary K-wire stabilisation; larger associated hamate fragments may require screw fixation.
• Delayed diagnosis may result in chronic CMC instability, painful prominence, reduced grip strength and post-traumatic arthritis.

• Multiple metacarpal fractures are mechanically different from an isolated fracture because the neighbouring intact metacarpals no longer provide internal stability.
• They are commonly associated with crush injuries and significant soft-tissue damage.
• Shortening, rotation and collapse of the transverse metacarpal arch are more likely.
• Multiple unstable metacarpal fractures have a substantially lower threshold for operative fixation because restoration of the metacarpal arch and early mobilisation are critical to hand function.
• Plate fixation, screws, intramedullary devices and K-wires may be combined according to individual fracture morphology.

The thumb metacarpal differs functionally and anatomically from the finger metacarpals. Its highly mobile saddle-shaped CMC joint permits opposition, circumduction and powerful pinch. Malalignment at the first metacarpal therefore has major functional consequences.

• This fracture lies proximal in the first metacarpal but does not extend into the CMC articular surface.
• The fracture may angulate because of muscular forces acting on the thumb metacarpal.
• Mild deformity may be tolerated because of the mobility of the thumb CMC joint, but excessive angulation can narrow the first web space and interfere with opposition.
• Stable fractures are treated in a thumb-spica type immobilisation. Unstable or significantly displaced fractures may require closed reduction and percutaneous K-wire fixation or ORIF.

• A Bennett fracture is an intra-articular fracture-dislocation at the base of the first metacarpal producing a small volar-ulnar fragment that remains relatively attached to the trapezium while the major metacarpal fragment subluxes.
• The anterior oblique ligament contributes to maintaining the small volar-ulnar fragment, while muscular forces—particularly the abductor pollicis longus—promote displacement of the metacarpal shaft.
• The injury typically results from axial loading of a partially flexed thumb.
• Clinically there is swelling and tenderness around the thumb CMC joint, pain on axial loading and sometimes visible basal deformity.
• Dedicated thumb radiographs, including a Robert view, help define the fracture. CT is useful for complex patterns.
• Reduction: traction, thumb abduction and appropriate rotational correction combined with direct pressure over the metacarpal base are used to restore CMC congruity.
• Stable, minimally displaced injuries may occasionally be treated in a thumb spica with close radiographic surveillance. However, displaced or unstable Bennett fracture-dislocations commonly require percutaneous K-wire fixation or ORIF.
• Fixation strategies include first-to-second metacarpal pinning, trans-CMC pinning, fixation of a sufficiently large fragment with screw(s), or combinations of these methods.
• The key objective is not merely reduction of the fracture line—it is restoration and maintenance of THUMB CMC JOINT CONGRUITY.
• Complications include loss of reduction, malunion, CMC stiffness, weakness of pinch and post-traumatic CMC arthritis.

• A Rolando fracture is a comminuted intra-articular fracture of the base of the first metacarpal. The classic description is a three-part T- or Y-shaped fracture, although the term is commonly applied to comminuted intra-articular thumb metacarpal base fractures.
• It is generally produced by axial compression and carries a worse prognosis than a simple Bennett fracture because the articular surface itself is fragmented.
• Bennett = predominantly fracture-dislocation problem. Rolando = fracture-dislocation PLUS articular comminution problem.
• CT is useful for determining whether the fragments are sufficiently large for internal fixation.
• Large reconstructable fragments may be treated with ORIF using mini-fragment screws or plates.
• When fragments are too small for conventional fixation, percutaneous pinning or external fixation/ligamentotaxis may be considered while attempting to preserve length and joint alignment.
• Post-traumatic CMC arthritis, stiffness and loss of pinch strength are more frequent than after simpler fracture patterns.

• First metacarpal shaft fractures are less common than basal injuries and may be transverse, oblique or comminuted.
• Because the thumb CMC joint is highly mobile, some angular deformity can be compensated; however, excessive angulation may narrow the first web space and impair opposition.
• Rotation must be assessed clinically by comparing thumb nail orientation, opposition and the relationship of the thumb pulp to the fingers.
• Stable fractures may be treated in a thumb spica. Unstable fractures can be managed with K-wires, screws, intramedullary fixation or a mini-plate depending on morphology.

• Thumb proximal phalanx fractures may involve the base, shaft, neck or head and may be extra-articular or intra-articular.
• Base fractures require particular attention because collateral ligament avulsion injuries may accompany them.
• Stable extra-articular fractures with acceptable alignment can be treated in a thumb spica followed by early mobilisation.
• Unstable, rotated, markedly angulated or displaced intra-articular fractures may require K-wire, screw or plate fixation.
• At the ulnar base, an avulsion fragment may represent a UCL avulsion injury and should prompt assessment for MCP instability and a possible Stener lesion.

• Distal phalanx fractures commonly result from crush injuries and may be associated with subungual haematoma, nail-bed laceration or open fracture.
• Tuft fractures are usually comminuted but stable. Treatment is directed largely toward soft-tissue protection and pain control rather than attempting anatomical reduction of every small fragment.
• A nail-bed laceration associated with a distal phalanx fracture may make the fracture technically open and should be treated according to wound characteristics and contamination.
• The nail plate should be examined for disruption, displacement or avulsion from beneath the eponychial fold.
• Subungual haematomas causing substantial throbbing pain can be decompressed when appropriate, provided the nail plate and surrounding structures are adequately assessed.
• In fingertip trauma, the X-ray is only part of the injury. Nail-bed quality, pulp viability and soft-tissue coverage often determine the final outcome.

• The ulnar collateral ligament of the thumb MCP joint is a critical restraint against valgus stress and is essential for stable pinch.
• Skier’s thumb generally describes an acute traumatic UCL injury, whereas gamekeeper’s thumb historically describes chronic UCL insufficiency.
• The mechanism is forced abduction/radial deviation of the thumb MCP joint.
• Examine tenderness at the ulnar MCP joint and assess stability carefully. Plain radiographs should be obtained before aggressive stress testing when fracture is suspected.
• Stener lesion: the torn distal UCL becomes displaced superficial to the adductor aponeurosis, preventing the ligament from returning to its anatomical insertion and therefore preventing normal healing.
• Ultrasound or MRI may help identify complete tears and displacement when clinical assessment is uncertain.
• Partial, stable injuries are usually managed with thumb-spica immobilisation followed by rehabilitation.
• Complete unstable tears, displaced avulsion fractures and Stener lesions generally require surgical repair or fixation.
• Chronic untreated UCL deficiency causes painful pinch weakness and may ultimately lead to MCP joint degeneration.

• Radial collateral ligament injuries are less common than UCL injuries but may cause significant MCP instability.
• The mechanism is forced adduction/ulnar deviation of the thumb MCP joint.
• Examine for radial-sided tenderness and instability compared with the opposite thumb.
• Partial stable tears can generally be treated with thumb-spica immobilisation.
• Complete displaced or markedly unstable injuries may require repair, particularly in high-demand patients.
• Chronic RCL insufficiency may produce MCP subluxation, weakness and painful degenerative change.

• Dorsal dislocation is more common and usually follows forced hyperextension.
• Dislocations may be simple or complex. Complex dislocations contain interposed soft tissue—commonly the volar plate—that prevents closed reduction.
• Avoid forceful repeated longitudinal traction in a suspected complex MCP dislocation because it may tighten the soft-tissue noose around the metacarpal head and make reduction more difficult.
• After reduction, repeat radiographs and reassess UCL/RCL stability, neurovascular status and active tendon function.
• Irreducible dislocations require open reduction.

• Thumb IP dislocations are uncommon and usually result from hyperextension with axial loading.
• Closed reduction is usually possible after adequate anaesthesia.
• Failure of reduction suggests interposition of the volar plate, FPL tendon or other soft tissue and should prompt operative assessment.
• After reduction assess stability and obtain post-reduction radiographs. Stable injuries should undergo early protected motion to minimise stiffness.

• Proximal phalanx fractures are common and may be transverse, oblique, spiral, comminuted, condylar or intra-articular.
• Deforming forces from the interossei tend to flex the proximal fragment while the extensor mechanism influences the distal fragment, producing characteristic angular deformity.
• Rotation is particularly important in phalangeal fractures. A few degrees of fracture rotation may translate into obvious fingertip overlap when the patient makes a fist.
• Stable, minimally displaced fractures can often be managed with buddy taping or a short period of protective splinting followed by early mobilisation.
• Unstable transverse fractures may require K-wire fixation. Long oblique and spiral fractures may be suitable for lag screws.
• Plate fixation provides stability but can interfere with extensor tendon gliding; implant prominence and adhesions are important concerns.
• The ideal fixation construct is therefore the least invasive construct that provides sufficient stability for early motion.

• Condylar fractures involve one or both condyles of the proximal or middle phalanx and extend into the joint.
• They may appear relatively innocuous initially but are prone to displacement because the fragment is small and influenced by collateral ligament forces.
• Unicondylar fractures can produce joint incongruity and angular deviation.
• A displaced phalangeal condylar fracture is an ARTICULAR fracture: anatomical reduction and stable fixation are usually required to restore joint congruity.
• Fixation may be achieved with K-wires, mini-screws or headless screws depending on fragment size.

• Middle phalanx shaft fractures may behave differently depending on their relationship to the insertion of the flexor digitorum superficialis.
• The direction of angulation can therefore vary according to whether the fracture lies proximal or distal to the FDS insertion.
• Stable fractures without rotation can usually be managed with buddy support and early motion.
• Unstable, displaced or rotationally malaligned fractures may require K-wire, screw or plate fixation.
• Fractures involving the base of the middle phalanx require careful assessment because they may represent a PIP fracture-dislocation.

• A dorsal PIP fracture-dislocation typically involves fracture of the volar lip of the middle phalanx base with dorsal subluxation or dislocation of the middle phalanx.
• The size of the articular fragment and the amount of intact articular surface influence stability.
• Stable injuries remain reduced through functional range of motion. Unstable injuries redislocate as the PIP joint approaches extension.
• The critical question is not simply “How large is the fragment?” but “At what degree of PIP flexion does the joint remain concentrically reduced?”
• Stable injuries can be treated with an extension-block splint and early controlled flexion.
• Unstable injuries may require extension-block pinning, ORIF, dynamic external fixation, volar plate arthroplasty or hemi-hamate reconstruction depending on chronicity and fracture morphology.
• PIP stiffness is a major complication; unnecessarily prolonged immobilisation should be avoided.

• Pilon fractures of the middle phalanx base result from high-energy axial loading and produce central articular impaction with variable comminution.
• Both the dorsal and volar articular margins may be involved, resulting in loss of a stable buttress.
• These are among the most challenging finger fractures because anatomical reconstruction may be impossible.
• Management options include dynamic distraction external fixation, ORIF in selected reconstructable fractures and salvage procedures for severe chronic injuries.
• The goal is to restore alignment and permit early motion while allowing remodelling of the damaged articular surface.

• Dorsal PIP dislocation is the most common interphalangeal joint dislocation and usually results from hyperextension and axial load.
• The volar plate is injured and may avulse a small fragment from the volar base of the middle phalanx.
• Following reduction, determine whether the joint is concentrically reduced and stable through motion.
• Stable injuries are treated with early protected mobilisation and buddy taping.
• An extension-block splint is used when the joint is stable in flexion but tends to sublux near full extension.
• The greatest enemy after a stable PIP dislocation is prolonged immobilisation. Early controlled motion is central to achieving a useful final range of movement.
• Volar PIP dislocations are less common and may injure the central slip; this must be recognised to prevent subsequent boutonnière deformity.

• The central slip inserts onto the dorsal base of the middle phalanx and extends the PIP joint.
• Injury may occur after forced PIP flexion, dorsal laceration or volar PIP dislocation.
• Acute injury may initially present only with swelling and tenderness over the dorsal PIP joint; the classic deformity may not yet be present.
• Elson test: with the PIP flexed over the edge of a table, ask the patient to extend against resistance. Central slip disruption produces weak PIP extension with abnormal rigidity/extension of the DIP compared with the normal side.
• Missed central slip injury → progressive PIP flexion + DIP hyperextension = boutonnière deformity.
• Acute closed injuries are generally treated with continuous PIP extension splinting while allowing DIP motion. Open injuries and displaced bony avulsions may require repair or fixation.

• Distal phalanx fractures include tuft fractures, shaft fractures, intra-articular base fractures and physeal injuries.
• Tuft fracture: commonly caused by crush injury. These fractures are frequently comminuted but mechanically stable and usually require protection rather than fixation.
• Displaced shaft fractures may require reduction and occasionally K-wire fixation if unstable.
• Always inspect the nail bed because fracture and nail-bed injury frequently coexist.
• Open distal phalanx injuries require wound management, assessment of contamination and appropriate antibiotic/tetanus consideration according to the clinical situation.

• Mallet finger results from disruption of the terminal extensor mechanism at the DIP joint, either as a tendon rupture or a bony avulsion from the dorsal base of the distal phalanx.
• The mechanism is forced flexion of an actively extended DIP joint, classically when a ball strikes the fingertip.
• The patient cannot actively extend the DIP joint and presents with a characteristic flexion droop.
• Treatment of most closed mallet injuries = CONTINUOUS DIP extension splinting. If the DIP is allowed to flex during the treatment period, healing tissue may be disrupted and the continuous splinting period may effectively need to restart.
• The PIP joint should generally remain free to move.
• Surgery may be considered for open injuries, selected large bony fragments with joint subluxation, irreducible injuries or situations where adequate splint treatment cannot be maintained.
• Chronic mallet injury can progress to a swan-neck pattern because of extensor mechanism imbalance.

• Jersey finger is an avulsion of the flexor digitorum profundus tendon from its insertion on the distal phalanx.
• It occurs when an actively flexed DIP joint is forcibly extended—classically when a player grabs an opponent’s jersey.
• The ring finger is commonly involved.
• Key examination: isolate the DIP joint and ask the patient to flex it. In FDP avulsion, active DIP flexion is absent.
• Radiographs may be normal or show a bony avulsion fragment.
• These injuries require early hand-surgical assessment because tendon retraction and compromise of tendon nutrition can make delayed repair more difficult.
• Treatment is generally operative reinsertion of the FDP, with urgency influenced by the level of tendon retraction and injury pattern.

• A Seymour fracture is a paediatric distal phalangeal physeal or juxta-physeal fracture associated with nail-bed injury.
• It may resemble a mallet finger clinically, but the nail plate is often displaced superficial to the eponychial fold.
• A Seymour fracture should be regarded as an OPEN FRACTURE because the nail-bed injury communicates with the fracture.
• Management includes irrigation and debridement, removal of interposed tissue where necessary, reduction, nail-bed management, antibiotics as appropriate and stabilisation when unstable.
• Missed injuries may result in infection, osteomyelitis, growth disturbance and nail deformity.

• Dorsal MCP dislocation is more common than volar dislocation and usually follows hyperextension.
• In a simple dislocation, closed reduction is possible. In a complex dislocation, the volar plate and surrounding soft tissues become interposed around the metacarpal head.
• The index finger is a classic site of complex MCP dislocation.
• Do not repeatedly pull with longitudinal traction when the metacarpal head is buttonholed through the volar structures. This can convert a reducible injury into a more tightly incarcerated one.
• Irreducible injuries require open reduction through a dorsal or volar approach depending on surgeon preference and injury anatomy.
• Following reduction, assess joint stability, collateral ligaments and neurovascular function and obtain post-reduction imaging.

• The sagittal bands stabilise the extensor tendon centrally over the MCP joint.
• A direct blow or forced MCP flexion may rupture a sagittal band, allowing the extensor tendon to subluxate—commonly toward the ulnar side.
• The patient may report painful snapping or inability to initiate MCP extension from a flexed position.
• Dynamic examination demonstrates displacement of the extensor tendon during flexion and relocation during extension.
• Ultrasound or MRI can be helpful when the diagnosis is uncertain.
• Acute injuries can often be treated with a relative-motion or sagittal-band-type splint. Chronic symptomatic instability may require surgical repair or reconstruction.

• Collateral ligament injuries commonly result from sideways deviation of the finger during sport.
• Localised tenderness, swelling and pain with varus/valgus stress are typical.
• Plain radiographs exclude an associated avulsion fracture or joint subluxation.
• Most stable injuries are managed with buddy taping and early motion.
• Persistent PIP swelling for weeks or even months after a ligament injury is common and does not necessarily indicate failure of healing.
• Operative treatment is uncommon but may be required for irreducible injuries, major instability or selected displaced avulsion fractures.

• A fight bite occurs when the dorsal MCP region strikes another person’s teeth while the fist is clenched.
• The external wound may be only a few millimetres long but may penetrate the extensor tendon, capsule and MCP joint.
• When the fingers subsequently extend, the skin and tendon move relative to the original point of penetration, potentially carrying contamination deeper into the joint and tendon structures.
• Any wound over the dorsal MCP joint after punching another person should be considered a contaminated human bite with possible joint penetration until proven otherwise.
• Examine the wound with the MCP joint positioned appropriately to reproduce its position at injury and assess tendon and joint involvement.
• Management may require formal irrigation and debridement, particularly when the joint or tendon is penetrated, together with appropriate antimicrobial therapy and tetanus assessment.
• Human bite wounds are generally not treated like simple clean lacerations. Primary closure may be inappropriate in contaminated hand wounds.
• Complications include septic arthritis, extensor tendon infection, osteomyelitis and severe loss of hand function.

• Open hand fractures range from small puncture wounds communicating with otherwise stable fractures to devastating crush injuries with bone loss, tendon disruption and vascular injury.
• Initial priorities include haemorrhage control, neurovascular assessment, sterile dressing, appropriate antibiotics, tetanus prophylaxis and early surgical assessment.
• Document tendon and nerve function before local anaesthesia whenever possible.
• A small wound does NOT imply a minor open fracture. The mechanism, contamination, tendon involvement and joint penetration are more important than skin-wound length alone.
• Operative debridement is indicated for contaminated wounds, devitalised tissue, joint penetration, unstable fractures and other significant open injuries.
• Fixation strategy must balance stability against the condition of the soft-tissue envelope.

• Flexor tendon lacerations should be suspected in any volar hand or finger wound associated with loss of active flexion.
• Test FDS and FDP separately in every injured digit.
• Zone II injuries—historically termed “no man’s land”—are particularly challenging because both FDS and FDP run within the fibro-osseous sheath and postoperative adhesions may markedly impair gliding.
• Partial tendon injuries may preserve active motion and can therefore be missed unless strength, pain and tendon integrity are carefully assessed.
• Complete tendon lacerations generally require operative repair followed by a structured hand-therapy protocol.
• Successful flexor tendon treatment is not simply a good repair—it is a good repair PLUS controlled tendon gliding during rehabilitation.

• Extensor tendons are superficial and vulnerable to laceration over the dorsum of the hand and fingers.
• Injuries may present as mallet finger, central slip disruption, sagittal band injury or open tendon laceration depending on the anatomical zone.
• Because juncturae tendinum can transmit extension from adjacent digits, a proximal extensor tendon laceration may not always produce complete loss of apparent finger extension.
• Open extensor injuries should therefore be explored and assessed carefully rather than relying solely on gross active extension.
• Rehabilitation protocols depend on the level of injury and repair and may involve static or relative-motion splinting.

• Nail-bed injuries frequently accompany fingertip crush injuries and distal phalanx fractures.
• Assess the nail plate, nail folds, germinal matrix, sterile matrix and underlying distal phalanx.
• A painful subungual haematoma with an intact nail plate may be relieved by trephination in appropriate cases.
• Disrupted nail margins, nail avulsion, significant nail-bed laceration or an associated displaced fracture may require formal nail-bed assessment and repair.
• In paediatric patients, a nail plate lying superficial to the eponychial fold after trauma should immediately raise suspicion for a Seymour fracture.

The decision for surgery should not be based on a single radiographic number. Age, occupation, hand dominance, functional requirements, soft-tissue condition, fracture stability and the ability to participate in rehabilitation all influence treatment.

• K-wires: inexpensive, versatile and minimally invasive; useful for percutaneous pinning, transverse fixation and temporary joint stabilisation. Disadvantages include pin-site infection, less rigid fixation and potential need for immobilisation.
• Lag screws: excellent for sufficiently long oblique or spiral fractures and selected articular fragments; provide interfragmentary compression with minimal implant bulk.
• Headless compression screws: useful in selected metacarpal and phalangeal fractures and can provide stable fixation with minimal prominence.
• Intramedullary fixation: useful for selected metacarpal shaft and neck fractures; minimises dorsal soft-tissue dissection.
• Plates: provide strong fixation for unstable, comminuted or multiple fractures and facilitate early mobilisation, but may cause tendon adhesions, stiffness and hardware irritation.
• External fixation: useful for severe comminution, soft-tissue injury and selected intra-articular fractures where ligamentotaxis can restore length and alignment.
• The objective of fixation is NOT the strongest construct possible. It is sufficient stability for fracture healing and EARLY FUNCTION with the least additional soft-tissue injury.

• A perfectly reduced hand fracture that becomes permanently stiff is not a successful outcome.
• Early active movement should begin as soon as fracture stability and soft-tissue healing permit.
• Uninjured joints should remain mobile throughout treatment whenever possible.
• Elevation and oedema control are important during the acute phase because persistent swelling promotes stiffness and tendon adhesions.
• Hand therapy may include active range-of-motion exercises, tendon-gliding exercises, blocking exercises, scar management, oedema control, splint modification and progressive strengthening.
• Strengthening usually begins only after sufficient biological healing and clinical stability have developed.
• Return to sport and heavy manual work depends on fracture pattern, fixation, tenderness, motion, grip strength and risk of reinjury rather than X-ray appearance alone.

• Stiffness: probably the most common function-limiting complication; associated with prolonged immobilisation, intra-articular injury, oedema and tendon adhesion.
• Malrotation: produces scissoring and impaired grip and may require corrective osteotomy when symptomatic.
• Malunion: angular or shortening deformity may alter grip mechanics and tendon balance.
• Nonunion: relatively uncommon in many closed hand fractures but risk increases with severe soft-tissue injury, infection, bone loss and certain unstable patterns.
• Tendon adhesions: particularly relevant after open injury and dorsal plating.
• Infection: major concern in open fractures, bite injuries and contaminated wounds.
• Post-traumatic arthritis: may follow Bennett/Rolando fractures, metacarpal head fractures, PIP fracture-dislocations and other articular injuries.
• Complex regional pain syndrome: consider when pain, swelling, stiffness and autonomic changes are disproportionate or persistent.

• ROTATION is the deformity you must never miss. Check the finger cascade clinically; an apparently acceptable X-ray does not exclude rotational malalignment.
• Index and middle metacarpals tolerate less angulation because their CMC joints are relatively rigid; ring and little metacarpals tolerate progressively more sagittal angulation because their CMC joints are more mobile.
• Boxer’s fracture: fifth metacarpal neck fracture with apex dorsal angulation and volar displacement of the head.
• Jahss manoeuvre: uses the flexed proximal phalanx as a lever to correct metacarpal neck angulation.
• Bennett = two-part intra-articular first metacarpal base fracture-dislocation. Rolando = comminuted intra-articular first metacarpal base fracture, classically T/Y shaped.
• In Bennett fracture, maintaining thumb CMC congruity is the fundamental objective of treatment.
• Stener lesion: displaced UCL lies superficial to the adductor aponeurosis and cannot heal anatomically without restoring the ligament to its insertion.
• Volar PIP dislocation should raise suspicion for central slip injury.
• Mallet finger = cannot EXTEND DIP. Jersey finger = cannot FLEX DIP.
• Jersey finger most commonly involves the ring finger and requires early surgical assessment.
• Central slip injury may initially have no boutonnière deformity; use the Elson test when suspected.
• PIP fracture-dislocations are assessed according to articular involvement AND dynamic stability—not fragment size alone.
• Seymour fracture: paediatric distal phalangeal physeal injury + nail-bed injury = open fracture until proven otherwise.
• Fight bite: a tiny dorsal MCP wound can communicate with the extensor tendon and MCP joint. Never dismiss it because the skin wound looks small.
• Complex MCP dislocation may be irreducible because of volar plate and soft-tissue interposition; repeated traction can worsen incarceration.
• POSI / intrinsic-plus position: wrist approximately 20–30° extension, MCP joints 70–90° flexion and IP joints near extension when prolonged immobilisation is necessary.
• The three major causes of poor outcome after hand fractures are MALROTATION, ARTICULAR INCONGRUITY and STIFFNESS.
• The best fixation is not necessarily the most rigid fixation. The ideal construct provides adequate stability while minimising tendon and soft-tissue damage and permitting early controlled mobilisation.
• Always document tendon and neurovascular function before and after reduction.
• When a hand fracture is stable enough to move safely, movement is part of the treatment—not something that begins only after treatment is complete.

The successful management of hand trauma requires a balance between anatomical restoration and preservation of movement. Some markedly angulated fractures can function extremely well without surgery, whereas a subtle rotational deformity, small displaced articular fracture, missed tendon injury or unnecessarily immobilised PIP joint may cause major long-term disability. For this reason, clinical examination, fracture stability, soft-tissue assessment and rehabilitation must always be considered together rather than treating the radiograph in isolation.