Boxer 39;s Fracture Splint Australia

[Ahmend Studioz]

Metacarpalfractures are a common injury in older children and adolescents, particularly the little and ring fingers. They usually occur due to a blunt force applied to a clenched fist such as punching a fixed object or from falling onto a closed fist.

Closed metacarpal injuries not needing reduction should be splinted in the safe hand position (Wrist in 20 degrees of extension, MCP joints in 70 degrees of flexion, IP joints in full extension)

Where required, reduction can take place under procedural sedation and/or regional anaesthesia. After applying some longitudinal traction to the digit, the MCP is flexed to 90 degrees and then axial loading applied to the proximal phalanx to correct any flexion angulation. The hand is then splinted in the safe hand position as above.

The causes of hand injuries are varied and include sporting accidents, occupational injuries and bites of various types. This article provides a brief guide to the assessment of hand injuries and outlines the general principles of management for any hand injury followed by more specific detail about common injuries and their management. The aim is not to cover each injury in detail, but to provide a framework so that the general practitioner can confidently assess hand injuries and know which injuries they can manage in their practice and which should be referred to a hand specialist. #

The anatomy of the hand is complex (Figure 1a, b) and an understanding of all its structures is vital. In addition to the general principles common to the assessment of any injury, there are particular issues relevant to examining hand injuries.

Rotational deformity of hand fractures can only be assessed clinically. All fractures with rotational deformity require surgical evaluation. Assess metacarpal rotation by checking a relaxed fist (Figure 2a, b). Assess rotational deformity of the phalanges by examining the fingers end-on with distal interphalangeal (DIP) joint and proximal interphalageal (PIP) joint flexion.2

Figure 2. A) Normal hands. The fingers should sit next to each other without overlap, fingernails pointing in the same direction. As a normal variation, the fifth finger can rotate inward and sit under the fourth finger

B) Malrotation of the fifth finger

The integrity of all tendons needs to be established. Assess flexor digitorum profundus (FDP) (Figure 3a) and flexor digitorum superficialis (FDS) (Figure 3b) separately. If the ability to flex against resistance is absent or reduced, there is tendon damage. Another clue suggesting tendon injury is when resistance cannot be generated due to pain, particularly if the pain is in excess of expected.

Check the integrity of interphalangeal joint ligaments by stressing the joint into ulnar and radial deviation and also in anterioposterior direction. Pain, laxity and loss of the firm-end-feel suggest ligament injury. The PIP joint collateral ligaments should be checked with the joint in 30 degrees flexion and with the metacapophalangeal (MCP) joints flexed to 90 degrees.3

Figure 3A) Digitorum profundus (FDP); B) Digitorum superficialis (FDS)

FDP is assessed by stabilising the PIP joint and testing ability to flex the distal phalanx with and without resistance FDS is assessed by stabilising the MCP joint and testing ability to flex the finger with and without resistance

The hand is highly susceptible to permanent loss of joint range with immobilisation. Therefore the duration of full immobilisation is much less than for other fractures, and early movement is promoted through exercise and dynamic splints.4

Figure 5. Hand with volar plates at PIP highlighted. The volar plate is a thick fibrocartinolginous structure that reinforces the palmar surface of the interphalangeal joints and prevents hyperextension

Reproduced with permission Primal Pictures. Available at www.primalpictures.com

Hand fractures are highly prone to displacement (Figure 6a, b) due to the opposing pull of tendons and lack of muscles bellies in the finger. Therefore, most hand fractures require at least one follow up X-ray approximately 1 week after the injury.2,6

In general, closed and minimally displaced fractures with good alignment can be treated conservatively.4 Phalangeal fractures are fully immobilised for a maximum of 3 weeks2,4,6 followed by reduced immobilisation and active exercise. Unstable fractures require referral.

Dislocation of the PIP joint most commonly occurs dorsally from hyperextension stress. An X-ray should be performed before and after reduction. However, in practice, most of these dislocations are already reduced before presentation. Treat fractures as required. For dislocation to have occurred, the volar plate and collateral ligaments will have been damaged. If after reduction:

An X-ray should be ordered, as mallet finger can occur with an avulsion fracture. Surgery is required when an avulsion fracture involves more than 30% of the articular surface or if there is joint subluxation. Otherwise, mallet finger deformity responds well to conservative management.

Maintain the DIP joint in slight hyperextension via a splint for a minimum of 6 weeks. It is crucial to maintain extension at all times, even when removing the splint for hygiene purposes.9 Patients must be aware that failure to do this will result in permanent joint deformity. While research9 indicates similar outcomes for various splints, premade splints are only available in a small range of sizes, and custom made splinting may be required. After 6 weeks, check for active pain free extension and then begin intermittent splinting and active rehabilitation.

Injury to the central slip of extensor digitorum occurs from a direct blow to the PIP joint, or from the same mechanism of injury that causes mallet finger deformity. The patient initially presents with pain but no deformity. The injury is detected by examining active finger extension: the PIP joint will lag behind the DIP joint and full range can be lost.

Surgery is required if there is associated intra-articular fracture of >30%. Treatment involves splinting the PIP joint in full extension while allowing DIP joint flexion for 6 weeks. Intermittent splinting and active rehabilitation is then required.

Figure 9. Boutonnire deformity

The rupture of the central slip of extensor digitorum from its insertion allows the lateral bands to migrate in a palmar direction. In turn, the middle phalanx is then pulled into flexion by FDS; the PIP joint herniates through the central slip tear

Reproduced with permission: Brukner P, Khan K. Clinical Sports Medicine. 3rd edn. Mc-Graw Hill, 2006

Lacerations to the hand require exclusion of damage to underlying structures. Examine movement and sensation before the infiltration of local anaesthetic. Careful wound exploration can then take place. An X-ray should be performed if the mechanism of injury suggests a fracture is possible.

Simple lacerations should be copiously lavaged and irrigated then sutured loosely to allow ooze. Although normal saline is traditional, there is evidence12 to suggest that drinking-quality tap water is a viable option. Delayed closure is accepted practice in wounds that present after 6 hours of injury. Antibiotics should be prescribed as per antibiotic guidelines13 and tetanus toxoid administered as necessary.

Depending on the punching force, the bone may end up in multiple pieces or become significantly displaced resulting in a deformity. This will therefore determine whether the fracture can be treated conservatively versus surgically. Your doctor will generally request you to have an x-ray to help determine your treatment plan.

Conservative or non-surgical treatment generally involves fracture reduction, where the bone fragments are put back into place, followed by immobilisation through a custom-made hand-based splint and buddy taping, or the taping together of a fractured digit with a healthy one next to it (most likely the pinky and ring fingers) to help prevent malrotation of the pinky.

Inflammation: The fracture triggers an inflammatory response, eliciting migration of immune cells to the site. These cells remove debris, bacteria, and damaged tissue, creating a clean environment for healing

Soft callus formation: Within a few days, cells called fibroblasts begin to produce collagen, a protein that forms a soft callus bridging the fracture site. This soft callus stabilises the broken bone fragments and serves as a scaffold for subsequent healing.

Hard callus formation: Over several weeks, specialised bone-forming cells called osteoblasts start depositing minerals, such as calcium and phosphorus, onto the collagen framework. This process gradually converts the soft callus into a hard callus, made of woven bone.

Surgical intervention is often resorted to if the fracture is too displaced or significant malrotation of the bone. Upon reviewing the xray images and finger presentation, your GP/hand therapist may refer you to a surgeon for an opinion. If surgery is required, the surgeon will realign and stabilise the affected bone or bones, using wires, screws, pins, or plates, depending on the nature and extent of the damage.

Clamdigger (4th and 5th) metacarpal fracture splint. Malleable palmar and dorsal aluminium stays are easily bent to immobilize the patient's hand in the desired position. Moulded plastic clamshell design protects and supports the 4th and 5th metacarpals without restricting flexion of the other fingers.

Metacarpal fractures are caused by a blunt force such as a punch or a compression of the hand during trauma.\u00a0 Metacarpal fractures are often referred to as a \u2018boxer\u2019s fracture\u2019 due to this mechanism of injury.

No generally Metacarpal Fractures do not require surgery. Action Rehab therapists can assess the X-ray and can advise if your Metacarpal Fracture needs surgery and refer you immediately to our network of Upper Limb Specialist Surgeons.\u00a0

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