HAND INJURIES

QUESTIONS AND ANSWERS

Understanding the Hand’s Anatomy of Fractures

When discussing fractures in the hand, it’s crucial to understand its structural components. The hand is intricately connected to the arm through the forearm, which consists of the radius and ulna bones. This connection is vital, as it provides the necessary support and mobility.

Bone Structure

• Carpal Bones: These are the eight small bones that form the wrist. They play a critical role in the hand’s flexibility and are a common site for fractures, especially the scaphoid.
• Metacarpal Bones: Five longer bones stretch from the wrist to the fingers. Dubbed the “body” of the hand, they’re crucial for palm movement, frequently at risk in impact-related injuries.
• Phalangeal Bones: The fingers and thumb each consist of these bones. There are 14 in total, with each finger having three and the thumb having two. Given their location, they’re often involved in fractures due to direct blows or crushing injuries.

Fingers and Thumb Dynamics

• Fingers (Digits 2-5): Each is equipped with proximal, middle, and distal phalanges, which are essential for grip and dexterity. Fractures here can severely impede hand functionality.
• Thumb (Pollex): Composed of only two phalanges, the thumb is vital for pinching and grasping. Its unique structure makes it particularly susceptible to fractures that can affect overall hand utility.

In conclusion, understanding the hand’s anatomy—its carpal, metacarpal, and phalangeal components—is key to grasping the implications of fractures. These elements form the foundation of hand mobility and function.

Growth Plate Injuries

In every child’s and teen’s bones, growth occurs at specific points called growth centers or growth plates, found near the ends of the bone. If the growth plate becomes damaged by a fracture or another injury, the bone may stop growing — growth arrest. Growth arrest can permanently stop a bone’s development and change its functions. If only part of the growth plate becomes damaged and stops working, the bone may grow unevenly.

An injury that breaks a bone may also damage a child’s growth plates or soft tissues, such as skin, ligaments, or tendons. In addition, damage to growth plates or soft tissues may affect the way doctors treat your child’s fracture. Furthermore, seeing a pediatric orthopedic specialist who focuses on treatment options based on the location of the fracture and whether or not it will affect the growth plates is extremely important for the future of your child’s recovery.

Our physicians at Medical City Children’s Orthopedic and Spine Specialists have the experience and expertise in the treatment of hand fractures. Our board-certified physicians specialize in the treatment of children and adolescents and can give your child the care and attention they deserve at one of our five locations in the DFW area.

Symptoms of Hand Injuries

Some symptoms of hand injuries are clear, for instance, when the bone in the hand breaks through the skin. Other broken hand symptoms include:

• Swelling, bruising, and bleeding
• Severe pain
• Bone or joint with the wrong shape
• Poor range of motion in the affected area
• Inability to move the affected part

When to Seek Medical Care

If a child has a hand injury, seek medical attention as soon as possible to prevent complications. The injury can become more devastating as medical care is delayed. Even a seemingly innocent hand injury could need advanced treatment to prevent infection or loss of function. Any form of a laceration that needs stitches requires a medical evaluation. If you are not sure if the cut your child sustained needs stitching, get in touch with one of our doctors for guidance.

Hand injuries that cause the following symptoms require emergency medical care:

• Numbness
• Severe bleeding
• Severe pain
• Loss of strength or motion
• Tenderness, redness, local warmth, fever, pus, or any other signs of infection
• Deformity or amputation
• Exposure of the tendons, bones, joints, veins, arteries, or nerves

Diagnosis

To detect hand injuries, doctors begin with an examination of the child. While examining the child, the doctor will check how the bones line up as the child moves the hand (provided they can) and when the doctor tries to move it (if the child cannot move the hand). The doctor will look for damage to the fingernail, ligaments, tissue under the nail, tendons, or joints.

If at least one bone appears broken, the doctor will request X-rays to determine the actual type of treatment to provide. In most cases, the child will require X-rays from 3 angles to enable the doctor to closely observe the fracture or fractures.

Diagnosing Complex Hand Fractures

For a doctor to correctly diagnose a hand injury takes skill that encompasses years of experience. Doctors can treat simple fractures with a cast or splint. On the other hand, complex fractures may require surgery. The ability of a doctor to determine when a child’s broken hand requires surgery takes special training and expertise in pediatric trauma. Our doctors have the knowledge, skills, and abilities to make the correct decisions regarding surgery.

If the bone breaks at or near a growth plate, it can injure the growth plate. Because the growth plate does not appear on an X-ray (although some signs of damage can be seen), the doctor may request a magnetic resonance imaging (MRI) scan to determine injury to the growth plate.

The Role of Advanced Imaging in Diagnosis

Advanced imaging, such as CT or MR, is sometimes useful for a more comprehensive assessment. CT scans offer the advantage of viewing complicated fractures from multiple viewpoints, which helps in understanding the full extent of the injury. Moreover, modern CT technology allows for 3D reconstructions of injuries, providing enhanced viewing capabilities.

MRI scans, on the other hand, are best suited for adding additional information regarding soft tissue injuries associated with fractures. An MRI can image tendons, ligaments, and muscles, offering a detailed look at any associated damage. This detailed imaging is crucial for forming an accurate diagnosis and developing an effective treatment plan.

By combining these advanced imaging techniques with expert clinical evaluation, doctors can ensure a precise and thorough diagnosis, leading to optimal treatment outcomes for hand injuries.

What Does a Neurological Examination for a Hand Fracture Involve?

When you visit your hand surgeon, they’ll conduct a detailed neurological examination to assess the severity and impact of your hand fracture. Here’s what you can expect:

History and Symptom Review:

• Your surgeon begins by discussing your symptoms and reviewing relevant medical or family history. This dialogue helps identify any underlying conditions that may affect your recovery.

Physical Examination:

• The examination starts with a thorough check of the injured limb. The focus is on not just the hand but potentially related areas like the wrist, forearm, elbow, or shoulder. This ensures no associated injuries are overlooked.

Neurological Focus:

• Sensory Testing: The doctor will test your child’s ability to feel various stimuli. This involves light touch, pinprick, or temperature differentiation tests to assess nerve sensation in the fingers and hand.
• Motor Function Evaluation: The surgeon will examine the movement capabilities of your child’s hand. The doctor will ask your child to perform certain movements to see how well the hand’s muscles are working and to pinpoint any nerve impairment.

Vascular Assessment:

• The blood flow to the hand and fingers is thoroughly checked. This is crucial because any swelling from the fracture could impinge on the other vascular supply, potentially leading to complications.

Pain and Tenderness Analysis:

• The surgeon will gently press on different areas of your hand to identify spots of pain or tenderness. This can indicate the location of the fracture or if other injuries, like sprains, are present.

By thoroughly assessing both the neurological and vascular aspects of your injury, our doctors will develop a well-rounded treatment plan to ensure optimal healing and function.

Assessing Vascular Status of the Hand During an Examination

Evaluating the vascular status of the hand involves several key steps to ensure that blood flow is adequate and that swelling hasn’t compromised circulation. Here’s how it’s typically done:

• Visual Inspection: The examiner first checks for any visible signs of discoloration or swelling, which could suggest compromised blood flow.
• Palpation of Pulses: The radial and ulnar pulses are felt to ensure they are strong and regular. This step helps determine if the main arteries supplying the hand are functioning properly.
• Capillary Refill Test: A quick and simple method where pressure is applied to the nail bed until it turns white, then released to observe how quickly color returns. Normal refill time indicates good blood flow.
• Skin Temperature: The examiner touches the skin to check for warmth. A cooler temperature compared to the opposite hand might indicate poor blood supply.
• Observation for Signs of Compromise: Swelling, if present, should be assessed to see if it is affecting vascular supply. Any significant tenderness or changes in skin integrity, especially over areas suspected of injury, are also noted.

By thoroughly assessing these factors, healthcare providers can determine the vascular health of the hand and identify any issues that might require further investigation.

What Are the Risks Associated with Hand Fracture Surgery?

Hand fracture surgery, while generally safe, carries some risks that patients should be aware of before undergoing the procedure. The likelihood of blood loss during the surgery is typically low, so additional blood-thinning precautions, like deep vein thrombosis prophylaxis, are often unnecessary unless specifically recommended by a healthcare professional.

Nonetheless, here are some other potential risks involved:

• Infection: As with any surgical procedure, there is a chance of infection. It’s crucial to follow post-operative care instructions to minimize this risk.
• Bone Healing Complications: There may be instances where the fractured bones do not heal properly or as expected, potentially requiring further medical attention.
• Tendon Issues: There is a risk of tendon rupture, which could impact hand functionality and prolong recovery time.
• Stiffness: Post-surgery, some patients might experience stiffness in the hand that could necessitate physical therapy for full recovery.

Being informed about these possibilities can help you have a more comprehensive discussion with your surgeon and make a well-considered decision about undergoing surgery. Remember, following all aftercare guidelines and attending follow-up appointments significantly contributes to a successful recovery.

Treatment

The hand injury treatment that we provide for your child will depend on the fractured bone and the type of hand fractures sustained. The factors that determine the type of treatment to provide include:

• Stability of the bone (whether the fractured bone is stable or easily moves out of place)
• The alignment of the bone (whether the bone is properly aligned or out of position)
• The age of the child (the child’s growth stage affects how the bone heals)

Treatment of a Broken Hand

It is better not to do more or less than what is required to get the desired results. In most cases, children’s hand injuries heal perfectly with casting or splinting. However, it should be noted that hand fractures heal differently in kids than in adults.

Application of Buddy Tape, Splint, or Cast

If the child’s X-ray reveals a fracture but the bone remains aligned, the child may require a splint so that the bone keeps its place while healing. In some hand fractures, buddy taping takes place. In this case, two fingers are taped together to prevent the affected part of the bone from moving too much.

A splint or buddy taping may provide the solution to allow the bone to heal. Depending on the bone that was fractured and the severity of the break, doctors may apply a cast when the swelling goes down. A cast is usually applied if it is suspected that the fractured bone may not heal unless it is kept in one position. Our specialists also use casts because they make the child feel more comfortable, since the broken hand and wrist are kept still. Also, this makes the child feel less pain whenever the affected area gets moved or bumped.

Additional Considerations in Nonoperative Treatment

For effective healing, immobilization is often paired with elevation to reduce swelling. This initial step is crucial for both children and adults and typically involves positioning the hand in a specific way, known as the “intrinsic plus” position, where the proximal finger joint is flexed at 90 degrees while the distal joints are held in extension.

As the fracture heals, the immobilization method may change, with patients transitioning through various splints, casts, or braces. This progression is typical, reflecting the dynamic nature of the healing process. To prevent stiffness in joints that aren’t directly impacted by the fracture, incorporating range of motion exercises is essential. This helps maintain flexibility and function in areas not covered by the splint or cast.

Many patients benefit from hand therapy, where a therapist guides the delicate balance between necessary immobilization for bone healing and the movement required to avoid joint stiffness. This holistic approach ensures optimal recovery and function post-injury.

Fracture Reduction

If the X-ray reveals that the fractured bone occurs in a bad position, the doctor will try to perform fracture reduction (which involves trying to move the bone back into position) before applying a splint, tape, or cast. For instance, this can occur by the doctor moving the child’s finger or hand (closed reduction). Before carrying out this procedure, we give the child anesthesia or a sedative.

Surgical Treatment

When dealing with hand fractures, it’s crucial to determine the appropriate treatment method. If the doctor cannot perform a closed reduction, they will consider surgery. Our surgeon will make a small incision to see the fracture and move the fractured bone (open reduction).

To ensure proper healing, we may use various types of hardware:

• Pins (Kirschner wires): These are often used due to their effectiveness in stabilizing small bones, like those in the hand.
• Specialized Plates and Screws: These help reposition bone fragments into their normal alignment. Given the smaller size of hand bones, proportionately smaller screws and plates are used.

This hardware helps keep the affected bone in place during the healing process. Because of the specialized structure of the hand, hardware removal may sometimes be necessary. These components will be removed when the child comes for a clinic visit. By using the appropriate hardware, we aim to restore function and strength to the hand efficiently.

Maintenance of alignment typically requires placing hardware, like pins, plates, and screws, into the hand. This ensures that the bones remain correctly aligned while healing progresses, providing the best possible outcome for recovery. Most children with hand injuries do not need surgical treatment. If your child needs surgery, our specialists will ensure that he or she gets the appropriate surgery for his or her injury.

How Does a Hand Surgeon Identify Related Injuries in a Hand Fracture?

When you visit a hand surgeon for a fracture, they conduct a thorough evaluation not only of your hand but also of other connected areas. Here’s how they determine if additional injuries are involved:

Patient History and Symptoms

• The surgeon will first discuss your symptoms and delve into any relevant family or medical history. Understanding your background helps in identifying risk factors and predisposing conditions.

Physical Examination

• Next, the surgeon examines the injured hand carefully. They pay close attention to how the injury occurred and to which specific movements cause pain or discomfort.

Assessment of Nearby Structures

• The focus isn’t solely on the hand. They also examine other areas on the same side of the body, including:
  • Wrist
  • Forearm
  • Elbow
  • Shoulder

  This helps in detecting any other potential injuries you may have overlooked that could influence treatment and recovery.

Additional Diagnostic Tools

• Depending on the initial findings, the surgeon might use imaging techniques like X-rays, MRIs, or CT scans. These tools provide detailed insights into any associated injuries that are not visible during the physical examination.

By combining these methods, a hand surgeon ensures that all potential injuries are recognized and addressed in your treatment plan, leading to a more comprehensive recovery.

What to Expect After Hand Fracture Treatment

Receiving treatment for a hand fracture generally leads to significant improvements in mobility and strength. However, it’s essential to have realistic expectations about the recovery process. Patients often notice some level of stiffness following treatment, which is a common aspect of healing. Additional procedures could be necessary if complications arise, but these are not always required.

Return to Normal Activities:

• Sports and Physical Activity: Resuming sports or intense physical activities typically takes about three to six months. During this period, it’s crucial to follow a tailored rehabilitation program to ensure proper healing.
• Daily Improvements: Many patients experience gradual enhancements in their hand function for up to a year post-treatment.

While each individual’s journey varies, understanding these outcomes helps in setting achievable recovery goals.

Postoperative Care Recommendations After Hand Fracture Surgery

After hand fracture surgery, achieving optimal recovery requires a comprehensive care plan. Here’s what to expect:

Initial Steps

• Elevation and Mobility: Right after surgery, it’s crucial to keep the affected hand elevated to minimize swelling. Start practicing range of motion exercises for fingers that weren’t involved in the surgery to preserve flexibility and function.

Two Weeks Post-Surgery

• Suture Removal: At about two weeks, sutures typically come out. Some may transition into a removable brace designed for support and mobility.

Six Weeks Onwards

• Healing Progress: By this time, significant healing often allows for gradual weaning from any splint or brace.
• Exercise Routines: Begin intensive work on range of motion exercises if not already started. These can be carried out at home or under the guidance of a hand specialist.
• Strength Training: Emphasize strengthening exercises for the hand, wrist, and arm. Consistent efforts in building strength and flexibility are crucial; diligent practice substantially improves the functionality of the wrist and hand.

By following these steps and collaborating with healthcare professionals, most individuals regain excellent use of their hands and wrists, allowing them to return to daily activities efficiently.

What is the “Intrinsic Plus” Position in Immobilization?

The “intrinsic plus” position is a specific technique used in immobilizing hand injuries to ensure optimal healing. This position involves flexing the proximal finger joint to approximately 90 degrees while keeping the distal finger joints extended.

Why Use the Intrinsic Plus Position?

• Prevents Stiffness: By placing the fingers in this configuration, it helps maintain balance in the soft tissues.
• Promotes Healing: This position supports the ligaments and tendons, reducing strain on the injured area and promoting a quicker recovery.

When is it used

The intrinsic plus position is commonly applied after specific hand injuries or surgeries to stabilize the affected area. It is essential for conditions like fractures and tendon repairs, enabling the hand to heal in a more functional alignment. In summary, the intrinsic plus position offers a protective structure for the hand, facilitating recovery while minimizing the risk of developing complications such as contractures or stiffness.

Recovering from a Hand Fracture: When Can Children and Teenagers Get Back to Sports?

Suffering a hand fracture can be frustrating for athletes eager to return to their sport. The recovery time largely depends on the specifics of the injury and the individual’s healing process. Typically, a return to sports might take anywhere from three to six months.

Factors Influencing Recovery Time

• Severity of the Fracture: Minor fractures could lead to a quicker recovery, while more complex breaks might necessitate extended healing.
• Type of Treatment: Whether your injury requires surgery or just immobilization can significantly influence the timeline.
• Rehabilitation Process: Consistent physiotherapy and following medical advice can hasten recovery and improve outcomes.

Typical Recovery Stages

• Initial Recovery (0-6 weeks): Immobilization is crucial during this phase to ensure proper healing. Swelling and pain management are also key focuses.
• Intermediate Phase (6-12 weeks): As mobility gradually returns, physical therapy helps regain strength and flexibility.
• Final Stages (3-6 months): This period involves re-introducing sport-specific movements under professional guidance to ensure a safe and effective return.

It’s essential to follow your healthcare provider’s recommendations closely and listen to your body to avoid setbacks. Remember, rushing back too soon can lead to re-injury or prolonged recovery time.

Rehabilitation Progression After Hand Fracture Surgery

Recovering from hand fracture surgery is a structured process designed to restore function and strength gradually. Here’s how rehabilitation typically unfolds:

Initial Post-Surgery Care

In the early days following surgery, patients are guided to elevate the affected area to reduce swelling. Focus is initially on mobilizing the unaffected fingers to maintain their range of motion.

Two-Week Milestone

Around the two-week mark, patients may have their stitches removed. Depending on recovery, a removable brace might be introduced to support the healing hand while allowing for more flexibility.

Six-Week Checkpoint

By the sixth week, significant healing is usually evident. Patients often begin to transition out of splints, shifting focus to improving movement. Rehabilitation can be pursued through guided exercises at home, although some may benefit from consulting a hand specialist.

Strengthening Phase

As healing progresses, strengthening the hand, wrist, and arm becomes crucial. Exercises aimed at enhancing these muscle groups ensure that patients regain optimal use of their hands and wrists. With dedicated effort to improve both mobility and strength, many achieve excellent recovery outcomes.

Regular follow-up appointments will help track progress and make any necessary adjustments to the rehabilitation plan.

Why is Hand Therapy Essential for Hand Fractures?

Hand therapy plays a crucial role in the effective recovery from hand fractures. Here’s why it deserves a pivotal place in your treatment plan:

• Balancing Immobilization and Mobility: As your fracture starts to heal, the need to balance between keeping your hand still and encouraging movement becomes critical. Hand therapists specialize in ensuring that joints stay flexible without compromising the healing process. This dual focus helps prevent joint stiffness while the fracture mends.
• Customized Care Plans: Every hand fracture is unique, and so should be the recovery strategy. Hand therapists offer tailored exercises designed to strengthen your muscles and tendons as the bones heal. This personalized approach ensures faster and more efficient recovery.
• Progressive Brace Adjustments: The braces that are used to protect fractures often require adjustments over time to support healing progress. Hand therapists monitor your improvements and can advise when it’s necessary to modify the brace, ensuring optimal protection and comfort throughout the recovery period.
• Preventing Long-term Issues: Engaging with a hand therapist can significantly reduce the risk of long-term complications, such as restricted motion or chronic pain. By addressing these issues early, you can preserve the functionality and strength of your hand.

Incorporating hand therapy into your recovery not only addresses immediate healing needs but also safeguards the long-term health and functionality of your hand.

Medical City Children’s Orthopedic and Spine Specialists Provides Children and Teenagers Relief from Hand Injuries.

At Medical City Children’s Orthopedic and Spine Specialists, we understand the growing bones in children and teenagers. We are adept at providing the appropriate hand fracture care, including surgery for the most complicated injuries.

Finally, we treat thousands of children and teens every year at our offices in  Dallas, Arlington, Flower Mound, Frisco, and McKinney, TX.  Contact us today to learn more about our hand injury treatment options, which cater to hand fractures and growth plate injuries in children.

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Footnote:

Lifespan: Hand Injury