Analysis of 1430 hand fractures and identifying the ‘Red Flags’ for cases requiring surgery

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Summary

Background

Hand fractures constitute 20% of hand injury patients who apply to emergency services. Conservative approaches are satisfactory in the majority of the cases. However, the minority group in need of surgery reaches a serious number of patients considering the frequency of these injuries. Retrospective questioning of the indications of the performed surgeries is a proper way of understanding the decisional process for surgery.

Patients/Methods

Patients treated for hand fractures were retrospectively reviewed. Patient gender, age, finger/fingers involved, soft tissue involvement, treatment method (conservative/surgery) and if operated, devices used for fixation were noted. Plain radiographs of the patient were evaluated. Descriptive statistics of these variables and the effect of each variable on the decision for surgery were analyzed.

Results

The study involved 1430 fractures of 1303 patients (1016 male and 287 female). Fifth finger was the most commonly injured digit (31%). Comminuted fractures (29%) followed by transverse fractures (29%) and spiral/oblique fractures (22%) were commonly diagnosed fracture types. Thirteen percent (13%) of the study group needed tendon/nerve/vessel repairs. Male patients, cases with soft tissue involvement, second, third and fourth finger fractures, fractures involving multiple digits, fractures with an intra-articular component, fractures with dislocation more than 4 mm and angulation more than 15° had a significantly higher rate of surgery.

Conclusion

Less than half of the hand fractures require surgery, and conservative treatment is usually preferred. Certain variables that indicate surgical treatment were identified with our study. These findings may help to weigh the options and choose the right path in doubtful conditions.

Level of Evidence: Level 4, Case-control study

Introduction

Hand fractures constitute 20% of hand injury patients who apply to emergency services.1 The human hand is a highly specialized and complex organ that needs individualized treatment protocols. For a patient to sustain his/her life without any compromise after a hand injury, the application of an appropriate treatment protocol is essential.

In the treatment of hand fractures, two main principles are imperative: 1) Reducing the fracture and 2) Stabilising the fracture in the reduced state.2 If these two principles are applied, surgically or not, well vascularized long bones of the hand will heal predictably. Conservative approaches are satisfactory in the majority of the cases.3,4 However, for selected cases, surgery should be performed. K-wires, regular plates, screws, cerclage wiring, intramedullary pinning, external fixators and sutures can be used for surgical treatment of hand fractures. The common purpose of all of these devices is to fixate reduced fracture segments and stabilise the fracture line during the recovery period.

Although the ‘reduce & stabilise’ principle is of essence during fracture treatment, a decision between treating with surgical and conservative approaches still needs to be made. For hand fractures, components that make up the injury can have endless combinations, and creating a guideline with strict principles for each injury is unfeasible. Yet, there are some indicators or ‘red flags’, which usually indicate the need for surgical treatment. Cheah and Yao reported that comminuted and spiral fractures, fractures with rotational deformities, excessive angulation and shortening should be considered for surgery.5 However, further studies are needed. The aims of the study are 1) to make a detailed descriptive analysis of injuries of patients presenting with hand fractures, 2) to determine the variables effective on the decision for surgery by retrospective questioning of the indications of the performed surgeries and 3) to present our departmental consensus on hand fracture treatment based on our experience.

Section snippets

Patients/Methods

After permission from the Local Ethics Committee (application number: E20–272), patients treated for metacarpal and phalangeal fractures at our institution between January 2015 and December 2019 were retrospectively reviewed. Patients with records lacking treatment details and plain radiographs, finger replantations and multi-trauma patients (e.g. cerebral haemorrhage and acute abdomen) were excluded.

Patient gender, age, finger/fingers involved in the injury, accompanying soft tissue injury,

Results

The study involved 1430 fractures of 1303 patients. Of 1303 patients, 1016 were male (77%) and 287 were female patients (23%). Age-based analysis showed 57% of all fractures were diagnosed in patients aged between 18 and 55 years (yrs). Preschool children (≤6 yrs, 4.5%) and geriatric patients (≥71 yrs, 2.1%) faceless hand fractures than other age groups (Table 1). Ninety-three percent of fractures occurred in single digits, and the remainder had multiple-digit involvement (Table 2). The fifth

Discussion

Hand injuries have physical, social and psychological effects on patients.7 Social and psychological effects may even be beyond the physical impairment.8 Successful treatment of hand injuries has a primary role in patient's returning to daily activities. This can only be achieved with a treatment plan developed after the evaluation of the patient in all aspects. The first and most important decision to be made during the planning of the treatment is whether to perform surgery.

Both in the

Declaration of Competing Interest

None of the authors have a financial interest in any of the products, devices or drugs mentioned in this manuscript. No funding was received for this article.

References (40)

  • E. Guerado et al.

    Pin tract infection prophylaxis and treatment

    Injury

    (2019)
  • J.J. Roth et al.

    Fixation of hand fractures with bicortical screws

    J Hand Surg Am

    (2005)
  • R.J. Strauch et al.

    Metacarpal shaft fractures: the effect of shortening on the extensor tendon mechanism

    J Hand Surg Am

    (1998)
  • N.M. Caggiano et al.

    Management of proximal inter-phalangeal joint fracture dislocations

    Hand Clin

    (2018)
  • P.C. Amadio et al.

    Scaphoid mal-union

    J Hand Surg Am

    (1989)
  • N.F. Jones et al.

    Common fractures and dislocations of the hand

    Plast Reconstr Surg

    (2012)
  • N.G. Harness et al.

    The history of fracture fixation of the hand and wrist

    Clin Orthop Relat Res

    (2006)
  • M. Farzad et al.

    Does disability correlate with impairment after hand injury?

    Clin Orthop Relat Res

    (2015)
  • G.S. Sorock et al.

    Acute traumatic occupational hand injuries: type, location, and severity

    J Occup Environ Med

    (2002)
  • V.C. Bachelet

    Work-related injuries resulting in death in Chile: a cross-sectional study on 2014 and 2015 registries

    BMJ Open

    (2018)
  • Cited by (2)

    None of the authors have a financial interest in any of the products, devices or drugs mentioned in this manuscript. No funding was received for this article.

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