Hand Injuries: Standard Treatment Guidelines

The hand is a very complex organ with multiple joints, different types of ligament, tendons and nerves. With constant use, it is no wonder that hand disease injuries are common in society. Hand injuries can result from excessive use, degenerative disorders or trauma.

The Ministry of Health and Family Welfare has issued the Standard Treatment Guidelines Critical Care for Hand Injuries. Following are the major recommendations:

Carpal Injuries

Scaphoid Fracture

Introduction : Fracture of the carpal scaphoid bone is the most common fracture of the carpus, and frequently diagnosis is delayed.

Incidence & classification: Scaphoid fracture accounts for about 50-80% of carpal injuries. It is most common in young men. It is caused by a fall on the outstretched palm, resulting in severe hyperextension and slight radial deviation of the wrist. Herbert’s classification is most commonly used for scaphoid fracture:

Diagnosis & Investigations : Clinical evaluation + X-rays (PA, Lateral, scaphoid view, clenched fist view), MRI, CT, bone scan may be used to diagnose occult scaphoid fractures

Complications : Delayed union, malunion, nonunion, osteonecrosis, CRPS

Management :

1. Tuberosity fractures and Nondisplaced distal third fractures: Conservative with scaphoid cast for 6-8 weeks

2. Other Non-displaced fractures: Conservative or Percutaneous fixation

3. Displaced but reducible fractures: Percutaneous fixation

4. Irreducible displaced fractures: ORIF

Reasons for referral to higher centre : Lack of expertise, lack of infrastructure, Fracture dislocations

Other carpal injuries : Triquetrum, trapezium, lunate are commonest after scaphoid fracture. Trapezoid, capitate, pisiform and hamate are relatively rare fractures. Specialized views or CT scan may be required for their diagnosis. Undisplaced fractures are treated conservatively; however displaced fractures may require ORIF. Complications can be osteonecrosis, missed dislocations, osteoarthritis, CRPS etc.

Hand Fractures :

Metacarpal and phalangeal fractures are common, comprising 10% of all fractures. There is a high degree of variation in mechanism of injury accounting for broad spectrum of patterns of fractures in hand.

Incidence & classification : Distal phalanx fractures are most common of all hand fractures (45%) followed by metacarpal fractures (30%), proximal phalanx (15%) and middle phalanx (10%). These fractures can be classified in various ways:

1. Location of fracture e.g. head, shaft, base

2. Open vs. closed

3. Displaced vs. Undisplaced

4. Extraarticular vs. Intraarticular

5. Stable vs. Unstable

6. Fracture pattern : transverse, comminuted, spiral, split

Diagnosis & Investigations : Clinical evaluation + X-rays (PA, latéral and oblique radiographs). CT may be required to assess the intraarticular fractures.

Complications : Delayed union, malunion, nonunion, CRPS, stiffness and loss of motion, infection, post-traumatic osteoarthritis etc.

Management :

Metacarpal fractures :

Metacarpal head : Undisplaced stable fractures can be treated conservatively with MCP joint immobilized at >70 degrees. Displaced fractures usually require ORIF with k-wires or mini-plates

Metacarpal neck : Stable fractures: Conservative

Unstable fractures : CRIF or ORIF (K-wires, mini-plates)

Metacarpal Shaft : Stable fractures: Conservative

Unstable fractures: CRIF or ORIF (K-wires, mini plates)

Metacarpal Base : Undisplaced: Conservative

Displaced: CRIF or ORIF

Proximal and middle phalanx

Intraarticular fractures : ORIF is preferred. For comminuted fractures, ligamentotaxis with external fixators or specialized reconstruction techniques can be used.

Extraarticular fractures : Stable fractures: Conservative

Unstable fractures: CRIF or ORIF (K-wires, mini plates)

Distal Phalanx

Intraarticular fracture (Mallet finger) : Extension block pinning for bony mallet finger, Extension splinting for soft mallet finger

Extraarticular fractures : Usually treated as soft tissue injury. If displaced widely, CRIF is recommended.

Reasons for referral to higher centre : Lack of expertise, lack of infrastructure, Fracture dislocations

Tendon Injuries

Extensor Tendon Injuries are usually treated with primary repair Flexor tendon injuries are treated according to zone of injuries:

Zone 1: Direct Repair, tenodesis or arthrodesis in some cases

Zone 2: Need expertise, primary repair or delayed grafting

Zone 3: primary repair

Zone 4: primary repair

Zone 5: primary repair

Complication include stiffness, rupture of the graft or repair site, bowstringing etc. referral should be made in case of lack of expertise or infrastruacture.

Comments :

The common deficiency

(q) The writing style is not consistent. Radial head fracture is given as 33% of elbow region while distal radius as 1/6 of fracture (not known) of what?

(r) Imaging – just mentioned AP, Lateral and sometime oblique. Why and for what a particular special x-ray is needed?

(s) Complication has been clubbed as most common to least common, early or late in one list. This will not help.

(t) When to refer – Generally written type B & C to higher center. Can we make such guidelines in the issue.

The outcome of treatment depends on –

i) Training of the surgeon.

j) Infrastructure – operating theatre & available instrumentation

We need to define what all we should have in primary health center, secondary and tertiary care centre. If we refer all type B & C fracture for all fractures than how the patients in Village, Tehsil, District will be treated as we do not have any networking of referral centers (they are all concentrated in the cities.

Summarily the objective of the guidelines should be well stated. Is it to stop small centers in cities to stop operating the particular type of fractures and force them to refer or to make a national policy for the overall effective management of the orthopaedic patients?

Guidelines by The Ministry of Health and Family Welfare :

Group Head Coordinates of Development Team Dr. P.K. DAVE, Rockland Hospital, New Delhi Dr. P.S. Maini, Fortis Jessa Ram Hospital, New Delhi

Reviewed By

Dr. V.K. Sharma, Professor Central Instiute of Orthopaedics, Safdarjung Hospital, New Delhi