Aims. To evaluate patient-reported outcomes three months after treatment of metacarpal and phalangeal fractures or dislocations, and to identify factors that are associated with worse patient-reported outcomes. Methods. This cross-sectional, multicentre snapshot study included all adult patients with metacarpal and phalangeal fractures or dislocations during a three-month period between August and October 2020. The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) three months after injury. The MHQ scores were compared to normative MHQ scores of 90 points of the affected hand of patients who sustained unilateral trauma derived from a previous study. Subgroup analyses were performed for the most common injury types. Multivariable linear regression was used to study associations between patient characteristics and worse MHQ scores. Results. The MHQ scores of 512 patients were analyzed. The median MHQ score was 80 (IQR 65 to 91) for nonoperatively treated patients (n = 398) and 78 (IQR 66 to 85) for operatively treated patients (n = 114). After nonoperative treatment, 104/398 patients (26%) reached a MHQ score equal to or better than the normative MHQ score, ranging between 11% (1/9) and 42% (13/31) among the nine most common injury types. After operative treatment, this was 11% (13/114), ranging between 10% (3/29) and 31% (5/16) among the three most common injury types. No significant differences in MHQ scores were found between common injury types. Older age, the presence of hand comorbidities, and referral to hand therapy were associated with a worse MHQ score after nonoperative treatment. Conclusion. These results suggest that most patients have not returned to a normal hand function within three months following metacarpal and phalangeal fractures or dislocations. Older age, the presence of hand comorbidities, and referral for hand therapy were associated with worse hand functioning after nonoperative treatment. The findings are relevant for clinicians to evaluate recovery and for patients to manage their expectations. Cite this article: Bone Jt Open 2025;6(2):227–236

The Poole Traction Splint (PTS) is a non-invasive technique that applies dynamic traction to the affected digit using materials readily available in the outpatient department. The primary aim of this study was to document the outcome of the PTS for hand phalangeal fractures. Over a four-year period (2017–2021), suitable patients were reviewed and referred for PTS to the hand physiotherapists. Functional outcome measures included range of motion (ROM), return to work, and a DASH score. In addition, a healthcare cost analysis was carried out. A total of 63 patients were treated with a PTS from 2017 to 2021. Data was analysed for 54 patients with 55 digits. The mean age was 43 years (17–72) and 53.7% (n=29) were female. There were 43 fractures involving the proximal phalanx and 12 involving the middle phalanx. The mean final composite range of movement averaged 209˚ (110–270°), classified as ‘good/excellent’ by ASSH criteria. The mean DASH score was 13.6 (0-43.2; n=45). All patients were able to return to work. Only two (3.7%) digits required conversion to surgical fixation. The PTS resulted in approximate savings of £2,452 per patient. The PTS is a cost-effective non-invasive low risk outpatient treatment method which provides a functional ROM and good functional outcomes in the treatment of complex phalangeal hand fractures, with minimal risk of surgical intervention being required

The second wave of COVID-19 infections in 2021 resulting from the delta strain had a significantly larger impact on the state of New South Wales, Australia and with it the government implemented harsher restrictions. This retrospective cohort study aims to explore how the increased restrictions affected hand trauma presentations and their treatment. Retrospective analysis was performed on patients who underwent hand surgery from the period of June 23 – August 31 in 2020 and 2021 at a level one trauma centre in Western Sydney. During the second-wave lockdown there was an 18.9% decrease in all hand trauma presentations. Despite widespread restrictions placed on the manufacturing, wholesale, retail and construction industries, there was an insignificant difference in work injuries. Stay-at-home orders and reduced availability of professional tradespersons likely contributed to an increase in DIY injuries. Significant reductions in metacarpal and phalangeal fractures coincided with significantly curtailed sporting seasons. The findings from this study can assist in predicting the case-mix of hand trauma presentations and resource allocation in the setting of future waves of COVID-19 and other infectious diseases

Introduction: Metacarpal and phalangeal fractures are frequent (13% of the total number of fractures). It seems that the best treatment for the displaced fractures is fixation. Various methods have been used, such as plates and screws, wires, IM-nailing, external fixation. The main problems are adhesions of extensor tendons, scarring and stiffness of the joints. The purpose of this study is to examine the efficacy of internal fixation using Kirschner wires, applied open or closed, treating metacarpal and phalangeal fractures. MATERIALS AND Methods: Between 1998 and 2005 145 out of a total of 2848 (5.2%) metacarpal and phalangeal fractures underwent operative treatment. Fixation was achieved by placing extrarticularly two or more Kirschner wires. The wires were removed after 4 weeks and patients underwent physiotherapy for 2 to 4 weeks. The follow-up period was 3 – 15 mos (average 12 mos) and total range of movement and function of the injured hand was evaluated. Results: Bone union was evident in 3 to 5 weeks. Range of movement was approximately 90% of normal, except for cases of comminuted intraarticular fractures and also in 6 cases of elderly non-cooperative patients. One case of infection, complicating a metacarpal fracture and well responding to antibiotic treatment, was recorded. Three further infections resulted after neglected intraarticular fractures, all of which underwent arthrodesis. No rotational deformities were observed. There was no mechanical failure of the fixation in any case. Conclusion: The fixation of metacarpal and phalangeal fractures using K-wires seems to be a useful method minimally invasive, stable and well tolerated by the patient, not interfering with the mobility of the joints. K-wires are easily removed and of low cost. The functional outcome of this method seems to be quite satisfactory

Background. Proximal phalangeal fractures are caused by an injury to the dorsum of the hand. This usually causes volar angulation which is unstable when reduced. K-wiring or external fixation can damage the soft tissue envelope, can introduce infection and can loosen or displace. Traction splinting is not well described for these fractures. Objectives. Functional and radiographic assessment of all patients with proximal phalangeal fractures treated with traction splinting. Methods. Theatre records were examined for relevant injuries over a 2 year period. These patients were then assessed using a QuickDASH score, a questionnaire specific to traction splinting and with pre-op, intra-op, post-op and follow-up radiographs. Results. A total of 7 patients were treated with traction splinting, all by the senior author (FJS). Clinical follow was 16 months (range12-20). QuickDASH scores were 0, 0, 0, 0, 0, 2.5, 25/100. With regard to work (n=6), all patients but one scored 0/100 for disability with one patient describing mild work related difficulties. Those participating in sports/performing arts (n=6) scored 0/100. There were no finger-tip pain or numbness issues. Finger length perception was satisfactory in all patients. The splint slipped in 3 patients, secondary to horse riding, showering and through scratching. Two patients reported having a measurable loss of motion in the affected digit (follow-up 18 and 20 months), both with mild functional deficit. Radiographic outcomes showed that traction achieved acceptable length restoration, with no angular deformities. Finger length was maintained in all but one patient who had a shortening of 3.2mm. Conclusions. Traction splinting is a non-invasive, safe and inexpensive method of treating proximal phalangeal fractures. Results of our follow-up study show excellent functional and radiographic outcomes with minimal long term morbidity for this treatment option

We conducted a prospective review of patients treated specifically for phalangeal fractures over a period of 6 months. Data was sourced from patient records, Emergency Dept records and theatre records. X-rays were reviewed by the senior authors using the AGFA IMPAX Web1000 v5.1 System. A total of 654 patients presented to our hospital during the study. Of these, 257 (39%) patients were referred to the plastics and hand surgical team on-call. Remaining 397 (61%) patients were seen and treated at the local accident and emergency. Our review identified a patient group of 75 out of 654 (11.5%) patients who required operation. Mechanism of injury: Direct impact: n=60 (80%), Hyperextension n=11 (15%), Hyper-flexion injury n=4 (5%). Mode of injury: sports related, commonly rugby or football: 23 (31%) patients, crush injury 13 (17%), road traffic accident 10 (13%), punching either wall or a fellow human being in 10 (13%), fall 8 (11%), circular saw related injury in 8 (11%). The average patient age for a phalangeal fracture was 37.3 years. 47 (63%) patients were in the age group 20–40 years. The mean age for a phalangeal fracture in males was 35.9 (16–75) years and 42.2 (23–70) years in females. The gender distribution of these patients reveals that 58/75 (77%) patients were males. This indicates that males were at an increased relative risk of 3.4 for sustaining a hand fractures than females. The fractures were studied with respect to their complexity, digit(s) involved, phalanx and the site on the phalanx, pattern of fracture and finally the involvement of the MCP or the IP joints. Our study revealed that fifty-two (69%) of the fractures were closed while twenty-three (31%) were open. Injuries to the distal phalanges accounted for the most of the open fractures (15/23, 67%). The little finger and the ring finger were the common fingers to be involved. The fractures were treated with various standard techniques of operative fixation. Postoperatively patients were mobilised as soon as possible and fitted with a removable thermoplastic splint to allow daily active and passive exercises. Hand therapists followed unit protocol including at least one visit per week, with follow up for four to six weeks. Final review was undertaken by a clinician in a dedicated Hand clinic six weeks post fixation. Our work provides data on incidence and demographic distribution of phalangeal injuries presenting acutely to an NHS Trust covering a population area of 500,000. In our trust it is standard protocol for all such injuries to be reviewed by the Hand team to institute optimal hand therapy for patients. The study enabled us to develop a patient care pathway which will improve both patient and resource management

1. Rotational deformity of a finger caused by malunion of a phalangeal fracture has been corrected by metacarpal osteotomy. 2. Because of the anatomical arrangement of the metacarpo-phalangeal joint this method gives good control of the distal phalanges. 3. Division through the metacarpal rather than through the phalanx avoids adhesions in the flexor and extensor mechanisms and in the joints of the fingers, allows early mobilisation and is an easier procedure

From 1987 to 1993 we treated 33 patients with 29 phalangeal and seven metacarpal fractures by external fixation using a mini-Hoffmann device. There were 27 open and 25 comminuted fractures. In 12 patients one or more tendons was involved. The mean follow-up was 4.4 years. Complications occurred in ten fractures; two required repositioning of the fixator. All the fractures healed. The functional results after metacarpal fractures were better than those after phalangeal fractures and fractures of the middle phalanx had better recovery than those of the proximal phalanx. Twenty-eight of the 33 patients were satisfied with their result. External fixation proved to be a suitable technique for stabilising unstable, open fractures with severe soft-tissue injuries

Malunion of digital fractures can be difficult to correct especially for rotational phalangeal malunion. We describe the simple closed corrective technique. Materials/Methods: Patients whose phalangeal fractures were treated closed (mobilised or POP +/− K wires) and malunited, typically with mal-rotation. The technique is performed under LA. The bone is cut by percutaneous passage of a 1.1 mm K wire multiple times until the bone is fractured. The malunion is corrected and held with one longitudinal 1.1 mm K wire. The osteotomies are supported for 6 weeks in POP/splint and the wire(s) removed. Results: 11 patients with 12 post fracture malunion–All metaphyseal osteotomies healed within 6 weeks with correction of malrotation and no significant angular deformity. The one diaphyseal osteotomy united late healing only partially (inadequately) corrected and requires revision. Apart from the malunion there were no major complications albeit short-term PIP joint stiffness. Conclusion: This is a safe and reliable technique that avoids most of the complications of more challenging open techniques in the phalanges or the compromises of distant techniques e.g. metacarpal correction of phalangeal malrotation. It does however require immobilisation precluding any major simultaneous soft tissue releases. It appears unsuited to diaphyseal correction

Introduction: In clinical practice The Cascade sign is widely used to assess the rotational deformity of the fingers associated with metacarpal and phalangeal fractures. We carried out a scientific study on thirty volunteers to evaluate the validity or otherwise of this standard sign. Material and Methods: Metal pointers were attached to the dorsum of the fingers, flexed at MCP and PIP joints. These pointers represented the mid longitudinal axis of the phalanges. Standardised AP radiographs of the closed fist were taken in all cases with the wrist placed in neutral position, in a custom made jig. The radiographs were assessed by two different observers using Picture Archiving and Communication System, software version VA42B, to determine the convergence of the metal pointers towards the scaphoid tubercle, as described in the cascade sign and Lister method. Statistics: Power of the study was determined with an assumption of a type-2 error of 0.05 and a two sided test. Descriptive statistics and confidence limits were calculated using SPSS 11 software. Results: We observed that the metal pointers did not equivocally converge towards the scaphoid tubercle. The persistent pattern of convergence was within a 2–3cm radius of the scaphoid tubercle. The statistical analysis, two tailed paired t-test of this pattern showed strong association with this latter finding. (p< 0.003). Conclusion: Our study suggests that the cascade sign is sensitive but not specific to access the rotational deformity of the fingers. Radiological there is significant scatter about the scaphoid tubercle

Horse riding is a common pursuit and is more dangerous than believed. Most injuries of the hand and wrist are caused by falls, as in other sports. However, exclusive to riding are injuries sustained whilst leading a horse. Avulsion injuries are well recognised but little has been reported on phalangeal fractures in this situation. We report on seven cases that required hospitalisation in our hand unit, for injuries from horses over a two year period. Six of these patients sustained multi-fragmented spiral periarticular fractures involving the middle and proximal phalanx and one a horse bit. We will discuss in detail the mechanism of their injuries, the surgery undertaken, their post-operative rehabilitation and overall outcome. Furthermore we review the recommended horse handling technique and contrast it with the mechanism of injury in our cases. In our experience the fractures seen were unstable, comminuted and needed internal fixation. One patient developed a delayed union and three post-operative stiffness. Our results suggest that fractures whilst leading horses are more complex than recognised, usually need surgery and often have a relatively poor outcome. All of these cases were largely preventable and could be attributed to incorrect horse leading technique

1. A series of 106 central slip injuries has been reviewed. 2. Although the boutonnière deformity in many cases may be no more than a cosmetic defect, this survey has shown that in some instances it can constitute a slowly progressive lesion, with considerable disability and gross deformity of a digit. 3. Conservative treatment seems to be superior to operation, at least in those patients seen within six weeks of injury. Treatment by splintage alone yielded in this series a 75 per cent success rate, whereas operation showed only 50 per cent success. 4. When a sizeable fragment of bone has been avulsed from the middle phalanx, suture of the fragment in position is indicated and gives remarkably satisfactory results. 5. Injuries with soft-tissue loss over the proximal interphalangeal joint may yield successful results after suture or plastic repair of the tendon, and wound closure by split-skin grafts or local rotation flaps. 6. Poor results tend to occur in cases complicated by phalangeal fracture or by multiple hand injuries, and it may be advisable to defer the repair of the central slip until recovery from the other injuries has been completed. 7. With gross disruption of the proximal interphalangeal joint primary arthrodesis is probably indicated

Aims: Thirty-three patients with condylar fractures of the middle and proximal phalanges were treated with internal fixation using self-tapping titanium lag screws. The results were studied prospectively and prognostic factors identified. Methods: The age range was 14–45 (mean 26 years). Five patients presented at more than five weeks post injury. Four patients had bicondylar fractures. The surgical technique, which utilises a lateral approach, is outlined. All surgery was performed by the senior author (DS), semi-electively, within five days of presentation. Patients were seen in the 4th postoperative day for mobilisation and protective splintage. Results: The results were satisfactory in the majority of cases. 21 patients had achieved a full range of movement when reviewed at six weeks and further eight at 12 weeks. The remainder were left with a flexion contracture of 10–35 degrees (mean 26). All patients achieved full flexion. All fractures healed and there was no loss of fixation. Conclusions: Internal fixation using a single lag screw through a lateral approach restores joint congruity, facilitates union and provides fixation stable enough to allow early mobilisation. Bicondylar and proximal phalangeal fractures had a poorer prognosis. Fractures presenting even at eight weeks can be taken down and reduced. Delay in fixation does not appear to influence the long-term outcome

Purpose. To analyse the early results of unconstrained pyrocarbon joint replacements in patients with osteo-arthritis of the metacarpo-phalangeal joints. Background. Silicone arthroplasty, as introduced by Swanson in 1962 has remained the most popular procedure to treat arthritis of the metacarpo-phalangeal (MCP) joints. However, despite providing good pain relief, they have shown to demonstrate breakage rates up to 82% at 5 years. This is of great concern in the osteoarthritis (OA) patient group, who tend to be younger and have higher functional demands compared to their rheumatoid counterparts. The newer unconstrained pyrolytic carbon MCP joint prostheses may therefore be more suitable in OA patients whose soft tissue constraints are intact and whose hand function is strong. This study is the first to analyse the results of this implant in a cohort of OA patients only, with prospective data. Methods. 19 primary pyrocarbon metacarpo-phalangeal joint replacements, in 11 patients (5 men and 6 women) were reviewed, with prospective data collection. The diagnosis was primary osteoarthritis in all patients. The mean age at operation was 66.4 years (range 55–82 years). 2 patients underwent concomitant trapiezectomy and one underwent DIPJ fusion. All patients were right hand dominant −75% underwent surgery in their dominant hand. Eleven of the nineteen joints were performed in the index finger, with the remainder in the middle finger. Mean follow up is 22.1 months (range 11–37). Results. At the 3 month post-operative hand therapy assessment, the arc of motion had improved from a mean of 32 degrees to 45 degrees and flexion had improved from a mean of 51 degrees to 66 degrees. Grip strength improved from a mean 20 to 27Kg. DASH scores significantly improved from a mean of 40 to 10 (p=0.01). All patients were satisfied with their outcomes and would have the surgery again. Pre-operative radiographs demonstrated joint narrowing in all patients but no evidence of heterotopic ossification, cystic change or erosions. Post-operatively, there has been no radiographic evidence of joint dislocation, resorption stress-shielding, loosening, migration or heterotopic ossification. There were three intra-operative complications of phalangeal fractures that were immediately treated with a cerclage wire. In one patient there has been a fracture of the proximal phalangeal implant at 14 months which was asymptomatic. One patient has required revision for mal-rotation of the implant leading to loss of index finger supination. Conclusion. Our results demonstrate excellent early results of pyrocarbon MCP joint arthroplasty in OA patients