THE CONSERVATIVE MANAGEMENT OF PROXIMAL PHALANGEAL FRACTURES OF THE HAND IN AN ACCIDENT AND EMERGENCY DEPARTMENT A. MAITRA and P. BURDETT-SMITH From the Accident and Emergency Department, Royal Victoria Injrmary, Newcastle Upon Tyne
147 proximal phalangeal fractures of the hand were managed by Accident and Emergency doctors and hand surgeons. Most were treated conservatively with good results. Those treated in A. and E. were usually transverse or basal fractures of the shaft. Articular, oblique, cornminuted and compound injuries were associated with greater morbidity and required specialist care. Journal of Hand Surgery (British Volume, 1992) 17B : 332-336
The treatment and outcome of phalangeal fractures by specialist hand surgeons have been well documented (Barton, 1979; O’Rourke, Gaur and Barton, 1989). Most can be treated conservatively without splintage if clinically stable (Benke and Stableforth, 1979). Even in articular fractures, conservative methods give good results unless associated with subluxation or involving the P.I.P. joint (Barton, 1984). It is therefore logical for the Accident and Emergency department to manage phalangeal fractures conservatively provided that the results are satisfactory and that complicated and potentially complicated injuries are correctly diagnosed and referred to specialist hand surgeons. This paper reports the results of the management of proximal phalangeal fractures of the hand treated by A. and E. doctors and hand surgeons over a two-year period, to determine the ability of the A. and E. doctors to treat these injuries effectively and to identify factors which may affect the outcome and which indicate a need for specialist care.
Management programme Stable fractures with no displacement and full extension of the P.I.P. joints were treated by controlled active mobilization in strapping to the adjacent digit. If the P.I.P. joints were held flexed, the hand was splinted in a malleable aluminium splint with the metacarpophalangeal and interphalangeal joints of the affected finger at 90” and 0” respectively to hold the collateral ligaments taut preventing adhesions and subsequent shortening (James, 1970). Angulated stable fractures were reduced under metacarpal nerve block (Semple, 1979) and then treated as above. A number of these fractures were splinted solely for pain relief. Unstable fractures, fractures with irreducible rotational deformities and those involving 25% or more of the articzdar surface and/or subluxation or joint instability were referred to the hand surgeons. All patients were followed up until they had fully recovered or there was no further improvement.
Material and methods
Results
From 1 September 1988 to 21 September 1990 (just over two years), 100,851 patients attended the A. and E. department at the Royal Victoria Infirmary, Newcastle. Of these, 2,004 (2%) had fractured their hands. 242 of these injuries were phalangeal fractures and 147 (61%) involved the proximal phalanx. Proximal phalangeal fractures formed 7% of all hand fractures and 0.3% of all attendances. The age and sex of the patients were recorded, as were the side and location of the fractures, mechanism of injury, any deformity and definitive treatment. Follow-up details included length of treatment, time off work or normal activities, and complications. Steel’s clinical assessment scale (1988) was used to measure pain, deformity, movement and function, 400 being rated “excellent”, 350-399 “good”, 300-349 “fair” and 300 or less “poor”. Pain was graded as “cold aches” or as needing no analgesia, occasional analgesia or regular analgesia. Deformity was graded less than or more than 1.5”and movement and function as percentages of the normal opposite joint.
88 of the 147 patients (60%) were male and 59 female, with a mean age of 26 years. The right hand was injured in 51%. 50% of the injuries were due to falls; sports accounted for 18x, direct blow and crush injuries each caused 9% and twisting injuries 3%. 11% were due to miscellaneous causes. 23% of the fractures required manipulation. Figure 1 shows the location, site and type of the fractures. The little finger was most frequently injured (5 1%). Transverse fractures (55%) and fractures of the proximal (basal) shaft (71%) were most common. The mean treatment time was 46.5 days (S.D. f27.7), requiring on average three hospital visits per patient. The mean time off work or normal activities was 20 days (S.D. f 27.7). Excellent or good results were obtained in 136 (92.5%) ; eight (5.4%) were judged to be fair and only three (2%) with severe stiffness had a poor outcome. 93 out of 147 (63.3x)patients were treated in the A. and E. department with strapping or splint/cast and 53 (36.7%) by the hand surgeons following referral. Those treated with strapping 332
MANAGEMENT
OF PROXIMAL
PHALANGEAL
A
FRACTURES
IN AN A. AND E. DEPARTMENT
7(5)
Comminuted
I
\ --A
Fig. 1
Distribution
Table l-Details
of the location,
site and type of the fractures (“A).
had a lower mean age (20.9 years) than those managed by splintage or a cast (34.2) or by the hand surgeons conservatively (310.9) and operatively (35.5). Males outnumbered females by one and a half times, except for patients treated by splintage in whom the sexes were equally divided. Table 1 gives the details of injuries treated by A. and E. doctors and the hand surgeons. Most fractures treated in A. and E. were transverse and basal (Figs 2 and 3); those managed by the hand surgeons were articular, oblique, comminuted or compound. The mean duration of treatment was shorter in A. and E. (strapping taking 14.1 days and splintage 33.8 days) than for those treated by the hand surgeons (conservative 67.3 days and operative 110.2 days) as one would expect, since the worse fractures were referred to the hand surgeons. Patients treated by strapping required the least time off work or normal activities: 7.9 days compared to those treated by splintage (23.6) or by the hand surgeons conservatively (24.2) or operatively (39.9). Table 2 shows details of the outcome for different types of treatment. Only 4.3% of the A. and E. and 13% of the hand surgical patients had significant complications. Increased morbidity (pain, deformity and stiffness) was associated with compound injuries (P = 0.02), displaced fractures (P = 0.02) which required manipulative correction (P=O.O03) and oblique and comminuted fractures (P=O.O05).
of injuries treated by A. and E. doctors and hand surgeons (%) A. and E.
Variables
Fracture Location 1. 2. 3. 4. 5. 6.
333
Index Middle Ring Little Thumb Multiple
Site
1. Articular
Strapping (n = 69)
(13.0) (14.5) (59.4)
2 (8.3) 1 (4.2) 6 (25.0) 13 (54.2)
(7.2)
: (8.3)
4 (5.8) 9 10 41 0 5
l(l.4)
Hand surgeons
Splint (n=24)
Total (n=93)
6 (6.5)
Conservative (n=21)
0
Operative (n=33)
1 (3.0)
Total (n=54)
(7.5)
0 9 (42.9) 7 (10.1) 5 (23.8) 0
2 (6.1) 0 14 (42.4) 15 (45.5) 1 (3.0)
l(l.9) 2 (3.7) 9 (16.7) 21 (38.9) 20 (37.0) l(l.9)
4 (16.7)
5 (5.4)
7 (33.3)
12 (36.4)
19 (35.2)2
10 16 54 0 7
(10.8) (17.2) (58.1)’
2. Shaft Proximal Middle Distal
58 (84.1) 5 (7.2) 5 (7.2)
17 (70.8) 0 3 (12.5)
75 (80.3)3 5 (5.4) 8 (8.6)
12 (57.1) 1 (4.8) 1 (4.8)
18 (54.5) 3 (9.1) 0
30 (55.5) 4 (7.4) 1 (1.9)
Type 1. Transverse 2. Oblique 3. Comminuted
60 (87.0) 6 (8.7) 3 (4.3)
14 (58.3) 9 (37.5) 1 (4.2)
74 (79.2)r I5 (16.1) 4 (4.3)
5 (23.8) 14 (66.7) 2 (9.5)
2 (6.1) 22 (66.6) 9 (27.3)
7 (12.9) 36 (66.6)* 11 (20.4)3
5 (7.2) 16 (23.2)
1 (4.2) 8 (33.3)
6 (6.4) 24 (25.7)
1 (4.8) 8 (38.1)
6 (18.2) 2 (6.1)
Nature 1. Compound 2. M.U.A. 1pco.04 *P
147 proximal phalangeal fractures of the hand were managed by Accident and Emergency doctors and hand surgeons. Most were treated conservatively with good results. Those treated in A. and E. were usually transverse or basal fractures of the shaft. Articular, oblique, cornminuted and compound injuries were associated with greater morbidity and required specialist care. Journal of Hand Surgery (British Volume, 1992) 17B : 332-336
The treatment and outcome of phalangeal fractures by specialist hand surgeons have been well documented (Barton, 1979; O’Rourke, Gaur and Barton, 1989). Most can be treated conservatively without splintage if clinically stable (Benke and Stableforth, 1979). Even in articular fractures, conservative methods give good results unless associated with subluxation or involving the P.I.P. joint (Barton, 1984). It is therefore logical for the Accident and Emergency department to manage phalangeal fractures conservatively provided that the results are satisfactory and that complicated and potentially complicated injuries are correctly diagnosed and referred to specialist hand surgeons. This paper reports the results of the management of proximal phalangeal fractures of the hand treated by A. and E. doctors and hand surgeons over a two-year period, to determine the ability of the A. and E. doctors to treat these injuries effectively and to identify factors which may affect the outcome and which indicate a need for specialist care.
Management programme Stable fractures with no displacement and full extension of the P.I.P. joints were treated by controlled active mobilization in strapping to the adjacent digit. If the P.I.P. joints were held flexed, the hand was splinted in a malleable aluminium splint with the metacarpophalangeal and interphalangeal joints of the affected finger at 90” and 0” respectively to hold the collateral ligaments taut preventing adhesions and subsequent shortening (James, 1970). Angulated stable fractures were reduced under metacarpal nerve block (Semple, 1979) and then treated as above. A number of these fractures were splinted solely for pain relief. Unstable fractures, fractures with irreducible rotational deformities and those involving 25% or more of the articzdar surface and/or subluxation or joint instability were referred to the hand surgeons. All patients were followed up until they had fully recovered or there was no further improvement.
Material and methods
Results
From 1 September 1988 to 21 September 1990 (just over two years), 100,851 patients attended the A. and E. department at the Royal Victoria Infirmary, Newcastle. Of these, 2,004 (2%) had fractured their hands. 242 of these injuries were phalangeal fractures and 147 (61%) involved the proximal phalanx. Proximal phalangeal fractures formed 7% of all hand fractures and 0.3% of all attendances. The age and sex of the patients were recorded, as were the side and location of the fractures, mechanism of injury, any deformity and definitive treatment. Follow-up details included length of treatment, time off work or normal activities, and complications. Steel’s clinical assessment scale (1988) was used to measure pain, deformity, movement and function, 400 being rated “excellent”, 350-399 “good”, 300-349 “fair” and 300 or less “poor”. Pain was graded as “cold aches” or as needing no analgesia, occasional analgesia or regular analgesia. Deformity was graded less than or more than 1.5”and movement and function as percentages of the normal opposite joint.
88 of the 147 patients (60%) were male and 59 female, with a mean age of 26 years. The right hand was injured in 51%. 50% of the injuries were due to falls; sports accounted for 18x, direct blow and crush injuries each caused 9% and twisting injuries 3%. 11% were due to miscellaneous causes. 23% of the fractures required manipulation. Figure 1 shows the location, site and type of the fractures. The little finger was most frequently injured (5 1%). Transverse fractures (55%) and fractures of the proximal (basal) shaft (71%) were most common. The mean treatment time was 46.5 days (S.D. f27.7), requiring on average three hospital visits per patient. The mean time off work or normal activities was 20 days (S.D. f 27.7). Excellent or good results were obtained in 136 (92.5%) ; eight (5.4%) were judged to be fair and only three (2%) with severe stiffness had a poor outcome. 93 out of 147 (63.3x)patients were treated in the A. and E. department with strapping or splint/cast and 53 (36.7%) by the hand surgeons following referral. Those treated with strapping 332
MANAGEMENT
OF PROXIMAL
PHALANGEAL
A
FRACTURES
IN AN A. AND E. DEPARTMENT
7(5)
Comminuted
I
\ --A
Fig. 1
Distribution
Table l-Details
of the location,
site and type of the fractures (“A).
had a lower mean age (20.9 years) than those managed by splintage or a cast (34.2) or by the hand surgeons conservatively (310.9) and operatively (35.5). Males outnumbered females by one and a half times, except for patients treated by splintage in whom the sexes were equally divided. Table 1 gives the details of injuries treated by A. and E. doctors and the hand surgeons. Most fractures treated in A. and E. were transverse and basal (Figs 2 and 3); those managed by the hand surgeons were articular, oblique, comminuted or compound. The mean duration of treatment was shorter in A. and E. (strapping taking 14.1 days and splintage 33.8 days) than for those treated by the hand surgeons (conservative 67.3 days and operative 110.2 days) as one would expect, since the worse fractures were referred to the hand surgeons. Patients treated by strapping required the least time off work or normal activities: 7.9 days compared to those treated by splintage (23.6) or by the hand surgeons conservatively (24.2) or operatively (39.9). Table 2 shows details of the outcome for different types of treatment. Only 4.3% of the A. and E. and 13% of the hand surgical patients had significant complications. Increased morbidity (pain, deformity and stiffness) was associated with compound injuries (P = 0.02), displaced fractures (P = 0.02) which required manipulative correction (P=O.O03) and oblique and comminuted fractures (P=O.O05).
of injuries treated by A. and E. doctors and hand surgeons (%) A. and E.
Variables
Fracture Location 1. 2. 3. 4. 5. 6.
333
Index Middle Ring Little Thumb Multiple
Site
1. Articular
Strapping (n = 69)
(13.0) (14.5) (59.4)
2 (8.3) 1 (4.2) 6 (25.0) 13 (54.2)
(7.2)
: (8.3)
4 (5.8) 9 10 41 0 5
l(l.4)
Hand surgeons
Splint (n=24)
Total (n=93)
6 (6.5)
Conservative (n=21)
0
Operative (n=33)
1 (3.0)
Total (n=54)
(7.5)
0 9 (42.9) 7 (10.1) 5 (23.8) 0
2 (6.1) 0 14 (42.4) 15 (45.5) 1 (3.0)
l(l.9) 2 (3.7) 9 (16.7) 21 (38.9) 20 (37.0) l(l.9)
4 (16.7)
5 (5.4)
7 (33.3)
12 (36.4)
19 (35.2)2
10 16 54 0 7
(10.8) (17.2) (58.1)’
2. Shaft Proximal Middle Distal
58 (84.1) 5 (7.2) 5 (7.2)
17 (70.8) 0 3 (12.5)
75 (80.3)3 5 (5.4) 8 (8.6)
12 (57.1) 1 (4.8) 1 (4.8)
18 (54.5) 3 (9.1) 0
30 (55.5) 4 (7.4) 1 (1.9)
Type 1. Transverse 2. Oblique 3. Comminuted
60 (87.0) 6 (8.7) 3 (4.3)
14 (58.3) 9 (37.5) 1 (4.2)
74 (79.2)r I5 (16.1) 4 (4.3)
5 (23.8) 14 (66.7) 2 (9.5)
2 (6.1) 22 (66.6) 9 (27.3)
7 (12.9) 36 (66.6)* 11 (20.4)3
5 (7.2) 16 (23.2)
1 (4.2) 8 (33.3)
6 (6.4) 24 (25.7)
1 (4.8) 8 (38.1)
6 (18.2) 2 (6.1)
Nature 1. Compound 2. M.U.A. 1pco.04 *P
