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Hand & Upper Limb

Finger Fracture Fixation (Phalangeal & Metacarpal)

Surgical technique guide for Finger Fracture Fixation covering metacarpal and phalangeal fractures - FRCS exam preparation

Core Procedure
intermediate
By OrthoVellum Medical Education Team

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High-yield overview

Phalangeal and metacarpal fractures — most common hand injuries. Phalangeal fractures least forgiving: 1° of malrotation equals 5mm of digital overlap at fingertip. Rotation always requires correction. Acceptable angulation varies by ray and fracture type. K-wire, lag screw, mini-plate or intramedullary pin chosen by fracture pattern. Bennett's and Rolando are intra-articular thumb MC base fractures requiring anatomical reduction. | intermediate

Surgical Imaging

Malrotation and key pitfalls in finger fracture fixation
Key pitfalls: malrotation/scissoring (nail-plane check — all nails should point toward the scaphoid on flexion) and the importance of immobilising in the intrinsic-plus position.Credit: AI-generated medical image · OrthoVellum
Finger and metacarpal fracture fixation by pattern
Fixation matched to fracture pattern: lag screws for an oblique phalangeal fracture, crossed Kirschner wires for a transverse fracture, and a dorsal plate and screws for a comminuted metacarpal fracture.Credit: AI-generated medical image · OrthoVellum
Lag screw fixation of an oblique phalangeal fracture
Oblique phalangeal fracture stabilised with two lag screws — pre-operative, fixation and healed radiographs.Credit: via Open-i (NIH), CC BY
Crossed K-wire fixation of a phalangeal fracture
Crossed K-wire fixation of a proximal phalangeal fracture on post-reduction radiographs.Credit: via Open-i (NIH), CC BY

Critical Exam Pitfalls — Finger Fractures

Rotation Testing

Clinical test: Ask the patient to gently flex all digits toward the palm together. All fingernails should be parallel and fingers should converge toward the scaphoid tubercle.

The rule: 1° of malrotation at the fracture site causes 5mm of digital overlap at the fingertip. Even subtle scissoring on clinical examination is unacceptable — requires surgical correction.

Acceptable Angulation by Ray

Metacarpal shaft (transverse):

  • Index: up to 10°
  • Middle: up to 10°
  • Ring: up to 20°
  • Small (5th): up to 30°

MCP neck (Boxer's): 5th ray up to 40-70° sagittal angulation may be functionally acceptable — but rotation must be zero.

Oblique/spiral: shortening greater than 5mm is unacceptable regardless of ray.

1°=5mm Scissoring Rule

Mechanism: The long lever arm of the finger amplifies small proximal rotational errors to large distal displacements.

Practical implication: A fracture that looks only mildly malrotated on radiograph may cause dramatic finger crossing in flexion. Always clinically assess rotation under anaesthesia before accepting a closed reduction.

Surgical correction: Even 5-10° of rotational malunion warrants surgical correction to prevent permanent functional deficit.

Bennett's vs Rolando

Bennett's: Two-part intra-articular fracture at thumb MC base. Small volar ulnar fragment retained by anterior oblique ligament (AOL). MC shaft displaces radially and proximally by APL pull. Treat with ORIF (lag screw) or percutaneous K-wire reduction.

Rolando: Comminuted Bennett's (three or more fragments). Large fragments: ORIF with mini-plate or lag screws. Severely comminuted: external fixation or traction. Prognosis is worse than simple Bennett's regardless of treatment.

PIP Condylar Fractures

Why they are difficult: The condylar anatomy of the proximal phalanx head is complex. Even 2mm of articular displacement leads to PIP joint incongruity, cartilage damage and post-traumatic arthritis.

Management: Anatomical open reduction and lag screw fixation under loupe magnification. Do NOT accept displacement at this joint. Post-op early active motion critical to prevent PIP stiffness — the most common complication.

Extensor Tendon Zone of Injury

Zone relevance: Mini-plates applied to the dorsum of phalanges lie directly beneath the extensor mechanism. Plate bulk causes extensor tendon adhesions and PIP/DIP stiffness.

Surgical implication: Prefer lag screw (less bulk) over plate for phalangeal shaft fractures when possible. If plate is required, use lowest-profile implant and plan early motion rehabilitation to minimise extensor adhesions.

Mnemonic

ROTATORROTATOR — Rotation Assessment in the Hand

Mnemonic

FRACTUREFRACTURE — Fixation Principles for Finger Fractures

Indications for Operative Fixation

Metacarpal Fractures — Operative Indications

Absolute Indications:

  • Any rotational deformity (clinically confirmed scissoring)
  • Intra-articular fractures with displacement greater than 1-2mm (MCP joint or CMC joint)
  • Open fractures (relative — debridement mandatory, fixation depending on contamination)
  • Multiple metacarpal fractures with instability
  • Bennett's fracture (intra-articular base of 1st MC with AP joint involvement)

Relative Indications:

  • Angulation exceeding acceptable limits for the specific ray (see table below)
  • Shortening greater than 5mm in oblique or spiral patterns
  • Failure of closed reduction to achieve acceptable alignment
  • Soft tissue interposition preventing reduction
  • Boxer's fracture with rotation or greater than 50-70° of angulation depending on patient demand

Acceptable Angulation Reference Table

Acceptable Metacarpal Shaft Angulation by Ray

Phalangeal Fractures — Operative Indications

Proximal and Middle Phalanx Shaft:

  • Any rotational deformity
  • Angulation greater than 10° in sagittal or coronal plane (phalangeal fractures less tolerant)
  • Shortening greater than 2-3mm
  • Condylar fractures (PIP or DIP joint) with displacement greater than 1-2mm
  • Unstable patterns (transverse with cortical comminution, oblique, spiral)

Evidence Base

Soft wrap and buddy taping is non-inferior to reduction and casting for boxer's fracture with palmar angulation up to 70° and no rotation

2b
van Aaken J, Fusetti C, Luchina S, et al. • Arch Orthop Trauma Surg
Clinical Implication: In boxer's fractures with up to 70° palmar angulation and NO rotation, functional treatment without formal reduction gives equivalent outcomes — rotation, not angulation, drives the decision to operate.
Verify on PubMed (PMID 26559192)

No single non-operative regimen is superior for closed fifth metacarpal neck fractures

1a
Poolman RW, Goslings JC, Lee JB, et al. • Cochrane Database Syst Rev
Clinical Implication: Most isolated boxer's fractures do well regardless of the specific conservative regimen — favour the least restrictive, earliest-motion option that maintains acceptable alignment.
Verify on PubMed (PMID 16034891)

Stiffness is the most frequent complication after plate fixation of phalangeal fractures

4
Kurzen P, Fusetti C, Bonaccio M, Nagy L • J Trauma
Clinical Implication: Plate fixation of phalanges carries a high stiffness burden — reserve it for fractures not amenable to lag screw or K-wire, use low-profile implants, and commit to early active motion.
Verify on PubMed (PMID 16612306)

Outcomes of phalangeal shaft fractures depend on accurate reduction; comminuted fractures fare worse

4
Barton NJ • The Hand
Clinical Implication: Phalangeal shaft fractures have a historically high rate of unsatisfactory results — anatomical reduction and a stiffness-minimising rehabilitation plan are essential.
Verify on PubMed (PMID 488787)

Two-screw ORIF of Bennett fractures gives durable reduction and near-normal strength at 7 years

4
Leclère FM, Jenzer A, Hüsler R, et al. • Arch Orthop Trauma Surg
Clinical Implication: Two-screw fixation reliably maintains Bennett reductions and restores strength; while anatomical joint reduction remains the goal, later CMC arthritis is not predicted by sub-2mm residual incongruity alone.
Verify on PubMed (PMID 22438128)

Viva Scenarios — Finger Fracture Fixation

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 35-year-old carpenter sustains a spiral fracture of the 4th metacarpal shaft with 5mm of shortening confirmed on radiograph. There is no clinical rotation. Would you operate?"

PRACTICAL APPROACH
This is borderline. The key issue is not the shortening alone, but whether there is rotational deformity. Five millimetres of shortening in an oblique or spiral metacarpal fracture of the ring ray is at the upper limit of acceptable (my threshold is 5mm shortening for the ring and small rays). Most importantly, I would perform a thorough clinical examination under anaesthetic block — flexing all digits simultaneously to assess for scissoring. If there is any rotational deformity, operative fixation is mandatory. If rotation is truly absent and shortening is exactly 5mm, I could observe with close follow-up. If shortening is greater than 5mm, or if there is any doubt, I would proceed with ORIF using two lag screws — the spiral pattern is ideal for this technique provided the fracture length is at least twice the shaft diameter.
FURTHER QUESTIONS
"How would you technically perform lag screw fixation for this fracture? Describe your incision, reduction manoeuvre, and screw placement sequence."
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 22-year-old university student presents with a Boxer's fracture of the 5th metacarpal neck with 55° of apex dorsal angulation. How do you manage this?"

PRACTICAL APPROACH
This is a classic Boxer's fracture — 5th metacarpal neck fracture typically sustained from a closed-fist punch. With 55° of apex dorsal angulation in the small ray, I would first perform a focused clinical assessment. The critical question is rotation: I flex the injured digit and compare it to adjacent fingers — the fingernail should be parallel and the finger should converge toward the scaphoid. If there is no rotation, 55° of angulation is within the range that most authors consider functionally acceptable for the small ray (40-70°), and conservative management is appropriate. I would counsel the patient that they may notice a slight flattening of the small knuckle on the back of the hand, but grip strength and function will be near-normal. I would apply a metacarpal brace with buddy taping to the ring finger, and start early active ROM at 1-2 weeks. If, however, there is clinical rotation, I would proceed with percutaneous cross-pinning under image intensifier control: flex the MCP 90°, reduce the angulation with the Jahss manoeuvre (pressure over flexed proximal phalanx), and place two cross K-wires from the metacarpal head.
FURTHER QUESTIONS
"The patient returns at 3 weeks and has developed 15° of rotation that was not present initially. What has happened and what do you do?"
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 45-year-old physiotherapist sustains a Bennett's fracture of the thumb. What are your principles of management and how would you perform the ORIF?"

PRACTICAL APPROACH
A Bennett's fracture is a two-part intra-articular fracture at the base of the thumb metacarpal involving the trapezio-metacarpal (CMC) joint. The key anatomy is that the anterior oblique ligament (the beak ligament) retains the small volar-ulnar fragment, while the APL pulls the metacarpal shaft proximally, radially and into supination — causing CMC subluxation. The goals of treatment are anatomical reduction of the CMC joint and stable fixation to allow early mobilisation. For this active patient, I would choose ORIF. I use a volar-radial approach (Wagner incision) along the thenar eminence. I protect the radial artery (deep to APL and EPB) and incise the joint capsule longitudinally. I identify the volar fragment and directly reduce it to the metacarpal — sometimes requiring a dental pick to elevate the impacted fragment. I hold the reduction with a 1.5mm or 2.0mm lag screw directed from the metacarpal shaft into the volar fragment. I confirm CMC joint congruency directly and fluoroscopically. After repair of the capsule, I immobilise in a thumb spica for 4 weeks, then commence mobilisation. An alternative for cooperative patients is percutaneous K-wire technique: closed reduction under image intensifier, then K-wire from 1st MC into trapezium plus a wire into the 2nd MC base for rotational control.
FURTHER QUESTIONS
"What is the difference in outcome between a Bennett's fracture and a Rolando fracture, and how does this influence your surgical planning?"

Finger Fracture Fixation — Exam Cheat Sheet

Clinical summary

References

  1. van Aaken J, Fusetti C, Luchina S, et al. Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial. Arch Orthop Trauma Surg. 2015;136(1):135-142. PMID: 26559192. DOI: 10.1007/s00402-015-2361-0

  2. Poolman RW, Goslings JC, Lee JB, et al. Conservative treatment for closed fifth (small finger) metacarpal neck fractures. Cochrane Database Syst Rev. 2005;(3):CD003210. PMID: 16034891. DOI: 10.1002/14651858.CD003210.pub3

  3. Kurzen P, Fusetti C, Bonaccio M, Nagy L. Complications after plate fixation of phalangeal fractures. J Trauma. 2006;60(4):841-843. PMID: 16612306. DOI: 10.1097/01.ta.0000214887.31745.c4

  4. Barton NJ. Fractures of the shafts of the phalanges of the hand. The Hand. 1979;11(2):119-133. PMID: 488787. DOI: 10.1016/s0072-968x(79)80024-8

  5. Leclère FM, Jenzer A, Hüsler R, et al. 7-year follow-up after open reduction and internal screw fixation in Bennett fractures. Arch Orthop Trauma Surg. 2012;132(7):1045-1051. PMID: 22438128. DOI: 10.1007/s00402-012-1499-2

  6. Wolfe SW, Pederson WC, Kozin SH, Cohen MS, eds. Green's Operative Hand Surgery. 8th ed. Philadelphia: Elsevier, 2022.

  7. AO Foundation. AO Surgery Reference — Metacarpal and Phalangeal Fractures. Available at: surgeryreference.aofoundation.org