Finger Fracture Fixation (Phalangeal & Metacarpal)

Indication. Operative fixation of a metacarpal or phalangeal fracture is driven by three things — rotation, joint congruity, and unacceptable alignment — not by the radiograph in isolation. Rotation cannot be read reliably from a plain film and is the single non-negotiable indication for surgery. Metacarpal fractures — absolute indications - Any rotational deformity (clinically confirmed scissoring).

• Intra-articular fractures with displacement greater than 1–2 mm (MCP or CMC joint).
• Open fractures (debridement mandatory; fixation depends on contamination).
• Multiple metacarpal fractures with instability.
• Bennett's fracture (intra-articular base of the 1st MC with CMC joint involvement). Metacarpal fractures — relative indications - Angulation exceeding the acceptable limit for the specific ray (see table below).
• Shortening greater than 5 mm in oblique or spiral patterns.
• Failure of closed reduction to achieve acceptable alignment.
• Soft-tissue interposition preventing reduction.
• Boxer's fracture with rotation, or with greater than 50–70° of angulation depending on patient demand.

Phalangeal fractures — operative indications (proximal and middle phalanx shaft) - Any rotational deformity.

• Angulation greater than 10° in the sagittal or coronal plane (phalangeal fractures are less tolerant).
• Shortening greater than 2–3 mm.
• Condylar fractures (PIP or DIP joint) with displacement greater than 1–2 mm.
• Unstable patterns (transverse with cortical comminution, oblique, spiral). Consent specifically for digital numbness or a painful neuroma (digital nerve), PIP stiffness (the commonest problem after phalangeal fractures), pin-site infection, non-union, residual rotational deformity needing a derotation osteotomy, and post-traumatic arthritis for intra-articular injuries. Setup. Supine, arm on a hand table, upper-arm tourniquet, regional (axillary/supraclavicular) or general anaesthesia. The image intensifier is essential for reduction and fixation; loupe magnification is used for articular and Bennett's work. Position the hand so the cascade can be assessed intra-operatively.

The goal is to restore alignment, rotation and joint congruity with the least fixation compatible with early motion. Expose through the approach matched to the fracture, protect the digital neurovascular bundles and the extensor mechanism, reduce the fracture anatomically, confirm rotation clinically under anaesthesia, fix to suit the pattern, and splint in the intrinsic-plus position. The exposure is laid out in full as the first operative steps below — it is the heart of the procedure.

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Operative sequence

Step 1Position, setup & imaging

• Supine, hand table, upper-arm tourniquet; exsanguinate and inflate.
• Image intensifier available for the whole case; loupes for condylar and Bennett's work.
• Plan the approach from the fracture pattern and the at-risk structures before cutting.

Step 2Choose & mark the exposure (the key step)

The exposure is chosen to give fracture access while protecting the neurovascular bundles and the extensor mechanism: - Dorsal longitudinal (metacarpal shaft) — over the dorsum between the extensor tendons; the digital neurovascular bundles (volar-lateral) are protected and out of field.

• Mid-lateral (phalanx) — an incision along Cleland's ligament at the axis of rotation, working between the dorsal and volar neurovascular bundles; safe, but gives limited access to volar structures.
• Volar zig-zag / Bruner (phalanx) — full access to the flexor sheath; the neurovascular bundles on each side must be protected.
• Wagner volar-radial (thumb CMC, Bennett's) — for the base of the thumb metacarpal; identify and protect the radial artery (deep/dorsal to APL and EPB) and the superficial branch of the radial nerve before the capsulotomy.

Step 3Deep dissection — protect the at-risk structures

• The digital neurovascular bundle runs volar-lateral on each side of the digit, volar to the axis of rotation at MCP level; it is at risk with incisions too far volar or with aggressive retraction.
• The extensor mechanism overlies the phalanx dorsally — plates placed here lie directly beneath it and drive adhesions, so keep dissection tight and the periosteal stripping limited to the fracture zone.
• The extensor digitorum communis runs as the central slip to the middle phalanx base; lateral bands join to form the terminal tendon at the DIP.

Step 4Reduce the fracture & correct rotation

• Reduce with bone reduction clamps, restoring length, angulation and rotation.
• Confirm rotation clinically — flex all digits together in a cascade: the fingernails must be parallel and the fingers must converge toward the scaphoid tubercle. Any scissoring is unacceptable.
• Re-check rotation after definitive fixation, not only after reduction.

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Step 5Match fixation to the pattern

Choose the implant from the fracture geometry: - Transverse shaft — crossed K-wires or a mini-plate.

• Oblique or spiral shaft — lag screws (fracture length at least twice the shaft diameter).
• Comminuted shaft — mini-plate (bridging).
• Condylar / intra-articular — lag or headless compression screw.
• Bennett's — lag screw ORIF or percutaneous K-wire into the trapezium.

Step 6K-wire fixation (percutaneous)

Crossed K-wire — metacarpal neck (Boxer's):

1. Flex the MCP joint 90° to relax soft-tissue tension and aid reduction.
2. Apply longitudinal traction and use the Jahss manoeuvre (pressure over the flexed proximal phalanx) to correct the apex-dorsal angulation.
3. Introduce the first K-wire through the metacarpal head at about 45° to the shaft, crossing the fracture site.
4. Introduce a second K-wire from the opposite side, crossing the first at the fracture.
5. Confirm reduction fluoroscopically in AP, oblique and lateral views; bend and cut the wires outside the skin. Parallel K-wire — phalangeal shaft: two parallel wires through the distal fragment across the fracture into the proximal fragment give better rotational control than a single wire. K-wires give minimal rotational stability alone — rotation must be corrected before insertion. Avoid transfixing joints (causes stiffness); remove wires at 3–4 weeks.

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Step 7Lag screw fixation

Indications: spiral or oblique metacarpal shaft fractures (length at least twice the shaft diameter); condylar fractures of the PIP joint; Bennett's fracture. Technique — metacarpal spiral fracture:

1. Expose through a dorsal longitudinal incision; protect the extensor tendon.
2. Reduce with bone reduction clamps and confirm no rotation clinically.
3. Drill the gliding hole in the near cortex (drill bit equal to the outer screw diameter).
4. Drill the pilot hole in the far cortex (drill bit equal to the inner screw diameter).
5. Measure, tap if required, and insert the cortical screw — the head compresses the near cortex to give the lag effect.
6. Use a minimum of two lag screws for rotational stability (a single screw allows rotation). Technique — condylar fracture (PIP joint): mid-lateral or dorsal approach; lever the condylar fragment into anatomical position and check articular congruity directly; hold with a temporary K-wire; replace it with a 1.3 mm or 1.5 mm countersunk headless screw (Herbert technique). The screw must sit flush or sub-articular — a protruding head causes PIP impingement.

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Step 8Mini-plate fixation

Indications: comminuted metacarpal fractures not suitable for lag screws alone; transverse metacarpal shaft fractures needing absolute stability (high-demand patient); Rolando fracture with large reconstructable fragments; revision after K-wire failure. Technique — dorsal mini-plate (metacarpal shaft):

1. Longitudinal dorsal incision; reflect the extensor tendon or pass through the interval between EDC slips.
2. Limited periosteal elevation over the fracture zone only.
3. Reduce with reduction clamps.
4. Apply a 2.0 mm or 2.4 mm straight plate to the dorsum with at least two screws each side of the fracture in cortical bone.
5. Repair the periosteum and close the extensor interval; early active motion at 3–5 days. Phalangeal plates lie directly under the extensor mechanism — use the lowest-profile system available (1.0 mm or 1.3 mm) and commit to an early active mobilisation protocol.

Step 9Bennett's fracture — ORIF

• Anatomy of injury: the anterior oblique ligament (beak ligament) retains a small volar-ulnar fragment at the base of the 1st MC; APL pulls the metacarpal shaft proximally, radially and into supination, producing CMC subluxation.
• Approach: Wagner volar-radial incision at the thumb CMC joint.
• Protect the radial artery (deep/dorsal to APL and EPB) and the superficial branch of the radial nerve.
• Longitudinal capsulotomy; identify the volar fragment held by the AOL and reduce the thumb CMC joint (sometimes a dental pick is needed to elevate an impacted fragment).
• Fix: a 1.5 mm or 2.0 mm lag screw from the metacarpal shaft into the volar fragment, OR a percutaneous K-wire from the 1st MC into the trapezium (plus a second wire into the 2nd MC base for rotational control).
• Confirm anatomical reduction of the CMC joint fluoroscopically; repair the capsule and close in layers.

Step 10Confirm, close & immobilise

• Final clinical rotation check and fluoroscopic confirmation.
• Layered closure; release the tourniquet and confirm digit perfusion.
• Bury or trim K-wires; dress.
• Immobilise in the intrinsic-plus (safe) position — MCP joints 70–90° flexion, IP joints fully extended, wrist 20–30° extension.
• Bennett's fracture: thumb spica for 4 weeks, then mobilise.

Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0–3 weeks | Intrinsic-plus splint (K-wires removed at 3–4 weeks) | Wound care, elevation; gentle active ROM; buddy taping | | 2 | 3–6 weeks | Removable splint | Progressive active and active-assisted ROM; dynamic splinting if PIP stiffness develops | | 3 | 6–12 weeks | Splint for heavy tasks only | Strengthening (putty, grip); graded return to function | | 4 | 12+ weeks | None | Full activity; contact sport from 8–12 weeks once united | Intrinsic-plus (safe) position. MCP joints at 70–90° flexion (collateral ligaments under maximum tension, preventing MCP stiffness), IP joints at full extension (volar plate at maximum tension, preventing IP flexion contracture), wrist at 20–30° extension. Use it for any post-operative splint. Duration by fixation: K-wire fixation 3–4 weeks in an intrinsic-plus splint then mobilise; stable lag-screw or mini-plate fixation — early active motion at 3–5 days with buddy taping; Bennett's fracture — thumb spica 4 weeks then mobilise. Rehabilitation milestones - Week 0–3: wound care, elevation; intrinsic-plus splint between exercises; gentle active ROM 3–5 times per day; buddy taping to the adjacent digit.

• Week 3–6: remove K-wires at 3–4 weeks (confirm healing on radiograph); progressive active and active-assisted ROM; dynamic splinting if PIP stiffness develops; avoid strengthening until union.
• Week 6–12: progressive strengthening (putty, grip); return to light duties; sport or manual labour from 8–12 weeks depending on stability. Return to activity - Light work (keyboard, sedentary): 3–4 weeks.
• Medium work (non-dominant hand tasks): 4–6 weeks.
• Manual labour / gripping: 6–12 weeks.
• Contact sport: 8–12 weeks, with radiographic union before full loading. Boxer's fracture specific protocol - Buddy taping to the ring finger immediately; a metacarpal brace for comfort (not essential).
• Early active ROM at 1–2 weeks if acceptable alignment is maintained.
• Most patients regain full function by 6 weeks.
• A cosmetic dorsal knuckle prominence may persist — warn the patient pre-operatively. Complications

Epidemiology & context. Metacarpal and phalangeal fractures are among the most common skeletal injuries, and the hand's long lever arms make small angular and rotational errors clinically significant. The metacarpal rays compensate for sagittal angulation through their CMC joints — the index and middle are essentially fixed, the ring has about 15° of flexion, and the small has 25–30° of flexion and rotation. This progressive ulnar CMC mobility is exactly why the small ray tolerates far more metacarpal shaft angulation than the index. Phalangeal fractures are the least forgiving hand fractures: the intrinsic tendons (lumbricals and interossei) volarly and the extensor mechanism dorsally create strong deforming forces — a proximal phalanx shaft fracture tends to apex volar, while a middle phalanx base fracture (FDS insertion) tends to apex dorsal. Bennett's vs Rolando — classification and pathomechanics. Both are intra-articular fractures of the thumb metacarpal base involving the trapezio-metacarpal joint. In a Bennett's fracture the anterior oblique (beak) ligament retains a small volar-ulnar fragment while the APL displaces the metacarpal shaft proximally, radially and into supination; a Rolando fracture is the comminuted (three-or-more-part) equivalent.

Key evidence. The modern management of these fractures rests on a few pivotal studies. For Boxer's fractures, van Aaken's multicentre RCT showed that a soft wrap with buddy taping is non-inferior to reduction and casting for 5th metacarpal neck fractures with up to 70° of palmar angulation and no rotation — rotation, not angulation, drives the decision to operate. The Cochrane review (Poolman) found no single conservative regimen superior. For phalangeal plating, the Kurzen series documented a 57% major-complication rate (stiffness commonest) — the basis for preferring lag screws and lowest-profile implants. Barton's foundational phalangeal shaft series showed that only about 57% achieved a satisfactory result, underpinning the principle that phalangeal fractures are the least forgiving. For Bennett's fractures, Leclère's 7-year follow-up of two-screw ORIF showed reduction maintained in 96% with near-normal strength — while radiographic CMC arthritis was common but correlated poorly with sub-2 mm residual incongruity.

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

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