The Fracture Handbook
The Fracture Handbook is divided into the following sections for easy reference:
This is not a comprehensive account of all the management options for hand fractures. It is however, a practical guide to hand fracture management that works for us in Bath, for our patients and for our other team members (especially the ‘Hand Therapists’). Alternatives are available to almost all our recommendations and we have alluded to them but have stressed our preferences. We believe that our approach is reliable and above all safe. There are a number of guiding principles but the most important is that it is better to have the majority of patients satisfied with good pain-free function and very few complications rather than risking those inevitable surgical disasters in an effort to gain a slightly better or a slightly earlier return to function.
Every technique is associated with complications; the most spectacular tend to occur with more aggressive interventions. We use more than K wires infrequently and have rarely regretted this approach. Kirschner (K) wires are simple to insert percutaneously, cause little extra damage and if inserted incorrectly can usually be revised easily and effectively. We therefore avoid open surgery in most cases. However this does require careful follow-up in the outpatient clinic, particularly for the first 2-3 weeks when the fractures may lose position or the soft tissues stiffen.
What is the aim of hand fracture management? It is not to achieve bone union, the body’s natural healing processes will do that. The aim is to ensure bone union in a good enough position whilst maintaining soft tissue gliding.
What is “good enough”? Ideally we are aiming for anatomical reduction and bone union. Striving excessively to achieve this may increase the risks and the complications, which are not justified by little improvements in outcome. This is another of our guiding principles in hand fracture management.
Hand fracture management is therefore mainly an outpatient exercise. This suits us and seems to suit our patients. A more interventional approach may suit other Hand Surgery units.
Most hand fractures can be treated with limited support and early mobilisation. Some fractures will require a little more intervention. We apply plaster of Paris (POP) and splints, we manipulate fractures in the outpatient’s clinic under local anaesthetic and above all we keep a close eye on our patients, particularly in the first few weeks following the fracture.
In more severe injuries particularly compound (open) fractures the primary care of open wounds in the emergency department is of great importance: upon presentation the hand should be elevated and at an early stage local anaesthetic instilled around the wound or ideally as a more proximal block, such as a ring block. Early cleaning, (scrubbing) and washout of the wound are probably the most important steps to prevent of infection (“dilution is the solution to pollution”). This should ideally be undertaken within 6 hours and preferably earlier. Antibiotics, typically one dose of IV Cefuroxime (or other second generation Cephalosporin), or Amoxycillin and Flucloxacillin as well as ensuring Tetanus cover are simply important adjuncts to cleaning. The skin should either be closed, or if there is any doubt about skin tension, dressed with Jelonet and a Betadine or saline soaked gauze dressing. Initially the hand should be immobilised. Very early mobilisation is likely to be painful, may increase swelling and we believe has more disadvantages than advantages. This will result in safe primary management of most injuries and the avoidance of infection.
Definitive treatment can then be undertaken within the next week to ten days. There is no evidence that earlier definitive treatment improves the final outcome for most fractures. This allows for planned treatment by an appropriate surgeon whilst the patient can wait safely at home. This does not mean that there is any particular advantage in delay but neither is there any need to rush treatment. In the interim the patient must elevate their hand. In most cases further doses of antibiotics are not required.
Most injuries requiring surgery can be operated upon under local anaesthesia. We typically use up to 30mls of 0.5% plain Bupivicaine (in adults) as a local anaesthetic or distal regional anaesthetic such as a wrist block. K wiring typically does not require a tourniquet (although we usually apply one but keep it deflated as a precaution). Open reduction and internal fixation (ORIF) more often requires general/regional anaesthesia and a tourniquet.
If surgery is required K wiring is typically safe and reliable but there are a number of key steps in achieving good results with K wiring and these principles are outlined in appendix A. Rigid internal fixation with screws/plates is even more demanding and should not be undertaken without appropriate skills and experience/supervision.
Advice to the patient is critical, especially in the early post-operative period. This can start in the operating theatre if the patient is awake.
In this book we have divided hand fractures into finger bones, thumb bones and carpal bones. We address both fractures and dislocations. We are not addressing the important topics of either the common soft tissue injuries e.g. tendon injuries or complex soft tissue injuries requiring fasciotomies, debridement or soft tissue coverage. They are outside the remit of this book.