Hand immobilization is required for severe fractures and tendon injuries

PubMed: Factors influencing flexor tendon adhesions.. https://pubmed.ncbi.nlm.nih.gov/4093463/

Factors influencing flexor tendon adhesions. Formation of adhesions is precipitated by injury to the tendon sheath, suturing of the tendon, and immobilization. Of the factors associated with formation of adhesions, immobilization has been most extensively investigated clinically and experimentally. Early protected passive mobilization to improve flexor tendon healing is currently the most effective means of inhibiting formation of adhesions. Published in Hand clinics (1985)

PubMed: Primary care of the injured hand, part 1.. https://pubmed.ncbi.nlm.nih.gov/450821/

Primary care of the injured hand, part 1. Because the hand is the most frequently injured part of the body, primary recognition of injured structures, careful assessment of damage, and appropriate treatment or referral by the primary care physician are critical. Most fingertip injuries heal with conservative care. Ideally, the healed wound should be covered with well-padded skin, be free of scar tissue, and not adhere to underlying bone. Crushing fingertip injuries associated with underlying fractures are often overlooked initially, with resultant infection, nonunion, and nail deformity. In the evaluation of flexor tendon injuries, recognition of the location of severed tendon is critical. Improved surgical techniques, when performed by an experienced hand surgeon, have yielded gratifying results, especially in the primary repair of tendon severance in the distal portion of the digit and palm. Mallet deformities at the distal interphalangeal joint are treated with extension splinting for minimum of six weeks without immobilization of the proximal interphalangeal joint. Open reduction is often required when an associated fracture involves more than 30% of the articular surface.

Intramedullary screw fixation of ballistic metacarpal and phalanx fractures.. 2026. https://doi.org/10.1016/j.jpra.2026.04.030

<h4>Introduction</h4>Ballistic hand fractures present a complex problem for surgeons. Traditionally, these have been treated with K-wires, necessitating prolonged immobilization. While fixation of hand fractures using intramedullary (IM) screws has been shown to have excellent outcomes in blunt trauma, their use in ballistic fractures has not been well studied. Here, we report our early outcomes of fixation of ballistic hand fractures with IM screws.<h4>Methods</h4>Our retrospective study reviewed adult patients from March 2023 to August 2024 treated for ballistic hand fractures with IM screws. Demographic data, operative details, complications, and return to motion were recorded.<h4>Results</h4>Thirty-two patients were included. The average age was 31.6 ± 14.0 years old, with the majority (29/32, 87.9%) being male. Most injuries involved the metacarpal and proximal phalanx, and 24/32 patients (75.0%) had intraarticular involvement. The average operative time was 75.9 min, including time required for other concurrent hand procedures in 19/32 (59.4%) of patients.The mean time from surgery to initiation of range of motion was 11.1 days, with 12/32 patients (37.5%) allowed to start range of motion immediately post-operatively. Time to full range of motion was 30.2 days and time to weightbearing was 51.6 days. Four patients (13.3%) had unplanned re-operations, all of which were due to proximal screw migration.<h4>Conclusion</h4>Our study demonstrates the feasibility of IM screw fixation of ballistic hand fractures. Our complication rate was minimal, and patients were able to safely return to normal activities of daily living at an accelerated pace. 5 , 6 , 7 Ballistic fracture fixation in the hands specifically have derived management principles from wartime injuries and are traditionally treated with operative debridement and Kirschner wire (K-wire), plating, or external fixation. 8 , 9 However, this method of bony fixation requires prolonged immobilization and can lead to significant stiffness and infection. 10 , 11 , 12 Intramedullary (IM) screw fixation has been used extensively in long bone fractures and, expounding on principles introduced by Foucher in the 1970s, has become increasingly more common in fractures of the phalanges and metacarpals. Patients chosen for IM screw fixation had maintained at least 1 cm of uninjured bone proximal and distal to the fracture site. Patients were followed-up in an Patients were splinted with a volar resting or ulnar gutter splint depending on the location of injury. If patients had other injuries requiring urgent or emergent intervention, this was coordinated on a case-by-case basis with Trauma Surgery and other services. Patients requiring admission were placed on antibiotic coverage if indicated by other injuries; they were not placed on antibiotics for hand fracture alone, as long as the fracture was not grossly contaminated and was amenable to irrigation and closure in the Emergency Department. None of the included patients had any significant chronic past medical history. Mean time to surgery was 3.9 days. Nearly half of the included patients (15/32, 46.9%) had injury to other areas in addition to hand fracture, with the vast majority attributed to assault. Most injuries were sustained to the metacarpal and proximal phalanx, and the majority (24/32, 75.0%) had intraarticular involvement. The average operative time was 75.9 min, though this included time required for other concurrent hand procedures in 19/32 (59.4%) of patients ( Table 2 ). Table 1 Demographics. 19 Standard trauma guidelines should be followed for assessment of these patients to exclude any life-threatening injuries, after which a focused hand exam to determine acute vascular compromise, functional and neurologic deficits, and bony involvement is conducted. The presence of fractures after GSWs increases the potential for possible neurovascular damage and threatened limb or digits if not assessed acutely. 20 Bony fixation in the setting of comminuted ballistic fractures has traditionally relied on percutaneous pinning and a period of immobilization, risking possible infection, soft tissue tethering, and stiffness of the affected digit. 3 , 21 , 22 , 23 , 24 In a retrospective study by Hsu et al., the group found complications in 14% of all pins including superficial and deep infections, as well as fractures through the pin tracks, pin migration, and pin loosening. 23 The use of external fixation has also been reported, though this method can preclude full stability in these injuries. 21 Open reduction with plating can be technically challenging in the setting of significant comminution and risks stiffness, periosteal stripping, plate prominence, and tendon rupture. The incidence of ballistic hand fracture are associated with a significantly increased risk of tendon and nerve injury, which in turn leads to higher risk of more long-term disability. 26 Though more than half (59.4%) of included patients in this study required concomitant hand procedures, there were no instances of vascular compromise or concern for ischemic digit. The majority of concomitant procedures were extensor tendon repairs, followed by joint fusions which were separate from ballistic fracture treated with IM fixation. Concern for acute carpal tunnel was noted in two patients, and ulnar nerve decompression with Guyon canal release was noted in one patient. Despite mean operative time of over an hour, the time for the bony fixation portion of the case was significantly less – a mean of 44.9 min when only accounting for patients undergoing fracture fixation without concomitant hand procedures, 32.1 min per screw when accounting for the mean of 1.3 screws per patient in those undergoing bony fixation alone. The treatment of ballistic injuries as open or closed fractures remains controversial and may be predicated on factors such as velocity of injury and contamination of the wound bed on presentation.

Treatment of Sagittal Band Injuries and Extensor Tendon Subluxation: A Systematic Review. 2020. https://doi.org/10.1177/1558944719895622

Background: This systematic review assesses the current literature and reviews the clinical outcomes of treatment for sagittal band injuries and extensor tendon instability. Materials: A systematic search of MEDLINE, EMBASE, and the Cochrane databases was performed for English-language articles on the treatment of nonrheumatoid adult sagittal band injuries between 1969 and 2019. Two independent reviewers were involved in screening, data extraction, and critical appraisal. The level of evidence was assigned using the Sackett scale, and the methodological quality of the studies was evaluated using the Structured Effectiveness Quality Evaluation Scale (SEQES). Outcome measures were persistent pain, extensor lag, and recurrent tendon subluxation. Results: In all, 1653 abstracts were identified, with 43 articles reviewed in full text and 17 articles (429 treated digits) included in the final systematic review. There were 10 studies on surgical management, 3 on nonoperative management, and 4 on both. There were 4 retrospective case series and 13 retrospective case reports (Sackett level 4) with an average SEQES score of 15 (low quality). Studies on nonoperative management had on average more digits per study and higher SEQES scores (n = 27.7, SEQES = 19) compared with studies on surgical management (n = 11.8, SEQES = 13.8). Variability in reported outcome measures precluded meta-analysis. Conclusion: Qualitative synthesis of available literature suggests that acute sagittal band injuries can be successfully treated by splinting the injured digit in neutral or hyperextension. Patients with chronic injuries or those failing nonoperative management may benefit from surgical exploration. A lack of consistent outcome measures precluded comparison of surgical techniques.