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DOI: 10.1016/J.JHSE.2007.06.017
Fractures of the Tubular Bones of the HandFrom the Essex Rivers NHS Trust, Colchester, UK, the University Hospitals of Leicester NHS Trust, Leicester, UK and the Pulvertaft Hand Centre, Derbyshire Royal Infirmary, London Road, Derby, UK Correspondence: Mr J.J. Dias MD, Frcs, Consultant Orthopaedic and Hand Surgeon, Glenfield Hospital, University Hospitals of Leicester, Groby Road, Leicester LE3 9PQ, UK. Tel.: +44 116 256 3089; fax: +44 116 250 2676. E-mail:joseph.dias{at}uhl-tr.nhs.uk
Age related differences in demographics, morphology, treatment and outcome were investigated in 701 fractures of the metacarpals or phalanges, including fracture-dislocations, in 655 patients. Fractures mainly due to sport occurred in 184 children, usually after 10 years of age. The base of the proximal phalanx was especially vulnerable. Thirty-seven percent of 256 young adults fractured their fifth metacarpal. The thumb was rarely involved. Half of these two groups fractured the fifth ray. Older adults had more fractures of the distal phalanx and displaced extraarticular fractures requiring stabilisation. Women predominated in the patients over 65. Forty percent of this group sustained their fracture on the road and more fractures involved the thumb, were oblique, intraarticular or multiple than in other groups. Detailed analysis of 423 X-rays demonstrated that only 10% of 70 intraarticular fractures and 19% of 363 extraarticular fractures were completely undisplaced. Patient response to postal questionnaire based outcome assessment using SF-12, MHQ was very poor.
Key Words: fractures • metacarpal • phalanges • epidemiology • outcome Hand and wrist injuries are responsible for up to 29% of the patients seen in an Accident and Emergency Department (Angermann and Lohmann, 1993), with hand fractures representing up to 19% of all hand injury patients seen (Edwards, 1975). Hand fractures are frequent but are mainly treated in an outpatient setting. Only a minority require surgery, commonly stabilisation with K-wires. These injuries are primarily recreational and domestic, rather than industrial. This may, in part, be related to Health and Safety legislation and a declining manufacturing base in the UK. There has been relatively little published work in Europe on the demographics, nature, treatment and outcome of fractures and dislocations involving the metacarpals and phalanges of the hand. In particular, there is little information on displacement of extra-articular and intraarticular fractures and the age-related differences in the patterns of fractures in the digital skeleton. A prospective audit of all injuries was conducted (Burke et al., 2004) and data from this audit was used to investigate the patterns of fractures of the digital skeleton and their displacement.
We studied all patients who had sustained fractures of the metacarpals and phalanges, including those patients with a dislocation of an adjacent joint. One thousand four hundred and forty-four trauma cases presented in the six month period of this study. Of these cases, 653 patients had fractures of metacarpals or phalanges, with two patients sustaining a further fracture, resulting in 655 patient episodes (an average of 109 patients presenting each month). This represented 45% (655/ 1444) of the total number of patients seen as a result of hand injuries during this period. These 655 patient episodes included a total of 701 tubular bone fractures. There were 486 male and 167 female patients in this patient group. All aspects of treatment for every new patient attending were documented. The age, sex, dominance and occupation of the patients were noted, as was the place where the injury occurred, the mechanism of injury and the day and time of injury. The ray that was injured, the bone within each ray fractured and the location of the fracture within each bone was recorded in each case. We divided the 655 patients into four age groups as follows: Group 1 – children 0 to 16, Group 2 – young adults 17 to 40, Group 3 – older adults 41 to 65 and Group 4 – those of retirement age, 65+. To evaluate these fractures further, the X-rays of these patients were analysed for the fracture morphoogy, the degree of split, depression and angulation of intraarticular fractures and the degree of angulation and displacement of extraarticular fractures. Four hundred and twenty-three sets of X-rays were analysed further with specific measurement of displacement, accounting for 65% of the patients. In intraarticular fractures, the degree of split and depression were measured in mm. In extraarticular fractures, undisplaced fractures were graded: Grade 1 (0–25% of the shaft diameter displacement), Grade 2 (26–50%), Grade 3 (51–75%), Grade 4 (76–100%) and Grade 5 (greater than 100% displacement). Fracture angulation was graded as none, mild (0–10°), moderate (10–20°) and severe (greater than 20°). The resources used to treat these injuries were noted, including the number of clinic visits, whether an operation was performed, the duration of inpatient stay in days and the duration of surgery in minutes. To assess outcome we used the SF-12 general health questionnaire and the Michigan Hand Questionnaire (MHQ), which is a hand-specific outcomes instrument measuring the health outcomes of patients with chronic hand conditions (Chung et al., 1998). We also recorded the patients’ and surgeons’ view of outcomes as ‘poor’, ‘fair’, ‘good’ or ‘back to normal’. The time of return to work was recorded in days. Analysis was conducted looking at the pattern for each age group using cross-tabulation and analysis of variance.
Table 1 presents demographic and injury details. Males were affected approximately three times as often as females (2.9:1, i.e. 74% overall). However, there were significant differences in sex distribution between the different age groups. In children and in older adults, the distribution was similar to the overall distribution. In young adults, more males sustained fractures. In patients of retirement age, females sustained slightly more fractures than males. The fracture involved the dominant hand in 65% (396/613) of cases, with no difference in the distribution between the different age groups.
Fractures were most common in the 10 to 15 year olds, comprising 19% (121/631) of the total. Fractures were less common in those above 45 years of age and the overall age range was from 11 months to 102 years. Twenty-eight percent (185/653) of the patients were still at school. Thirty-eight percent (245/653) of the cases were individuals involved in light, moderate or heavy manual work. Professionals and desk workers only represented 11% (73/653) of all cases. The commonest place for the injury to happen was either in the home or while playing sport (Table 1). Sport was responsible for 44% (76/174) of the paediatric fractures, but only 24% (64/271) of those fractures occurring in young adults. Work was responsible for 15% (41/271) of the fractures in young adults, but 29% (32/111) in older adults. Road related injuries were more common in young adults and those above retirement age, accounting for 23% (61/271) of the injuries in young adults and 43% (13/30) in those above retirement age. The proportion of fractures occurring in the home remained constant, at around 30%, in all the younger age groups, but increased at retirement age to 43% (13/30). The commonest mechanism of injury was by crush/direct injury to the finger itself, occurring in 83% (535/648) of cases. Lacerations tended to cause soft tissue rather than bony injury. Indirect injuries were defined as those injuries to the fingers or hand which occurred as a consequence of an injury mechanism not directly over the fracture site, as, for example, when injury was a result of twisting of the skeleton. These represented only 13% (82/648) of cases. A crushing mechanism was responsible for around 85% of paediatric, young adult and retirement age injuries, but for only 73% (94/129) in older adults, who were more prone to indirect injuries. Young adults had peaks in incidence around midday, between 6 pm and 9 pm and a further peak around midnight until 3 am (Fig 1). There were very few injuries in children before 9 am, with an increase in incidence at school and a further rise around 6 pm. Older adults showed a roughly similar distribution to children, with an increase in incidence between 9 am and 1 pm, a decrease during the afternoon, then an increased incidence between 5 pm and 8 pm. In the retired population, the only slight peak (5 of 36 fractures) occurred around noon, in common with all other age groups.
There was an uneven distribution in respect of the day of presentation of these injuries. Twenty percent (129/648) of fractures presented to hospital on a Saturday, compared with a low of only 10% on a Wednesday. Presentation on all other days was similar and varied between 13(83/648) and 15% (96/648). The fifth ray was the most commonly fractured ray (47% overall, 322/691), due principally to the very high fracture rate of fifth metacarpals in young adults (120 cases in this series). Fifty percent of fractures in children (92/187) and young adults (159/327) involved the fifth ray. This proportion then fell as age increased, to 31% (14/45) in the retirement group. The first ray was twice as vulnerable to fracture in children (22%, 41/187) and those of retirement age (20%, 9/45) as in young adults (12%, 40/327). Considering only fractures of the phalanges, and excluding metacarpal injuries, the little finger was still the commonest injured (32%, 121/382) with the thumb the next most commonly injured (23%, 86/382), followed by the ring, middle and index fingers in that order. There were significant differences between the age groups. The little finger was most commonly injured in children, young adults and older adults, comprising 41% (44/108), 26% (39/153) and 33% (31/94) of cases, respectively. However, the distribution was different in those of retirement age, in whom the thumb was the most commonly injured digit (33%, 9/27 cases) (Fig 2, Table 2).
There were significant differences in the bone involved both within and between age groups. The commonest bone fractured was the metacarpal, accounting for 47% (302/637) of all cases. The majority of these were fractures of the fifth metacarpal, which was the most frequently injured metacarpal in all age groups. Fifth metacarpal fractures represented 26% (48/187) of all hand tubular bone fractures in children. This increased to 37% (120/327) in young adults then decreased to 16% (7/45) in the retirement age group. Fractures of the distal phalanx (24%, 152/637 cases) were much more common than those of the middle (14%, 88/637 cases) and proximal phalanges (15%, 95/637 cases). Metacarpal neck fractures constituted one third of the fractures sustained both by children and by young adults and represent 29% (183/637) of all fractures seen. The rate of metacarpal neck fractures decreased in the older adult group to approximately 19% (23/124), with this rate being 14% (6/42) in those of retirement age. The tuft and base of the distal phalanx were common sites of injury, each representing 10% (64/637 and 66/ 637) of cases respectively, followed by the diaphysis of the metacarpal (10%, 62/637 cases) (Table 3). The base of the distal phalanx appears to be particularly vulnerable to fracture in the older adult group, making up 22% (27/124) of all fractures in this group, compared to between 7% and 8% in the other age groups. These are primarily bony mallet injuries. The tuft of the distal phalanx was also more vulnerable in older adults (15%, 18/124 cases). Base of proximal phalangeal fractures constituted 15% (27/180) of children’s fractures, a number over three times higher than in any other age group, (these fractures being primarily epiphyseal in nature).
The 655 episodes in 653 patients involved 701 fractures. Thirty-eight patients had two fractures and four patients had three fractures of the digital skeleton. Of the 42 patients (6.4% of 653 patients) with multiple fractures, only one had both hands involved. Nine had more than one fracture in the same ray. The remainder had different rays affected in the same hand. In four of these, different bones were involved in different digits. However, the commonest was multiple metacarpal fractures in the same hand (20 cases) with multiple phalanges at the same level (for example, neighbouring proximal phalanges) accounting for eight cases. Thirteen point nine percent of fractures in retired patients were multiple, double that in children (6.5%) and young adults (6.2%) and treble the rate in older adults (4.6%). Oblique fractures were the commonest overall (37%, 162/433 cases). In children, epiphyseal injury predominated (47%, 51/108 cases). The ratio of oblique to transverse fractures increases with age from a ratio of 1:1 in children, 1.5:1 in young adults, 2:1 in older adults to 3.8:1 in those of retirement age. Spiral fractures were unusual (6%, 28/433 cases) (Table 4). Forty-eight percent (93/195) of all metacarpal fractures were oblique, whereas oblique fractures only accounted for about one third of cases in the other bones (proximal phalanx 31%, middle phalanx 33% and distal phalanx 24%). The fracture line was spiral in 28 fractures and these occurred almost exclusively in the proximal phalanx (9) and the metacarpal (18). Avulsion injuries were more common in the distal and proximal phalanges.
Seventeen percent (70/423) of fractures were intraarticular and 70 sets of X-rays were retrieved. Approximately one third of intraarticular fractures had no gap, one third had a gap of one mm and one third had a gap of two mm or more. Only 4% (3/70) of intraarticular fractures had a gap of 3+ mm. Seventy-three percent (51/70) of intraarticular fractures showed no depression, with only 9% (6/70) being 2, or more, millimeter depressed. In 87% (61/70) of intraarticular fractures, the fracture fragment was angulated by 10° or less. There were no significant differences between the age groups with respect to the degree of gap, depression or angulation. Only seven intraarticular fractures (10%) were completely undisplaced. Eighty-three percent (302/363) of extraarticular fractures were displaced by less than 25% of the shaft diameter. There were differences between the age groups, with fractures being undisplaced in 60% (63/105) of children, 37% (62/166) of young adults, 27% (20/73) of older adults and 53% (10/19) of patients of retirement age. Seventy four percent (269/363) of the fractures were angulated by less than 10 degrees, with no difference between the age groups.
Nineteen percent (70/363) of extraarticular fractures were completely undisplaced. In the retired age group, 47% (9/19) of these fractures were completely undisplaced, whereas, in children, only 22% (23/105) were undisplaced. In younger and older adults, the proportion of undisplaced fractures was even lower (17% and 14%, respectively) and these differences were statistically significant ( Ninety-six of the 655 patients required surgery (Table 6), a rate of 15%. These 96 patients required 119 operative procedures. Seventy-eight patients required one operation, 13 required two and five required three operations. Of these 119 operations, 17% (20/119) involved soft tissue surgery only, 11% (13/119) involved a manipulation under anaesthetic of the fracture, 40% (48/119) required the use of K-wires and, in 32% (38/119) of cases, internal fixation was carried out with plates and/or screws.
In the 18 cases requiring a second operation, 14 of these involved K-wire removal, two required soft tissue surgery and two more needed further fixation of the fracture. In all of the five cases requiring three operations, the final operation involved removal of K-wires. Intraarticular fractures accounted for 17% of all fractures, but 26% of the fractures which required surgery were intraarticular. There was a significant difference between the number of outpatient visits between the various age groups (Table 6). The average number of outpatient visits in children was 2.3, increasing to 3.5 in older adults and 2.7 in those of retirement age. Age did not affect the number of operative procedures required. The duration of surgery was significantly less in children, with a mean duration of 25 minutes of anaesthetic. The duration of surgery in young adults was almost one hour, with a mean of 31 minutes in those of retirement age. Only 20% (130/655) of patients returned their final MHQ questionnaires, even after repeated attempts to obtain this information.
Assessment of descriptive views of outcome revealed strong concordance between patient and surgeon outcome assessment ( There was no difference between the age groups in the time taken to return to work.
This study reports the patterns of fractures and their displacement in four age groups. Fractures of the digital skeleton occur mostly in men. The male to female ratio of between two and three to one noted by most previous studies of hand fractures was confirmed by our study. There is an increased male preponderance with increasing severity of injury (Campbell, 1985). In children, too, males predominate (Rajesh et al., 2001). However, this study suggests that patients over 65 years of age who sustain a fracture of the digital skeleton are more likely to be women. Brown (1967) found no variation in the number of patients with hand fractures presenting on different days of the working week and reported that the number of patients presenting at the weekend was one third that on a week day. Packer and Shaheen (1993) identified an uneven spread of attendance to hospital in patients with hand fractures, with 25% of cases presenting on a Monday. In our study, 20% of all cases presented on a Saturday. Clark et al. (1985) also found the commonest day of presentation to be a Saturday. In our study, the least number of cases presented on a Wednesday, accounting for 10% of patients. The number presenting on all other days of the week was similar, at between 13% and 15%. Clark et al (1985) found 48% of the fractures in their series presented between 8 am in the morning and 4 pm in the afternoon, 44% between 4pm in the afternoon and midnight and 8% between midnight and 8 am in the morning. Usal (1992) noted no pattern when correlating presentation of injury with regards to day of week or time of day. Bhende et al. (1993) found that 67% of paediatric hand injuries occurred between 3pm and midnight. Smith et al. (1985) correlated time and place of injury: work injuries were distributed throughout the working day, sport injuries were commonest in the afternoon, home injuries in the evening and those involving violence were commonest at the weekend. We have shown differences in the time of injury between the four age groups. There was an increase in night-time injuries in young adults, as might be expected, due to the preponderance of neck of fifth metacarpal fractures. Children had few fractures before the start of the school day, but tended to present in the afternoon and early evening, concurring with one previous study in this respect (Bhende et al., 1993). The place of injury has changed very little in the last 25 years, with injuries sustained in the workplace comprising 15% of the total in 1977 and 12% in our study. These rates are less than half the rates for work related hand and forearm fractures in the USA (Chung and Spilson, 2001). This difference may reflect the types of employment and differences in the Health and Safety regulations in the two countries. We found that the most common group sustaining injuries at work were young adults, presumably because heavy manual work is carried out more frequently by younger, rather than older, adults. However, as a proportion of injuries sustained within each age group, a higher proportion of injuries were work related in older adults than in younger adults, despite increasing experience. There is an increased risk of injury with both inexperience and ‘over-familiarity’ (Absoud and Harrop, 1984). If metacarpal fractures are looked at in isolation, De Jonge et al. (1994a) from the Netherlands found that some 30% of metacarpal fractures were caused by transport accidents and half of these were due to bicycle and scooter use. The Dutch would appear to make more frequent use of two wheel transport; in this study, only 18% of metacarpal fractures were due to transport-related injury. The majority of the fractures were caused by a direct, or crushing, mechanism, even in the retired population, in contrast to other studies, in which falls were the commonest cause of phalangeal injuries in the over seventies (De Jonge et al., 1994b). The mechanism of children’s injuries appears similar to that reported by Barton (1979), with a significant number of crush injuries to the distal phalanx and very few intra-articular injuries. Age has an important effect on the type of fracture encountered. In common with Packer and Shaheen (1993), roughly 70% of all metacarpal and phalangeal fractures in our study occurred in patients between 11 and 40 years of age. However, there was a reduction in incidence of these fractures after 45 years of age, which concurs with Barton’s (1977) findings. Fractures of the tuft of the distal phalanx represent a higher proportion of fractures in older patients than, even, in children, in whom crush injuries of the distal phalanx in doors are common. In the older adults, the base of the distal phalanx is the area most at risk, while the tuft is most at risk in children. The fifth metacarpal was involved in 29% of all fractures. It was the most commonly fractured tubular bone in our paediatric age group, which is at variance with the experience of Hastings and Simmons (1984) and of Worlock and Stower (1986), in whose studies the proximal phalanx was more commonly affected in children. Our series, in agreement with Worlock and Stower (1986), demonstrated a vulnerability in this age group to fracture at the base of the proximal phalanx. This confirms that the most vulnerable parts of the proximal and middle phalanges are their bases and that the most vulnerable part of the metacarpal is the neck. Region specific factors may also be important. For example, children in Saudi Arabia sustained more middle phalangeal fractures than any other, as a result of crush injuries from heavy domestic doors (Mirdad, 2001). In all age groups except for the retired, the metacarpal neck is the region of the metacarpal most affected. In the retired population, diaphyseal fractures of the metacarpal are more common than neck fractures, and basal fractures of the metacarpal are almost as common. The ratio of phalangeal to metacarpal fractures is lowest in young adults, higher in children and also increases with increasing age. The incidence of intraarticular fractures is very low in the 0 to 16 age group, and then, gradually, increases to a maximum in the retired group. Barton (1977) reported that the proximal phalanx was the most commonly injured bone and that right and left sides were equally affected, whereas our study revealed that the distal phalanx was the most commonly injured of the phalanges and that the right side and dominant side were affected in 60% of cases. Hill et al. (1998) found that phalangeal fractures were commoner than metacarpal fractures. Our study found that the metacarpal is the most commonly fractured hand bone, confirming the observation of Hove (1993). The border digits were the most commonly affected in our study, refuting the theory that the incidence of digital fractures is proportional to the length of the digit (Brown, 1967). In children, also, the border digits are most at risk. This distribution of fractures in the hand is different to the distribution of hand injuries of all types, in which the middle (Frazier et al., 1978) and the index finger (Goldwyn and Day, 1969; Page, 1975) are most commonly injured. The fifth ray was involved in half of all cases of fractures in both children and young adults, but only 30% of all fractures in the retired patients. The incidence of fractures of the first ray in children and the retired (20%) was almost double that in young adults (12%). There is little information in the literature on the morphology, displacement and angulation of digital fractures. Rajesh et al. (2001) identified different fracture patterns in four different paediatric age groups in children up to 16 years of age. In our study, we found that around one third of digital fractures were oblique, with the ratio of oblique to transverse fractures steadily increasing from one in the 0 to 16 age group up to four in patients of retirement age. Intraarticular fractures were rare, and completely undisplaced in terms of split and depression in 10% of cases, severely displaced in 10%, with the remainder being minimally displaced. Extra-articular fractures were common, with almost half undisplaced, or slightly displaced, in terms of shift and angulation. Shift in excess of 50% of bone diameter was rare, and angulation in excess of 20° only occurred in 11% of cases. These features are relatively unaffected by age (Table 5). To our knowledge, these patterns have not previously been described in the orthopaedic, or hand, literature.
The incidence of surgery of 15% in this study was almost three times higher than the 5% incidence reported by Barton (1984). This could be explained, in part, by the inclusion of metacarpal fractures. Forty percent of our cases required the use of K-wires and the overwhelming reason for more than one operation was for removal of a K-wire. Despite the fact that only a minority of fractures require surgery, digital fractures are common and the financial costs to society are considerable. Patients frequently require several out-patient visits (Table 6) to monitor fracture alignment and recovery of function. The majority of papers looking at this subject include no outcome data and those few papers that do utilise a very simple outcome classification. Despite significant resources expended and effort made to enable outcome collection and analysis, there was an extremely low rate of outcome questionnaire responses, which is commonly the case in young patients with injuries. It may well be that ‘simple’ is best when it comes to assessment of outcome (Table 7).
This study prospectively analysed a large number of metacarpal and phalangeal fractures and identified significant differences between age groups in fracture demographics, incidence, causation, anatomy and morphology (Table 8). While some of the differences may be explained, for example the increased incidence of fifth metacarpal neck fractures in young adults, there are other differences that are not so intuitive, for example the increasing ratio of oblique to transverse fractures with increasing age, or the thumb being more frequently injured than the little finger in the retired age group. It is evident from Table 8 that children sustain less significant injuries than do older age groups, they require less treatment and overall have a better outcome. As age increases, so displacement in extraarticular fractures increases to a maximum in the 41 to 65 age group, the group which also requires the greatest in-patient resources. Intraarticular fractures are most common in the retired but these patients require the least in-patient resources, reflecting the small number of cases in this age group as compared to the other groups. The group who appear most ‘at risk’ are the older adults, aged 41 to 65. However, because of numbers, children and young adults account for the biggest out-patient workload and consume most resources.
The authors would like to acknowledge the work of all colleagues working at the Pulvertaft Hand Centre for contributing to this study. In particular, Mrs Mary Bradley Mr Heras-Palou and Ms Clare Wildin were instrumental in helping to set up and run the data collection. Mr Srivastava helped in collecting and measuring X-rays. Received for publication January 31, 2006. Accepted for publication June 13, 2007.
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Abstract
PATIENTS AND METHODS
2 =12.2, p = 0.007) There is a significant correlation between angulation and displacement of extra-articular fractures of the metacarpals and phalanges in children and those of retirement age, but not in young, or older, adults.