Malunited fracture of a finger: diagnosis and treatment

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Fractures of the hand bones are the most common fractures among all the bones of the human skeleton. Such fractures occur in the workplace or at home as a result of being hit by or about heavy objects, during a fall, as well as when playing various sports.

Most of these fractures are treated conservatively without surgery, however, some fractures: open, intra-articular, unstable, with angular or rotational displacement, require surgical treatment, that is, fixation of fragments using pins, screws or plates. If left untreated, fractures of the metacarpal bones and phalanges of the fingers heal incorrectly and can lead to limited function and cosmetic appearance of the hand. Improperly healed intra-articular fractures cause post-traumatic osteoarthritis, which can cause pain and limitation of movement in the damaged joint.

It should be remembered that not all displaced fractures cause dysfunction of the hand or finger. Also, in parallel with an unevenly healed fracture, there may be other problems that are not related to the injury.

A malunited fracture of a finger is a more complex problem than any other malunited fracture. After all, good hand function also depends on joint mobility, sensitivity, skin coverage, blood supply, and gliding of flexor and extensor tendons. Any pathology of these structures may limit the options for surgical reconstruction of the finger.

If a broken finger has healed incorrectly, you must first weigh all the possible risks and benefits of surgical intervention, discuss the goals and possibilities of treatment with a hand surgeon.

How to diagnose?

It is usually not difficult to identify dysfunction of the hand associated with improper healing of a fracture. There are often external signs, such as pathological rotation, a hump on the back of the hand, angular deformation of the finger, and others. To clarify the nature of the bone deformation, an x-ray is usually sufficient. It is very important to photograph each finger separately in a clear frontal and lateral view.

Rotational displacement is assessed when clenching the fingers into a fist: whether there is crossing or not. And here difficulties may arise, for example, we assume that the finger is simply not yet developed and therefore does not bend, but in fact there is a slight rotational displacement, which makes it difficult to bend.

So for a complete diagnosis, both analysis of radiographs and examination by a specialist are important. After all, tendon mobility can only be assessed during examination; ultrasound or MRI are not very helpful in assessing the condition of soft tissues when it comes to fingers.

In the case of intra-articular fractures, a computed tomography scan may be ordered to assess displacement.

Types of finger fracture

Because of

Traumatic fractures are damage to the finger bone due to trauma.
Pathological fracture - a fracture of a finger in the area of pathological restructuring (affected by any disease - osteoporosis, tumor, osteomyelitis, etc.) Osteoporosis is the most common cause of a pathological fracture.

The nature

Closed fractures (without breaking the skin)

— Incomplete

— Complete

Open fractures (with skin damage)

— Primary open

— Secondary open

Based on the presence of offset:

Fractures without displacement of fragments
Displaced fractures.

Treatment

So what to do if your finger is not fused correctly?

It is worth contacting a specialist in the treatment of hand pathologies. A regular emergency room or traumatology department in a hospital is unlikely to take on the treatment of the consequences of a wrist fracture, and they will be right.

First, it is necessary to find out whether the patient’s complaints are a consequence of malunion or a lack of rehabilitation. Post-traumatic contractures of the hand joints are almost always first treated by a hand therapist using dynamic orthosis and other techniques for non-surgical joint development.

If the bone of the finger on the hand has really fused incorrectly, then the surgeon, together with the patient, decides on the timing and methods of correcting this deformity. Most fractures of the phalanges and metacarpals can be repaired and fixed with pins.

I prefer to perform such operations with local anesthesia because it is safe and convenient. Directly on the operating table, the patient moves the newly fixed fingers, which makes it possible to verify the correction of the deformity and the stability of the fixation. In the postoperative period, this gives confidence to allow early development of movements.

Usually I don't leave the knitting needles sticking out, but rather bite them under the skin. They are removed after 5-6 weeks through small punctures, also under local anesthesia.

While the fracture is healing after surgery, an individual orthosis is made from thermoplastic, which is much lighter and more comfortable than conventional plaster.

Fracture of the phalanx of the finger

Our fingers make very fine, coordinated movements and disruption of these movements can have a huge impact on daily and professional activities. To maintain full hand function, it is important that all finger fractures are evaluated by a physician to determine appropriate treatment. If you think that a broken finger is a minor injury, then you are seriously mistaken. Without proper treatment, a fracture of the finger can cause serious problems: limited flexion of the finger (contracture), pain with minor loads, decreased grip of the hand, whether it is a fracture of the nail or the main phalanx of the finger.

Anatomy of hand bones

The human hand is formed by 27 bones:

8 carpal bones;
5 metacarpal bones;
The 14 bones that form the fingers are called phalanges. The first finger has only two phalanges: proximal and distal. Unlike the rest of the fingers, which consist of three phalanges: proximal, middle and distal.

Fractures of the metacarpal bones of the hand account for 30% of all hand fractures in adults.

Case study No. 1

A girl whose phalanx of her finger fused incorrectly described her complaints like this:

“If the hand is at rest, there is a pulling sensation in the finger somewhere from the middle of the palm, as if it is heavier than the rest, or as if stiff, this does not bother you, it is just noticeable. When vibrating, shaking a finger, it hurts from slightly to very much, for example, if you touch something with your hand (not hit, but lightly) - get caught on clothes, hand in hand, furniture - it already hurts, I wince, but tolerable. My husband suddenly took my hand - I screamed, there was sharp pain. Holding a weighty object (salad bowl, book) in your hand (4 fingers at the bottom, big at the top) hurts, I immediately grab it with my other hand. I unclench my fist after I bring the bag from the store and have to endure it for a couple of minutes until the pain subsides - although the load seems to be greater on the other fingers, and it didn’t hurt to carry it. At the same time, it hurts to bend and unbend a finger only if you try to do it with effort, further than he can do” (the author’s spelling and punctuation have been preserved).

The image clearly shows a displacement along the articular surface of the middle phalanx, which was not eliminated during treatment of the fracture.

In this case, corrective osteotomy is impossible and plastic surgery was performed with an osteochondral graft from the hamate bone (hemi-hamate arthroplasty).

In this operation, a piece of bone with cartilage from the hamate is taken, which is ideal for replacing a defect in the articular surface of the base of the middle phalanx.

This is what the finger looks like after surgery.

Three months later, the girl wrote about him in a completely different way:

“I perform all the actions that I couldn’t do with my hand before the operation because of pain in the finger without any problems, the only slightly painful sensations are when I try to fully bend it and immediately straighten it completely and vice versa, but the pain is not sharp and goes away immediately.

The set of rehabilitation exercises that the doctor showed me at the handclinic began slowly - now I perform it much more actively, the strength in the finger is almost on par with the rest, plus the steering wheel (a good compression trainer), plus briefcases - I use my hand actively, even the muscle of the left forearm is already aligned with the right, otherwise I compared them in August by accident, I was quite surprised at how weak my left arm was in six months after the fracture.

As far as I understand your forecasts, things with the finger are, in principle, as expected.”

Tests and diagnostics

The diagnosis of a “fracture of a particular bone in the arm” is made based on a physical examination of the patient, a history, and the presence of characteristic symptoms. The diagnosis of a bone fracture is based on instrumental examination methods: X-ray examination, which makes it possible to identify the location of the fracture, assess its severity and features (presence of displacement, bone fragments, intra-articular damage). In cases of suspected damage to soft tissues, nerve fibers, blood vessels, an MRI or CT scan is additionally performed. In case of extensive open fractures and wound contamination, a laboratory blood test and bacteriological analysis of the wound contents can be performed.

Contraindications for

X-rays of fingers are not recommended for pregnant women (especially in the 1st and 3rd trimesters). If possible, it is better to postpone this diagnostic procedure to the postpartum period.

X-rays are also rarely prescribed for patients in serious condition, non-transportable patients.

Caution should be exercised in giving directions for x-rays to children under 15 years of age. X-rays are prescribed only when the potential harm from an incorrect diagnosis significantly exceeds the harm from the influence of ionizing radiation.

First aid

A fracture of the little finger on the hand requires professional treatment. If a person experiences symptoms consistent with a broken finger, first aid should be provided.

What you should do:

calm the person down and give him an analgesic (for example, analgin, ibufen, etc.),
call an ambulance or a taxi,
if there is an open wound, carefully treat it with an antiseptic and carefully apply a bandage,
if heavy bleeding occurs, you should use a tourniquet, remembering exactly the time of application,
immobilization of the upper limb: apply a bandage using branches, sticks or other available means. The hand should be fixed in the position in which the patient feels the least pain. The splint should rest on the finger at one end, extending 2-3 cm above it, and on the palm at the other. You need to bandage from palm to finger. If it is not possible to apply a splint, bandage the injured finger to the adjacent one,
Apply ice from time to time
It is better to keep your hand suspended on a scarf over your shoulder.

Read also: Features of using plaster splints

Remember that the victim may have a complex comminuted fracture, so all actions should be as careful as possible so as not to aggravate the situation.

Main outcomes:

Amputation within healthy tissue is performed by general surgeons and does not allow any functionality to be preserved.
Necrotomy followed by plastic closure of wounds - is performed after restoration of blood flow and allows for maximum preservation of the limb, since only dead tissue is removed
Sepsis and death of the patient - occurs when the patient refuses surgical treatment in most cases of gangrene of the hand.
Self-amputation - the rejection of dead tissue with subsequent independent healing of the stump is an extremely rare but possible outcome of gangrene of the hand.

Sprain or fracture, how to determine

A sprain is a ligament injury characterized by tearing of the fibers. Most often, ligaments are damaged in the area of the middle joints of the limbs. This injury is characterized by a clear clinical picture consisting of the following symptoms:

pain syndrome, the severity of which depends on the severity of the injury. The pain can be so intense that it leads to traumatic shock and loss of consciousness;
swelling and hematoma. The intensity depends on the severity of vascular damage. Thus, with severe damage to the ankle ligaments, the leg can sometimes more than double in volume;
loss of mobility. It may be almost complete, as in a fracture, or almost insignificant.

Important: a third-degree sprain can often be accompanied by an avulsion fracture, in which the ligaments tear off the bone and take a small fragment of it with it.

Mild sprains are easy to distinguish from a fracture and usually do not require special medical attention. More serious degrees of injury differ in the nature of the pain syndrome: pain when the ligaments are torn is acutely manifested at the moment of movement or palpation. With a fracture, it is always strong, does not weaken over time, and an acute reaction to palpation is also observed.

A good way to tell the difference between a sprain and a fracture is to apply ice to the injured area. For sprains of any severity, cold compresses help well: they reduce inflammation and muffle pain, causing numbness in the nerve endings that transmit a signal about the injury. Cold is especially useful for second- and third-degree sprains, since the inflammatory process with such injuries tends to intensify. Cold compresses should be applied for 10-15 minutes every 1-2 hours throughout the day. For a fracture, a cold compress may slightly dull the pain, but will not relieve inflammation. In addition, the pain syndrome will gradually begin to intensify.

For any sprains, if the ligaments have not been torn from the bone, the patient’s condition improves after a few days, by limiting the load on the injury site and applying compresses. If the condition does not change or worsens, you need to seek medical help and take an x-ray to confirm the diagnosis: most likely, it has a fracture, crack, or the ligaments have been torn from the bone.

How to understand a fracture or severe bruise by symptoms

Fractures and bruises have similar symptoms, but the nature of the damage is completely different. Bruises come in varying degrees of severity: with the mildest, only soft tissue is injured, bone tissue is not affected in any way. There is also an intermediate stage between a bruise and a fracture - a crack in the bone.

You can understand whether a person has received a fracture or a bruise by the dynamics of pain: if they do not go away over time and intensify when you press on the site of injury, this indicates the presence of a broken bone. In case of rib injury, the patient has severe difficulty breathing, paleness, cold sweat, and coughing up blood. The last symptom may indicate that bone fragments have caused damage to internal organs.

If a finger is broken, its mobility is completely limited. With such an injury to the leg - the knee, or the heel bone - you will not be able to stand on it - it will break and respond to the load with severe pain. If an arm is broken, there will be displacement and it will be impossible to bend it in the damaged area. If your shoulder is fractured, you will not be able to move your hand or fingers freely.

The easiest way to recognize a severe bruise is to track the pain syndrome over time. The pain may last from several hours to several days, but it does not get worse and should gradually decrease. Swelling, bruises, swelling, especially in the areas of the knuckles when the little finger or other finger is bruised, also gradually disappear when cold is applied.

Signs and symptoms of a fracture

The main sign by which you can recognize a fracture is severe pain that does not subside or even intensifies over time. The patient also experiences increasing swelling and severe hematoma. Visible swelling in hip or shoulder injuries develops within 2–3 days, since the muscle density in these areas is higher. With impacted closed fractures, soft tissue damage may not be observed at all.

Attempts to move with a broken bone cause severe pain: if your leg is injured, you will not be able to lean on it; if your arm is injured, you will be unable to clench your fist or take an object in it. When some bones are damaged, the fragments can touch internal organs, causing severe pain. Nevertheless, there are cases when the dysfunction is almost imperceptible: with trauma to the fibula, metatarsal bones, as well as impacted fractures of the shoulder and hip.

It is easier to understand that a bone is broken if there is displacement of its fragments. In this case, the limb noticeably changes shape and may look shorter or longer than the healthy one. There may be a change in the axis of the limb, for example, with a hip fracture, the leg is often tilted outward, which is clearly visible in the foot. If a leg is broken, stuck heel syndrome occurs: the patient, in a lying position, is unable to independently tear his leg off the surface. At the time of injury or upon palpation, you can feel the crunch of fragments if there is no muscle pinching between them. When bone fragments are displaced, pathological mobility is also present when the bones move outside the joint.

An open fracture is very easy to recognize: there is a breakdown of the skin, an open wound in which bone fragments may stick out, and severe bleeding.

The axial load symptom can be checked to confirm the diagnosis. This test involves applying pressure to the length of the bone. To do this, you need to lightly lean on the limb or tap on the site of injury or press on the injured area in the longitudinal direction. When a fracture occurs, this always causes acute pain, since there are many pain receptors in the periosteum, and impact on the bone in the longitudinal direction irritates this layer. For doctors, this is one of the ways to distinguish a bruise from a fracture.

Signs and symptoms of bruise

A bruise is an injury to soft tissues (skin, subcutaneous tissue, muscles) without external violation of their integrity.

It can be identified by the following symptoms:

swelling, edema, bruising, which may increase over several hours without medical attention;
limited mobility at the site of injury due to swelling;
partial dysfunction of the injured limb: it may bend heavily and not obey.

In case of severe bruise of soft tissues, a noticeable hematoma sometimes appears only after 2-3 days, the mobility of the damaged areas gradually returns on its own. The pain in the bruised area at the time of injury can be quite severe, but gradually decreases.

Causes and risk factors

Occlusive diseases of the arteries of the upper extremities

Atherosclerosis of the arteries of the upper extremities is the development of atherosclerotic plaques in the vessels.
Obliterating endarterteritis is an inflammatory disease of blood vessels that leads to their blockage.
Thoracic outlet syndrome is compression of the subclavian artery between the first rib and the collarbone, with congenital narrowing of this space.
Embolism of the arteries of the upper limb is an acute blockage of an artery by a thrombus that comes with blood flow from the cavities of the heart or dilatations of large arteries.
Spastic disease (Raynaud's disease) is a persistent spasm of the small arteries of the fingers and hand, leading to their gradual overgrowth.

Arteries carry oxygen- and nutrient-rich blood from the heart to the rest of the body. Some vascular diseases cause narrowing or blockage of the arteries, which can develop gradually or suddenly. With gradual development, chronic arterial insufficiency of the hand may occur, which leads to pain in the hand during exercise, finger ulcers and death. In case of acute blockage, rapid death of the limb (ischemic gangrene) can develop. In this case, urgent surgery is necessary to restore blood circulation, otherwise there is a high probability of major amputation.

Traumatic gangrene of the hand

Severe injuries of the upper limb lead to damage to vascular bundles and persistent tissue swelling. Compression of tissue by edema, especially in a plaster cast, can cause a sharp decrease in blood circulation and death of the soft tissues of the hand.

Deep burns and secondary infection can cause death of soft tissues and limb segments, which requires subsequent amputation. Frostbite of the fingers and hand leads to a similar result.

The development of gangrene of the hand is possible due to erroneous injections of drugs into arteries instead of veins, this is especially common among drug addicts. The course of the disease in this case is accompanied by the rapid development of necrosis and general intoxication.

Complications

Extensive wounds requiring reconstructive surgery
Amputation (of hand or finger),
Sepsis
Death

It is very important to begin treating gangrene before it becomes a life-threatening situation. Early treatment can help reduce the damage caused by gangrene to some extent. To prevent illness:

Control your diabetes
Treat wounds well
Do not delay contacting a doctor if your fingers become dark or you have pain in your hand.

Gangrene, if left untreated, can cause infection to spread into the bloodstream and cause life-threatening sepsis. Cases of self-amputation with dry gangrene are rare enough to be taken into account as a factor in refusing surgical treatment.

Which doctor should I contact?

Regardless of the results of self-diagnosis, in case of any serious injuries, you should go to the emergency room at your place of residence or to the emergency room of a hospital, where there is a surgical or, even better, trauma department, as soon as possible.

An orthopedic traumatologist treats fractures, bruises and torn ligaments, but a surgeon can also provide assistance. If this is not possible, you should consult a general practitioner, and if a child is injured, consult a pediatrician. After confirming the diagnosis with an x-ray and prescribing treatment, you can make an appointment with a nutritionist to avoid complications associated with limited mobility, as well as with a chiropractor, massage therapist, or physiotherapist.

If the injury was caused by increased fragility of the bones, you should additionally consult a rheumatologist; if the fall was due to loss of consciousness or an attack of lightheadedness, you should consult a cardiologist or neurologist.