Managing Hand Fractures: 15 Years Experience from a Tertiary Care Hospital from Pakistan

Background: Fractures of hand bones predisposes a man to great disability by restricting daily working ability. We want to share our experience of dealing with hand fractures and its outcome in hand injuries. Methods: 15 years of data was retrieved from a tertiary care hospital and analyzed for age, gender, comorbidities, etiology, frac-tures involved, management and outcome in terms of days to return to daily activities. Results: We managed 969 patients with hand bones fractures, which had total of 1764 bones involved. Median age of presentation was 41 years. Carpal bones accounted for 187 (10.6%), metacarpals 627 (35.5%) and phalanges 950 (53.8%). Most were managed with K-wires (63.2%) and screws (3.9%) with return of daily activity was within 45 ± 10 days. Most common complica-tion was soft tissue infections followed by osteomyelitis due to nature of injuries. Conclusion: Early surgical management and mobilization of hand after fractures fixation remains vital for good functional outcome of hand. Close follow up is required for timely intervention of associated complications.


Introduction
Hand fractures contribute to major disability for a man. Being third eye of the body, injuries of hand not only hampers function but also disturb earning of a home. Though many fractures of hand can be treated non-operatively but most, if not intervened, will result in hand deformity or stiffness [1,2]. Multidisciplinary team interventions are required for maximum functional return of hand, with most important role played by hand surgeon whose skills are paramount in early phase of management. In United States there was bimodal pattern of distribution of age in patients with hand fractures with majority had meta-carpal bones involvement [3]. Another retrospective study from Saudi Arabia, over a period of 6 years, showed that among the age group of 13-18 years most hand fractures occurred in home [4]. In an Indian study on patients attending in accident and emergency department with fractures, 5.4% had hand fractures [5]. Many authors have presented rationale and principles of managing hand fractures [6][7][8], with majority emphasize on surgical management in the initial phase of fractures for stabilization. Phalanges and metacarpal fractures account for most of hand fractures [9,10]. Surgical options ranges from Krischner (K-) wiring, metallic plates, external fixation or screw fixation [11,12].. Study from Pakistan showed good postoperative range of motion after K-wire placement in phalangeal and meta-carpal fractures [10]. We aim to share our 15 years of experience in managing hand fractures including carpal bones in a tertiary care center with multidisciplinary team.

Methods
This is a retrospective observational study over a period of 15 years (May, 2000 to January, 2016), conducted at the department of plastic surgery, at a private hospital in Karachi, Pakistan. This department is unique as it is the only unit in the city with two hand surgeons, who offers training in hand fellowship. This is a private tertiary care hospital with 700 beds and serving for more than 50 years. Due to this specialized department, this hospital has 1.
Two-dimensional X-ray views were used to diagnose the fractures, however computed topography (CT) scan was also used in selected carpal bone injuries.

Outcomes
Nine hundred and ten (94%) patients were followed for once per week for a minimum of 8 weeks. Post-operative splints were removed at 4 weeks (6 weeks for conservatively managed) and patients were advised night splints for 2 more weeks with physiotherapy to improve range of movements of joints. Sutures were removed at 10-14 days and K-wires at 6 weeks post-operatively, after getting a follow-up X-ray film. Three hundred and seventy-five (21.2%) patients had secondary procedures (Table 3).  Mostly 52 (13.8%) requiring out-patient based wound debri-dement and 87 (23.2%) had late amputation of digit (after 24 hours of intervention). Mean days to return to daily activity was 45 ± 10 (p-value: 0.04), with light weight bearing (2 pounds). Mean day for finger to palm distance to reach ≤1 cm for phalangeal fractures was 18±7 days. At 8 weeks follow up mode flexion angles atmeta-carpo-phalangeal joint (MCPJ) was 50⁰ (p-value: 0.06), proximal inter-phalangeal joint (PIPJ; p-value: 0.10) was 70⁰ and at distal inter-phalangeal joint (DIPJ; p-value: 0.08) was 10⁰.

Discussion
Hand fractures are common injuries, which poses difficulties for hand surgeons. The treatment has to be individualized depend-ing on site and pattern of fracture, with goals to restore congruity, stability and alignment thus allowing early range of motion and preventing stiffness and arthritis. Occurring most commonly in males in their thirties to forties [13,14], as seen in our observation too. Up to 34% of fractures are secondary to trauma or industrial injuries (crush and machine sharp cut) [15], while other causes include trivial injuries. The complex anatomical arrangement of the eight carpal bones, maintained by ligaments, makes it diffi-cult for fractures to be seen in simple radiographs, thus requiring Computed Topography. About 8 to 19% of hand injuries results in carpal bones injuries, with 90% damaging proximal row [16,17]. We observed 22.4% scaphoid, 15.5% lunate, 14.9% capitate frac-tures as compared to a study, evaluating carpal bones involvement in distal radius fractures, showed triquetrum, lunate and scaphoid in decreasing frequencies [17]. We managed scaphoid using AO lag screws (2mm mini fragment) with change in trend to cannu-lated compression screws (2.4mm)in our unit over the past few years. Indication of intervention included greater than 1 mm of displacement, lateral intrascaphoid angle greater than 35 degrees, bone loss or comminuted fracture, perilunate fracture or disloca-tion and proximal pole fractures. Metacarpal fractures account for the most of hand fractures, as in literature it makes up 40% of all hand fractures as compared to our observation of 35.5% [18]. Even than phalangeal fractures make up 53.8% in our study. 'Boxer's fracture' as labelled by many authors [18][19][20], 5th metacarpal bone fracture, comprises of 24.8% of all metacarpal fractures in our se-ries. Phalanges were managed with K-wires, but those with un-displaced, incomplete or those stable after closed reduction were managed conservatively.
Surgical options were chosen for open, intra-articular, unstable (oblique, comminuted, transverse), irreducible fractures and those with angulation more than 30 degrees, however closed fractures, with angulation <30 degree and <10-degree rotation were managed conservatively. Surgical options ranges from placing Kwires to intraosseous wires, tension wire bands, compression screws, open reduction and internal fixation with plates and screws or external fixation [21], especially for phalanges fixation. From our study we managed most fractures with K-wires, both for pha-langes and metacarpals, however compression screws were used for carpal fracture fixation especially in scaphoid fractures. Many patients required nail bed repair especially those having underlain distal phalangeal fracture. Conservative management comprised close reduction and splint in intrinsic plus position of James (70-degree flexion at metacarpo-phalangeal joint and 90-degree exten-sion at distal and proximal inter-phalangeal joints) for at least 4 weeks [7,22]. Early mobilization is needed for good functional outcome of hand, irrespective of conservative or surgical manage-ment. Outcomes after hand fractures fixation has been assessed by objective, subjective or with radiologic improvements, how-ever not a single measure has been accepted as the gold standard for accurately assessing functional improvement [13,15,23]. We assessed functional outcomes in terms of return to daily activi-ties and angle of joint flexion on follow-up. As a team work with occupational and physiotherapists we observed early compliance to at least 2lb of weight bearing and house hold activities, with statistical significance as compared to joints mobility angles. We managed cases with soft tissue and bone infections, even after recommended initial washout, debridement and antibiotic coverage, which were related to nature of etiology [24].