Ask a Doctor – Hand Fractures

Hand surgeon Brian P. Kelley, MD, answers your questions about a broken hand.

How do I know if I broke a bone in my hand?

Breaking a bone, or fracturing a bone as a doctor may refer to it, is a common injury that can occur at any age.  In fact, fractures of the bones of the hand represent one of the most common reasons for a visit to the emergency department in the United States (about 1.5% of all emergency visits). Also, fractures of the fingers represent about 10% of all types of fractures.

Fractures often occur after physical trauma, such as during sports, work, or falls. However, it’s important to remember that not all hand injuries involve a fracture of the bone.  Other injuries, such as sprains or dislocations, may occur around the bones, but may not actually involve a break. In these cases, the soft tissues that hold bones together may be injured (such as ligaments, tendons, muscles, or cartilage).

Signs that you may have a broken bone include:

  • Deformity (the hand appears to be bent in a way that is not natural)
  • Swelling or bruising
  • Pain that interrupts sleep
  • Pain directly over the shaft of a bone
  • Pain with weight bearing
  • Fingers out of alignment
  • Inability to move the fingers or hand normally

How do hand fractures happen?

In specific terms, hand fractures occur when a force from a fall or impact is transmitted across a bone exceeding the strength of that bone to resist that force.

In easier-to-understand terms, fractures should be thought of as similar to tree branches. When we are young, our bones are much suppler and bend – like a small tree or sapling. Because of this, children are much more likely to have “greenstick fractures,” or breaks that only snap the bone but don’t break all the way through. In adult bones, like older tree branches, the strength of the bone makes it more rigid and less likely to bend. While that makes the bones stronger and harder, it also means that when a force is stronger than their ability to bend then they are more likely to break completely.

Fractures are also linked to our behavior.  Children suffer fractures to their fingers more frequently than adults since they are more likely to get caught in doors or other objects.  Young men are more likely to get fractures from boxing or punching injuries. Therefore, doctors expect different patterns of fractures depending on the mechanism of injury and the characteristics of the patient.

Is there a test to see if I broke a bone?

Yes. Your doctor may get a study like an x-ray or CT scan to look at your bones. These tests use low doses of radiation to see bones through your skin and are not painful.  Doctors may use caution because of the radiation if you are pregnant or if getting the test on young children.

What should I do if I think I broke my hand?

It is often advisable to see a physician urgently after you have injured your hand. Most of the time an ambulance or other emergency services are unnecessary. If a hand surgeon is not immediately available, it is useful for your primary care physician or an urgent care provider to see you so that they can obtain x-rays and potentially stabilize your hand in a splint. These providers may recommend a reduction, meaning to put the bones back into place, which can help to reduce your pain or may be adequate treatment for the fracture.  Ideally, it is best to see a hand surgeon early on after the injury because some fracture reductions or dislocations may be very difficult to perform. Also, if surgery is necessary, the operation will be easier if you are seen earlier while the fracture is fresh.  If there is any concern for the fracture causing the blood or nerve supply to the hand or fingers to be compromised, you should see a hand surgeon emergently as this could result in an injury that is limb-threatening. Signs such as a pale or cold hand should be seen in the emergency department immediately. Numbness or tingling that is new should also prompt an urgent evaluation.

What should I expect when I see the surgeon?

The surgeon will typically need imaging studies (x-ray, CT scan, MRI, or ultrasound) and physical exam to help diagnose your problem. If a fracture is present, the surgeon may give you multiple options that are adequate to treat your fracture. These might include:

  • “Buddy taping” – taping one finger to an adjacent finger to protect and guide motion
  • Splinting – a supportive orthosis that blocks motion but can be removed
  • Casting – a hard cast that wraps around the entire injured area and cannot be removed
  • Surgery

All of these may require frequent visits to your surgeon for repeated x-rays or imaging to make sure the bones are healing together well.  Splinting and casting may both have a risk for stiffness after treatment, meaning that because of prolonged immobilization you lose some motion in your joints that can be permanent. In some cases, occupational therapy may be used to help regain motion after your fractures have healed.

My surgeon said I need surgery, what can I expect?

If you need surgery for a fracture, it is likely because the fragments of the bone are not able to stay together without some internal support holding them in the right place. This may involve plates and screws, pins, or external fixators (cages) that hold the bones into place. In some cases, you may even need more than one of these things to get all of the bones back together.  The day of surgery, you should expect to not eat for 6-8 hours prior to anesthesia. Different types of anesthesia are available and you can discuss these with your surgeon and the anesthesiologist. A regional or local anesthesia block is often useful because this will numb either the affected finger or extremity completely for the duration of surgery. Regional blocks may even provide complete analgesia for much of the day after your surgery is complete.  If you are having anesthesia, make sure to bring someone with you to help you with the surgery and to drive you home.

After surgery, you will likely be placed in a splint or cast that will immobilize your fractures to allow healing to begin. The length of time you need immobilization depends on the type of fracture and the type of repair performed. Your surgeon will be able to give you expectations for your recovery after your surgery.

Will I have pain after surgery?

You will definitely have pain after surgery, but your doctor will give you support and medications to help manage the symptoms. Surgeons will often prescribe a narcotic to help treat pain (hydrocodone, oxycodone, or codeine are the most common types). If you are having pain, it is ok to take narcotics for a short period of time, but it is VERY important to limit your use after the first few days as up to 10% of patients may have difficulty stopping these medications because of the addictive nature of these drugs.  The most important medication after surgery is acetaminophen (Tylenol®) because it helps the narcotic work better. If your surgeon says it is ok, NSAIDs, such as ibuprofen, may be used. However, some surgeons are hesitant to use these medications as there is a theoretical risk for delaying bone healing or they can affect your kidneys and stomach. NSAIDs help with swelling and pain relief, thus they can be used at the same time as either acetaminophen or narcotics.  Other medications that may be helpful include vitamin C or gabapentin.

What if your pain initially improves after surgery, but suddenly begins to increase again? In this scenario, this could be a sign of a surgical complication like an infection or a problem with the fracture.  Call your surgeon as soon as possible to discuss.

Does the bone always heal?

No. In some cases, broken bones may heal inappropriately (malunion) or not at all (nonunion).  In these cases, your surgeon will help you decide if further treatment is necessary.  If an infection caused your bones to not heal, you may need antibiotics or additional surgery to treat the infection before fixing the bones. Risk factors for infection include immune system problems, steroids, old age, diabetes, smoking, and open fractures.

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