General Guideline Principles for Middle and Proximal Phalangeal
and Metacarpal Fractures for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Middle and Proximal Phalangeal and Metacarpal Fractures.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Middle and Proximal Phalangeal and Metacarpal Fractures of Hand, Wrist and Forearm Injuries

Approximately 46% of fractures in the hand and wrist are proximal and middle phalange fractures. Fortunately, most don’t require surgery and aren’t complicated. A third of hand fractures are metacarpal fractures, of which the fifth metacarpal neck fracture, also known as a “Boxer’s fracture,” accounts for one-third to one-half and thumb fractures for the remaining 25%.

In order to prevent permanent impairment and disability from bone shortening, permanent angulation, joint and finger stiffness, and loss of hand function, doctors who treat hand fractures must be able to diagnose and treat them properly.

Due to the importance of this bone in the longitudinal transfer of axial forces between the carpal and distal phalangeal joints and the PIP joint for digit mobility, proximal phalangeal fractures in particular have a significant potential for hand impairment, particularly if suboptimally managed.

With the knowledge that nonoperative therapy can be improved upon, decisions for surgical intervention should be made after careful consideration balancing the risk of superior radiographic reduction with the higher risk of crippling stiffness from the post-operative rehabilitation state.

1. Diagnostic Studies of Middle and Proximal Phalangeal and Metacarpal Fractures

   Diagnostic Studies of Middle and Proximal Phalangeal and Metacarpal Fractures X-Rays

   Diagnostic Studies of Middle and Proximal Phalangeal and Metacarpal Fractures X-Rays is recommended three projections, including a posteroanterior, lateral, and oblique view, are required for diagnosing phalangeal or metacarpal fractures. It is necessary to isolate the affected digit using a true lateral projection.

    

2. MRI, CT, Ultrasound, or Bone Scanning for Diagnosing Phalangeal or Metacarpal Fractures

   MRI, CT, Ultrasound, or Bone Scanning for Diagnosing Phalangeal or Metacarpal Fractures are not recommended for identifying metacarpal or phalangeal fractures.

Medications of Middle and Proximal Phalangeal and Metacarpal Fractures

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even though the majority of research indicates it is only marginally less effective than NSAIDs.

There is proof that NSAIDs are less dangerous and just as effective at treating pain as opioids, such as tramadol.

Non-steroidal anti-inflammatory drugs (NSAIDs) for Phalangeal or Metacarpal Fracture Pain: Acute, Subacute, and Chronic

Medications of Middle and Proximal Phalangeal and Metacarpal Fractures

Medications of Middle and Proximal Phalangeal and Metacarpal Fractures are recommended for the treatment of pain from phalangeal or metacarpal fractures that is acute, subacute, or chronic.

Indications –NSAIDs are advised as a treatment for acute, subacute, or chronic phalangeal or metacarpal fracture pain. First, try over-the-counter (OTC) medications to see if they work.

Frequency/Duration: Many patients might find it reasonable to use as needed. warning signs of

Discontinuation: the symptom’s resolution, the medication’s ineffectiveness, or the emergence of side effects that require stopping.

1. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

   NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is recommended for patients at high risk of gastrointestinal bleeding to take misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors concurrently.

   Indications:For patients with a high-risk factor profile who also have indications for NSAIDs, cytoprotective medications should be considered, particularly if longer term treatment is contemplated.

   Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

   Frequency/Dose/Duration: H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.

   Indications for Discontinuation: Intolerance, the emergence of negative effects, or the stopping of NSAIDs.

   NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

   The advantages and disadvantages of NSAID therapy for pain should be discussed with patients who have a history of cardiovascular disease or who have multiple cardiovascular risk factors

    

2. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    

   1. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

      NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended As far as adverse cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options.

       

   2. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

      NSAIDs for Patients at Risk for Cardiovascular Adverse Effects are recommended If necessary, non-selective NSAIDs are preferred to COX-2-specific medications. To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in patients receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.

       

3. Acetaminophen for Treatment of Phalangeal or Metacarpal Fracture Pain

   Acetaminophen for Treatment of Phalangeal or Metacarpal Fracture Pain are recommended for the treatment of pain from phalangeal or metacarpal fractures, especially in patients who should not take NSAIDs.

   Indications: All patients, including those with acute, subacute, chronic, and post-operative phalangeal or metacarpal fracture pain.

   Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of hepatic toxicity.

   Indications for Discontinuation: pain, side effects, or intolerance are gone.

    

4. Opioids of Middle and Proximal Phalangeal and Metacarpal Fractures

   Limited Use of Opioids for Acute and Post-operative Pain Management

   Limited Use of Opioids for Acute and Post-operative Pain Management are recommended for brief periods of time (less than seven days) as an adjunctive therapy to more potent treatments for the management of acute and post-operative pain.

   Indications:A brief prescription of opioids is frequently necessary for acute injury and post-operative pain management, especially at night, as an adjunct to more effective treatments (especially NSAIDs, acetaminophen, elevation, and splinting).

   Frequency/Duration: As needed during the day, only at night later, and finally completely discontinued.

   Rationale for Recommendation: When NSAIDs are ineffective in relieving a patient’s pain, opioids should be used sparingly, especially at night. Opioids are advised for brief, selective use in postoperative patients, with nighttime use being the main recommendation for achieving postoperative sleep.

    

5. Antibiotic Prophylaxis

   Antibiotic Prophylaxis is not recommended for open fractures of the phalanges.

   Tetanus Immunization Status for Open Fractures

   Tetanus Immunization Status for Open Fractures is recommended status will be changed as required.

   Indication – if more than 5 years have passed since the last tetanus vaccination, burns or dirty wounds.

Initial Management of Middle and Proximal Phalangeal and Metacarpal Fractures

Treatment of soft tissue injuries and pain relief should be part of initial management after the physical examination is finished.

Regional anaesthesia may be used when clinically necessary to perform the closed reduction of the fracture, complete the diagnostic assessment (passive range of motion, rotational alignment), and other related procedures.

There is Support for the Use of Digital Block for Metacarpal or Middle and Proximal Phalangeal Fractures

Immobilization of Middle and Proximal Phalangeal and Metacarpal Fractures

The physical and radiographic findings determine the best immobilisation or fixation technique. The majority of phalangeal fractures can be treated without surgery. Padded aluminium splints, buddy tape, functional splinting, and gutter casting are a few non-operative management strategies.

Immobilization of Middle and Proximal Phalangeal and Metacarpal Fractures

1. Immobilization

   Immobilization of Middle and Proximal Phalangeal and Metacarpal Fractures are recommended for the treatment of fractures of the middle and proximal phalanx.

   Frequency/Duration – When using percutaneous fixation with wire, it is also recommended to use supplemental stabilisation for three to four weeks with a splint or casting because the wire does not provide enough rigidity.

    

2. Non-operative management (immobilization) of nondisplaced and stable transverse diaphyseal fractures of the middle and proximal phalanges

   Non-operative management (immobilization) of nondisplaced and stable transverse diaphyseal fractures of the middle and proximal phalanges are recommended because these fractures can be treated without surgery and don’t need to be fixed.

   Frequency/Duration – three-week immobilisation of the affected digit in 70–90 of MCP flexion with the adjacent digit.

   Rationale for Recommendation – With non-operative management, these fractures have positive outcomes. Following closed reduction, the following tolerance levels are acceptable: angulation of 10°, shortening of less than 2mm, bone apposition of more than 50%, and absence of malrotation.

   If displacement occurs outside of these parameters, it should be assessed to determine whether it can be treated with closed reduction and percutaneous fixation, or if closed reduction fails, open reduction and internal fixation.

    

3. Non-operative Management of Middle and Proximal Phalange Non-displaced Oblique Fractures

   Non-operative Management of Middle and Proximal Phalange Non-displaced Oblique Fractures are recommended due to the fact that these fractures are typically stable and only need rigid immobilisation.

    

4. Closed Reduction with Splinting

   Closed Reduction with Splinting is recommended if the base phalanx is broken.

   Signs – Less than 40% of the middle phalanx base is involved.

   Restoring the functional ability necessary to meet the patient’s needs should be the main goal of any rehabilitation (supervised formal therapy) required as a result of a work-related injury. daily tasks and return to work; attempting, to the extent practical, to return the injured worker to their pre-injury condition.

   Active therapy calls for the patient to put forth an internal effort to finish a particular exercise or task. The interventions known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their part.

   Passive interventions are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Interventions that are active should be prioritised over those that are passive.

   To extend the therapeutic process and maintain improvement levels, the patient should be advised to continue both active and passive therapies at home.

   To facilitate functional gains, assistive devices may be used as an adjunctive measure in the rehabilitation plan.

Therapy – Active of Middle and Proximal Phalangeal and Metacarpal Fractures

Therapeutic Exercise are recommended for Post-operative Middle and Proximal Phalangeal

Therapeutic Exercise is recommended for Post-operative Middle and Proximal Phalangeal and Metacarpal Fractures

Frequency/Dose/Duration –With documentation of ongoing objective functional improvement, the total number of visits may be as low as two to three for patients with mild functional deficits or as high as 12 to 15 for those with more severe deficits.

If there is evidence of functional improvement toward specific objective functional goals (e.g., increased grip strength, key pinch strength, range of motion, or improving ability to perform work activities), more than 12 to 15 visits may be necessary to address persistent functional deficits.

A home exercise programme should be created as part of the rehabilitation strategy and carried out alongside the therapy.

Therapy: Passive of Middle and Proximal Phalangeal and Metacarpal Fractures

Compression, and Elevation for Acute Metacarpal and Phalangeal Fractures

Compression, and Elevation for Acute Metacarpal and Phalangeal Fractures are recommended for reducing edema brought on by recent phalangeal and metacarpal fractures.

Management of Middle and Proximal Phalangeal and Metacarpal Fractures

1. Surgery

   Surgical Management of Condylar Fractures

   Surgical Management of Condylar Fractures is recommended due to the instability of these fractures.

   Surgical Management for Malrotated Phalangeal Fractures

   Surgical Management for Malrotated Phalangeal Fractures are recommended if closed reduction cannot correct and stabilise malrotation.

   Rationale for Recommendation – If malrotation cannot be corrected and stabilised by closed reduction, surgical management for malrotated phalangeal and metacarpal fractures is advised to prevent or reduce rotational deformity that can cause fingers to cross over one another or interfere with hand function

   Metacarpal Fractures Non-Operative Treatment of Distal Metacarpal Head

   Fracture using closed reduction and protective immobilization with radial or ulnar gutter splint

   Metacarpal Fractures Non-Operative Treatment of Distal Metacarpal Head

   Fracture using closed reduction and protective immobilization with radial or ulnar gutter splint are recommended for fractures where the involvement of the joint is under 20%.

   Rationale for Recommendation -Cases with more than 20% joint involvement probably need an internal fixation followed by an open reduction and almost immediate motion.

    

2. Non-Operative Non-operative Treatment of Distal Metacarpal Neck Fracture with Acceptable Angulation

   Non-Operative Non-operative Treatment of Distal Metacarpal Neck Fracture with Acceptable Angulation is recommended Size of the angle 10° in the long and index fingers, and 30° in the ring finger.

   Non-operative of Management

   Non-operative Treatment of Boxer’s Fractures of the Fifth Metacarpal Neck

   Non-Operative Non-operative Treatment of Distal Metacarpal Neck Fracture with Acceptable Angulation

   Non-Operative Non-operative Treatment of Distal Metacarpal Neck Fracture with Acceptable Angulation is recommended prior to most 5th metacarpal neck fractures undergoing surgical treatment (less than 45 degrees angulation).

   Use of Functional Therapies (including taping, functional bracing and strapping) for Fifth Metacarpal Neck Fractures

   Use of Functional Therapies (including taping, functional bracing and strapping) for Fifth Metacarpal Neck Fractures are recommended as opposed to ulnar splinting or castin

   X-rays in Follow-up of Non-Operative Fifth Metacarpal Neck Fractures

   X-rays in Follow-up of Non-Operative FifthMetacarpal Neck Fractures are recommended for patients who might be displaced following reduction Reasons for

   Recommendation -. If a physical examination reveals loss of reduction or instability, follow-up radiographs are advised. 7 to 10 days after the injury, radiographs might be advised to make sure there hasn’t been any (more) displacement or malrotation.

    

3. Shaft Metacarpal Fractures

   The most common types of shaft metacarpal fractures are transverse, oblique, spiral, or comminuted. The choice between non-operative and surgical intervention weighs the risks associated with non-operative intervention against the potential for metacarpal shortening.

    

   1. Surgery of Middle and Proximal Phalangeal and Metacarpal Fractures

      Surgical Management of Metacarpal shaft fractures is recommended fixation (pinning, wire, plate, lag screws)

      Indication: for fractures that are unstable, difficult to reduce, or have several nearby shaft fractures

       

   2. Surgical Management for Base Fractures of the Proximal Metacarpal

      Surgical Management for Base Fractures of the Proximal Metacarpal is recommended because these fractures rarely heal properly.

       

   3. Surgical Management Bennett’s Fracture and Rolando’s Fracture

      Surgical Management Bennett’s Fracture and Rolando’s Fracture is recommended for the unstable fracture types in Bennett’s and Roland’s bones.

       

   4. Surgical Management for Malrotated Phalangeal fractures

      Surgical Management for Malrotated Phalangeal fractures is recommended since it could lead to deformity and impairment.

       

   5. Hardware Removal

      Hardware Removal is recommended In certain circumstances where hardware exists.

      Hardware removal is recommended after it has been put, as per patient and doctor preferences.

      Indications: if there is 1) protruding hardware, 2) pain related to the hardware, 3) broken hardware on imaging, and/or 4) a positive anaesthetic injection response, as determined by the doctor and the patient.

       

   6. Non-Operative

      Non-operative Management of Metacarpal Shaft Fractures

      Non-operative Management of Metacarpal Shaft Fractures is recommended for a stable fracture if sufficient closed reduction is achieved.

What our office can do if you have Middle and Proximal Phalangeal and Metacarpal Fractures

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

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