William W. Forgey, MD
ORTHOPEDICS part 7 – Wrist, Thumb, Hand, Finger - Fractures, Dislocations and Sprains
Updated: Nov 13, 2020
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Wrist Fractures and Dislocations
Wrist fractures and dislocations are common in young adults who extend their arms and hands to help break a fall. The three most common problems are fractures of the navicular (or scaphoid) bone, dislocation of the lunate, and perilunate dislocation. (See wrist anatomy in figure 7-10.) Navicular fractures frequently do not heal even with appropriate casting.
Dislocations of the lunate or of the remaining carpals from the lunate would ideally be reduced, but without X-ray, experience, or at least local anesthesia, this is not possible. Symptoms of lunate dislocation would be pain in the wrist and frequently numbness in the thumb, index, and middle fingers.
There is pain with any attempt to move the wrist. An abnormal knob on the palm side of the wrist at the crease, when compared to the other wrist, should be obvious to palpation. The numbness described indicates pressure on the median nerve from the dislocated navicular bone, and an attempt at reduction should be made. As in figure 7-11, with the wrist in extreme dorsiflexion, apply traction while attempting to push the lump back into position. The reduction often is accompanied by an obvious pop.
Perilunate dislocation will have similar symptoms and signs, with pain on attempted movement of the wrist and possible median nerve compression causing thumb, index finger, and middle finger numbness. The knob will not be present, but there will be a slight deformity of the back side of the wrist, sometimes called a modified silver fork deformity, or hump at the upper side (dorsum) of the wrist. The technique of reduction is similar; apply traction to the wrist and place your thumb firmly over the location of the lunate bone (just beyond the end of the ulna) to hold the lunate in position as the wrist is then gradually flexed to bring the rest of the carpal bones down into proper position with the lunate and the ends of the radius and ulna. There is generally no snap when this occurs. The numb feeling should wear off within the next hour if the pressure has been removed from the median nerve.
Navicular (scaphoid) fractures will have pain on the thumb side of the wrist, and while the entire wrist will be sore to palpation, it will be particularly sore below the thumb at the wrist. This fracture seldom dislocates, but it often doesn’t heal, even after being placed in a tight plaster cast for several months.
After attempting to reduce a dislocation of the wrist or treat the possible fracture of the navicular, splint the wrist and thumb so they are as immobile as possible. While it is not a rigid dressing, a thick wrap using a 2-inch Ace elastic bandage applied in the manner called a thumb spica, as illustrated in figure 7-12, can do well. Under survival conditions, fusion, arthritis, and even loss of median nerve function may have to be accepted. This is a terrible loss that proper orthopedic treatment can almost always avoid. The thumb spica wrap will also be adequate for sprains of the wrist and thumb.
Thumb Sprains and Fractures
Injuries causing severe pain and swelling of the thumb may be sprains or fractures. A severe sprain will cause loss of strength of the thumb for many weeks, even months. Swelling can be substantial with either injury. First aid management is splinting until treatment by a physician can be arranged. In an extended survival situation, reduce any obvious deformity and hold in position with a thumb spica wrap, as in figure 7-12. Severe sprains and all fractures will take 8 weeks to heal. There is risk of arthritis and loss of function depending upon the injury, patient’s age, adequacy of reduction, and suitability of your splinting technique.
A hand fracture of the first metacarpal can be treated with a thumb spica wrap (see figure 7-12) that immobilizes the entire wrist. The fifth metacarpal is the most commonly broken bone in the hand. The name given to this fracture, a “boxer’s fracture,” indicates its frequent method of origin. Perfect reduction of this fracture is not required; in fact, up to 30 degrees of angulation is acceptable. Only 5 to 10 degrees of angulation is acceptable in the third and fourth metacarpals.
Measuring the amount of angulation will be impossible without an X-ray. If you are used to seeing these fractures, before-and-after X-rays become merely a legal maneuver and are not medically necessary. In a survival situation one may be able to tell if too much angulation has occurred by palpating the palm of the hand. If the nodular head of the metacarpal is felt where it joins the finger, there may be too much angulation. If too much angulation is allowed, a lump in the palm of the hand will make holding tools and objects uncomfortable for the rest of the patient’s life. Unacceptable angulation will have to be snapped back into place. Splinting should be maintained in a position of function for 6 weeks.
Finger Fractures and Sprains
Gross lateral or sideways deviations of fingers should be corrected, and the finger splinted in the position of function. These deviations may be corrected by tugging and thus resetting the fracture, or by placing a pencil or similar object between fingers and thus getting leverage to snap a deviated finger shaft back into place. Deviations at the joints probably represent dislocations, and generally these may be easily reduced by the tugging technique. An alternate technique to tugging is to place the dislocated joint into partial flexion; it will then be easier to lever the joint into position.
Swelling associated with “jammed” fingers can become permanent if use of the finger is allowed before adequate healing has taken place. After the acute injury, splinting in the position of function is always appropriate for at least 3 weeks, followed by “buddy splinting” to the adjacent finger for another 2 to 3 weeks. Fingers should not be splinted straight. Buddy splinting may be used initially if the victim must use the hand immediately, as in gardening, wood cutting, or chores that require all hands on deck.
Ruptured tendons can be repaired generally by splinting in a position of function, with the exception of a rupture of the distal extensor tendon of a finger. This injury is rather common and can be caused by an object hitting the tip of the finger or catching the finger in something (often in a sheet while making a bed). While making beds may not be a problem you expect to encounter, this illustrates how easily the injury may occur. Figure 7-13 illustrates the appearance of this injury, commonly called a mallet finger deformity. The splinting technique for this injury is not the position of function, but as illustrated in figure 7-14.
Be sure to check out the next post in our ongoing Orthopedic series where we'll cover diagnosis and care protocols for hip dislocation and fracture, thigh fractures, kneecap dislocation, knee sprains, dislocations and fractures.