Metacarpal and finger phalangeal fractures and dislocations: clinical guidelines

List of Abbreviations

ACT – activated clotting time

Td**-M – diphtheria-tetanus toxoid** with reduced antigen content

aPTT – activated partial thromboplastin time

ALT – alanine aminotransferase

TT** – tetanus toxoid**

AST – aspartate aminotransferase

ATX – Anatomical Therapeutic Chemical (ATC) Classification System

BF – Biofeedback

VTE – venous thromboembolism

SSI – surgical site infection

CT – computed tomography

PT – physical therapy

MRI – magnetic resonance imaging

MMA – multimodal analgesia

INN – International Nonproprietary Name

HC – healthcare organization

UE – upper extremity

NSAIDs – nonsteroidal anti-inflammatory drugs (see terms and definitions)

CBC – complete blood count

UA – urinalysis

SAP – surgical antibiotic prophylaxis

vMF – variable magnetic field

TAS** – tetanus antitoxin (INN: tetanus antitoxin**)

TIG** – tetanus immunoglobulin human**

PRM – physical and rehabilitation medicine

PTL – physical therapy treatment

AO/OTA – AO (Arbeitsgemeinschaft für Osteosynthesefragen) – Association for the Study of Internal Fixation (AO), OTA – American Orthopaedic Trauma Association

HC – healthcare organization

UHF – ultra-high frequencies

Terms and Definitions

Antibacterial drug, antibiotic – a medicinal product from the group of "Antibacterials for systemic use" (J01).

Beta-lactam antibiotics are a group of antibacterial drugs sharing a common structural element — the beta-lactam ring. They inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins, leading to lysis and death of the microbial cell. According to the Anatomical Therapeutic Chemical classification, beta-lactam antibiotics include the following main groups: "Beta-lactam antibacterials, penicillins" (J01C) and "Other beta-lactam antibacterials" (J01D), of which cephalosporins of the first (J01DB), second (J01DC), third (J01DD), and fourth (J01DE) generations, "other cephalosporins and penems" (J01DI), "carbapenems" (J01DH), and "monobactams" (J01DF) are of the greatest clinical significance.

Immobilization is the creation of immobility or reduction of mobility of body parts in certain diseases and, predominantly, in injuries.

Consolidation is the process of fusion of a damaged bone with the restoration of its integrity, during which resorption of necrotic elements and the formation of new bone structures occur.

Nonsteroidal anti-inflammatory drugs – nonsteroidal anti-inflammatory drugs from the group "Anti-inflammatory and antirheumatic products, non-steroids" (M01A).

Osteosynthesis is a surgical method for joining bone fragments and eliminating their mobility using fixation devices.

Reposition is a surgical intervention for a fracture consisting in the elimination of displacement and alignment of bone fragments in order to restore normal anatomical relationships.

Fracture is a complete or partial disruption of the anatomical integrity of a bone, accompanied by damage to the soft tissues surrounding the bone and impaired function of the injured segment.

Dislocation is a disruption of the articulation of the articular surfaces of a joint.

External fixation device is an orthopedic device containing an implant (a transosseous or extracorporeal element protruding from the skin, reaching the bone or inserted into it) and an external (non-implantable) support connecting bone fragments via transosseous elements in the treatment of fractures, pseudarthrosis, or gradual lengthening (correction of deformity) of a segment.

Internal fixation device – an orthopedic implant implanted beneath the patient's skin that connects bone fragments in the treatment of fractures, deformities, or nonunions.

Consolidation is the process of fusion of a damaged bone with the restoration of its integrity.

Bone fragment is a part of a bone separated as a result of injury, surgical intervention, or a destructive process.

Load – mechanical force applied to a limb, bone, and fixation system during treatment, typically recurring with constant periodicity (cyclically).

Osteosynthesis is the surgical joining of bone fragments using various devices and apparatuses.

Unfractionated heparin is a parenteral anticoagulant representing a molecule-size heterogeneous sulfated mucopolysaccharide with a molecular weight ranging from 3,000 to 30,000 kDa with a mean value of 15,000 kDa, which corresponds to approximately 45 monosaccharide residues. It is represented by heparin sodium** (or heparin) (B01AB01).

Low molecular weight heparins are a type of parenteral anticoagulants that are fragments of unfractionated heparin obtained as a result of enzymatic or chemical depolymerization processes, resulting in polysaccharide chains with an average molecular weight of about 5 kDa. They belong to the heparin group (B01AB).

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Fractures of the metacarpal bones and phalanges of the hand represent a non-classified concept including the disruption of the integrity of the metacarpal bones and phalanges [1–4].

Phalangeal dislocations are a disruption of the articulation of articular surfaces in the distal, proximal interphalangeal joints, or metacarpophalangeal joints [1–4, 63].

Metacarpal dislocation is a disruption of the articulation of articular surfaces in the carpometacarpal joints [1–4].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The most common mechanism for the development of fractures of the metacarpal bones and phalanges is direct trauma, in particular crushing or impact with a heavy object (blow from a fall, hand trapped in moving parts of a mechanical machine, falling of a heavy object onto the hand), as well as indirect trauma (twisting). A relatively less frequent mechanism of metacarpal injury, which includes a combination of hyperabduction and/or hyperextension, is a fall. There is also a type of fracture known as a subcapital fracture. It can develop in the event of a direct blow to the hand, usually a punch [2–5].

A frequent mechanism of dislocations of the phalanges and metacarpal bones is direct trauma associated with a fall or active sports (football, volleyball, etc.); motorcycle trauma, excessive hyperextension in the joint, or axial loading can also be the cause of dislocations [63, 151].

1.2.1 Specifics of etiology and pathogenesis of the disease or condition (group of diseases or conditions) in children

An important feature of pediatric patients is the presence of ossification centers, as well as growth plates in the area of the metaphyseal cartilage. In the metacarpal bone, there are two ossification centers – diaphyseal and epiphyseal. The appearance of the diaphyseal ossification center is noted in the third month of intrauterine development, resulting in the formation of the body and proximal epiphysis of the II–V metacarpal bones and the distal epiphysis of the I metacarpal bone. Epiphyseal ossification centers appear at the base of the I metacarpal bone and the heads of the II–V metacarpal bones by 3–4 years of age. Synostosis in the I metacarpal bone is noted at 13–15 years, and synostoses of the II–V metacarpal bones appear at the age of 18–20 years. Ossification of the phalanges of the hand occurs with the help of the diaphyseal (main) center – the body and head of the phalanx of the hand. The diaphyseal ossification center appears in the second month of intrauterine development in the proximal and distal phalanges and in the third month in the middle phalanges of the II–V digits. The epiphyseal ossification center appears at the base of the proximal phalanges at 1–2.5 years and at 2.5–3 years in the middle and distal phalanges. Synostosis is noted at 15–16 years in the proximal phalanges and at 18–20 years in the middle and distal phalanges [6].

The main mechanism of injury in metacarpal fractures in children is striking a hard object with the hand (accidental or intentional), as well as sports injuries. Closed fractures of the II–V metacarpal bones prevail. The most common metacarpal injury is a fracture at the neck level (subcapital) – 56–80%. In this case, the so-called "boxer's fracture" damages the IV or V metacarpal bones [7–10].

In preschool children, the main cause of phalangeal fractures is trauma from a door. In the age group over 12 years, sports and domestic trauma predominate [11–12].

In children, dislocations of the metacarpal bones and phalanges of the fingers occur approximately 5 times less frequently than fractures of the same anatomical regions [164, 171]. Metacarpal dislocations are quite rare and are mainly associated with a fall on the hand or high-energy trauma [154, 157]. Dislocations in the metacarpophalangeal joints in children are very rare, prevail in pre-adolescence and adolescence, and are most often associated with sports injuries [153].

1.3 Epidemiology of the Disease or Condition

Metacarpal fractures account for over 30% of all traumatic injuries to the skeletal system, significantly exceeding the frequency of injuries in other anatomical locations, of which metacarpal fractures comprise from 19% to 35.7%. In the structure of traumatic hand injuries, the prevalence of metacarpal fractures is 50–65%. Fractures at the level of the metacarpal head and neck account for 74%. Metacarpal fractures are more common in middle-aged and older adults. It is estimated that up to 80% of patients with such fractures are working-age men aged 18–50 years [3-5].

A significant proportion of metacarpal fractures are intra-articular in nature. Moreover, the total frequency of joint involvement in the pathological process reaches 20%, which significantly affects treatment outcomes, manifesting, in particular, in an increase in the duration of temporary disability [14]. Metacarpal fractures represent an urgent medical problem, as they can lead to prolonged loss of general working capacity (in approximately 30% of patients), loss of occupational capacity in patients whose work involves hand strain (industrial workers, athletes, musicians, etc.), and a decrease in quality of life and daily activities. Despite ongoing treatment, adverse outcomes are observed in 15.2–17% of victims [15]. For this reason, there is an increase in the duration of disability, as well as an elongation of the medical rehabilitation period, the duration of which reaches 4–7 months or more in 10.5–13.6% of patients [16]. In the overall structure of patients in specialized departments for the treatment of victims with hand pathology, 20% to 30% have the consequences of fractures, of which 25–35% have metacarpal fractures [17]. There is data from both domestic and foreign studies indicating that victims with the consequences of metacarpal and hand bone fractures who require various volumes of treatment account for up to 30% of patients receiving care in specialized outpatient and inpatient departments [18].

The incidence of the first metacarpal fracture reaches 25% in the structure of all metacarpal fractures, second only to fractures of the fifth metacarpal ("boxer's fracture"). In the vast majority of cases (up to 80%), fractures of the first metacarpal are localized in the base of the bone [19]. The peak incidence of injuries to the first metacarpal occurs in adolescence and young adulthood (10–29 years) [20-21].

Hand phalangeal fractures account for 29.7% of all upper extremity fractures and 7.6% of all emergency trauma conditions [1-4].

The stability of the carpometacarpal joint is formed by numerous anatomical structures surrounding these joints: various ligamentous structures (dorsal, palmar, and interosseous ligaments), other surrounding soft tissues such as flexor and extensor tendons, as well as the intrinsic muscles of the hand. All these structures collectively provide excellent stability and resistance to dislocation of the metacarpal bones in the carpometacarpal joints [155].

Isolated carpometacarpal dislocations and metacarpophalangeal dislocations of the thumb are extremely rare and account for less than 1% of all hand injuries [158, 167].

1.3.1 Specific epidemiology of the disease or condition (group of diseases or conditions) in children

Metacarpal fractures account for 10–40% of all fractures in children, with 1/5 of pediatric patients experiencing growth plate injury [9, 22]. Fractures occur most frequently in adolescents aged 12–17 years, with male patients injured 2–3 times more often than female patients [23-24].

An anatomical feature of metacarpal bones in children is the presence of only a single epiphyseal growth plate (zone). In the first metacarpal, as in the phalanges, the growth plate is located at the base, whereas all other metacarpals have distal subcapital growth zones. In the region of the base of the II–V metacarpals, "pseudo-epiphyses" are often present, while a subcapital "pseudogrowth plate" may occur in the first metacarpal. It is important not to confuse these physiological structures in children with fractures. "Pseudogrowth plates" or "pseudo-epiphyses" are secondary ossification centers of the proximal epiphyses of the II–V metacarpals and the distal epiphysis of the first metacarpal [25].

Phalangeal fractures of the hand in children account for 15–30% of all upper extremity fractures [26]. Distal phalangeal fractures are more common at 3–6 years of age. In school-aged children and adolescents, the incidence of proximal phalangeal fractures increases. Furthermore, fractures of the proximal portion of the proximal phalanges occur, accompanied by growth plate injury in 10–15% of cases. In adolescence, the frequency of subcapital fractures of the proximal phalanges increases [27].

Rare, isolated clinical cases of carpometacarpal joint dislocations (II–IV joints) occur in children [154, 156]. Fracture-dislocation of the base of the first metacarpal, dislocation of the first metacarpal in the carpometacarpal joint without base fracture (Bennett's fracture), dislocation of the metacarpophalangeal joint of the thumb, and dislocation of the base of the fifth metacarpal are extremely rare [157, 159, 160, 161, 167, 168]. Closed dislocations of the middle and distal phalanges of digits 2–5 can also be classified among such rare types of injuries [164-166, 170].

1.4 Features of Coding the Disease or Condition

S62.2 – Fracture of first metacarpal bone

S62.20 – Closed fracture of first metacarpal bone

S62.21 – Open fracture of first metacarpal bone

S62.30 – Closed fracture of other metacarpal bone

S62.31 – Open fracture of other metacarpal bone

S62.40 – Closed multiple fractures of metacarpal bones

S62.41 – Open multiple fractures of metacarpal bones

S62.50 – Closed fracture of thumb

S62.51 – Open fracture of thumb

S62.60 – Closed fracture of other finger

S62.61 – Open fracture of other finger

S62.70 – Closed multiple fractures of fingers

S62.71 – Open multiple fractures of fingers

S62.8 – Fracture of other and unspecified parts of wrist and hand

S63.1 – Dislocation of finger

S63.2 – Multiple dislocations of fingers

S63.3 – Traumatic rupture of wrist and metacarpal ligament

S63.4 – Traumatic rupture of ligament of finger at metacarpophalangeal and interphalangeal joint(s)

S63.6 – Sprain and strain of joint capsule and ligaments of finger

S63.7 – Sprain and strain of joint capsule and ligaments of other and unspecified parts of hand

1.5 Classification of the disease or condition

All metacarpal bones are assigned the identification number 77.

Metacarpal bones are identified as follows: I (thumb) – 1; II (index finger) – 2; III (middle finger) – 3; IV (ring finger) – 4; V (little finger) – 5.

The identifier for the sequential number of the metacarpal bone is placed after the main code 77 for metacarpal bones (between dots._.).

Next, the sequential number of the bone segment is added: proximal segment – 1; diaphysis – 2; distal segment – 3.

Example – 77.2.2 – diaphysis of the second metacarpal bone.

Figure 1.

The fracture type is determined in accordance with the AO morphological classification (ABC).

For diaphyseal fractures:

Type A – simple fracture (Fig. 2).

Figure 2.

Example: 77.2.2 A – simple fracture of the diaphysis of the second metacarpal bone.

Type B – wedge fracture (Fig. 3).

Figure 3

Example: 77.2.2 B – wedge fracture of the diaphysis of the second metacarpal bone.

Type C – multifragmentary fracture (Fig. 4).

Figure 4.

Example: 77.2.2 C – multifragmentary fracture of the diaphysis of the second metacarpal bone.

For proximal and distal segments (Fig. 5).

Type A – extra-articular fracture type. Example: 77.2.1/3 A – extra-articular fracture of the proximal/distal segment of the second metacarpal bone.

Type B – partial intra-articular fracture type. Example: 77.2.1/3 B – partial intra-articular fracture of the proximal/distal segment of the second metacarpal bone.

Type C – complete intra-articular fracture type. Example: 77.2.1/3 C – complete intra-articular fracture of the proximal/distal segment of the second metacarpal bone.

Figure 5.

Classification of fractures of the base of the first metacarpal bone

Fractures of the first metacarpal bone:

Class A: extra-articular fractures of the base and diaphysis (Winterstein fractures).

Class B: intra-articular fractures of the base (Bennett fractures and T-Y-shaped Rolando fractures). Multifragmentary intra-articular fractures are also distinguished.

AO classification of hand phalangeal fractures [28]

Hand phalanges are assigned the identification number 78.

Hand phalanges are identified as follows: I (thumb) – 1; II (index finger) – 2; III (middle finger) – 3; IV (ring finger) – 4; V (little finger) – 5 (Fig. 6).

Figure 6.

The ordinal number of the phalanx is determined as follows: proximal phalanx – 1; middle phalanx – 2; distal phalanx – 3.

The identifier of the finger's ordinal number, as well as its phalanx, is placed after the code common to the phalanges of the hand (between dots ._._.).

Next, the sequential number of the bone segment is added: proximal segment – 1; diaphysis – 2; distal segment – 3.

Example – 78.2.2.2 – diaphysis of the middle phalanx of digit II.

The type of fracture of the hand phalanges is determined in accordance with the AO morphological classification (ABC).

For diaphyseal fractures:

Type A – simple fracture (Fig. 7).

Figure 7.

Example: 78.2.2.2 A – simple fracture of the diaphysis of the middle phalanx of digit II.

Type B – wedge fracture (Fig. 8).

Figure 8.

Example: 78.2.2.2 B – wedge fracture of the diaphysis of the middle phalanx of digit II.

Type C – comminuted fracture (Fig. 9).

Figure 9.

Example: 78.2.2.2 C – comminuted fracture of the diaphysis of the middle phalanx of digit II.

For the proximal and distal segments (Fig. 10).

Type A – extra-articular fracture type. Example: 78.2.2.1/3 A – extra-articular fracture of the distal/proximal segment of the middle phalanx of digit II.

Type B – partial intra-articular fracture type. Example: 78.2.2.1/3 B – incomplete intra-articular fracture of the distal/proximal segment of the middle phalanx of digit II.

Type C – complete intra-articular fracture type. Example: 78.2.2.1/3 C – complete intra-articular fracture of the distal/proximal segment of the middle phalanx of digit II.

Eaton classification of fracture-dislocations of the hand phalanges in the proximal interphalangeal joint (Fig. 11) [173-174]

Eaton I – avulsion fracture of the volar plate with longitudinal injury of the collateral ligament.

Eaton II – avulsion of the volar plate, complete injury of the collateral ligament, dorsal subluxation of the middle phalanx.

Eaton III:

Eaton IIIА – fracture-dislocation of the middle phalanx with a bone fragment comprising less than 40% of the articular surface. The dorsal part of the collateral ligament maintains its attachment site to the middle phalanx.

Eaton IIIБ – fracture-dislocation of the middle phalanx with a bone fragment comprising more than 40% of the articular surface.

Figure 11.

Leddy-Packer classification (supplemented) of the avulsion fracture of the distal phalanx base with flexor digitorum profundus tendon injury (Fig. 12) [175]

Type 1 – avulsion of the tendon from its insertion site at the base of the distal phalanx, with no bone tissue injury. The central end of the tendon retracts proximal to the A1 pulley.

Type II – avulsion of the tendon from its insertion site at the base of the distal phalanx, with no bone tissue injury. The central end of the tendon retracts to the level of the proximal interphalangeal joint.

Type III – avulsion of the tendon with a bone fragment of the distal phalanx base (Jersey finger). The bone fragment blocks the tendon at the level of the A4 pulley.

Type IV – avulsion fracture of the distal phalanx base, tendon retraction proximal to the A1 pulley.

Type V – comminuted fracture of the distal phalanx, avulsion fracture of the base with tendon entrapment at the level of the distal interphalangeal joint.

Figure 12.

Doyle classification of distal phalanx base fractures with extensor tendon injury

Type I – closed avulsion fracture of the base of the hand's distal phalanx (with or without a bone fragment).

Type II – open injury of the extensor tendon in zone I without a bone fragment.

Type III – open injury of the extensor tendon with skin and/or tendon defect without a bone fragment.

Type IV – A. Fracture of the distal phalanx (physeal fracture).

Type IV – B. Fracture of the distal phalanx involving 20–50% of the articular surface.

Type IV – C. Fracture of the distal phalanx involving more than 50% of the articular surface.

Figure 13.

1.5.1 Specifics of the classification of the disease or condition (group of diseases or conditions) in children

In patients with a functioning growth plate, an important aspect is the likelihood of its injury during trauma. Fractures involving the growth plate are located in the metaphysis and/or epiphysis. Currently, the most convenient is the Salter-Harris classification, which reflects various options of growth plate involvement in trauma. This classification includes 5 types of injuries, while the risk of subsequent growth disturbance increases as fractures progress from type I to type V (Fig. 14).

Salter I: epiphyseolysis (the fracture line passes directly through the growth plate).

Salter II: metathesioepiphyseolysis / metaepiphyseal fracture (the fracture line passes partially through the growth plate with a metaphyseal fracture (extra-articular above the growth plate, most common)).

Salter III: epiphyseal fracture (the fracture line passes partially through the growth plate with an epiphyseal fracture (intra-articular fracture)).

Salter IV: metaepiphyseal fracture (the fracture line passes through the metaphysis, growth plate, and epiphysis (intra-articular fracture)).

Salter V: impacted fracture resulting in the destruction of the growth plate (rare, leads to premature closure of the growth plate).

Classification of dislocations of finger phalanges and metacarpal bones

By joint location:

1) Distal interphalangeal joint.

2) Proximal interphalangeal joint.

3) Metacarpophalangeal joint.

4) Carpometacarpal joint.

By direction of displacement:

1) Volar.

2) Dorsal.

3) Lateral.

1.6 Clinical presentation of the disease or condition

Metacarpal fracture

Patients complain of pain in the affected area of the bone or joint, impaired limb function (limitation, painful movements in the joint, decreased or limited hand grip function, deformation of the metacarpal bones). They complain of edema of the dorsal surface of the hand and fingers, increasing over time. Clinical manifestations of extra-articular metacarpal fractures include local pain, edema of the dorsal surface of the hand localized predominantly in the area of the metacarpal bones, as well as restricted motion in the metacarpophalangeal and interphalangeal joints, decreased or absent hand grip strength, and finger deformity [29-31].

Fracture of hand phalanges

Patients complain of pain in the affected finger, metacarpophalangeal or interphalangeal joint, and hand dysfunction. Rotational and angular finger deformities and decreased hand grip strength are possible [29-31].

Dislocations of the phalanges of the fingers and metacarpal bones

Patients complain of pain in the area of the injured joint and its constituent phalanges. In the first hours after the trauma, pronounced edema is observed; active and passive movements provoke sharp pain. Patients report a decrease in hand grip strength. A deformity may occur, indicating the localization and direction of displacement of the distal segment [63, 142, 151].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition: the diagnosis of fracture of the metacarpal bones and phalanges of the hand is established based on the following list of examinations [1-4], [30-31].

1) Taking anamnesis and complaints related to bone system pathology;

2) Physical examination: presence or absence of skin integrity disruption in the area of the injured segment, presence of tenderness in the trauma zone, impaired function of the upper extremity, local edema and/or deformity, pathological mobility (visual examination of the bone system, palpation of the bone system, and percussion of the bone system);

3) Instrumental examination: hand radiography (wrist radiography, metacarpus radiography, phalangeal bones of the hand radiography, phalangeal bones of the fingers of the hand radiography, radiography of the 1st digit of the hand, radiocarpal joint radiography) in the anteroposterior, lateral, and additional ¾ projections, or according to computed tomography of the bone (and/or computed tomography of the upper extremity, or magnetic resonance imaging of bone tissue (one region) and/or magnetic resonance imaging of the upper extremity);

4) Laboratory diagnostic examinations (performed upon hospitalization as part of planning further treatment, including surgical treatment).

Criteria for establishing the diagnosis/condition: the diagnosis of dislocation of the phalanges of the fingers and metacarpal bones is established based on the following list of examinations [63, 142-143].

1) Taking anamnesis and complaints related to bone system pathology;

2) Physical examination: presence or absence of skin integrity disruption in the area of the injured segment, presence of tenderness in the trauma zone, impaired function of the upper extremity, local edema and/or deformity, pathological mobility (visual examination of the bone system, palpation of the bone system, and percussion of the bone system);

3) Instrumental examination: hand radiography (wrist radiography and/or metacarpus radiography and/or phalangeal bones of the hand radiography and/or phalangeal bones of the fingers of the hand radiography and/or radiography of the 1st digit of the hand and/or radiocarpal joint radiography) in the anteroposterior, lateral, and additional ¾ projections, or according to CT or MRI (computed tomography of the bone and/or computed tomography of the upper extremity, or magnetic resonance imaging of bone tissue (one region) and/or magnetic resonance imaging of the upper extremity);

4) Laboratory diagnostic examinations (performed upon hospitalization as part of planning further treatment, including surgical treatment).

Criteria for establishing the diagnosis/condition: the diagnosis of fracture-dislocation of the phalanges of the fingers of the hand is established based on the following list of examinations [1-4, 30-31, 63, 142-143].

1) Taking anamnesis and complaints related to bone system pathology;

2) Physical examination: presence or absence of skin integrity disruption in the area of the injured segment, presence of tenderness in the trauma zone, impaired function of the upper extremity, local edema and/or deformity, pathological mobility (visual examination of the bone system, palpation of the bone system, and percussion of the bone system);

3) Instrumental examination: hand radiography (wrist radiography, metacarpus radiography, phalangeal bones of the hand radiography, phalangeal bones of the fingers of the hand radiography, radiography of the 1st digit of the hand, radiocarpal joint radiography) in the anteroposterior, lateral, and additional ¾ projections, or according to CT or MRI (computed tomography of the bone and/or computed tomography of the upper extremity and/or magnetic resonance imaging of bone tissue (one region) and/or magnetic resonance imaging of the upper extremity);

4) Laboratory diagnostic examinations (performed upon hospitalization as part of planning further treatment, including surgical treatment).

2.1 Complaints and Anamnesis

Comment: when taking the anamnesis, it is necessary to take into account the presence of chronic diseases affecting tissue trophism, such as diabetes mellitus, rheumatoid arthritis, vascular pathology, smoking, and glucocorticoid intake. It is important to ascertain whether the patient is taking drugs that affect the blood coagulation system. The intake of these drugs, along with the condition of the soft tissues, affects the timing of the surgical intervention.

2.2 Physical Examination

Comments: in ununited or stale fractures of the metacarpal bones and phalanges of the fingers, contractures of the corresponding fingers and wrist joint, and median and ulnar neuropathies may be observed due to prolonged unresolved soft tissue edema; complex regional pain syndrome of type 1 (without peripheral nerve injury) or type 2 (combined with nerve injuries) may develop, with an incidence ranging from 5% to 40% [30-33]. The development of this complication can lead to prolonged (multi-month) disability, primarily in manual workers, and in some cases to permanent disability, pain syndrome, secondary displacement of fragments, and recurrence of hand and finger deformity; furthermore, assessing the condition of the soft tissues in the injury area is an important aspect in choosing patient management tactics [34-35].

2.3 Laboratory Diagnostics

Comment: laboratory test results are not definitive for establishing the diagnosis, but are necessary for planning inpatient surgical intervention, determining further treatment tactics, and performing postoperative laboratory monitoring. Additional diagnostic methods may be applied if the patient has comorbid conditions.

When performing outpatient surgical interventions, the necessity of laboratory tests is determined by the attending physician depending on the patient's condition and the presence of comorbid diseases.

2.4 Instrumental Diagnostics

Comment: three projections are required to identify a fracture – in addition to the lateral and oblique views, it is advisable to use a direct anteroposterior view (Robert's view). The examination performed with maximum pronation provides high-quality visualization of the metacarpophalangeal joint. The lateral view, which ensures the detection of metaepiphyseal fractures, has maximum diagnostic value when the hand is positioned in supination at an angle of 80–90 degrees with the beam directed at 30 degrees.

2.5 Other Procedures

Not required.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

Metacarpal fractures.

Comment: conservative treatment involves closed manual reduction after anesthesia (local anesthesia) of the fracture sites with a 1% solution for injection of procaine** or lidocaine** taking into account the dosing regimen and age restrictions specified in the instructions for medical use. Next, the assistant performs traction on the hand digits, while the orthopedic trauma surgeon presses with a finger on the dorsal surface of the hand in the fracture area, shifting the fragments palmward. Treatment consists of closed reduction and external splinting in a neutral position using a cast that involves the metacarpophalangeal joint, proximal interphalangeal joint, and carpometacarpal joint.

An alternative treatment strategy is functional treatment using tape or a bandage that does not restrict movement. No conservative treatment regimen for fifth metacarpal neck fracture can be considered superior to others in terms of outcome [46-47].

Comment: during closed reduction (reduction of bone fragments in fractures) and external immobilization (plaster casts or slabs, thermoplastic splints, braces, body taping), the hand must be fixed in the position of safe immobilization to prevent the development of contractures in the 2nd–5th metacarpophalangeal joints.

Comment: there are various approaches to treating patients with such fractures [44-46]. This is largely due to the individual characteristics of the patient, the nature and severity of pathological changes, the presence of concomitant diseases, and local and regional features of medical care provision. However, in any case, unstable fractures require internal fixation [47].

The vast majority of victims with uncomplicated extra-articular fractures of the metacarpal bones and hand phalanges, whose injury severity ranges from 2 to 10 points on the HISS (Hand Injury Severity Score, which correlates with the degree of disability) [48, 49], receive specialized medical care in outpatient settings [9, 50]. Conservative treatment methods are used in 68–80% of cases, consisting of closed reduction (reduction of bone fragments in fractures) and external immobilization using plaster casts or slabs, thermoplastic splints, braces, and body taping. It is believed that conservative therapy may be indicated for the majority of patients with uncomplicated metacarpal fractures and non-displaced fractures, and generally allows for a significant improvement in condition [49-51].

Phalangeal fractures.

Comment: displacement is clinically significant if there is a deformation angle of more than 25 degrees in any direction, a width deformation with fragment overlapping of more than 20 mm, or rotational displacements around the axis of more than 15 degrees.

Finger phalangeal dislocations (reduction of joint dislocation).

Comment: following joint dislocation reduction, immobilization of the digit in a position of slight flexion at the distal interphalangeal joint is necessary for 2–3 weeks.

Comment: a strictly lateral projection must be obtained during X-ray examination to diagnose an avulsion fracture of the base of the distal phalanx. Plaster immobilization should be performed in a position of hyperextension at the distal interphalangeal joint for 6 weeks. It is permissible to leave the proximal interphalangeal joint free. Differential diagnosis with fracture-dislocation in the distal interphalangeal joint must be performed [142].

Comment: immobilization of the injured finger to the adjacent one using tapes (buddy-taping) is performed for a week from the moment of injury, followed by active movements in the proximal interphalangeal joint (application of an immobilization bandage in bone fractures and/or application of an immobilization bandage in joint dislocations (subluxations)). Differential diagnosis with fracture-dislocation in the proximal interphalangeal joint must be performed. On the lateral radiograph, the "V" sign may appear, indicating dorsal subluxation of the middle phalanx in the proximal interphalangeal joint [152].

Comment: damage to the central slip of the extensor mechanism should be suspected; immobilization in extension at the proximal interphalangeal joint should be performed for 4 weeks, while the distal interphalangeal joint remains free.

Comment: collateral ligament stability must be assessed after reduction of the dislocation. Immobilization (application of an immobilization bandage for joint dislocations (subluxations)) is performed in the extension position at the proximal interphalangeal joint for 3 weeks.

Comment: a fracture-dislocation can be considered stable when the articular surface lesion of the base of the middle phalanx ranges from 10 to 30%. Immobilization with restriction of extension helps maintain joint congruence, although it does not allow anatomical fracture reduction [152].

Features of conservative treatment of metacarpal and phalangeal fractures and dislocations in children.

Comments: the success of conservative treatment is determined by the significant remodeling capacity and rapid consolidation of growing bone [56–57]. In long-term follow-up of conservative treatment, post-traumatic changes in the growth plate were noted both in patients without reduction and after fragment reduction (22.2–55% of patients). These manifest as uniform or nonuniform narrowing, cystic transformation, or partial (insular) ossification of the metacarpal bone. In children who underwent reduction of bone fragments, growth plate changes may be caused by the traumatic impact of the primary force or reduction maneuvers on the physis [58]. Closed reduction of a joint dislocation is usually easily achieved by gentle traction and direct pressure on the dislocated base of the metacarpal or finger phalanx, followed by plaster immobilization for 4–6 weeks [156, 160, 161, 167, 169].

3.2 Surgical Treatment

Treatment of metacarpal fractures.

Comment: open, closed, minimally invasive, and instrument-assisted reduction of bone fragments followed by their fixation with medical devices (reduction of bone fragments in fractures) can be used for fragment reduction; external fixation devices can be used as a staged and definitive method of bone fragment fixation (bone reconstruction).

Comment: intramedullary osteosynthesis is comparable to percutaneous transverse fixation for fifth metacarpal neck fractures in terms of fixation stability and minimal tissue trauma [72]. Osteosynthesis with low-profile plates (non-absorbable sterile bone fixation plate with screws***; absorbable bone fixation plate with screws***; non-absorbable sterile bone fracture fixation set with plates***; non-absorbable non-sterile bone fixation plate with screws***; non-absorbable sterile internal orthopedic fixation system using plates/screws***) is performed for diaphyseal fractures when shorter treatment times are required, which is especially useful for manual laborers [79, 80, 81].

Comment: screw fixation (orthopedic bone screw, non-absorbable, sterile***; orthopedic bone screw, absorbable***; dynamic bone screw***) may be the best choice for open fixation of long oblique diaphyseal fractures and bases of the metacarpal bones. For short oblique fractures, plates (bone plate for fracture fixation with screws, non-absorbable, non-sterile***; internal orthopedic fixation system using plates/screws, non-absorbable, sterile***; bone plate for fracture fixation with screws, non-absorbable, sterile***; bone plate for fracture fixation with screws, absorbable***; set of devices for bone fracture fixation with a plate, non-absorbable, sterile***; plate for screwless bone fixation made of shape memory alloy***) and screws (orthopedic bone screw, non-absorbable, sterile***; orthopedic bone screw, absorbable***; dynamic bone screw***) are used, providing rigid fixation to allow early mobilization [84-86].

Comment: a systematic review and meta-analysis revealed no differences in clinical outcomes between various surgical treatment methods for metacarpal and neck fractures (intramedullary screw, interfragmentary screw, plate, intramedullary Kirschner wire, transverse Kirschner wire, cross Kirschner wire). Further high-evidence studies are needed to evaluate the efficacy of treatment methods for closed unstable metacarpal fractures [90].

Comment: the difficulties in choosing the optimal treatment strategy in cases of Bennett's fracture are largely due to the fact that surgical intervention is associated with a high risk of damage to nearby tendons and sensitive nerve fibers.

Surgical methods for this fracture are diverse: percutaneous surgery, open surgery, and arthroscopic surgery. Osteosynthesis methods are also diverse: fixation plates, direct or indirect screw fixation, or pinning [94-95]. Moreover, there is no consensus on acceptable reduction parameters, including articular step-off or gap, with some case series suggesting that displacement of up to 2 mm is acceptable [96]. As a general principle, preference should be given to the treatment option that provides the desired reduction volume and degree of fixation, allows early mobilization, and minimizes soft tissue damage [14].

Comment: closed reduction can be expected to succeed if the injury is up to 10 days old, with the optimal timeframe being up to 3-4 days. In chronic cases and cases of closed reduction failure, open surgical intervention must be performed [16]. Arthroscopic assistance allows direct visualization of the articular surface during reduction, joint lavage, and is associated with minimal pain and related complications [97-99]. A comparative analysis of the efficacy of various fixation methods (wires, plates, screws) identified closed reduction and Kirschner wire fixation (orthopedic bone wire***) (intramedullary wire osteosynthesis) as the most acceptable treatment method [101].

Comment: there are few comparisons in the literature regarding the results of various treatment methods for Bennett's fracture, leaving the surgeon without a clear treatment algorithm. Moreover, there is no consensus regarding acceptable reduction parameters, including joint space or step-off, with some case series claiming that displacement of up to 2 mm is acceptable [96], although most researchers define the acceptable displacement value as 1 mm [104]. Closed reduction and percutaneous Kirschner wire fixation (orthopedic bone wire***, closed fracture reduction with internal fixation, intramedullary wire osteosynthesis) or cannulated headless compression screws (orthopedic bone screw, non-absorbable, sterile***; orthopedic bone screw, non-absorbable, non-sterile***; orthopedic bone screw, absorbable***; dynamic bone screw***) are generally suitable treatment methods for Bennett's fractures. Superior results compared to open reduction internal fixation and fluoroscopically controlled closed reduction with percutaneous fixation have not been demonstrated.

Comment: if the palmar and dorsal displaced fragments of a Rolando fracture are of sufficient size, preference is given to open reduction followed by internal fixation using fixation screws (orthopedic bone screw, non-absorbable, sterile***; orthopedic bone screw, non-absorbable, non-sterile***; orthopedic bone screw, absorbable***; dynamic bone screw***), T- or L-shaped buttress plates (bone plate for fracture fixation with screws, non-absorbable, sterile***; bone plate for fracture fixation with screws, absorbable***; set of devices for bone fracture fixation with a plate, non-absorbable, sterile***; bone plate for fracture fixation with screws, non-absorbable, non-sterile***; internal orthopedic fixation system using plates/screws, non-absorbable, sterile***) [105, 107, 198].

Comment: distraction osteosynthesis is a good treatment method for open comminuted metacarpal fractures [108]. The distraction method for treating multi-fragmentary Rolando-type fractures using various apparatuses is also described by other authors [109, 110].

Specifics of surgical treatment for metacarpal fractures in children.

Comment: the average healing time for metacarpal bones is 3–4 weeks [113]. Surgical treatment in children consists of closed reduction and fragment fixation with a Kirschner wire (orthopedic bone wire***) (1.5–1.8 mm), microplates (bone plate for fracture fixation with screws, non-absorbable, sterile***; bone plate for fracture fixation with screws, absorbable***; set of devices for bone fracture fixation with a plate, non-absorbable, sterile***; bone plate for fracture fixation with screws, non-absorbable, non-sterile***; internal orthopedic fixation system using plates/screws, non-absorbable, sterile***), or a mini-Ilizarov fixator, and does not differ in technique from that for adult patients [111, 113, 114]. However, it is necessary to take into account the risk of premature closure of the epiphyseal plate following internal fixation. This may be associated with repeated attempts to pass the Kirschner wire (orthopedic bone wire***) through the physis [111]. In addition, intra-articular pressure from hemarthrosis during trauma may contribute to the development of avascular necrosis, followed by closure of the physis and shortening of the metacarpal bone [9]. Following fixation with Kirschner wires (orthopedic bone wire***), joint contractures in adjacent joints may develop due to the fact that, in addition to wire fixation, immobilization with a plaster splint (application of immobilization bandage during bone surgeries) is required [113]. When using a miniplate (bone plate for fracture fixation with screws, non-absorbable, sterile***; bone plate for fracture fixation with screws, absorbable***; set of devices for bone fracture fixation with a plate, non-absorbable, sterile***; bone plate for fracture fixation with screws, non-absorbable, non-sterile***; internal orthopedic fixation system using plates/screws, non-absorbable, sterile***), subsequent immobilization with a plaster splint is not required, allowing early mobilization (on day 2) of active movements in the fingers and adjacent joints.

Specifics of surgical treatment for metacarpal dislocations in children

• In all children with no effect from closed reduction (joint dislocation reduction) or secondary displacement at late stages, surgical treatment is recommended, which consists of reduction of the metacarpal dislocation with fixation using a Kirschner wire (orthopedic bone wire***) or a bone plate (bone plate for fracture fixation with screws, non-absorbable, sterile***; bone plate for fracture fixation with screws, absorbable***; set of devices for bone fracture fixation with a plate, non-absorbable, sterile***; bone plate for fracture fixation with screws, non-absorbable, non-sterile***; internal orthopedic fixation system using plates/screws, non-absorbable, sterile***) for 4–6 weeks. However, the risk of potential epiphysiodesis associated with surgical treatment must be considered [154, 159, 160, 163, 206, 207].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

In addition to implant fixation, surgical treatment aimed at reconstructing carpometacarpal ligaments using anchor sutures is also possible. This reduces the risk of instability and recurrent dislocation in children [157, 163].

Treatment of phalangeal fractures and fracture-dislocations.

Comment: good outcomes in intra-articular fractures are achieved by using hinged distraction-compression devices, which allow reliable fragment fixation while simultaneously enabling early motion in the injured joint [115-116].

Comment: an alternative treatment option in the acute period is the use of a dynamic external distraction fixator (orthopedic bone wire***) [115]. In cases of neglected fracture-dislocations of the proximal interphalangeal joints, the hemi-hammate arthroplasty technique may be used [145-146].

Specifics of surgical treatment for phalangeal fractures in children.

Treatment of hand finger dislocations.

Features of surgical treatment of hand finger dislocations in children.

Comment: via a dorsal or volar approach, one or more potential interposition sources preventing closed reduction must be eliminated (volar plate, joint capsule, flexor pollicis longus tendon). In cases of recurrent dislocation, reconstruction of the ulnar collateral ligament is necessary [172].

Comment: surgical treatment is performed via a dorsal or volar approach made in the projection of the metacarpophalangeal joint of the 2nd digit of the hand. The dorsal approach is technically simpler and safer. In cases of volar plate injury, surgical treatment is performed via a volar approach with its primary repair.

3.3 Other Treatment

3.3.1 Antibacterial prophylaxis

• Due to the lack of a clear evidence base for or against surgical antibiotic prophylaxis (SAP) of surgical site infection (SSI) in the surgical treatment of patients with phalangeal fractures, dislocations of the fingers and metacarpal bones in an outpatient setting without the need for subsequent hospitalization, the decision to perform SAP to reduce the risk of SSI is recommended to be made individually based on the presence of SSI risk factors in the patient, the scope of the planned surgery, and the local protocol of the medical organization [121, 122].

GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)

• In patients with risk factors for SSI development (diabetes mellitus, arterial hypertension, smoking, etc.) undergoing surgical treatment for closed fractures of the metacarpals or phalanges of the fingers, as well as dislocations and fracture-dislocations of the phalanges in an outpatient setting without the need for subsequent hospitalization, SAP with one of the systemic antibacterial drugs is recommended, taking into account age restrictions in the instructions for medical use, to reduce the risk of SSI development (cefazolin**, cefuroxime**, #clindamycin**, vancomycin**) [123, 124, 201]. Single doses of the main systemic antibacterial drugs for SAP in surgical interventions in traumatology and orthopedics in adults: cefazolin** 2 g (for patient weight ≥ 120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion [201]. Single doses for children should be calculated based on actual weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin** 10 mg/kg, vancomycin** 15 mg/kg; the use of fluoroquinolones (ATC: J01MA) during the period of formation of the osteoarticular system is contraindicated due to the risk of arthropathy [201, 202, 203].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comment: patients with closed fractures of the metacarpal bones or phalanges of the fingers, as well as dislocations and fracture-dislocations of the phalanges of the fingers, who required hospitalization and are scheduled for surgery using any implants, must undergo SAP for no more than 24 hours to reduce the risk of SSI [122]. For adult patients with an unburdened allergic history and no significant risk factors for methicillin-resistant Staphylococcus carriage, first- and second-generation cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes before skin incision. In case of intolerance to beta-lactam antibiotics, vancomycin** should be prescribed, administered for at least 60 minutes starting the IV infusion 2 hours before the incision, or #clindamycin**. In the presence of significant risk factors for methicillin-resistant Staphylococcus carriage (MRS), the SAP regimen should include systemic antibacterial drugs (ATC: J01) with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of a systemic antibacterial drug is sufficient for effective prophylaxis. For prolonged procedures (more than 3 hours) or massive blood loss, an additional intraoperative dose of one of the systemic antibacterial drugs (ATC: J01) should be administered (the estimated time for intraoperative administration is 2 half-lives after the preoperative dose).

Administration of systemic antibacterial drugs (ATC: J01) after wound closure in the operating room is impractical even in the presence of established drains. A prospective randomized clinical trial showed that the administration of an antibiotic (ATC: J01) for SAP 1 minute after tourniquet application demonstrated a statistically significant advantage in terms of reducing the incidence of SSI, wound healing time, and overall satisfaction.

• Patients with open fractures of the hand bones are recommended to receive antibiotic therapy for no more than 72 hours after wound closure to reduce the risk of SSI: the antibiotic of choice is cefazolin** [126-127].

GCR ALeE 3Grade of Recommendation A (Level of Evidence – 3)

• Adult patients with open high-energy fractures of the hand bones with displacement and segmental loss; major vascular injury; heavily contaminated wounds are recommended to consider adding #gentamicin** to cefazolin** at a dose of 6 mg/kg intravenously once daily for 2–4 days [128, 129].

GCR BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comment: in case of open fractures, prophylactic antibiotic administration is effective in preventing early infection. At the same time, the systemic antibacterial drug should be administered as soon as possible after the injury.

3.3.2 Pain management

No specific pain management protocol has been developed.

Comment: the choice of medicinal products depends on the extent of injury and the severity of pain, and may include prescribing NSAIDs from the M01A group (non-steroidal anti-inflammatory and antirheumatic products), opioids (ATC: N02A) either as monotherapy or as part of multimodal analgesia (MMA), which involves the use of several analgesics (opioid and non-opioid) from the N02 Analgesics group. It must be remembered that the duration of parenteral administration for most NSAIDs is limited to two days, which requires timely switching of the patient to oral administration, changing the drug, or approving further administration with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually, in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization (MO).

• In adult patients undergoing perioperative MMA, a single administration of #dexamethasone** 1.25–20 mg IV/before surgery (60 min before incision) is recommended as an adjuvant to reduce postoperative pain [132].

GPP ALoE 1Grading of Recommendations Assessment, Development and Evaluation (GRADE) A (Level of Evidence – 1)

3.3.3 Prophylaxis of nosocomial venous thromboembolic events

• For patients requiring surgery on the distal upper extremity, routine pharmacological prophylaxis of venous thromboembolism (VTE) is not recommended in the absence of additional VTE risk factors [133].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: to assess the individual risk of VTE development, it is advisable to use the Caprini scale (Appendix G1). Recommended doses, frequency, and route of administration of antithrombotic agents for high-risk VTE prophylaxis during conservative treatment and orthopedic surgeries in adult patients are presented in Appendix A3.2 in accordance with the instructions for medical use.

3.3.4 Tetanus prevention

Comment: in accordance with clauses 4156-4157 of the Sanitary and Epidemiological Rules and Regulations on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is performed for any injuries involving a breach of the skin and mucous membranes. Emergency tetanus prophylaxis is performed up to the 20th calendar day from the moment of injury [134-135]. The prescription of drugs for emergency tetanus immunoprophylaxis is carried out differentially, depending on the presence of documented confirmation of preventive vaccination or data from immunological monitoring of anti-tetanus immunity, and also taking into account the nature of the injuries.

The algorithm for selecting prophylactic agents when performing emergency specific tetanus prophylaxis is given in Appendix A3.1.

3.4 Dietary Therapy

4. Medical Rehabilitation and Sanatorium-Resort Treatment

In domestic and foreign literature, individual authors present the possibilities and necessity of rehabilitation without an evidence base for the efficacy of the proposed rehabilitation methods and techniques. While emphasizing the importance of restoring hand function after injuries, no scientific research has been conducted to determine the effectiveness of various programs and the permissible timelines for axial loading.

The protocols recommended below are based on an understanding of the course of reparative processes in bone tissue, functional impairments caused by trauma, and the mechanisms of action of specific therapeutic techniques and factors.

The goal of rehabilitating patients after hand surgeries is full functional, social, domestic, and occupational recovery. Rehabilitation includes medical rehabilitation or restorative treatment, social rehabilitation aimed at social and domestic adaptation, and vocational rehabilitation, which consists of vocational guidance, vocational education, and occupational adaptation [137].

Patient rehabilitation is based on well-known principles: early initiation once the patient achieves an adequate level of analgesia through the multimodal use of both various pharmacological agents and non-pharmacological methods, continuity, consistency, comprehensiveness, and an individualized approach to therapeutic measures [138].

Comment: rehabilitation measures must be initiated in the hospital immediately after surgery and continued throughout the entire hospitalization (first stage of rehabilitation). After discharge from the hospital, if necessary, restorative treatment should be continued (if possible) in rehabilitation departments (second stage of rehabilitation), and completed in day hospital medical rehabilitation departments, sanatoriums, outpatient clinics, or at home (third stage of rehabilitation) [139].

Comment: There is limited evidence that a well-designed and effectively implemented home exercise program leads to a statistically significant improvement in hand function and total active range of motion of the fingers compared to traditional physical therapy postoperatively [141]. Full weight-bearing / active load on the operated hand is permitted after fracture consolidation has occurred, depending on the nature of the bone injury, the technique, and the specifics of the surgical intervention. The basis of therapeutic measures after the removal of immobilization consists of medical physical therapy (physiotherapy) (including in a swimming pool), exercise machine workouts, and balneological procedures, which are advisable to conduct in specialized centers or sanatorium-resort institutions [140].

5. Prevention and Dispensary Observation

Specific prophylaxis for fractures and dislocations of the phalanges of the fingers and metacarpal bones has not been developed. Measures aimed at reducing traumatism and complying with safety regulations in everyday life and at the workplace remain relevant.

Comments: physical examinations must be supplemented by control radiography of the wrist joint and/or radiography of the hand (hand radiography, wrist radiography, metacarpal radiography, radiography of the phalanges of the hand, radiography of the phalangeal bones of the hand, radiography of the 1st digit of the hand) in one projection/two projections, and in additional projections if necessary.

Depending on the patient's condition, the severity of the trauma, the scope of surgical intervention, the state of soft tissues, concomitant diseases, the stability of bone fragment fixation, and/or fracture consolidation, the attending physician, both in adults and children, may determine alternative schedules for control examinations of the patient following trauma or surgery, as well as the required number of such examinations. In pediatric patients with functioning growth plates, if they are damaged, an examination and radiological control should be performed in the long term, 12 to 24 months after the trauma, due to the possibility of premature partial or complete closure of the growth plate.

6. Organization of Medical Care

Indications for hospitalization

Metacarpal bones

• displaced fractures of one or more of the II–V metacarpal bones, fracture-dislocations;

• isolated fractures of the 1st metacarpal bone requiring closed or open reduction with hardware fixation or treatment using an external fixation device;

• unstable fractures of the first metacarpal bone (such as Bennett, Rolando, Winterstein fractures);

• presence of rotational displacement of bone fragments;

• presence of palmar angulation exceeding 15° for the 2nd and 3rd metacarpal bones, exceeding 30° for the 4th, and 40° for the 5th metacarpal bones in subcapital fractures;

• presence of any angulation for the 2nd and 3rd metacarpal bones, exceeding 20° for the 4th and 5th metacarpal bones in diaphyseal fractures;

• open fractures, especially those combined with injuries to tendons, blood vessels, nerves, or soft tissue defects;

• multiple metacarpal fractures;

• intra-articular fractures of the metacarpal bones with displacement;

• fractures with bone tissue defects, comminuted fractures.

• fractures with unreduced displacement, secondary displacement, malunions, non-unions;

• stale and neglected fracture-dislocations;

• pseudoarthrosis (non-unions).

Indications for hospitalization

Finger phalanges

1. Intra-articular closed type C fracture with displacement;

2. Type A and B fractures in cases of unsatisfactory reduction or secondary displacement during conservative treatment;

3. Presence of pronounced pain syndrome in the wrist joint area;

4. Fracture-dislocations of the phalanges of the fingers.

Indications for patient discharge from a medical organization

1) Regression of the pain syndrome, smooth postoperative course, patient activation, and initiation of medical rehabilitation.

7. Additional Information

Following immobilization, post-traumatic osteoporosis in the wrist joint area, post-immobilization contractures, and Sudeck's syndrome may develop, which manifests as tight edema of the fingers and hand; the skin on the dorsum of the hand is thinned, shiny, and sometimes cyanotic. Movements of the fingers and hand are restricted and painful. Radiographs reveal uneven ("patchy") osteoporosis [126].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Nosov Oleg Borisovich – Candidate of Medical Sciences, Trauma and Orthopedic Surgeon. Head of the Department of Traumatology and Orthopedics No. 3. Privolzhsky Research Medical University of the Russian Ministry of Health.

2. Gorshunov Evgeny Dmitrievich – Trauma and Orthopedic Surgeon, Privolzhsky Research Medical University of the Russian Ministry of Health.

3. Kachesov Anton Vladimirovich – Candidate of Medical Sciences, Trauma and Orthopedic Surgeon at the Department of Traumatology and Orthopedics No. 3, Privolzhsky Research Medical University of the Russian Ministry of Health.

4. Klenin Andrey Anatolyevich – Candidate of Medical Sciences, Trauma and Orthopedic Surgeon. Department of Traumatology and Orthopedics No. 3. Privolzhsky Research Medical University of the Russian Ministry of Health.

5. Alexandrov Nikolay Mikhailovich – Doctor of Medical Sciences, Trauma and Orthopedic Surgeon. Department of Traumatology and Orthopedics No. 3. Privolzhsky Research Medical University of the Russian Ministry of Health.

6. Avdeychik Natalya Valeryevna – Candidate of Medical Sciences, Trauma and Orthopedic Surgeon at the Department of Reconstructive Microsurgery and Hand Surgery, National Medical Research Center for Pediatric Traumatology and Orthopedics named after H.I. Turner of the Russian Ministry of Health, St. Petersburg.

7. Grankin Denis Yuryevich – Trauma and Orthopedic Surgeon at the Department of Reconstructive Microsurgery and Hand Surgery, National Medical Research Center for Pediatric Traumatology and Orthopedics named after H.I. Turner of the Russian Ministry of Health, St. Petersburg.

The developers of the clinical guidelines "Fractures and dislocations of metacarpal bones and phalanges of the hand" reported no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of these clinical guidelines:

1. Trauma and orthopedic surgeons;

2. Surgeons;

3. General practitioners (family physicians);

4. Medical rehabilitation physicians;

5. Physical therapy physicians;

6. Physical and rehabilitation medicine physicians;

7. Physiotherapists;

8. Ambulance physicians;

9. Paramedics;

10. Emergency department physicians;

11. Radiologists.

The evidence base for these clinical guidelines consists of relevant English-language and Russian-language publications in the electronic databases PubMed and Web of Science (Russian Science Citation Index).

In these clinical guidelines, data are ranked by level of evidence according to Tables 1 and 2; the strength of recommendation statements was determined according to Table 3 (Appendix No. 2 to the Requirements for the Structure of Clinical Guidelines, Composition and Scientific Validity of Information Included in Clinical Guidelines, approved by Order of the Russian Ministry of Health No. 103n dated February 28, 2019).

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Decree of the Government of the Russian Federation No. 588 dated April 5, 2022 (as amended on February 3, 2025) "On the recognition of a person as disabled" (together with the "Rules for the recognition of a person as disabled"). Official Internet Portal of Legal Information http://pravo.gov.ru, April 8, 2022, "Collected Legislation of the Russian Federation", April 11, 2022, No. 15, Art. 2506 (accessed date).

2. Federal Law No. 351-FZ dated December 9, 2010, «On Amendments to the Federal Law „On Veterans“ and Articles 11 and 11.1 of the Federal Law „On Social Protection of Disabled Persons in the Russian Federation.“»

Appendix A3.1 Scheme for selecting prophylactic agents in emergency specific tetanus prophylaxis [96]

1. Instead of 0.5 ml of TT**, ADS**-M can be used if diphtheria vaccination with this drug is required. If the wound location allows, it is preferable to administer TT** into the surrounding area by subcutaneous infiltration.

2. Use one of the specified drugs: HTIG** or TIG**; for children, it is preferable to administer HTIG**.

3. For "infected" wounds, 0.5 ml of TT** is administered if 5 or more years have passed since vaccination.

4. A full course of immunization with TT** for adults consists of two injections of 0.5 ml each, administered 30–40 days apart, followed by a booster dose of the same amount after 6–12 months. According to the accelerated schedule, a full course of immunization includes a single vaccination with a double dose of TT** (1 ml) and a booster dose of 0.5 ml of TT** after 6 months to 2 years.

5. Two injections according to the standard immunization schedule (for adults and children) or one injection according to the accelerated immunization schedule for adults.

6. For "infected" wounds, HTIG** or TIG** is administered.

7. All individuals who have received active-passive prophylaxis must receive a booster dose of 0.5 ml of TT** or 0.5 ml of ADS**-M after 6 months to 2 years to complete the immunization course.

8. During active-passive prophylaxis, children are administered 0.5 ml of TT**. After normalization of their post-traumatic condition, children should be vaccinated with DTaP** (INN: diphtheria, pertussis and tetanus vaccine**. ATC: combined viral and bacterial vaccines) or DT** (INN: diphtheria-tetanus toxoid**. ATC: immune sera).

Appendix A3.2 Recommended dosing regimen of antithrombotic agents for high-risk VTE prophylaxis in adult patients receiving conservative treatment and undergoing orthopedic surgery

It should be noted that spinal or epidural anesthesia can be performed only 12 hours after the administration of a low-molecular-weight heparin dose and no earlier than 4–6 hours after the administration of unfractionated heparin (meanwhile, APTT or ACT values must be within normal limits) [97, 98].

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

During the first few days after plaster splint application, it is necessary to monitor the condition of the fingers. Excessive compression by the plaster bandage may cause increased edema and peripheral nerve neuropathy. In case of circulatory impairment, the soft bandage is cut, and the edges of the splint are slightly flared. Active finger movements are permitted from the 1st day after the fracture. After the resolution of edema and pain syndrome, active movements in the elbow joint must be initiated, including pronation and supination under the supervision of a physical and rehabilitation medicine physician (or medical rehabilitation physician, or physical therapy physician, or physical therapist).

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Caprini individual risk assessment scale for venous thromboembolic complications

Russian title: Caprini individual risk assessment scale for venous thromboembolic complications Caprini.

Original name: Caprini Score for Venous Thromboembolism.

Source: Lobastov K.V., Barinov V.E., Schastlivtsev I.V., Laberko L.A.

The Caprini scale as a tool for individual risk stratification of postoperative venous thromboembolism in the high-risk group. Surgery. N.I. Pirogov Journal. 2014; (12):16-23.

Type: scale.

Purpose: assessment of venous thromboembolism risk.

Content:

1 point

Age 41–60 years

Lower extremity edema

Varicose veins

Body mass index > 25 kg/m²

Minor surgery

Sepsis (< 1 month)

Severe pulmonary disease (including pneumonia < 1 month)

Use of oral contraceptives (G03A), hormone replacement therapy

Pregnancy and postpartum period (< 1 month)

History of: unexplained stillbirths, miscarriages (≥ 3), premature births with gestosis, or intrauterine growth restriction

Acute myocardial infarction

Chronic heart failure (< 1 month)

Bed rest in a non-surgical patient

History of inflammatory bowel disease

History of major surgery (< 1 month)

Chronic obstructive pulmonary disease

2 points

Age 61–74 years

Arthroscopic surgery

Malignant neoplasm

Laparoscopic surgery (duration > 45 min)

Bed rest > 72 h

Limb immobilization (< 1 month)

Central venous catheterization

Major surgery (duration >45 min.)

3 points

Age > 75 years

Personal history of VTE

Family history of VTE

Factor V Leiden mutation

Prothrombin G20210A mutation

Hyperhomocysteinemia

Heparin-induced thrombocytopenia

Elevated anticardiolipin antibodies

Lupus anticoagulant

5 points

Stroke (< 1 month)

Multiple trauma (< 1 month)

Major joint arthroplasty

Femur and lower leg fractures (< 1 month)

Spinal cord injury/paralysis (< 1 month)

Key: depending on the total score obtained from the patient's medical history and examination, the patient is assigned to a specific risk group:

low risk: 0–1 points;

moderate risk: 2 points;

high risk: 3–4 points;

very high risk: 5 points or more.