Hand Fractures: How Your Orthopedic Surgeon Decides Between Immobilization and Surgery

The Hand Is More Complex Than It Looks

The hand contains 27 bones — the metacarpals that form the palm, and the phalanges that make up the fingers and thumb. Any one of these can fracture from a direct blow, a fall onto an outstretched hand, crushing trauma, or an athletic collision. Fractures are most common in the fingers (phalanges) and the metacarpals, particularly the fifth metacarpal at the base of the small finger, known as a boxer's fracture.

When a patient comes in with hand pain after an injury, the first step is determining what is broken and how the fracture has displaced. Not all hand fractures require surgery — and not all fractures that appear minor on X-ray are truly stable. The decision hinges on alignment, stability, joint involvement, and which bones are affected.

When Immobilization Is Appropriate

A fracture is considered stable if the bones are well aligned and unlikely to shift further during healing. For stable fractures without joint involvement, the standard approach is immobilization with a splint or cast for three to six weeks, followed by protected motion and, often, a course of hand therapy.

Specific circumstances where immobilization is typically sufficient:

• Non-displaced or minimally displaced phalanx fractures with intact tendon function
• Metacarpal shaft fractures with acceptable angulation (specific tolerance thresholds vary by which metacarpal is involved)
• Boxer's fractures of the fifth metacarpal with less than 40 degrees of apex-dorsal angulation
• Avulsion fractures that are small and do not involve a significant joint surface

Even within these parameters, alignment must be monitored with repeat X-rays during the healing period, because initially stable fractures occasionally displace as swelling resolves.

When Surgery Becomes Necessary

Surgery is indicated when the fracture cannot be held in acceptable alignment with external immobilization alone, or when non-operative treatment would produce unacceptable results. Common indications include:

• Displaced or rotated fractures that cause finger scissoring (fingers crossing over each other) — even small amounts of rotational malunion in the hand cause significant functional impairment
• Intra-articular fractures (fractures entering the finger joints) that require precise reduction to preserve smooth joint mechanics
• Open fractures with bone exposed through the skin, which require irrigation, debridement, and fixation
• Multiple fractures or fracture-dislocations involving the carpometacarpal joints
• Unstable metacarpal neck fractures with unacceptable dorsal angulation, particularly in the index and middle fingers, where tolerance for deformity is lower

Surgical fixation options include percutaneous pinning, where small stainless steel pins are inserted through the skin to hold the fragments in position, or open reduction with plate and screw fixation for more complex fractures. The choice of technique depends on fracture geometry and the surgeon's assessment of what will provide the most stable, functional result.

Recovery and Hand Therapy

Regardless of treatment, hand fractures require structured rehabilitation. Stiffness is the most common complication, and it develops quickly — even a few weeks of immobilization can significantly reduce finger range of motion. Hand therapy with a certified hand therapist begins as soon as your surgeon determines the fracture is sufficiently stable, often within two to four weeks.

Therapy initially focuses on edema control and gentle range-of-motion exercises. As healing progresses, resistance and grip strengthening are introduced. Return to full activity — particularly for patients who use their hands in work or sport — depends on both fracture healing and functional recovery, and typically takes eight to twelve weeks for uncomplicated fractures.

The goal is always the same regardless of which treatment is used: a well-healed fracture with a hand that can grip, pinch, and function without pain.

If you're experiencing a hand injury, the specialists at Maryland Orthopedic Specialists can help. Call (301) 515-0900 or [schedule an appointment online](https://www.mdorthospecialists.com/contact).