The non-operative management of hand fractures

Most hand fractures can be treated non-operatively. Some hand fractures, such as open injuries or markedly displaced intra-articular fractures, are almost always treated operatively. The treatment of many fractures, such as proximal interphalangeal joint fracture subluxations or spiral phalangeal fractures, is unclear. The aim of this review is to establish those injuries where the outcome of non-operative treatment is unlikely to be improved with surgery. This may help to prevent unnecessary surgery, concentrate work on finding the sub-groups that may benefit from surgery and to establish which injuries do so well with non-operative treatment that the only valuable clinical research in future will be large cohort studies of non-operative treatment or randomized controlled trials comparing operative and non-operative treatments. The relevant fractures are spiral metacarpal fractures, transverse metacarpal shaft and neck (boxer's) fractures, base of proximal phalanx avulsion fractures, thumb metacarpophalangeal joint ulnar and radial collateral ligament injuries and bony mallet injuries. For the majority of these injuries, current knowledge suggests that the outcome of non-operative treatment cannot reliably be improved upon with surgery. Level of evidence IV