Fracture Fixation

Fracture fixation surgically stabilizes a broken bone using plates, screws, wires or pins to restore alignment and allow healing.

Most fractures of the hand and wrist heal without an operation. Fixation is used where the fragments will not stay in an acceptable position on their own, where the joint surface is disrupted, or where holding the bone still in plaster for long enough would cost more in stiffness than it gains in alignment. Plates, screws, wires or an external frame hold the bone in the corrected position while it heals biologically. The metal does not heal the fracture — it holds the conditions in which the bone heals itself, and in the hand its main advantage is that it allows movement to start early.

Patients with displaced or unstable fractures, fractures involving the joint surface with a step or gap, rotational deformity of a finger — which is functionally important even when it looks minor on an X-ray — open fractures, multiple fractures in the same hand, and fractures that have already slipped in plaster. Scaphoid fractures are a special case: displaced fractures are fixed, and undisplaced ones may be fixed to shorten immobilisation or where the risk of non-union is high. Undisplaced stable fractures in a reliable position are better treated in a cast or splint, and no operation improves on that.

The technique is chosen for the fracture. Kirschner wires are placed through the skin under X-ray control for many finger and metacarpal fractures and are removed in clinic afterwards. Plates and screws are placed through an open incision and give fixation stable enough for immediate movement, which is their main justification in the hand. Headless compression screws are used for scaphoid and some intra-articular fractures. An external fixator is used where the soft tissues are too damaged for internal fixation or where length needs to be maintained across a comminuted fracture. Most procedures are day cases under regional or general anaesthesia with X-ray guidance throughout, and the fixation is tested intraoperatively before closing.

Bone union in the hand and wrist typically takes six to twelve weeks, and the scaphoid longer. Where fixation is stable, protected movement starts within days — this is the entire point of operating. Kirschner wires are usually removed at three to six weeks. A removable splint is often used between therapy sessions. Light activity resumes early, driving at around four to six weeks depending on the hand and the fixation, and heavy manual work or contact sport at around three months once union is confirmed. Hand therapy runs alongside throughout. Swelling and stiffness take longer to settle than the bone takes to heal, and full recovery of grip strength often takes six months.

Stiffness is the commonest problem after hand fractures and is the reason early movement matters more than perfect radiographs. Infection occurs, particularly around percutaneous wires, where pin-site care is important. Hardware can become prominent or irritating and sometimes needs removal as a second, smaller procedure. Non-union and malunion occur, more often in the scaphoid and in smokers, and may require revision surgery or bone grafting. Tendon irritation or rupture over a plate is recognised, particularly on the back of the wrist. Nerve injury, complex regional pain syndrome and post-traumatic arthritis after intra-articular fractures are all possible. Smoking measurably impairs bone healing and stopping is one of the few things fully within your control.