Every hand surgery fellow has seen the classic scaphoid waist fracture. Cast vs. percutaneous screw — straightforward decision tree.

But what about the proximal pole fracture with questionable vascularity in a 28-year-old rock climber who needs to be back on the wall in 3 months? Or the scaphoid nonunion with DISI deformity that's been missed for 2 years?

These are the cases that separate a fellow who "knows hand" from one who actually manages hand trauma.

Here's how I think through it:

1. Vascularity first. MRI with gadolinium before any fixation decision. If the proximal pole is avascular, you're looking at a vascularized bone graft (1,2-ICSRA pedicled graft) — not just a headless screw and a prayer.

2. DISI means the carpus has already adapted. You can't just bone graft and fixate. You need to correct the dorsal intercalated segment instability first, or your construct will fail under load.

3. Return-to-activity is a contract, not a timeline. I tell patients: "I'll tell you when the bone is healed. You tell me when the function is back." CT at 8 weeks, grip strength testing at 12.

This is the kind of structured, case-based thinking I built The Trauma Hand around — fractures, dislocations, tendon injuries, and complex reconstructions organized the way we actually reason through cases in the OR.

If you're a hand surgery fellow who wants a trauma reference that doesn't read like a textbook, check it out.

Welcome aboard. This is the home of structured, case-based hand and wrist trauma education.

📚 Trauma Course — Structured lessons covering fractures, dislocations, tendon injuries, and complex reconstructions.

💬 Fellows Chat — Connect with other hand surgery fellows. Share cases, ask questions, and sharpen your clinical decision-making.

📢 Updates & Resources — New content drops, case breakdowns, and resource updates.

Built by a practicing hand surgeon for fellows who want to be sharp on day one of practice. Let's get after it.

After years of seeing the same patterns in fellowship training, here are the hand fractures that trip up nearly everyone early on — and the mental models that changed my approach.

1. Bennett's Fracture — Everyone knows it's an intra-articular thumb metacarpal fracture. The mistake? Underestimating the deforming force of APL and accepting "close enough" reduction. If you can't hold it closed, pin it. Don't wait for the re-displacement X-ray at 2 weeks.

2. Volar Plate Avulsion (Middle Phalanx) — The classic "buddy tape it" fracture. But if that fragment involves >40% of the articular surface, you're looking at a subluxation injury. Extension block pinning saves joints here.

3. Scaphoid Waist Fracture — Not technically a "hand" fracture, but fellows treat these constantly. The trap: negative initial X-rays with a clinical scaphoid fracture. Get the MRI. A 3-month malunion is harder to fix than a 2-week diagnosis.

4. Fifth Metacarpal Neck (Boxer's Fracture) — You know the fracture. The mistake is over-treating it. The 5th CMC joint tolerates 40-50° of angulation. Most of these don't need surgery. Save the OR time.

5. PIP Fracture-Dislocations — The high-stakes one. Dorsal fracture-dislocations with >40% articular involvement need surgical management. But stable concentric reduction with dynamic splinting works for smaller fragments. The clinical exam under block is your best imaging.

These aren't obscure injuries — they're the bread and butter. But the nuance in management separates good outcomes from mediocre ones.

Building a structured course on exactly these kinds of cases. Fractures, tendons, complex reconstructions — all case-based, all designed for fellows who want to be sharp on day one of practice.