One Ray, Four Breaks: Isolated Closed Second Ray Fractures in the Dominant Hand,  A Rare and Unusual Pattern of Injury. 

One Ray, Four Breaks: Isolated Closed Second Ray Fractures in the Dominant Hand, A Rare and Unusual Pattern of Injury. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article One Ray, Four Breaks: Isolated Closed Second Ray Fractures in the Dominant Hand, A Rare and Unusual Pattern of Injury. Reem Alaraibi, Khalifa Al Alawi, Iqbal Rasool Wani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8611769/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Fractures involving multiple phalanges and metacarpal of a single ray are extremely rare, especially in the absence of more widespread hand trauma. We report a unique case of isolated single ray digit fractures involving the metacarpal, proximal, middle, and distal phalanges simultaneously in the dominant hand following a workplace crush injury. Case Presentation: A 34-year-old right-handed male presented to the emergency department with pain and limited mobility in his right dominant hand's index finger after sustaining workplace crush injury. Physical examination revealed tenderness, pain induced reduced ROM and swelling in the affected finger. Radiographs revealed fractures of the metacarpal, proximal phalanx, middle phalanx, and distal phalanx of the same digit. There were no other associated injuries. Surgical fixation by K-wire of the distal and middle phalanyx with close reduction and external slab fixation for proximal and metacarapal bone fractures. 6 weeks after the operation K-wires were removed, the involved joints demonstrated an excellent outcome based on Crawford’s criteria for outcome assessment of mallet finger injury after management. Conclusion: This rare presentation highlights the importance of careful and meticulous evaluation of all phalanges, metacarpals and carpal bones of a single digit in case of crush injuries, as isolated ray involvement can be easily overlooked. Prompt diagnosis and appropriate surgical management can preserve function in such complex injuries. Phalangeal fractures single ray fracture crush injury occupational trauma metacarpal hand injury Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Occupational injuries is a well-recognized cause of admission to the main trauma centre in Qatar (Hamad Trauma and Emergency Center); accounting for 29% of the admissions to the emergency department based on data analyzed from 2010 to 2012.[ 1 ] Hand injuries are the second most common work-related musculoskeletal injury and are among the most frequently encountered skeletal injuries, accounting for approximately 10% of all fractures globally.[ 2 , 3 ] Surprisingly they are not only frequent among construction workers, but also healthcare workers, notably physical therapists.[ 4 ] In low-middle and middle Socio-demographic Index countries there is an increased rates of hand trauma by as much at 25%.[ 2 ] In Qatar and other Gulf Cooperation Council (GCC) countries, upper limb injuries accounts nearly around 18.5% of all workplace trauma cases with hand trauma representing a significant portion of occupational injuries.[ 1 ] In Saudi Arabia construction industry contributes to 42%-48% of occupational trauma.[ 5 ] Based on epidemiological study on the trends of work-related injuries in Qatar from 2008 to 2016 93% of affected workers were males with a mean age of 29.3 years.[ 6 ] Metacarpal and phalangeal bones are commonly involved; as metacarpal fracture represents nearly 18–44% of all hand fractures, [ 7 ]whereas phalangeal fractures make up more than 50% of hand fractures as they are more exposed to external forces.[ 8 ] In labor-intensive occupations, such as construction and mechanical trades, frequent forceful hand use and lack of awareness of the importance of protective equipment contribute to higher injury rates, approximately 64% of those who sustained trauma were not using protective device increasing risk of direct trauma or crush injuries especially in the dominant hand.[ 1 ] Despite the overall frequency of hand fractures, isolated injury pattern, encompassing the metacarpal, proximal phalanx, intermediate phalanx, and distal phalanx of a single digit without involvement of adjacent rays is exceedingly rare. To the best of our knowledge, this in the first case of simultaneous closed fractures involving all bones of isolated ray to be published in literature. This case report describes a rare presentation of a simultaneous fracture of both the metacarpal and its associated phalanx in a single ray of the dominant hand, sustained by a construction worker during occupational activity. Such a presentation is scarcely reported and highlights the importance of detailed clinical evaluation and high index of suspicion for simultaneous fractures involving single digit in crush injuries. Case Presentation A 34-year-old right-handed male construction worker presented to the emergency department of Hamad General Hospital following a crush injury to his right hand, which he sustained at his workplace when a heavy steel object fell directly onto his right index finger. The patient reported immediate, severe pain and marked swelling of the affected digit. On examination swelling noted over the dorsal aspect of the right hand. The patient exhibited a limited and painful range of motion and was unable to flex the affected finger. Neurovascular assessment revealed an intact capillary refill time at the fingertip but altered sensation over the distal aspect of the index finger. Plain radiographs of the right hand revealed multiple fractures involving the index finger. These included: a non displaced fracture of the neck of the second metacarpal bone (Figure 1 e), a non displaced transverse fracture of the proximal phalanx (Figure 1 f), a closed displaced transverse fracture of the middle phalanx, which is volubly angulated (Figure 1 d), and a mallet fracture of the distal phalanx classified as Type IVB — an intra-articular fracture involving 20–50% of the joint surface (Figure 1 c). Management The patient initially received emergency care with limb splinting, elevation, and pain management. He was admitted inpatient for emergent definitive management. Next day following trauma, surgical intervention was performed under regional anaesthesia. The operation included closed reduction and K-wire fixation of the middle and distal phalanx fractures. Additionally, closed reduction and external slab fixation were applied to address proximal phalanx and metacarpal fractures. Postoperatively, the hand was immobilized, and physiotherapy was initiated one week after surgery. Early rehabilitation was emphasized to enhance blood flow, reduce pain, and prevent joint stiffness and fibrosis, thereby promoting mobility and restoring function.[ 9 ] The patient was also educated on a home-based regimen of gentle active and passive range of motion (ROM) exercises targeting the affected joints. At the six-week follow-up, both K-wires were removed; the patient tolerated the procedure well. Occupational therapy continued with a focus on ROM improvement. Initially, the patient regained full range of motion. He was advised to return to work gradually. However, he resumed his job as a construction laborer earlier than recommended. At the 6-week postoperative follow-up, repeat X-rays showed healed metacarpal, distal phalanx, and proximal phalanx fractures with good alignment. However, the middle phalanx fracture demonstrated volar angulation. In the 3rd months postoperative, the patient was assessed and found to have a full range of motion at the finger. (Fig. 5 ) Discussion To our knowledge this is the only case in literature describing fractures of an entire finger ray without involvement of neighbouring digits. Occupational crush injuries, especially in industrial and construction settings, are most commonly seen in young adult males; due to their overrepresentation in high-risk manual labor jobs.[ 10 ] The hand is particularly vulnerable, being most frequent part used in human body; making it more susceptible to be injured.[ 11 ] Based on the Saudi Epidemiological study of hand fractures common causes include falls, road traffic accidents, crushing and machinery injuries (40.5%, 20.3%, 9.5%, 9.5%).[ 12 ] The complex anatomy of the hand requires precise management to ensure functional preservation, especially in dominant hands, as seen in this case. This infrequently encountered case serves as a reminder for physicians to maintain a high index of suspicion for multiple fractures within the same finger ray, particularly following a crush injury to the hand, in order to avoid missing simultaneously occurring fractures. Additionally, this case report highlights the management challenges and the need to formulate a comprehensive treatment strategy, specifically, determining which fractures require surgical intervention versus conservative management, while ensuring proper alignment across all joints, preservation of tendon function, and prevention of stiffness. Postoperative rehabilitation plays a big role in recovery in hand trauma. Hamad Medical Corporation (HMC) has a well-established Hand Therapy Unit in the Physiotherapy Department that provides comprehensive rehabilitation services tailored to the needs of orthopaedic and trauma patients. The patient benefited from early and structured occupational hand therapy at HMC, which facilitated improvements in range of motion and functional use of the hand. In this patient, early and consistent therapy contributed to regaining full range of motion by 10 weeks post-surgery. Conclusion Besides reporting such rare case occurrences, a vigilant work up and a simple management can lead to good results. This case emphasizes the need for a high index of suspicion for simultaneous fractures involving a single digit in crush injuries. Timely surgical management and rehabilitation can result in good functional recovery even in such complex patterns. Declarations Consent for publication The patient signed written consent for the surgical procedure. Consent for publication is available. Ethics approval All procedures performed in the study involving human participants followed the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Funding Publication of this article was funded by the Qatar National Library" Declaration of competing interest All authors declare they have no conflict of interest. Acknowledgment N/A Author Contribution R.A was primarily responsible for manuscript development and preparation for publication,and managed journal submissions.K.A manuscript editing, completed the ethical approval process and provided interpretation and commentary on the X-ray images radiological findingI.R supervision and guidanceAll authors approved the final manuscript. References Al-Thani H, El-Menyar A, Abdelrahman H, Zarour A, Consunji R, Peralta R et al (2014) Workplace-related traumatic injuries: insights from a rapidly developing Middle Eastern country. J Environ Public Health [Internet] J Environ Public Health. [cited 2025 Sep 27];2014 https://doi.org/10.1155/2014/430832 Crowe CS, Massenburg BB, Morrison SD, Chang J, Friedrich JB, Abady GG et al (2020) Global trends of hand and wrist trauma: a systematic analysis of fracture and digit amputation using the Global Burden of Disease 2017 Study. Tuomo J Meretoja [Internet] 26:50 [cited 2025 Oct 5];. https://doi.org/10.1136/injuryprev-2019-043495 Fortané T, Bouyer M, Le Hanneur M, Belvisi B, Courtiol G, Chevalier K et al (2021) Epidemiology of hand traumas during the COVID-19 confinement period. Injury [Internet] Injury 52:679–685 [cited 2025 Sep 27];. https://doi.org/10.1016/J.INJURY.2021.02.024 Gyer G, Michael J, Inklebarger J (2018) Occupational hand injuries: a current review of the prevalence and proposed prevention strategies for physical therapists and similar healthcare professionals. J Integr Med Elsevier 16:84–89. https://doi.org/10.1016/J.JOIM.2018.02.003 Asiri SM, Kamel S, Assiri AM, Almeshal AS (2023) The Epidemiology of Work-Related Injuries in Saudi Arabia Between 2016 and 2021. Cureus [Internet]. Cureus; [cited 2025 Oct 5];15. https://doi.org/10.7759/CUREUS.35849 Consunji RJ, Mehmood A, Hirani N, El-Menyar A, Abeid A, Hyder A et al (2017) Epidemiologic and temporal trends of work-related injuries in expatriate workers in a high-income rapidly developing country: Evidence for preventive programs. Prevention of Accidents at Work [Internet]. CRC, pp 55–59. [cited 2025 Oct 5]; https://doi.org/10.1201/9781315177571-8 Kollitz KM, Hammert WC, Vedder NB, Huang JI (2014) Metacarpal fractures: treatment and complications. Hand (N Y) [Internet]. Hand. 9:16–23 [cited 2025 Oct 5];. https://doi.org/10.1007/S11552-013-9562-1 . (N Y) Kang HT, Lee J-K (2025) Current concepts in the management of phalangeal fractures in the hand. Journal of Musculoskeletal Trauma [Internet]. 38:109–123 [cited 2025 Oct 5];. https://doi.org/10.12671/JMT.2025.00136 . The Korean Orthopaedic Trauma Association Vikhe CS, Ramteke SU, Jaiswal PR (2024) Crushing Consequences: A Case Report on the Rehabilitation of a Middle Phalangeal Fracture in an Industrial Incident. Cureus [Internet] Cureus. [cited 2025 Oct 5];16 https://doi.org/10.7759/CUREUS.63965 Crush injuries of the hand (2025) - PubMed [Internet]. [cited 2025 Oct 5]. https://pubmed.ncbi.nlm.nih.gov/7839916/ . Accessed 5 Oct Bhatti DS, Ain NU, Fatima M, Bhatti DS, Ain NU, Fatima M (2020) Occupational Hand-Related Injuries at a Major Tertiary Care Burn and Reconstructive Center in Pakistan. Cureus [Internet]. Cureus; [cited 2025 Oct 5];12. https://doi.org/10.7759/CUREUS.10444 Alhumaid FA, Alturki ST, Alshareef SH, Alobaidan OS, Alhuwaymil AA, Alohaideb NS et al (2019) Epidemiology of hand fractures at a tertiary care setting in Saudi Arabia. Saudi Med J [Internet]. 40:732 [cited 2025 Oct 5];. https://doi.org/10.15537/SMJ.2019.7.24286 . Saudi Arabian Armed Forces Hospital Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8611769","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":577309685,"identity":"3aeea0d8-1df9-4291-b116-530ab7b57ff5","order_by":0,"name":"Reem 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07:02:51","extension":"html","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":46387,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8611769/v1/42a3869bb24b65c49d52be22.html"},{"id":100949859,"identity":"ed3f6ce4-3d9d-4469-818a-906f5501fd9f","added_by":"auto","created_at":"2026-01-23 07:06:03","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83000,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative X-rays\u003c/p\u003e\n\u003cp\u003e1a: X-ray AP view hand\u003c/p\u003e\n\u003cp\u003e1b: X-ray hand Oblique view\u003c/p\u003e\n\u003cp\u003e1c: Distal phalanx: Mallet Fracture Type IVB\u003c/p\u003e\n\u003cp\u003e1d: Middle phalanx Closed displaced transverse fracture\u003c/p\u003e\n\u003cp\u003e1e: Fracture of neck of 2nd metacarpal bone\u003c/p\u003e\n\u003cp\u003e1f: Proximal phalanx non-displaced transverse fracture\u003c/p\u003e\n\u003cp\u003e1g: soft tissue edema over PIP joint\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8611769/v1/f3562fd6a22636063ec23cd2.jpg"},{"id":100866250,"identity":"87a4dece-c096-46e0-b4ae-ec58adf920bd","added_by":"auto","created_at":"2026-01-22 08:32:30","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":38019,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-operative images. Left is anteroposterior view, Right is lateral view. The pictures show two 1mm K-wire fixation of middle and distal Phalanx fractures. One wire is axial intramdullary, fixing both distal and middle phalanx. The second wire is oblique crossing the fracture of the middle phalanx.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8611769/v1/58c5c3ef3bc956dd96fa897d.jpg"},{"id":100949829,"identity":"742e005a-d64c-4ec2-9111-e238adc265e7","added_by":"auto","created_at":"2026-01-23 07:05:58","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":53030,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8611769/v1/dcebfcccd1e53d8b1dbfa1e4.jpg"},{"id":100949638,"identity":"b24fce06-e208-4da8-883f-bd853dbb44d1","added_by":"auto","created_at":"2026-01-23 07:04:44","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":48038,"visible":true,"origin":"","legend":"\u003cp\u003eLeft anterioroposterior view and right lateral view X-ray taken at the 6\u003csup\u003eth\u003c/sup\u003e week postoperative. The films shows mildly angulated middle phalanx fracture.\u0026nbsp;\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8611769/v1/d8e91c06ea576b3684ebacfb.jpg"},{"id":100949818,"identity":"68b8c4fd-9781-4796-9d5b-064777b9d99a","added_by":"auto","created_at":"2026-01-23 07:05:54","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":45506,"visible":true,"origin":"","legend":"\u003cp\u003eLeft anterioroposterior view and right lateral view X-ray taken at the 3\u003csup\u003erd\u003c/sup\u003e month postoperative. The films shows well healed fracture in an acceptable alignment\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8611769/v1/97ec93a25e6950031312e55d.jpg"},{"id":104397116,"identity":"29f8b3cf-e35b-4b38-a9ff-b5bffb66a4fe","added_by":"auto","created_at":"2026-03-11 11:28:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":569443,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8611769/v1/e2664d3d-cd2d-446d-884e-6c18607a3219.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"One Ray, Four Breaks: Isolated Closed Second Ray Fractures in the Dominant Hand, A Rare and Unusual Pattern of Injury. ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOccupational injuries is a well-recognized cause of admission to the main trauma centre in Qatar (Hamad Trauma and Emergency Center); accounting for 29% of the admissions to the emergency department based on data analyzed from 2010 to 2012.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHand injuries are the second most common work-related musculoskeletal injury and are among the most frequently encountered skeletal injuries, accounting for approximately 10% of all fractures globally.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Surprisingly they are not only frequent among construction workers, but also healthcare workers, notably physical therapists.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] In low-middle and middle Socio-demographic Index countries there is an increased rates of hand trauma by as much at 25%.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn Qatar and other Gulf Cooperation Council (GCC) countries, upper limb injuries accounts nearly around 18.5% of all workplace trauma cases with hand trauma representing a significant portion of occupational injuries.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] In Saudi Arabia construction industry contributes to 42%-48% of occupational trauma.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Based on epidemiological study on the trends of work-related injuries in Qatar from 2008 to 2016 93% of affected workers were males with a mean age of 29.3 years.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eMetacarpal and phalangeal bones are commonly involved; as metacarpal fracture represents nearly 18–44% of all hand fractures, [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]whereas phalangeal fractures make up more than 50% of hand fractures as they are more exposed to external forces.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] In labor-intensive occupations, such as construction and mechanical trades, frequent forceful hand use and lack of awareness of the importance of protective equipment contribute to higher injury rates, approximately 64% of those who sustained trauma were not using protective device increasing risk of direct trauma or crush injuries especially in the dominant hand.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite the overall frequency of hand fractures, isolated injury pattern, encompassing the metacarpal, proximal phalanx, intermediate phalanx, and distal phalanx of a single digit without involvement of adjacent rays is exceedingly rare. To the best of our knowledge, this in the first case of simultaneous closed fractures involving all bones of isolated ray to be published in literature.\u003c/p\u003e \u003cp\u003eThis case report describes a rare presentation of a simultaneous fracture of both the metacarpal and its associated phalanx in a single ray of the dominant hand, sustained by a construction worker during occupational activity. Such a presentation is scarcely reported and highlights the importance of detailed clinical evaluation and high index of suspicion for simultaneous fractures involving single digit in crush injuries.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 34-year-old right-handed male construction worker presented to the emergency department of Hamad General Hospital following a crush injury to his right hand, which he sustained at his workplace when a heavy steel object fell directly onto his right index finger. The patient reported immediate, severe pain and marked swelling of the affected digit. On examination swelling noted over the dorsal aspect of the right hand. The patient exhibited a limited and painful range of motion and was unable to flex the affected finger. Neurovascular assessment revealed an intact capillary refill time at the fingertip but altered sensation over the distal aspect of the index finger.\u003c/p\u003e\u003cp\u003e Plain radiographs of the right hand revealed multiple fractures involving the index finger. These included: a non displaced fracture of the neck of the second metacarpal bone (Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee), a non displaced transverse fracture of the proximal phalanx (Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef), a closed displaced transverse fracture of the middle phalanx, which is volubly angulated (Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed), and a mallet fracture of the distal phalanx classified as Type IVB — an intra-articular fracture involving 20–50% of the joint surface (Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec).\u003c/p\u003e\u003cp\u003eManagement\u003c/p\u003e\u003cp\u003eThe patient initially received emergency care with limb splinting, elevation, and pain management. He was admitted inpatient for emergent definitive management. Next day following trauma, surgical intervention was performed under regional anaesthesia. The operation included closed reduction and K-wire fixation of the middle and distal phalanx fractures. Additionally, closed reduction and external slab fixation were applied to address proximal phalanx and metacarpal fractures. Postoperatively, the hand was immobilized, and physiotherapy was initiated one week after surgery. Early rehabilitation was emphasized to enhance blood flow, reduce pain, and prevent joint stiffness and fibrosis, thereby promoting mobility and restoring function.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] The patient was also educated on a home-based regimen of gentle active and passive range of motion (ROM) exercises targeting the affected joints. At the six-week follow-up, both K-wires were removed; the patient tolerated the procedure well. Occupational therapy continued with a focus on ROM improvement. Initially, the patient regained full range of motion. He was advised to return to work gradually. However, he resumed his job as a construction laborer earlier than recommended. At the 6-week postoperative follow-up, repeat X-rays showed healed metacarpal, distal phalanx, and proximal phalanx fractures with good alignment. However, the middle phalanx fracture demonstrated volar angulation. In the 3rd months postoperative, the patient was assessed and found to have a full range of motion at the finger. (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge this is the only case in literature describing fractures of an entire finger ray without involvement of neighbouring digits.\u003c/p\u003e \u003cp\u003eOccupational crush injuries, especially in industrial and construction settings, are most commonly seen in young adult males; due to their overrepresentation in high-risk manual labor jobs.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] The hand is particularly vulnerable, being most frequent part used in human body; making it more susceptible to be injured.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Based on the Saudi Epidemiological study of hand fractures common causes include falls, road traffic accidents, crushing and machinery injuries (40.5%, 20.3%, 9.5%, 9.5%).[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] The complex anatomy of the hand requires precise management to ensure functional preservation, especially in dominant hands, as seen in this case.\u003c/p\u003e \u003cp\u003eThis infrequently encountered case serves as a reminder for physicians to maintain a high index of suspicion for multiple fractures within the same finger ray, particularly following a crush injury to the hand, in order to avoid missing simultaneously occurring fractures. Additionally, this case report highlights the management challenges and the need to formulate a comprehensive treatment strategy, specifically, determining which fractures require surgical intervention versus conservative management, while ensuring proper alignment across all joints, preservation of tendon function, and prevention of stiffness.\u003c/p\u003e \u003cp\u003ePostoperative rehabilitation plays a big role in recovery in hand trauma. Hamad Medical Corporation (HMC) has a well-established Hand Therapy Unit in the Physiotherapy Department that provides comprehensive rehabilitation services tailored to the needs of orthopaedic and trauma patients. The patient benefited from early and structured occupational hand therapy at HMC, which facilitated improvements in range of motion and functional use of the hand. In this patient, early and consistent therapy contributed to regaining full range of motion by 10 weeks post-surgery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBesides reporting such rare case occurrences, a vigilant work up and a simple management can lead to good results. This case emphasizes the need for a high index of suspicion for simultaneous fractures involving a single digit in crush injuries. Timely surgical management and rehabilitation can result in good functional recovery even in such complex patterns.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eThe patient signed written consent for the surgical procedure. Consent for publication is available.\u003c/p\u003e\n\u003cp\u003eEthics approval\u003c/p\u003e\n\u003cp\u003eAll procedures performed in the study involving human participants followed the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003ePublication of this article was funded by the Qatar National Library\"\u003c/p\u003e\n\u003cp\u003eDeclaration of competing interest\u003c/p\u003e\n\u003cp\u003eAll authors declare they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003eAcknowledgment\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eR.A was primarily responsible for manuscript development and preparation for publication,and managed journal submissions.K.A manuscript editing, completed the ethical approval process and provided interpretation and commentary on the X-ray images radiological findingI.R supervision and guidanceAll authors approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Thani H, El-Menyar A, Abdelrahman H, Zarour A, Consunji R, Peralta R et al (2014) Workplace-related traumatic injuries: insights from a rapidly developing Middle Eastern country. 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[cited 2025 Oct 5];16 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/CUREUS.63965\u003c/span\u003e\u003cspan address=\"10.7759/CUREUS.63965\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrush injuries of the hand (2025) - PubMed [Internet]. [cited 2025 Oct 5]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/7839916/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/7839916/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 5 Oct\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatti DS, Ain NU, Fatima M, Bhatti DS, Ain NU, Fatima M (2020) Occupational Hand-Related Injuries at a Major Tertiary Care Burn and Reconstructive Center in Pakistan. Cureus [Internet]. Cureus; [cited 2025 Oct 5];12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/CUREUS.10444\u003c/span\u003e\u003cspan address=\"10.7759/CUREUS.10444\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhumaid FA, Alturki ST, Alshareef SH, Alobaidan OS, Alhuwaymil AA, Alohaideb NS et al (2019) Epidemiology of hand fractures at a tertiary care setting in Saudi Arabia. Saudi Med J [Internet]. 40:732 [cited 2025 Oct 5];. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15537/SMJ.2019.7.24286\u003c/span\u003e\u003cspan address=\"10.15537/SMJ.2019.7.24286\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Saudi Arabian Armed Forces Hospital\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Phalangeal fractures, single ray fracture, crush injury, occupational trauma, metacarpal, hand injury","lastPublishedDoi":"10.21203/rs.3.rs-8611769/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8611769/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFractures involving multiple phalanges and metacarpal of a single ray are extremely rare, especially in the absence of more widespread hand trauma. We report a unique case of isolated single ray digit fractures involving the metacarpal, proximal, middle, and distal phalanges simultaneously in the dominant hand following a workplace crush injury.\u003cbr\u003e\n\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 34-year-old right-handed male presented to the emergency department with pain and limited mobility in his right dominant hand's index finger after sustaining workplace crush injury. Physical examination revealed tenderness, pain induced reduced ROM and swelling in the affected finger. \u0026nbsp;Radiographs revealed fractures of the metacarpal, proximal phalanx, middle phalanx, and distal phalanx of the same digit. There were no other associated injuries. Surgical fixation by K-wire of the distal and middle phalanyx with close reduction and external slab fixation for proximal and metacarapal bone fractures. 6 weeks after the operation K-wires were removed, the involved joints demonstrated an excellent outcome based on Crawford’s criteria for outcome assessment of mallet finger injury after management.\u003cbr\u003e\n\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nThis rare presentation highlights the importance of careful and meticulous evaluation of all phalanges, metacarpals and carpal bones of a single digit in case of crush injuries, as isolated ray involvement can be easily overlooked. Prompt diagnosis and appropriate surgical management can preserve function in such complex injuries.\u003c/p\u003e","manuscriptTitle":"One Ray, Four Breaks: Isolated Closed Second Ray Fractures in the Dominant Hand, A Rare and Unusual Pattern of Injury. 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