Phalanx Fractures - Hand - Orthobullets (2024)

• most common injuries to the skeletal system

• accounts for 10% of all fractures

• more common in males 2:1

• distal phalanx > middle phalanx > proximal phalanx

• small finger is most commonly affected (accounts for 38% of all hand fractures)

• mechanism of injury

  • depends on age

    • 10-29 years old - sports is most common

    • 40-69 years old - machinery is most common

    • >70 years old - falls are most common

• nail bed injuries

  • associated with distal phalanx fractures

• distal phalanx

  • 4 components

    • tuft

    • shaft

    • base

• middle and proximal phalanx

  • 4 components

    • head

    • neck

    • shaft

    • base

  • displacement of middle phalanx fracture

    • apex dorsal

      • fracture proximal to FDS insertion

    • apex volar

      • fracture distal to FDS insertion

  • displacement of proximal phalanx fracture

    • apex volar

      • proximal fragment flexed due to interossei

      • distal fragment extends due to central slip

• interphalangeal joint

  • hinge joint

    • dynamic stability from compressive forces during pinch and grip

    • passive stabiltiy from collateral ligament

• collateral ligaments

  • proper

  • accessory

• terminal extensor tendon

  • inserts on dorsal base of distal phalanx

• FDP

  • inserts on volar base of distal phalanx

• central slip

  • terminal slip of EDC inserts on dorsal aspect of middle phalanx

• FDS

  • inserts on volar shaft of middle phalanx

• proper digital arteries

  • dominant artery found on median side of phalanges (closer to midline)

• proper digital nerves

  • volar to proper digital arteries

• proximal phalanx

  • location

    • head fractures

      • type I - stable with no displacement

      • type II - unstable unicondylar

      • type III - unstable bicondylar or comminuted

    • neck/shaft fractures

      • short oblique

      • long oblique

      • spiral

      • transverse

    • base fractures

      • extra-articular

      • intra-articular

        • lateral base

  See Also

  Fracturen van de proximale vingerphalangen - RichtlijnMid- en distale phalangen & DIP-gewrichten - Richtlijn

• middle phalanx

  • location

    • head fractures

      • type I - stable with no displacement

      • type II - unstable unicondylar

      • type III - unstable bicondylar or comminuted

    • neck fractures

      • apex volar angulation

    • shaft fractures

      • transverse

      • short oblique

      • long oblique

      • spiral

      • deformity

        • apex volar angulation

          • distal to FDS insertion

        • apex dorsal angulation

          • proximal to FDS insertion

        • without angulation

          • due to inherent stability provided by an intact and prolonged FDS insertion

    • base fractures

      • deformity is usually apex dorsal angulation

        • proximal fragment in extension (due to central slip)

        • distal fragment in flexion (due to FDS)

      • can be further classified into

        • partial articular fractures

          • volar base

            • results from hyperextension injury or axial loading

            • represents avulsion of volar plate

            • unstable if > 40% articular surface involved

          • dorsal base

            • results from hyperflexion injury

            • represents avulsion of central tendon

          • lateral base

            • represents avulsion of collateral ligaments

        • complete articular fractures

          • know as pilon fractures

          • unstable in all directions

• distal phalanx

  • Classification

    • tuft fractures

      • mechanism is usually crush injury

      • usually stable due to nail plate dorsally and pulp volarly

      • often associated with laceration of nail matrix or pulp

    • shaft fractures

      • can be

        • transverse

        • longitudinal

    • base fractures

      • usually unstable

      • mechanism can be

        • shearing due to axial load, leading to fracture involving > 20% of articular surface

        • avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture

      • can be further classified into

        • volar base

        • dorsal base

    • Seymour fractures

      • epiphyseal injury of distal phalanx

      • resuls from hyperflexion

      • presents as mallet deformity (i.e. apex dorsal) due to

        • terminal tendon attaches to proximal epiphyseal fragment

        • FDP attaches to distal fragment

• intra-articular vs extra-articular

• fracture morphology

• amount of displacement

• open vs closed

• hand dominance

• baseline function

• occupation and hobbies

• mechanism of injury

• inspection

  • swelling

  • ecchymosis

  • deformity (angular, rotation, shortening)

  • open wounds

• motion

  • assess for scissoring of digits

    • indicates rotational component

    • assess via tenodesis

• neurovascular

  • digital nerve

    • two-point discrimination test

  • vascular assessment

    • cap refill <2 sec

• recommended views

  • PA

  • lateral

  • oblique

• findings

  • proximal phalanx

    • apex volar angulation due to

      • proximal fragment pulled into flexion by interossei

      • distal fragment pulled into extension by central slip

  • middle phalanx

    • apex volar angulation if distal to FDS insertion

    • apex dorsal angulation if proximal to FDS insertion

• indications

  • assess articular involvement

• findings

  • amount of articular displacement

  • degree of comminution

• Stress fracture

• Jammed finger

• fracture-dislocation

• gout

• finger infection

• neoplasm

• diagnosis confirmed by history, physical, and orthogonal radiographs

• buddy taping vs. splinting

  • indications

    • extraarticular fractures with < 10° angulation or < 2mm shortening and no rotational deformity

    • non-displaced intraarticular fractures

  • technique

    • 3 weeks of immobilization followed by aggressive motion

Operative

• CRPP vs. ORIF

  • indications

    • extraarticular fractures with > 10° angulation or > 2mm shortening or rotational deformity

    • displaced intraarticular fractures

    • unstable or irreducible fracture pattern

      • Unstable patterns include spiral, oblique, fracture with severe comminution

  • techniques

    • crossed K wires

    • Eaton-Belsky pinning through metacarpal head

    • minifragment fixation with plate and/or lag screws

      • lag screws alone indicated in presence of long oblique fracture

• buddy taping vs. splinting

  • indications

    • extraarticular fractures with < 10° angulation or < 2mm shortening and no rotational deformity

    • non-displaced intraarticular fractures

  • technique

    • 3 weeks of immobilization followed by aggressive motion

• CRPP vs. ORIF

  • indications

    • extraarticular fractures with > 10° angulation or > 2mm shortening or rotational deformity

    • displaced intraarticular fractures

    • irreducible or unstable fracture pattern

  • techniques

    • crossed K wires

    • extension block pinning

    • collateral recess pinning

    • minifragment fixation with plate and/or lag screws

    • volar plate arthroplasty

• closed reduction +/- splinting

  • indications

    • most cases

  • nail matrix may be incarcerated in fracture and block reduction

• remove nail, repair nailbed, and replace nail to maintain epi fold

  • indications

    • distal phalanx fractures with nailbed injury

    • • see nail bed injuries

• CRPP vs. ORIF

  • indications

    • displaced or irreducible shaft fractures

    • dorsal base fractures with > 25% articular involvement

    • displaced volar base fractures with large fragment and involvement of FDP

    • non-unions

  • techniques

    • longitudinal or crossed K wires

    • extension block pinning

    • minifragment fixation with lag screws

• most common complication

• risk factors

  • prolonged immobilization

  • intra-articular fracture

  • extensive surgical dissection

• treatment

  • aggressive hand therapy

    • first-line treatment

  • surgical release

    • failed nonoperative treatment

• types

  • malrotation

  • angulation

    • Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ
      

  • shortening

• treatment

  • nonoperative

    • asymptomatic, no functional impairment

  • surgery

    • indicated when associated with functional impairment

    • options

      • corrective osteotomy at malunion site (preferred)

      • metacarpal osteotomy (limited degree of correction)

• uncommon (<2%)

• most atrophic and associated with bone loss or neurovascular compromise

• surgical options

  • resection, bone grafting, plating

  • ray amputation or fusion