Fracture, Middle Phalanx

By admin On Dec 13, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Michael M. Linder

Andrew Harcourt

Basics

Description

Etiology

The flexor digitorum superficialis (FDS) and the central extensor slip (CES) insert onto the middle phalanx and account for the primary deforming forces on shaft fractures.
Fractures proximal to the insertion of the FDS result in volar angulation of the distal fragment.
Fractures distal to the insertion of the FDS will result in volar angulation of the proximal fragment.
The CES may also pull the proximal fragment in dorsal angulation if the fracture is proximal to the FDS insertion.
Interphalangeal collateral ligament injuries may result in avulsion fractures affecting articular surfaces.

Commonly Associated Conditions

Distal interphalangeal (DIP) or proximal interphalangeal (PIP) joint dislocations
Distal artery or nerve injury
Extensor mechanism injuries
Volar plate injuries and resulting swan neck deformities

Diagnosis

History

Elicit mechanism of injury:

Physical Exam

Diagnostic Tests & Interpretation

Imaging

All fractures require anteroposterior, true lateral, and oblique with affected finger in isolation.
May require preimaging anesthesia

Differential Diagnosis

Treatment

Open, unstable, spiral, comminuted, or those that fail to maintain reduction require orthopedic referral
Fractures at the base (2):
- Usually result from an axial load (jammed finger)
- Nondisplaced fractures should be splinted for 2 wks with a dorsal extension block splint and then buddy-taped for wks 2–4.
- Volar fractures that result from a dorsal dislocation, are nondisplaced, and involve <30% of the articular surface are considered stable and may be splinted for 4–6 wks.
- Fractures affecting the dorsum of the base are frequently associated with central slip attachment and may result in a boutonniere deformity; treatment of these requires 6 wks in extension splinting.

P.225

Fractures of the shaft (2):
- Transverse:
  - Nondisplaced may be treated with buddy taping for 2–4 wks.
  - Displaced: May attempt reduction under anesthesia (orthopedic referral recommended); longitudinal traction and gentle manipulation of distal fragment; a tape splint may be necessary for postreduction radiographs, generally 15-degree angulation in the plane of motion is tolerated; if postreduction films show adequate alignment, splint for 4–6 wks.
Fractures of the condyles (3):
- Nondisplaced fractures may be managed with buddy taping for 2–4 wks.
- Displaced fractures require orthopedic consultation.
Open fractures necessitate careful management:
- Appropriate antibiotic coverage, sterile dressing, elevation, and splinting maybe necessary until orthopedic consultation can be obtained.

Ongoing Care

Follow-Up Recommendations

Repeat radiographs at 2 wks may add to follow-up.
Deformity may result from no treatment or improper reduction.
Stiffness may result from overtreatment.
Referral to hand or occupational therapy is indicated for loss of function.
Return to play may be as early as 2 wks for nondisplaced simple transverse fracture, but as long as 6 wks for more complicated fractures (4).
A goal of lifelong function should take precedence when making return-to-play decisions.

References

1. Koval KJ, Zuckerman JD. Handbook of Fractures, 3rd Ed. Philadelphia: Lippincott Williams and Wilkins, 2006.

2. Eiff MP, Hatch RL, Calmbach WL. Fracture management for primary care, 2nd ed. Philadelphia: WB Saunders, 2003.

3. Browner, et al. Skeletal Trauma, 3rd ed. Philadelphia: WB Saunders, 2003.

4. DeLee JC, Drez D. Orthopaedic Sports Medicine, 2nd ed. Philadelphia: WB Saunders, 2003.

Codes

ICD9