Fracture, Proximal Phalanx

By admin Last updated Sep 30, 2023

Ovid: 5-Minute Sports Medicine Consult, The

James H. Lynch

Kevin deWeber

Basics

Epidemiology

2nd most common phalangeal fracture in adults
Base of proximal phalanx fracture is most common pediatric hand injury
Little finger is the most common ray involved, followed by the thumb.
Males affected 3x as often as females
Crush or direct blow to the finger accounts for more than 80% of injuries.

Etiology

Intrinsic muscles of the hand (interossei) insert into the extensor expansion on the dorsum of the proximal phalanx.
Proximal phalangeal fractures usually angulate volarly due to the proximal fragment flexed by interossei and the distal fragment extended by the central slip's insertion on the base of the middle phalanx.
Normally, flexed fingertips should all point toward the scaphoid without significant overlap.
Metacarpophalangeal (MCP) joint collateral ligaments are taut in 70–90° of flexion and provide stabilization of the MCP joint.

Commonly Associated Conditions

Digital nerve injury: Contusion, transection
Digital artery injury: Open or closed fracture; usually does not require treatment
Tendon injury: Complete or partial rupture; infrequent with proximal phalangeal fracture
Thumb avulsion fracture common with ulnar collateral ligament injury (skier's thumb)

Diagnosis

History

Mechanism of injury: Direct blow, axial load, axial traction, twisting/torque, or “grabbing a jersey”
History of previous injury, surgery, or deformity
Review treatment rendered

Physical Exam

Pain, swelling, bruising, tenderness, loss of motion, and function are typical findings.
Gross deformity in some cases
Open (compound) fractures usually are obvious and require emergent care.
May be mistaken for metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint dislocation
Malrotation is common with spiral and oblique shaft fractures, and must be detected and corrected early.
Inspection/observation: Location and degree of deformity, swelling, and ecchymosis
Rotational malalignment: With MCP and PIP flexed to 90°, all fingers should point toward the scaphoid. When viewed “end on,” the plane of all fingernails should be symmetrical.
Range of motion (ROM): Usually decreased. Compare with contralateral side.
Palpation: Feel for crepitus. Determine point of maximal tenderness.
Provocation: Axial loading or distraction often results in pain at the fracture site.
Adjacent structures: MCP and PIP joints, tendon function, and soft tissues
Neurocirculatory function: Sensation, capillary refill, skin color, and temperature

Diagnostic Tests & Interpretation

Imaging

Radiographs should be obtained before any manipulative examination.
Anteroposterior (AP), true lateral, and oblique views are diagnostic.
For the thumb, which is out of plane from the fingers, obtain Robert's view and Bett's view (1).
Describe rotation of fragments, angulation, and intra-articular vs extra-articular.
Differences in diameter of fragments suggest rotation.

Differential Diagnosis

MCP joint dislocation
PIP joint dislocation
Soft tissue contusion, sprain, strain, or rupture

Treatment

Open (compound) fractures: Sterile wet dressing, ice, elevate, splint, refer to orthopedic surgeon:
- Antibiotics not routinely necessary if aggressive irrigation/debridement is adequate (2)[C].
- Cephalosporin or penicillin to cover Staphylococcus aureus for contaminated wounds
- Tetanus toxoid and/or immune globulin if indicated
Reduction of fracture fragments to anatomical positions is desired to speed healing and maximize hand function. Closed reduction is often successful and should usually be attempted.
After reduction, immobilization should be applied and postreduction imaging should be obtained.

Pre-Hospital

Apply sterile dressing over any open wounds.
Splint in a position of comfort, apply ice if available, and transport for radiographs and definitive treatment.

ED Treatment

Stable, nondisplaced without angulation or rotational deformity:
- Dynamic splinting (“buddy taping”) to an adjacent normal digit
- Use absorbent material between digits for padding and to prevent maceration.
- Early ROM: Patient should use the hand normally as comfort allows.
Nondisplaced and impacted fractures:
- Some degree of intrinsic stability; do not require surgery
- Splint or short arm cast in the safe position (wrist dorsiflexed 30°, MCP joint flexed 70–90°, IP joints extended) for 3 wks. This position of function shifts the extensor aponeurosis distally to cover the majority of the proximal phalanx dorsally, which compresses and stabilizes the fracture.
Displaced or angulated transverse midshaft:
- Volar angulation common, generally unstable, with variable response to closed reduction, which should be attempted
- Technique:
  - Metacarpal or digital block
  - Longitudinal traction and flexion of the MCP joint with manual realignment of fracture fragments
  - If reduction achieved/maintained, apply gutter splint or Burkhalter splint (dorsal slab of stabilizing material placed from the end of a short arm cast to just proximal to the PIP, with MCP joints flexed 70–90°)
  - If reduction not achieved after splinting, refer to ortho/hand.
Displaced fractures of the base:
- Significant volar angulation requires reduction
- Technique:
  - Metacarpal or digital block
  - Longitudinal traction and flexion of the MCP joint and correct volar angulation with direct pressure
  - If reduction achieved/maintained, apply gutter or Burkhalter splint; if not, refer to ortho/hand.
Unstable: oblique—condylar (lateral or medial aspect of base), displaced or angulated—and displaced intra-articular fractures:
- Refer to ortho/hand for pin fixation or open reduction internal fixation (ORIF).

P.241

AP, true lateral, oblique to confirm reduction
Unacceptable, unstable, or unsure alignment: Early consultation with orthopedic surgeon advised
Persistence of significant displacement, angulation of more than 10°, intra-articular component, or any degree of rotational malalignment necessitates an orthopedic surgeon consultation(3)[C]

Medication

Oral analgesics may be used if needed; NSAIDs should be used with caution in acute fractures since they may impair acute fracture healing.
Digital or metacarpal block with local anesthetics may be used if reduction or repair of associated soft tissue injury is required.

Additional Treatment

Referral

The following phalangeal fractures in children warrant prompt orthopedic consultation, since many will require immediate surgery (4)[B]:

Phalangeal neck or condyle fractures: Failure to treat this injury with pin stabilization can result in a malunion that limits digital flexion.
Malrotation fractures
Widely displaced, irreducible proximal phalanx base fractures (due to entrapment of soft tissue)
Avulsion fractures of the thumb MCP ulnar collateral ligament insertion (pediatric equivalent of skier's thumb, usually a displaced Salter-Harris Type III intra-articular fracture)

Ongoing Care

Follow-Up Recommendations

On follow-up x-rays, any malalignment should prompt an orthopedic surgeon consultation.

Patient Monitoring

Monitor specific fractures as follows (5)[B]:
- Stable, nondisplaced without angulation or rotational deformity, treated with buddy taping:
Dynamic splinting for 3 wks; x-ray at 7–10 days to check alignment and stability
Daily ROM exercises after 1 wk as comfort allows
Continued dynamic splinting for athletic activities for another 4–6 wks
Nondisplaced and impacted fractures treated with splint or cast:
- Recheck radiographs in 7–10 days to assess healing.
- After 3 wks, early protected mobilization with buddy taping
Displaced or angulated transverse midshaft treated with closed reduction and splint or cast:
- X-ray at 5 and 10 days to assure reduction is maintained; if not, refer to ortho/hand.
- If reduction maintained, continue splint for 3–4 wks; if reduction fails, refer to ortho/hand for ORIF or percutaneous fixation.
Displaced fractures of the base:
- X-ray at 5 and 10 days to assure reduction is maintained; if not, refer to ortho/hand.

Complications

Joint stiffness and subsequent functional disability. Adhesions between extensor mechanism and periosteum may result in loss of motion requiring surgical intervention. Adhesions between flexor superficialis and flexor profundus may follow prolonged immobilization and require surgical intervention to restore function.
Arthritis can result from intra-articular fractures.
Nonunion is rare except for improperly immobilized or open fractures.

References

1. Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. J Hand Surg [Am]. 2009;34:945–952.

2. Suprock MD, Hood JM, Lubahn JD. Role of antibiotics in open fractures of the finger. J Hand Surg [Am]. 1990;15:761–764.

3. Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg. 2008;16:586–595.

4. Waters PM. Operative carpal and hand injuries in children. J Bone Joint Surg Am. 2007;89:2064–2074.

5. Stanton JS, Dias JJ, Burke FD. Fractures of the tubular bones of the hand. J Hand Surg Eur Vol. 2007;32:626–636.

Additional Reading

Cornwall R, Ricchetti ET. Pediatric phalanx fractures: unique challenges and pitfalls. Clin Orthop Relat Res. 2006;445:146–156.

Vadivelu R, Dias JJ, Burke FD, et al. Hand injuries in children: a prospective study. J Pediatr Orthop. 2006;26:29–35.

Codes

ICD9

816.01 Closed fracture of middle or proximal phalanx or phalanges of hand
816.11 Open fracture of middle or proximal phalanx or phalanges of hand