Phalangeal Injuries

By admin Last updated Nov 3, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Phalangeal Injuries

Lt. Col (P) Jeffrey C. Leggit

Basics

Attempt to reduce dislocations immediately if neurovascular compromise is suspected.
All finger phalangeal injuries require radiographic evaluation.

Description

Typically results from direct trauma, crushing injury to the distal phalanx
High likelihood of concomitant soft tissue injury (ie, nail bed trauma)

Epidemiology

Prevalence

10–15% of all sports-related injuries
50% of all hand fractures are distal phalanx fractures.

Risk Factors

Middle finger and thumb are the most commonly affected digits, due to the fact that they tend to be more exposed than the other digits.

Etiology

Crushing injury

Commonly Associated Conditions

Nail bed trauma
Soft tissue injury
Tendon injuries
Dislocations have high risk for concomitant ligamentous injuries/disruptions

Diagnosis

Posteroanterior (PA), lateral, and oblique radiographs
Oblique or spiral fractures may also be associated with malrotation (1)[C].

History

Hand dominance
Occupation and/or athletic position
Environment surrounding injury (risk of infection)
Mechanism of injury
Associated symptoms (ie, numbness, tingling)

Physical Exam

Pain, swelling, and ecchymosis are common findings.
Subungual hematoma frequently encountered with distal phalanx fracture
Gross deformity
Malrotation (flex distal interphalangeal and proximal interphalangeal while keeping metacarpophalangeal extended; all fingers should point toward scaphoid; if they do not, malrotation is present)

Diagnostic Tests & Interpretation

Imaging

PA, lateral, and oblique radiographs
Oblique or spiral fractures may also be associated with malrotation (1)[C].

Diagnostic Procedures/Surgery

Inspection of nail bed for suspected laceration or hematoma

Treatment

Nondisplaced fractures:
- Buddy tape nondisplaced fractures: Never leave 5th finger isolated, as tends to get snagged (remember to place absorptive padding between digits)
- Drain subungual hematoma if >50% nail bed, and repair nail bed if lacerated
- Splint to avoid inadvertent trauma to fingers
- Hard-sole shoe for toe fractures and weight-bearing as tolerated with crutches or cane
- Oral analgesics
- Pain improves over 2–3 wks
Displaced intra-articular fractures of interphalangeal joint:
- Closed reduction with longitudinal traction
- Short-leg walking cast with toe platform
- Acceptable reduction is <6 mm of shortening, <15 degrees of angulation, and no rotational deformity
- If unstable after closed reduction, then open reduction internal fixation is required.
Interphalangeal joint dislocations:
- Digital block anesthesia
- Longitudinal traction with gentle downward pressure on distal phalanx to reduce dislocation
- Buddy tape to next digit for 2–3 wks (caution with 5th finger)
- Unstable reductions require operative management (2)[C].

P.463

Surgery/Other Procedures

Unstable fractures
Irreducible dislocations
Consider referral for intra-articular fractures >30% surface area

Ongoing Care

Buddy tape/splint continuously for 2 wks and then during sporting events for another 4 wks
Soft shoe or splint for comfort

Follow-Up Recommendations

Patient Monitoring

Fractures that required reduction should be seen within 1 wk and repeat radiographs should be obtained to check for fracture stability.
Subungual hematoma: 24 hr

Prognosis

Most heal well, but may remain sensitive for months (3)

Complications

Chronic pain
Chronic deformity
Loss of range of motion

References

1. Lee SG, Jupiter JB. Phalangeal and metacarpal fractures of the hand. Hand Clin. 2000;16:323–332.

2. Walsh JJ. Fractures of the hand and carpal navicular bone in athletes. South Med J. 2004;97:762–765.

3. Peterson JJ. Clin Sports Med. 2006;25(3):527–542, vii–viii Injuries of the fingers and thumb in the athlete.

Additional Reading

Rettig AC. Athletic injuries of the wrist and hand. Part I: traumatic injuries of the wrist. Am J Sports Med. 2003;31:1038–1048.

Codes

ICD9

826.0 Closed fracture of one or more phalanges of foot
959.5 Other and unspecified injury to finger
959.7 Other and unspecified injury to knee, leg, ankle, and foot