High Yield Topics

Phalanx Fracture

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Phalanx Fracture

Phalanx Fracture
Dawn M. LaPorte MD
Mark Clough MD
Basics
Description
  • A phalanx fracture is a break in 1 or more phalanges in the fingers.
  • Finger fractures are classified by:
    • Which phalanx is involved
    • Location within the phalanx
    • Pattern
    • Complexity
    • Open or closed
    • Stable or unstable to motion
Epidemiology
  • Fractures of the metacarpals and the phalanges are common (1).
  • Occur among all ages
  • Common causes vary substantially with age.
Incidence
The reported incidence varies because patients with phalanx fractures present to a variety of medical practitioners.
Risk Factors
Involvement in a sport, job, or hobby that involves power tools or machinery.
Etiology
  • The specific cause depends on patient age (2,3).
    • Children >10 years old: Compression
    • Adolescents and young adults 10–39 years old: Sports
    • Adults 30–69 years old: Machinery
    • Elderly persons (≥60 years old): Falls
  • Other causes include crush injury and motor vehicle accidents.
  • The most common cause of a distal phalanx fracture is a crush injury.
  • The most likely cause of a transverse or comminuted fracture is a direct blow.
  • The most common cause of an oblique or spiral fracture is a twisting injury.
Associated Conditions
Possible additional fractures in the hand and upper extremity
Diagnosis
Signs and Symptoms
  • Pain, swelling, or deformity after some trauma to the finger
  • Laceration
  • Decreased ROM
  • Numbness of the affected digit
History
  • Determine the mechanism of injury and where it occurred (whether in a clean or dirty environment).
  • Determine how much time has elapsed since the injury.
  • Ascertain the patient’s age, hand dominance, occupation, and hobbies.
Physical Exam
  • Assess and document the patient’s neurovascular status.
  • Determine the precise area of tenderness and whether any lacerations and possible open fractures are present.
  • Evaluate for injury to soft tissues, including tendons, ligaments, nerves, and blood vessels.
  • Evaluate the digit for length, rotation,
    and angular alignment by comparing the appearance of the injured digit
    with that of adjacent digits.
  • Assess the nail plate by comparing with those of the surrounding digits.
Tests
Imaging
  • Radiography:
    • AP and lateral views of the finger should be obtained.
    • Oblique views assess intra-articular fractures.
  • Low-kilovolt mammography film is
    recommended as an initial screening test for a foreign body (e.g., wood
    splinter, glass) because many foreign bodies are not visible on plain
    film.
  • CT is the preferred method for detecting wood and thorns.
  • MRI detects all types of foreign bodies except gravel.
Pathological Findings
  • Proximal shaft fractures are angulated palmarly.
    • The proximal fragment is flexed because
      of interossei pull and the distal fragment is extended because of
      central slip insertion.
  • Digital function is impaired not only by
    fracture stability or deformity, but also by concomitant injury to soft
    tissues, including tendons, ligaments, blood vessels, and nerves.
  • Injury to soft-tissue structures is common.
Differential Diagnosis
Pathologic fracture, most commonly with an enchondroma (benign cartilage tumor)
Treatment
General Measures
  • Most fractures can be treated nonsurgically with closed reduction, splinting, and early motion.
  • Surgery is indicated for:
    • All displaced intra-articular fractures
    • Unstable fractures associated with severe soft-tissue injury
    • A fracture that remains unstable after closed reduction
    • A rotational deformity
  • >25° of palmar angulation causes functional deficits and cosmetic deformity and should be corrected surgically.
  • Nondisplaced and impacted transverse
    fractures of the phalanges are managed ideally with “buddy” taping, in
    which 2 fingers are taped together so that 1 acts as a splint for the
    other.
    • The fracture must truly be stable with minimal angulation in any plane.
  • Closed reduction and splinting:
    • Use digital nerve block for anesthesia.
    • Manipulate the distal fragment to align with the proximal fragment.
    • Place the splint.
    • The fracture must be stable after reduction for the splint to maintain reduction.
    • Splint the hand in the “intrinsic plus” position, with the MCP joints at 90° of flexion and the IP joints in full extension.
    • Use a gutter splint for the involved fingers.
Activity
  • Immobilize unstable closed fractures for 3–4 weeks.
  • Children tolerate immobilization better than adults, and adults will likely have more joint stiffness.
Special Therapy
Physical Therapy
  • To prevent stiffness, the patient is
    encouraged to perform ROM exercises as soon as possible for all fingers
    not included in the splint.
  • Digital performance deteriorates when active ROM is delayed >3 weeks.
  • Soft-tissue mobilization with active
    motion is initiated once clinical healing is achieved (as evidenced by
    minimally tender fracture site that is not painful when manipulated),
    usually at 3–4 weeks.
  • The radiographic appearance of union lags behind clinical union.
  • ROM exercises for the involved fingers usually are initiated at 2–4 weeks after surgery.

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Medication
First Line
  • NSAIDs or acetaminophen usually are sufficient for finger fractures.
  • Opioid medicines may be necessary for severe pain.
Surgery
  • Indications:
    • Failure of closed reduction to maintain rotation, length, or angular alignment
    • Intra-articular fracture in which joint congruity is lost, resulting in small joint dysfunction
    • Unstable fractures associated with severe
      soft-tissue injury in which fracture instability precludes a normal
      soft-tissue rehabilitation program
    • Rotational deformity
  • Distal tuft fractures may be treated with nail repair.
    • Pinning may be necessary.
  • Shaft fractures may be stabilized with Kirschner wires, lag screws, miniplates, or intramedullary devices (4).
  • The direct visualization afforded by an open approach permits more accurate reduction and adequate implant application (5).
  • Intra-articular volar fractures may be pinned or treated with volar plate arthroplasty (6).
  • Tension banding can supplement fixation, especially for small, less stable fragments.
  • Segmental defects should be treated with
    open reduction and internal fixation to preserve digital length and
    later with bone grafting.
  • Arthroplasty (constrained silicone or
    nonconstrained bicondylar implants) may be used as a salvage procedure
    in irreparable IP fractures or after failure for up to 2 years after
    injury.
  • Arthrodesis may be considered as an alternative to arthroplasty.
Follow-up
Prognosis
  • A poor prognosis is more likely with:
    • Age >50 years
    • Associated tendon injuries (especially extension)
    • Associated joint injury
    • >1 fracture in a finger
    • Crush injury
    • Skin loss
Complications
  • Malunion:
    • Malrotation requiring rotational osteotomy
    • Lateral deviation requiring closing wedge osteotomy
    • Volar angulation requiring volar closing wedge osteotomy
    • Intra-articular realignment osteotomy
  • Tendon adherence:
    • Common, especially in crush injuries
    • Intensive hand rehabilitation is needed.
    • Surgical treatment should be considered only after maximum passive joint motion is regained.
  • Nonunion:
    • Rare, but more common with open than with closed fractures
  • Soft-tissue interposition
  • Infections
  • Stiffness:
    • Immobilization for >3 weeks can result in permanent loss of motion.
    • Comminuted and open fractures treated with internal fixation have a higher rate of stiffness and poor outcomes (5).
Patient Monitoring
  • Obtain postreduction radiographs immediately and in 3–7 days to check for displacement.
  • Obtain subsequent radiographs every 4 weeks to monitor for displacement and to assess for healing.
  • Monitor the patient until the fracture has healed clinically and finger function is acceptable.
References
1. van Onselen EBH, Karim RB, Hage JJ, et al. Prevalence and distribution of hand fractures. J Hand Surg 2003;28B:491–495.
2. Larsen CF, Mulder S, Johansen AMT, et al. The epidemiology of hand injuries in The Netherlands and Denmark. Eur J Epidemiol 2004;19:323–327.
3. Vadivelu R, Dias JJ, Burke FD, et al. Hand injuries in children: a prospective study. J Pediatr Orthop 2006;26:29–35.
4. Horton
TC, Hatton M, Davis TRC. A prospective randomized controlled study of
fixation of long oblique and spiral shaft fractures of the proximal
phalanx: closed reduction and percutaneous Kirschner wiring versus open
reduction and lag screw fixation. J Hand Surg 2003;28B:5–9.
5. Tan V, Beredjiklian PK, Weiland AJ. Intra-articular fractures of the hand: treatment by open reduction and internal fixation. J Orthop Trauma 2005;19: 518–523.
6. Rettig ME, Dassa G, Raskin KB. Volar plate arthroplasty of the distal interphalangeal joint. J Hand Surg 2001;26A:940–944.
Additional Reading
Blazar PE, Steinberg DR. Fractures of the proximal IP joint. J Am Acad Orthop Surg 2000;8:383–390.
Freeland AE, Geissler WB, Weiss APC. Surgical treatment of common displaced and unstable fractures of the hand. Instr Course Lect 2002;51: 185–201.
Miscellaneous
Codes
ICD9-CM
  • 816.0 Closed phalanx fracture
  • 816.1 Open phalanx fracture
Patient Teaching
  • Underscore the importance of performing ROM exercises to prevent stiffness in affected and surrounding digits.
  • Emphasize the importance of maintaining therapy and ROM exercises to ensure functional outcome.
Prevention
  • Attention to prevention in sports and leisure activities.
  • Machine-related injuries should be prevented by attention to specific safety precautions.
FAQ
Q: How long should a phalanx fracture be splinted?
A: To prevent stiffness, a fracture should not be splinted for >3 weeks.

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