http://upload.orthobullets.com/topic/6114/images/proximal phalanx_moved.jpg
http://upload.orthobullets.com/topic/6114/images/middle phalanx_moved.jpg
http://upload.orthobullets.com/topic/6114/images/distal phalanx fx_moved.jpg
Introduction
  • Common hand injuries that can be broken into the following injuries
    • proximal phalanx
    • middle phalanx
    • distal phalanx
  • Epidemiology
    • incidence
      • most common injuries to the skeletal system
      • account for 10% of all fractures
      • distal phalanx is most common fractured bone in the hand
  • Pathophysiology
    • mechanism
      • depends on age
        • 10-29 years of age: sports is most common
        • 40-69 year of age: machinery is most common
        • >70 year of age: falls are most common
    • pathoanatomy
      • proximal phalanx fx
        • deformity is usually apex volar angulation due to
          • proximal fragment in flexion (from interossei)
          • distal fragment in extension (from central slip)
      • middle phalanx
        • deformity is usually apex dorsal OR volar angulation
          • apex dorsal if fracture proximal to FDS insertion (from extension of proximal fragment through pull of the central slip)
          • apex volar if fracture distal to FDS insertion (prolonged insertion from just distal to the flare at the base to within a few mm of the neck)
          • a fracture through the middle third may angulate in either direction or not at all secondary to the inherent stability provided by an intact and prolonged FDS insertion
  • Associated conditions
    • nail bed injuries 
      • associated with distal phalanx fractures
Presentation
  • Symptoms
    • pain
  • Physical exam
    • local tenderness
    • deformity
    • look carefully for open wounds
Imaging
  • Radiographs
    • finger xrays
      • must get true lateral of joint
    • hand xrays to rule out associated fractures
      • 30°pronated lateral to see 4th and 5th CMC x/dislocation
      • 30°supinated view to see 2nd and 3rd CMC fx/dislocation
Treatment - Proximal Phalanx Fracture
  • Nonoperative
    • buddy taping
      • indications
        • extraarticular with < 10° angulation or < 2mm shortening and no rotational deformity
      • 3 weeks of immobilization followed by aggressive motion
    • reduction and splinting
      • indications
        • most distal phalanx fx
  • Operative
    • CRPP vs. ORIF
      • indications 
        • irreducible or unstable fracture pattern
        • transverse fractures (all angulate volarly) with > 10° angulation or 2mm shortening or rotationally deformed 
        • long oblique proximal phalanx fractures
      • techniques
        • crossed k-wires
        • Eaton-Belsky pinning through metacarpal head
        • minifragment fixation with plate and lag screws, or lag screws alone
          • lag screws alone indicated in presence of long oblique fracture 
Treatment - Middle Phalanx Fracture
  • Nonoperative
    • buddy taping
      • indications
        • extraarticular with < 10° angulation or < 2mm shortening and no rotational deformity
      • technique
        • 3 weeks of immobilization followed by aggressive motion
  • Operative
    • CRPP vs. ORIF
      • indications
        • irreducible or unstable fracture pattern
        • transverse fractures with > 10° angulation or 2mm shortening or rotationally deformed 
      • techniques
        • crossed k-wires
        • collateral recess pinning
        • minifragment fixation with plate and lag screws
Treatment - Distal Phalanx Fracture
  • Nonoperative
    • reduction and splinting
      • indications
        • most cases
        • nail matrix may be incarcerated in fx and block reduction
  • Operative
    • remove nail, repair nailbed, and replace nail to maintain epi fold
      • indications
        • when distal phalanx associated with a nailbed injury
      • see nail bed injuries 
    • ORIF +/- bone grafting
      • indications
        • non-unions
Complications
  • Loss of motion
    • most common complication
    • predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection
    • treat with rehab, and surgical release as a last resort
  • Malunion
    • malrotation, angulation, shortening
    • surgery indicated when associated with functional impairment
      • corrective osteotomy at malunion site (preferred)
      • metacarpal osteotomy (limited degree of correction)
  • Nonunion
    • uncommon
    • most are atrophic and associated with bone loss or neurovascular compromise
    • surgical options
      • resection, bone grafting, plating
      • ray amputation or fusion
 

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Questions (2)

(OBQ12.49) A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. He undergoes closed reduction and pinning shown in Figure B to correct alignment. Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? Review Topic

QID:4409
FIGURES:
1

Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx

82%

(2941/3581)

2

Intrinsic muscle fibrosis and intrinsic minus contracture

1%

(48/3581)

3

PIP joint volar plate attenuation and extensor tendon disruption

2%

(58/3581)

4

Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands

9%

(328/3581)

5

Flexor tendon disruption with associated overpull of the extensor mechanism

5%

(175/3581)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The clinical presentation is consistent with a transverse proximal phalanx fracture. These fracture have an apex palmar angulated deformity under the indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx.

If proximal phalanx fractures are allowed to heal with the apex palmar deformity, an extensor lag will result. Therefore CRPP or ORIF is indicated in transverse fractures with > 10° angulation. To correct this deformity prior to surgical fixation, the MCP joint should be flexed, which allows the extensor mechanism as a whole to function as a tension band to help reduce the fracture. This is referred to as intrinsic plus splinting. Collateral ligament, capsule, and intrinsic muscle attachments render transverse fractures in the proximal 6 to 9 mm of the P1 base more stable than fractures located distally.

Henry provides a review of fractures of the proximal phalanx and metacarpals. He states that most transverse or short oblique P1 fractures without comminution are best stabilized by two 0.045-inch K-wires placed longitudinally through the fully flexed MCP joint. A single wire alone risks rotational malunion, but some fracture patterns may provide inherent rotational stability that would allow use of one wire for angular control.

Figure A shows a transverse fracture of the proximal phalanx with apex volar angulation. Figure B shows two K-wires placed transarticular through the MCP joint in a flexed (intrinsic plus) posture to correct the deformity and stabilize the fracture.

Incorrect Answers:
Answer 2: Intrinsic muscle fibrosis and contracture is usually associated with chronic crush injuries and significant soft tissue damage.
Answer 3: This is describing a swan neck deformity.
Answer 4: This is describing a Boutonnierre deformity.
Answer 5: Flexor tendon disruption is not likely in this closed injury pattern.


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Question COMMENTS (5)

(OBQ12.89) What is the optimal treatment for the proximal phalanx fracture shown in Figure A? Review Topic

QID:4449
FIGURES:
1

Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head

3%

(83/2736)

2

Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach

4%

(113/2736)

3

Open reduction and lag screw fixation with 1.3mm screws through a radial approach

86%

(2366/2736)

4

Placement of a 1.5-mm condylar blade plate through a radial approach

2%

(57/2736)

5

Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint

3%

(91/2736)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Open reduction and lag screw fixation through a radial approach is the treatment of choice for long oblique proximal phalanx fractures.

Lag screws (1.3 mm is preferred to 1.5 mm) can achieve stability through interfragmentary compression in a two-part spiral or long oblique fracture of the proximal phalanx that rivals the stability of an intact bone. This capability, combined with the need to achieve precise correction of rotation in spiral fractures, makes open reduction and lag screw fixation the treatment of choice for the spiral P1 shaft fracture.

Kawamura et al. discuss the treatment options for closed phalangeal and metacarpal fractures. They state that percutanous fixation with K-wires can be successful in the setting of an adequate closed reduction. However, lag screw fixation may be the best choice for open fixation of long oblique phalangeal and metacarpal fractures.

Henry et al. outline the methods of stablization for phalangeal and metacarpal fractures. With regards to long oblique proximal phalanx fractures, they state that open reduction and lag screw fixation the treatment of choice for the spiral P1 shaft fracture. This is due to the lack of inherent stability of the long fracture segment, and the tendency for the fracture to shorten even in the presence of smooth k-wire fixation.

Freeland et al. provide a review which cites new developments in the treatment of extra-articular hand fractures in adults.

Figure A shows a long obligue fracture of the index finger proximal phalanx. Illustration A demonstrates fixation of this injury with interfragmentary lag screws.

Incorrect Answers:
Answers 1,5: Most transverse P1 fractures without comminution are best stabilized by two 0.045-inch
K-wires placed longitudinally through the metacarpal head or PIP joint, depending on the location of the fracture.
Answers 2,4: Application of plates is usually reserved for comminuted bicondylar phalanx fractures, and is performed through a radial approach if possible to avoid postoperative adhesions.

ILLUSTRATIONS:

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