|
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
 

Please rate topic.

Average 3.4 of 23 Ratings

Questions (8)
EVIDENCE & REFERENCES (6)
CASES (6)
Topic COMMENTS (1)
Private Note