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Phalanx Fractures

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Topic updated on 02/22/14 9:43pm
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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Qbank (2 Questions)

TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx
2. Intrinsic muscle fibrosis and intrinsic minus contracture
3. PIP joint volar plate attenuation and extensor tendon disruption
4. Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands
5. Flexor tendon disruption with associated overpull of the extensor mechanism

PREFERRED RESPONSE ▶
TAG
(OBQ12.89) What is the optimal treatment for the proximal phalanx fracture shown in Figure A? Topic Review Topic
FIGURES: A          

1. Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head
2. Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach
3. Open reduction and lag screw fixation with 1.3mm screws through a radial approach
4. Placement of a 1.5-mm condylar blade plate through a radial approach
5. Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint

PREFERRED RESPONSE ▶



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