Updated: 10/13/2018

Phalanx Fractures

Topic
Review Topic
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Questions
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Evidence
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Cases
6
https://upload.orthobullets.com/topic/6114/images/proximal phalanx_moved.jpg
https://upload.orthobullets.com/topic/6114/images/middle phalanx_moved.jpg
https://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
      • accounts for 10% of all fractures
    • demographics
      • more common in males 2:1
    • location
      • distal phalanx > middle phalanx > proximal phalanx
      • small finger is most commonly affected (accounts for 38% of all hand fractures)
  • Pathophysiology
    • mechanism of injury
      • depends on age
        • 10-29 years old - sports is most common
        • 40-69 years old - machinery is most common
        • >70 years old - falls are most common
  • Associated conditions
    • nail bed injuries 
      • associated with distal phalanx fractures
Presentation
  • Physical exam
    • inspection
      • tenderness
      • swelling
      • deformity
      • crepitus
      • look for open wounds
    • motion
      • assess for scissoring of digits
        • indicates rotational component
        • can assess via tenodesis
    • neurovascular
      • assess for numbness indicating digital nerve injury
      • assess for digital artery injury via doppler
Imaging
  • Radiographs
    • recommended views
      • PA
      • lateral
      • oblique
    • findings
      • proximal phalanx
        • apex volar angulation due to
          • proximal fragment pulled into flexion by interossei
          • distal fragment pulled into extension by central slip
      • middle phalanx
        • apex volar angulation if distal to FDS insertion
        • apex dorsal angulation if proximal to FDS insertion
Proximal Phalanx Fractures
  • Classification
    • head fractures
      • can be further classified into
        • type I - stable with no displacement
        • type II - unstable unicondylar
        • type III - unstable bicondylar or comminuted
    • neck/shaft fractures
      • can be
        • transverse
        • short oblique
        • long oblique
        • spiral
      • deformity is usually apex volar angulation
        • proximal fragment in flexion (due to interossei)
        • distal fragment in extension (due to central slip)
    • base fractures
      • can be
        • extra-articular
        • intra-articular
          • lateral base
  • Nonoperative
    • buddy taping vs. splinting
      • indications
        • extraarticular fractures with < 10° angulation or < 2mm shortening and no rotational deformity
        • non-displaced intraarticular fractures
      • technique
        • 3 weeks of immobilization followed by aggressive motion
  • Operative
    • CRPP vs. ORIF
      • indications
        • extraarticular fractures with > 10° angulation or > 2mm shortening or rotational deformity
        • displaced intraarticular fractures
        • unstable or irreducible fracture pattern
      • techniques
        • crossed K wires
        • Eaton-Belsky pinning through metacarpal head
        • minifragment fixation with plate and/or lag screws
          • lag screws alone indicated in presence of long oblique fracture 
Middle Phalanx Fractures
  • Classification
    • head fractures
      • can be further classified into
        • type I - stable with no displacement
        • type II - unstable unicondylar
        • type III - unstable bicondylar or comminuted
    • neck fractures
      • deformity is usually apex volar angulation
        • proximal fragment in flexion (due to FDS)
        • distal fragment in extension (due to terminal tendon)
    • shaft fractures
      • can be
        • transverse
        • short oblique
        • long oblique
        • spiral
      • deformity can be
        • apex volar angulation
          • if distal to FDS insertion
        • apex dorsal angulation
          • if proximal to FDS insertion
        • without angulation
          • due to inherent stability provided by an intact and prolonged FDS insertion
    • base fractures
      • deformity is usually apex dorsal angulation
        • proximal fragment in extension (due to central slip)
        • distal fragment in flexion (due to FDS)
      • can be further classified into
        • partial articular fractures
          • volar base
            • results from hyperextension injury or axial loading
            • represents avulsion of volar plate
            • unstable if > 40% articular surface involved
          • dorsal base
            • results from hyperflexion injury
            • represents avulsion of central tendon
          • lateral base
            • represents avulsion of collateral ligaments
        • complete articular fractures
          • know as pilon fractures
          • unstable in all directions
  • Nonoperative
    • buddy taping vs. splinting
      • indications
        • extraarticular fractures with < 10° angulation or < 2mm shortening and no rotational deformity
        • non-displaced intraarticular fractures
      • technique
        • 3 weeks of immobilization followed by aggressive motion
  • Operative
    • CRPP vs. ORIF
      • indications
        • extraarticular fractures with > 10° angulation or > 2mm shortening or rotational deformity
        • displaced intraarticular fractures
        • irreducible or unstable fracture pattern
      • techniques
        • crossed K wires
        • extension block pinning
        • collateral recess pinning
        • minifragment fixation with plate and/or lag screws
        • volar plate arthroplasty
Distal Phalanx Fractures
  • Most common phalanx fracture
  • Classification
    • tuft fractures
      • mechanism is usually crush injury
      • usually stable due to nail plate dorsally and pulp volarly
      • often associated with laceration of nail matrix or pulp
    • shaft fractures
      • can be
        • transverse
        • longitudinal
    • base fractures
      • usually unstable
      • mechanism can be
        • shearing due to axial load, leading to fracture involving > 20% of articular surface
        • avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture
      • can be further classified into
        • volar base
        • dorsal base
    • Seymour fractures 
      • epiphyseal injury of distal phalanx
      • resuls from hyperflexion
      • presents as mallet deformity (i.e. apex dorsal) due to
        • terminal tendon attaches to proximal epiphyseal fragment
        • FDP attaches to distal fragment
  • Nonoperative
    • closed reduction +/- splinting
      • indications
        • most cases
      • nail matrix may be incarcerated in fracture and block reduction
  • Operative
    • remove nail, repair nailbed, and replace nail to maintain epi fold
      • indications
        • distal phalanx fractures with nailbed injury
        •  
          • see nail bed injuries 
    • CRPP vs. ORIF
      • indications
        • displaced or irreducible shaft fractures
        • dorsal base fractures with > 25% articular involvement
        • displaced volar base fractures with large fragment and involvement of FDP
        • non-unions
      • techniques
        • longitudinal or crossed K wires
        • extension block pinning
        • minifragment fixation with lag screws
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
  • most common injuries to the skeletal system
  • account for 10% of all fractures
  • distal phalanx is most common fractured bone in the hand
 

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Questions (8)
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(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%

(4155/5052)

2

Intrinsic muscle fibrosis and intrinsic minus contracture

1%

(65/5052)

3

PIP joint volar plate attenuation and extensor tendon disruption

2%

(79/5052)

4

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

9%

(436/5052)

5

Flexor tendon disruption with associated overpull of the extensor mechanism

5%

(269/5052)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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%

(122/4038)

2

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

4%

(177/4038)

3

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

86%

(3471/4038)

4

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

2%

(81/4038)

5

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

4%

(153/4038)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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ARTICLES (6)
CASES (6)
Topic COMMENTS (1)
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