summary Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. 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) Etiology 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 Diagnosis Radiographic diagnosis confirmed by history, physical exam, and radiographs 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 Unstable patterns include spiral, oblique, fracture with severe comminution 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 Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ 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
QUESTIONS 1 of 13 1 2 3 4 5 6 7 8 9 10 11 12 13 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ17SE.3) A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. An attempt at reduction and immobilization is made in the field by his unit physician assistant, and he returns to your office one week later. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: QID: 211138 FIGURES: A Type & Select Correct Answer 1 Rotational deformity 1% (22/1868) 2 >2mm shortening 4% (78/1868) 3 20° apex volar angulation 6% (110/1868) 4 5° apex dorsal angulation 85% (1594/1868) 5 Grossly contaminated open fracture 3% (49/1868) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 4409 FIGURES: A B Type & Select Correct Answer 1 Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx 83% (6706/8089) 2 Intrinsic muscle fibrosis and intrinsic minus contracture 1% (120/8089) 3 PIP joint volar plate attenuation and extensor tendon disruption 2% (129/8089) 4 Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands 7% (606/8089) 5 Flexor tendon disruption with associated overpull of the extensor mechanism 6% (466/8089) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ12.89) What is the optimal treatment for the proximal phalanx fracture shown in Figure A? QID: 4449 FIGURES: A Type & Select Correct Answer 1 Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head 3% (183/5525) 2 Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach 4% (244/5525) 3 Open reduction and lag screw fixation with 1.3mm screws through a radial approach 85% (4707/5525) 4 Placement of a 1.5-mm condylar blade plate through a radial approach 2% (103/5525) 5 Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint 4% (242/5525) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.63) A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. Which of the following is true regarding open reduction and screw fixation of this injury? QID: 3486 FIGURES: A B Type & Select Correct Answer 1 High risk of symptomatic implant 57% (2427/4256) 2 Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively 6% (249/4256) 3 High rates of post-operative infection are common 2% (90/4256) 4 Open reduction via an approach through the nail bed leads to significant post-operative nail deformity 24% (1018/4256) 5 Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively 10% (443/4256) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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