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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
  • 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
  • Anatomy
    • Osteology
      • distal phalanx
        • 4 components
          • tuft
          • shaft
          • base
      • middle and proximal phalanx
        • 4 components 
          • head
          • neck
          • shaft
          • base
        • displacement of middle phalanx fracture
          • apex dorsal
            • fracture proximal to FDS insertion 
          • apex volar  
            • fracture distal to FDS insertion 
        • displacement of proximal phalanx fracture
          • apex volar 
            • proximal fragment flexed due to interossei
            • distal fragment extends due to central slip
    • Arthrology 
      • interphalangeal joint 
        • hinge joint
          • dynamic stability from compressive forces during pinch and grip
          • passive stabiltiy from collateral ligament
    • Ligaments
      • collateral ligaments
        • proper
        • accessory 
    • Tendons
      • terminal extensor tendon 
        • inserts on dorsal base of distal phalanx
      • FDP 
        • inserts on volar base of distal phalanx
      • central slip
        • terminal slip of EDC inserts on dorsal aspect of middle phalanx
      • FDS 
        • inserts on volar shaft of middle phalanx
    • Blood Supply
      • proper digital arteries 
        • dominant artery found on median side of phalanges (closer to midline)
    • Nervous System
      • proper digital nerves
        • volar to proper digital arteries
    • Biomechancis
  • Classification
    • Descriptive
      • proximal phalanx
        • location 
          • head fractures
            • type I - stable with no displacement
            • type II - unstable unicondylar
            • type III - unstable bicondylar or comminuted
          • neck/shaft fractures
            • short oblique
            • long oblique
            • spiral
            • transverse
          • base fractures
            • extra-articular
            • intra-articular
              • lateral base
      • middle phalanx
        • location
          • head fractures
            • type I - stable with no displacement
            • type II - unstable unicondylar
            • type III - unstable bicondylar or comminuted
          • neck fractures
            • apex volar angulation
          • shaft fractures
            • transverse
            • short oblique
            • long oblique
            • spiral
            • deformity
              • apex volar angulation
                • distal to FDS insertion
              • apex dorsal angulation
                • 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
                • unstable in all directions
      • distal phalanx
        • 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
      • intra-articular vs extra-articular 
      • fracture morphology
      • amount of displacement 
      • open vs closed
  • Presentation
    • History 
      • hand dominance
      • baseline function
      • occupation and hobbies
      • mechanism of injury 
    • Physical Exam
      • inspection
        • swelling 
        • ecchymosis
        • deformity (angular, rotation, shortening)
        • open wounds
      • motion
        • assess for scissoring of digits
          • indicates rotational component
          • assess via tenodesis
      • neurovascular
        • digital nerve
          • two-point discrimination test 
        • vascular assessment   
          • cap refill <2 sec
  • 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
    • CT scan
      • indications
        • assess articular involvement 
      • findings
        • amount of articular displacement
        • degree of comminution 
  • Differential
    •  Differential Diagnosis 
      • Stress fracture
      • Jammed finger
      • fracture-dislocation
      • gout
      • finger infection
      • neoplasm
  • Diagnosis
    • Radiographs
      • diagnosis confirmed by history, physical, and orthogonal radiographs 
  • Proximal Phalanx Fractures
    • 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
    • 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
    • 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
      • risk factors
        • prolonged immobilization
        • intra-articular fracture
        • extensive surgical dissection
      • treatment 
        • aggressive hand therapy
          • first-line treatment
        • surgical release  
          • failed nonoperative treatment
    • Malunion
      • types
        • malrotation
        • angulation
          • Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ
        • shortening
      • treatment
        • nonoperative
          • asymptomatic, no functional impairment  
        • surgery
          • indicated when associated with functional impairment
          • options
            • corrective osteotomy at malunion site (preferred)
            • metacarpal osteotomy (limited degree of correction)
    • Nonunion
      • uncommon (<2%)
      • most atrophic and associated with bone loss or neurovascular compromise
      • surgical options
        • resection, bone grafting, plating
        • ray amputation or fusion
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