Review Question - QID 217387

This patient sustained a long oblique fracture of the middle finger proximal phalanx with rotational deformity. Long oblique proximal phalanx fractures are best treated surgically with open reduction and lag-screw fixation or closed reduction and percutaneous pinning.

Phalangeal fractures of the hand are extremely common, accounting for 10% of all fractures. They occur twice as often in men and occur most often in the distal, then middle, and finally proximal phalanges. Treatment for transverse and length stable fractures can be with conservative measures alone. However unstable fractures which include long oblique, spiral, and comminuted fractures are often best treated with surgical intervention. Multiple options exist and treatment should be guided by fracture pattern. For long oblique fractures, closed reduction and percutaneous pinning (CRPP) and open reduction and lag-screw fixation have been found to have similar long-term outcomes. Open reduction with plate and screw fixation historically was thought to have worse functional outcomes, however, more recent literature may contradict that fact. Even in more recent studies, plate fixation is associated with a higher complication rate than CRPP or lag-screw fixation.

Cheah et al. provide an updated review of the management of hand fractures. They note an increased prevalence of minimally invasive techniques with an immediate postop range of motion and the use of wide-awake anesthesia. They review extra- and intra-articular fractures of the metacarpals and phalanges. They provide an in-depth discussion of implant considerations and the choice for which bone is involved.

Nuland et al. provide an evidence-based medicine review of the operative treatment of unstable long oblique fractures. They present a case report followed by a review of several studies comparing screw-only fixation, screw and plate fixation, and percutaneous Kirshner wire fixation. Their final conclusion based on current literature is that CRPP and open reduction with screw-only fixation are the best treatment options with select circumstances where plate and screw may be better.

Kootstra et al. presented a retrospective review comparing 159 proximal phalanx fractures treated with k-wires (44%), lag-screws (26%), or plates (30%). They found when looking at patient-reported outcome scores and complications that all fixation strategies were equivalent on DASH and Patient-Rated Wrist/Hand Evaluation scores. They did find a higher rate of reoperation with plates compared to lag-screw and k-wire fixation. Additionally, k-wire fixation was associated with better aesthetic outcomes.

Figure A shows the scissoring of the middle phalanx over the index finger in this patient when making a fist. Figure B is an AP and lateral x-ray of the proximal phalanx showing a long oblique fracture.

Incorrect Answers:
Answer 1,3,4: These treatment options would be at risk of shortening due to the unstable nature of the fracture.
Answer 5: Plate and screw fixation of long oblique fracture of the phalanx have higher complication rates than CRPP.