You are in: eMedicine Specialties > Orthopedic Surgery > HAND AND UPPER EXTREMITY Phalangeal FracturesArticle Last Updated: Jul 11, 2005AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Brian J Divelbiss, MD, Attending Staff, Dickson-Diveley Midwest Orthopedic Clinic, Inc, and Kansas City Orthopedic Institute; Associate Clinical Professor, Department of Orthopedic Surgery, University of Missouri-Kansas City Brian J Divelbiss is a member of the following medical societies: Alpha Omega Alpha and American Society for Surgery of the Hand Editors: Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert J Nowinski, DO, Clinical Assistant Professor of Orthopaedic Surgery, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic Specialists and Sports Medicine, Newark, Ohio; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: finger fractures, finger dislocations, broken finger, finger jam, jammed finger INTRODUCTIONSection 2 of 11
  Phalangeal fractures are common injuries that may significantly affect hand function if not managed appropriately. Closed treatment has been the historical mainstay of treatment. Percutaneous pinning allowed the conversion of more unstable fracture patterns to stable configurations capable of tolerating early motion. More recently, minifragment screws and plates were developed to assist in the management of complex phalangeal fractures. ProblemInjuries to the phalanges can result in significant loss of hand function. Even subtle injuries, such as a simple finger jam, if not diagnosed and treated promptly, can lead to decreased motion and a poor outcome. This is especially true with injuries to the proximal interphalangeal joint (PIPJ). Fractures of the phalanges, if unstable, need fixation secure enough to allow early motion in order to prevent adhesion formation. FrequencyBecause many injuries to the phalanges go unreported, defining a true incidence is difficult. Fractures of the phalanges certainly are among the most common in the entire skeleton and may account for up to 10% of all fractures. EtiologyFractures and dislocations of the phalanges occur from a variety of mechanisms. In younger patients, these injuries are more likely to be sports related, while older patients are likely to be injured by machinery or by falls. Crush injuries are common at the distal phalanx, while the PIPJ is usually damaged by an axial blow to the finger. PathophysiologyStability of phalangeal fractures is dependent on location, fracture orientation, and degree of initial displacement. Distal tuft fractures usually are stable, despite comminution. Unicondylar and bicondylar fractures involving the interphalangeal joints are inherently unstable. Displaced fractures involving the diaphyses of the proximal and middle phalanges also are unstable secondary to the pull of the intrinsics and flexor tendons. Fractures with an intact periosteal sleeve and no initial displacement usually are stable. ClinicalClinical presentation of finger fractures and dislocations depends primarily on the mechanism of injury. Crushing injuries to the fingertip commonly involve the nail bed in addition to the underlying distal phalanx. Injuries at the interphalangeal joints usually manifest with swelling, ecchymosis, and decreased motion. Deformity may also be present at the joint, as well as in the diaphysis of a displaced unstable fracture. Transverse fractures in the proximal phalanx assume an apex volar deformity secondary to pull of the intrinsic tendons on the proximal fragment and the extensor tendon on the middle phalanx. Fractures of the middle phalanx may angulate apex dorsal or volar, depending on whether the fracture occurs proximal or distal to the sublimis insertion, respectively. Care must be taken to evaluate the digit for rotational deformity as well. This is best accomplished by flexing the fingers and viewing the nails on end. Comparison with the contralateral hand is essential. INDICATIONSSection 3 of 11
Phalangeal fractures that are nondisplaced or stable following reduction are amenable to closed treatment with splinting and early rehabilitation. Indications for operative treatment of phalangeal fractures include the following:
In general, management of soft tissues is the first priority. Open wounds are common and are an indication for irrigation and debridement. Wound management is aided by fracture fixation. Fractures should be treated with the least invasive method that can result in a stable configuration because this allows for early rehabilitation. If stability cannot be achieved or maintained following reduction, some form of fixation is required. The form of fixation chosen should involve a minimum amount of soft tissue disruption because surgical exposure increases the likelihood of postoperative scar formation between tendon and bone. RELEVANT ANATOMYSection 4 of 11
Few places in the body exist where function and anatomy are as closely intertwined as in the finger. Injuries and subsequent scar formation can upset the delicate balance that normally exists, particularly at the PIPJ and extensor apparatus. Anatomic considerations are based on the level of injury.
CONTRAINDICATIONSSection 5 of 11
No absolute contraindications exist in the management of these injuries. Relative contraindications include the use of internal fixation in a reduced and stable fracture or plating a fracture that could be managed with percutaneous pin fixation. WORKUPSection 6 of 11
Imaging Studies
TREATMENTSection 7 of 11
Medical therapyThe appropriate use of splinting is a key component in treating phalangeal fractures. Management must be individualized, but rarely should full-time immobilization exceed 3 weeks. After 3 weeks, removable custom splints can be used.
Surgical therapyDistal phalanx fracturesTuft fractures Most tuft fractures are comminuted and involve the nail bed. Management of these injuries focuses on the treatment of the nail. If the nail plate is intact, leave it in place, and drainage of a subungual hematoma can be carried out through the plate. Manage open tuft fractures involving damage or loss of the nail plate with remaining nail removal, meticulous nail bed repair with 6-0 chromic suture, and nail bed protection. Irrigation, debridement, and IV antibiotics are warranted and indicated in open fractures. Transverse shaft fractures Nondisplaced fractures are treated with stack splint immobilization. Displaced fractures can be associated with subluxation of the nail base. Reduce the nail plate back under the eponychial fold and consider placement of a single longitudinal Kirschner wire (K-wire), stopping short of the DIPJ. Longitudinal shaft fractures Most of these fractures can be treated with stack splint immobilization. Transversely oriented minifragment screws may be used for significant displacement (see Images 4-5). Flexor digitorum profundus avulsions Operative intervention is warranted for loss of active DIPJ flexion. A type I avulsion lacks a bony component, and the tendon retracts into the palm. This injury requires repair with pull-through sutures within 10 days of the injury. Types II and III include a variably sized portion of bone from the base of the distal phalanx. A small fleck of bone is caught at the A2 pulley at the level of the proximal phalanx in type II avulsions, while a larger bony avulsion is lodged at the A4 pulley in a type III avulsion. Types II and III may be managed with pull-through sutures over a button as late as 3-4 weeks after the injury. Larger type III fragments may be amenable to percutaneous pinning. Type IV avulsions involve an avulsion of bone from the distal phalanx as well as an avulsion of the flexor digitorum profundus tendon from the bony avulsion. Manage these as type I fractures. Mallet finger avulsions Occasionally, a mallet finger injury may include a bony avulsion. The majority of these can be treated with the standard mallet splint, keeping the DIP in extension for 6 weeks. Controversy exists as to the ideal treatment for bony avulsion involving more than 30% of the joint surface. Some authors recommend operative fixation to prevent the accompanying volar subluxation. Other authors prefer to treat all of these avulsions with splinting. The lone exception is the Salter III fracture, which is treated with percutaneous pin fixation. Middle and proximal phalanx fracturesUnicondylar and bicondylar fractures Even with minimal displacement, these fractures are unstable and warrant fixation. Open reduction often is necessary to assure articular reduction. Unicondylar fractures may be treated with screw fixation. Approach bicondylar fractures with restoration of the articular fragments first, followed by fixation of the articular portion to the shaft. Mini-condylar plates or intraosseous wiring techniques may be useful. Shaft fractures Transverse fractures commonly are unstable and require fixation. These can be managed easily with 2 longitudinal 0.045 K-wires placed either retrograde through the head of the phalanx or anterograde from the base. In either case, the pins should not remain crossing the PIPJ in order to facilitate motion. If placed in the retrograde fashion, the pins must be bent to prevent migration distally into the PIPJ. Longitudinal parallel pinning helps prevent fracture distraction, which can occur with crossed-wire configuration. Oblique and spiral fractures often are unstable as well. Short oblique fractures can be managed with longitudinal K-wires. As the length of the fracture increases, minifragment screws provide a better biomechanical construct. These screws can be placed percutaneously with minimal soft tissue disruption. Make the entrance incision in the midaxial line if possible. This minimizes the risk of injury to flexor and extensor tendons. Fractures at the base of the middle phalanx These are common injuries and are often associated with dislocation of the PIPJ. If not treated appropriately, long-term dysfunction of the finger can result. The dislocation usually is dorsal with an avulsion fracture of the volar base of the middle phalanx. Initial treatment is reduction, followed by an assessment of stability. Extension block is the treatment of choice if it can maintain a concentric reduction. If this is unsuccessful (see Image 6), extension block pinning can be utilized. Extension block pinning (see Image 7) involves placement of a longitudinal pin retrograde into the head of the proximal phalanx, keeping the PIPJ in flexion. Placing the joint in too much flexion is impossible. If the fracture involves more than 50% of the articular surface, external fixation, dynamic traction, or volar plate arthroplasty is indicated. Pilon fractures are especially amenable to dynamic traction. Preoperative detailsMore formal open reduction and internal fixation (ORIF) may be needed in fractures with comminution in which a more stable construct is necessary to allow early motion. Options for fixation include intraosseous wiring techniques, tension band wiring, intramedullary pinning, and plating. These all are associated with increased soft tissue disruption and should be reserved for more unstable fractures that cannot be managed with less invasive fixation. The authors favor using the midaxial approach when possible because implants placed laterally are less likely to interfere with flexor and extensor tendon function. External fixation is more commonly used as a temporary device for maintaining soft tissue balance and skeletal length in fractures with bone loss or contamination. Many of these fractures subsequently require bone grafting and internal fixation. Intraoperative detailsSeveral important intraoperative tips should be considered, including the following:
Postoperative detailsSee Treatment, Medical therapy, above. Follow-upDistal phalanx fracturesTuft fractures The DIPJ should be splinted in extension for 4 weeks with protection of the phalanx. Transverse/longitudinal fractures Remove pins at 3-4 weeks with the DIPJ splinted in extension. Manage nonoperatively treated fractures similarly to tuft fractures. Flexor digitorum profundus avulsions Repair is protected with a dorsal blocking splint with the wrist in 10° of flexion and the MCPJ in 80° of flexion. Several days after surgery, passive DIPJ flexion with the place and hold technique is instituted and continued for 4 weeks (if secure pullout fixation was obtained). Sutures and pins are removed at 4 weeks, and active motion is started with protection in a dorsal blocking splint. Splinting is discontinued at 6 weeks, and a 6-week lifting restriction for objects heavier than 10 pounds is initiated. Middle/proximal phalanx fracturesFollowing percutaneous pin fixation, use a dorsal block splint with straps that support the middle and proximal phalanges. The PIPJ should be freed 6 times a day to allow gentle passive range of motion. Pins are removed at 4 weeks, and progressive active motion is initiated. Cast padding can be placed between adjacent fingers if rotational control is a concern. In fractures treated with plates and/or screws, institute active motion as early as the fracture pattern allows. This decreases the risk of adhesion formation. PIPJ fracture/dislocationsThe pins are removed at 2-3 weeks, and a custom figure-of-eight splint blocking the terminal 20° of extension is fashioned. Splinting is continued for an additional 2 weeks. For heavy use or sports after 4 weeks, use buddy taping for an additional 4 weeks. COMPLICATIONSSection 8 of 11
Loss of motion Decreased motion may result from either tendon adhesions or joint contracture. Several factors increase the risk of poor motion, including extended immobilization past 4 weeks, severe soft tissue injury, intra-articular injury, and multiple fractures in the same finger. Management should start with an aggressive therapy program and can be aided with the use of serial splinting or casting. Surgery is indicated when soft tissue equilibrium has been reached and gains in motion have reached a plateau. Tenolysis is the treatment of choice for tendon adhesions, and capsulotomy should be utilized for joint contracture. Nonunion This is an uncommon complication of phalangeal fractures. Risk of nonunion rises with injuries involving severe soft tissue damage and bone loss. Consider surgical intervention at 3-4 months following injury. The nonunion site must be properly debrided prior to bone grafting. Fixation choices include K-wires or plates, followed by early motion as in acute fractures. Malunion Malunion is the most common complication and can take several forms, including malrotation, volar angulation, lateral angulation, shortening, and intra-articular malunion. Angular malunions most often are volar or lateral. Finger dexterity may be compromised if the malunion is greater than 20° Wedge osteotomies at the site of deformity are the treatment of choice. Rotational malunions can also impact finger function and grip strength. Corrective osteotomies may be performed at the phalangeal or metacarpal level. Fixation is usually accomplished with K-wires or minifragment screws. Shortening rarely is an indication for operative intervention, unless it is accompanied by another deformity. Intra-articular malunions are the most difficult to manage. Intra-articular osteotomies to realign the articular surface can be attempted but are technically demanding. The fundamentals of minimal soft tissue disruption and secure fixation to allow early motion are especially important with these osteotomies. Infection Infection is a very unusual complication in phalangeal fractures. Risk is increased in the presence of severe contamination, systemic illness, or delay in treatment greater than 24 hours. Flexor tendon rupture or entrapment This is an uncommon complication of phalangeal fractures and usually iatrogenic. It has been reported following both percutaneous pin fixation and plate fixation of these fractures. OUTCOME AND PROGNOSISSection 9 of 11
Outcome following phalangeal fractures depends on patient and injury factors, as well as surgical expertise. Poorer results have been documented with patients older than 50 years and with associated systemic illness. High-energy fractures with comminution and soft tissue injury also lead to poorer outcomes. Tendon injury, especially extensor tendon, in association with fracture, compromises results. Factors that the surgeon can control include selecting the appropriate fixation and assuring that immobilization does not exceed 3 weeks. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Broken Finger and Broken Hand. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
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