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Treatment of Phalangeal Fractures

  • Shannon Carpenter
    Affiliations
    Department of Orthopaedic Surgery, Oakland University William Beaumont School of Medicine, Beaumont Health System, 3535 West Thirteen Mile Road #742, Royal Oak, MI 48073, USA
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  • Rachel S. Rohde
    Correspondence
    Corresponding author. Michigan Orthopaedic Institute, P.C., 26025 Lahser Road, Second Floor, Southfield, MI 48033.
    Affiliations
    Department of Orthopaedic Surgery, Oakland University William Beaumont School of Medicine, Beaumont Health System, 3535 West Thirteen Mile Road #742, Royal Oak, MI 48073, USA
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Published:October 17, 2013DOI:https://doi.org/10.1016/j.hcl.2013.08.006

      Keywords

      Key points

      • Fractures involving the tubular bones of the hand are the most common skeletal injuries.
      • The primary goals of phalangeal fracture treatment are to restore anatomy and preserve function. Lost productivity attributed to these fractures exceeds $2 billion every year, making early return to activities a key goal as well.
      • The preferred method of treatment is one that offers limited soft tissue damage and enables mobilization of the injured digit(s) as soon as fracture stability permits.
      • Technical treatment of phalangeal fractures depends on characteristics of the fracture, requirements of the patient, and judgment of the treating physician. In general, operative treatment is reserved for unstable fractures or those creating unacceptable articular incongruity.
      • Optimal outcome from surgical treatment demands appropriate surgical plan, atraumatic soft tissue handling, and stable fixation to facilitate early motion; however, complications such as nonunion, malunion, infection, and stiffness can occur even in the setting of appropriate treatment.

      Introduction

      Philosophies regarding phalangeal fracture treatment have evolved over time. The principle of complete immobilization espoused by Sir Reginald Watson-Jones in 1943 remained uniformly accepted for many years.
      • Watson-Jones R.
      • Wilson J.N.
      It was not until 1962 that James proposed what is now known as the “safe position” for immobilization,
      • James J.I.
      Fractures of the proximal and middle phalanges of the fingers.
      also posing the question of whether complete immobilization of every hand fracture was necessary.
      • James J.I.
      The assessment and management of the injured hand.
      • Barton B.
      Fractures of the hand.
      Contemporaneously, Swanson
      • Swanson A.B.
      Fractures involving the digits of the hand.
      asserted that fractures of the hand can be complicated by deformity from no treatment, stiffness from overtreatment, and both deformity and stiffness from poor treatment. Ultimately, the primary objectives of phalangeal fracture treatment are to restore anatomy and preserve function. Given that the lost productivity associated with phalangeal fractures exceeds $2 billion per year,
      • Van Onselen E.B.
      • Karim R.B.
      • Hage J.J.
      • et al.
      Prevalence and distribution of hand fractures.
      a third goal is to minimize recovery time and expedite return to activity. The preferred treatment restores anatomy, minimizes soft tissue injury, and enables mobilization of the injured digit as soon as fracture stability permits.

      Treatment considerations

      Thorough clinical evaluation is required to determine the appropriate treatment course for each patient. The patient’s age, hand dominance, occupation, avocations, medical comorbidities (including tobacco use), goals, limitations, and tolerances are important factors for the treating physician to consider. The mechanism of injury and associated injuries also may dictate course of treatment. A careful examination, including clinical and radiographic evaluation is needed, and sometimes is supplemented with advanced medical imaging (eg, computed tomography).
      • Gaston R.G.
      • Chadderdon C.
      Phalangeal fractures: displaced/nondisplaced.
      • Kozin S.H.
      • Thoder J.J.
      • Lieberman G.
      Operative treatment of metacarpal and phalangeal shaft fractures.
      Acceptable alignment limitations vary based on the anatomic location of the fracture as well as the age of the patient, which suggests remodeling potential. However, one of the key general determinants of whether a fracture will require operative treatment is its inherent stability (Table 1).
      • Jupiter J.
      • Axelrod T.S.
      • Belsky M.R.
      Fractures and dislocations of the hand.
      Table 1Characteristics predictive of phalangeal fracture stability
      StableUnstable
      Anatomic locationDistal phalanxSubcondylar proximal phalanx
      Fracture characteristicsSimple, transverseShort oblique, spiral
      ImpactedComminuted
      DisplacementNone or minimalDisplaced, malrotated
      Articular incongruityNone or minimalIncongruous surface
      Soft tissue injuryMinimalSevere

      Treatment options

      A phalanx fracture can be addressed using one (or more) of several treatments based on clinical and radiographic assessment of the fracture and any associated injuries.

      Nonoperative Treatment

      A vast majority of phalangeal fractures can be managed nonoperatively.
      • Reyes F.A.
      • Latta L.L.
      Conservative management of difficult phalangeal fractures.
      • Maitra A.
      • Burdett-Smith P.
      The conservative management of proximal phalangeal fractures of the hand in an accident and emergency department.
      • Barton N.J.
      Fractures of the shafts of the phalanges of the hand.
      • Moberg E.
      Fractures and ligamentous injuries of the thumb and fingers.
      These include fractures that are incomplete, nondisplaced, or able to be reduced so that acceptable alignment and stability are maintained without operative fixation. Nonoperative treatments include the following:
      It is important to emphasize that “nonoperative” treatment is not without its pitfalls, and using the appropriate nonsurgical technique is as critical as using the appropriate operative one. The “safe” or “intrinsic plus” position of James
      • James J.I.
      The assessment and management of the injured hand.
      is used to prevent collateral ligament and volar plate contractures. The metacarpophalangeal joints (MPJs) are maintained at 70° of flexion and the proximal interphalangeal joints (PIPJs) in full extension (see Fig. 1). Exceptions to this are made when the position must be altered for treatment purposes (eg, dorsal block splinting of PIPJ fracture-dislocations).

      Operative Treatment

      Surgical treatment is necessary if the fracture pattern is unstable or if the fracture is intra-articular and creates an unacceptable articular incongruity (see Table 1).
      • Jupiter J.
      • Axelrod T.S.
      • Belsky M.R.
      Fractures and dislocations of the hand.
      Operative options and their potential uses are introduced in Table 2.
      • Gaston R.G.
      • Chadderdon C.
      Phalangeal fractures: displaced/nondisplaced.
      • Day C.
      • Stern P.
      Fractures of the metacarpals and phalanges.
      • Harman T.W.
      • Graham T.J.
      • Uhl R.L.
      Operative treatment of extra-articular phalangeal fractures.
      Table 2Operative techniques available for treatment of phalangeal fractures
      TechniquePrimary UsesAdvantagesDisadvantagesComplications
      K-wiresUnstable fractures amenable to closed reductionMinimal effect on soft tissue envelopeNeed for additional immobilization (cast/brace)

      Often delays mobilization
      Infection

      Loosening

      Pin migration

      Symptomatic hardware
      Intraosseous wiresTransverse fractures or articular avulsion fracturesPossible early mobilizationSoft tissue irritationSymptomatic hardware
      Tension band wiresAvulsion fracturesBiomechanically stable

      Early mobilization
      Increased operative exposure

      Technical difficulty
      Symptomatic hardware
      Compression screwsLarge intra-articular fragments

      Long oblique diaphyseal fractures
      Biomechanically stable

      Early mobilization
      Increased operative exposure

      Technical difficulty
      Fragmentation of fracture intraoperatively
      Open reduction internal fixation plate and screwsComplex periarticular or intra-articular fracturesMost stable fixationMost operative exposureProminent hardware
      Technical difficultyAdhesion formation
      External fixationOpen fractures with extensive soft tissue injuryLimits soft tissue injury

      Preserves length
      Potential interference with other digitsPin site infections

      Hardware failure
      Extensive bone loss or severe comminutionNonanatomic reduction

      Treatment of distal phalanx fractures

      Fractures of the distal phalanx constitute almost half of all hand fractures.
      • Gaston R.G.
      • Chadderdon C.
      Phalangeal fractures: displaced/nondisplaced.
      • Jupiter J.
      • Axelrod T.S.
      • Belsky M.R.
      Fractures and dislocations of the hand.
      • Schneider L.H.
      Fractures of the distal phalanx.
      Caused by crushing or axially loading mechanisms, these have been classified by the following:
      • Type of fracture (transverse, longitudinal split, or comminuted)
        • Jupiter J.
        • Axelrod T.S.
        • Belsky M.R.
        Fractures and dislocations of the hand.
      • Anatomically/soft tissue injury
        • Schneider L.H.
        Fractures of the distal phalanx.
      The authors prefer to consider these as extra-articular fractures of the tuft, shaft, or base, and intra-articular fractures.

      Distal Phalangeal Tuft Fractures

      Tuft fractures usually occur secondary to a crushing injury and are often associated with a laceration of the nail matrix, pulp, or both. “Closed” fractures, therefore, result in the formation of a subungual hematoma, which often is more painful than the fracture itself. In this case, decompression of the hematoma using a trephine or electrocautery will provide pain relief. This perforation of the nail bed converts a closed fracture into an open one and a short course of oral antibiotics should be considered as a result.
      • Day C.
      • Stern P.
      Fractures of the metacarpals and phalanges.
      • Sloan J.
      • Dove A.
      • Maheson M.
      • et al.
      Antibiotics in open fractures of the distal phalanx?.
      • Roser S.E.
      • Gellman H.
      Comparison of nail bed repair versus nail trephination for subungual hematomas in children.
      • Krusche-Mandl I.
      • Köttstorfer J.
      • Thalhammer G.
      • et al.
      Seymour fractures: retrospective analysis and therapeutic considerations.
      Open tuft fractures are less stable than closed fractures because the supporting pulp and nail plate are disrupted. Nevertheless, these rarely require internal fixation. Careful approximation of the associated lacerations of the pulp and nail matrix (following removal of the nail plate, if necessary) will restore alignment of the associated bony injury. Replacement of the nail plate or appropriate substitute beneath the eponychial fold prevents adherence of the fold to the matrix and serves as a splint for the fracture (Fig. 4). Rarely, a 0.028-inch Kirschner wire (K-wire) is used to support a fracture that remains unstable or displaced despite restoration of the soft tissue envelope.
      Figure thumbnail gr4
      Fig. 4An avulsed or extruded nail plate can be debrided and used as a biologic splint for distal phalanx and nail bed injuries. (A) The nail plate is prepared for reinsertion. (B) The nail plate is inserted beneath the eponychial fold and loosely sutured to prevent migration during the early postoperative period.
      A short (10–14-day) period of immobilization of the middle and distal phalanges will provide symptomatic relief and support of the fracture. Unrestricted PIPJ movement should be allowed to minimize subsequent motion loss. Radiographic delayed or nonunion frequently occurs, but symptom resolution is suggestive of fibrous union.
      Potential complications following distal phalangeal tuft injuries include persistent pain, infection, cold intolerance, altered sensibility, nail bed and nail deformity, malunion, and nonunion.
      • Schneider L.H.
      Fractures of the distal interphalangeal joint.

      Distal Phalangeal Shaft Fractures

      The distal phalangeal diaphysis generally fractures either longitudinally or transversely. Because of the inherent stability and minimal displacement of these fractures (Fig. 5), most require limited immobilization. Support is maintained until the patient’s comfort resolves or until radiographic union is evident.
      Figure thumbnail gr5
      Fig. 5Alignment of this longitudinal distal phalanx fracture resulting from crush injury is maintained by surrounding soft tissues and the nail plate.
      Open distal phalangeal shaft fractures are associated with disruption of the overlying nail matrix. As in treatment of an open tuft fracture, the nail should be removed, the fracture reduced, and the nail bed repaired with absorbable suture under loupe magnification. Although most of these fractures are supported adequately by the overlying (or replaced) nail plate, fractures that remain unstable can be supported by a 0.028-inch or 0.035-inch K-wire (Fig. 6). The distal phalanx and middle phalanx are splinted for 10 to 14 days.
      • Jupiter J.
      • Axelrod T.S.
      • Belsky M.R.
      Fractures and dislocations of the hand.
      Figure thumbnail gr6
      Fig. 6A small K-wire can be inserted percutaneously just below the hyponychium if fixation of distal phalanx fragments is needed.

      Distal Phalangeal Base Fractures

      Deforming forces of the flexor and extensor tendons and lack of intrinsic nail plate support render fractures at the base of the distal phalanx unstable. Because of these forces, the fracture tends to angulate with the apex pointing volarly (Fig. 7).
      Figure thumbnail gr7
      Fig. 7Flexion of the proximal fragment of a distal phalangeal base fracture is noted due to the deforming force of the FDP tendon.

      Fractures in the skeletally immature

      Although most pediatric fractures are beyond the scope of this text, 2 distinct physeal injury patterns occur in children and bear mentioning:
      • The Seymour fracture is a complete physeal separation that occurs from a hyperflexion injury.
        • Seymour N.
        Juxta-epiphysial fracture of the terminal phalanx of the finger.
        Typically seen in toddlers, this often is mistaken for a distal interphalangeal joint (DIPJ) dislocation or a mallet injury. The extensor tendon remains attached to the proximal ephiphyseal fragment while the unopposed flexor digitorum profundus (FDP) tendon pulls the remainder of the distal phalanx into flexion. A transverse laceration of the nail bed occurs, and the avulsed nail plate lies superficial to the proximal nail fold. Interposition of the germinal matrix within the distracted dorsal physis can prevent reduction.
        • Krusche-Mandl I.
        • Köttstorfer J.
        • Thalhammer G.
        • et al.
        Seymour fractures: retrospective analysis and therapeutic considerations.
        High suspicion and immediate recognition of this fracture pattern is imperative to prevent recurrent deformity, infection, residual nail deformity, DIPJ stiffness, and premature physeal closure.
        • Dolan M.
        • Water P.
        Fractures and Dislocations of the forearm, wrist, and hand.
      • Simple reduction without treatment of the soft tissue injury can result in loss of reduction and infection. After irrigation and debridement, the fracture is reduced using slight traction and manipulation of the distal fragment into extension. The nail matrix laceration is repaired and the nail plate replaced beneath the proximal nail fold. The use of K-wires should be avoided because these are associated with a higher risk of infection in these injuries.
        • Rider D.L.
        Fractures of the metacarpals, metatarsals, and phalanges.
        Although 30° of dorsal or volar angulation can be tolerated in a young child due to remodeling, it is preferable to attempt to regain anatomic reduction.
        • Jupiter J.
        • Axelrod T.S.
        • Belsky M.R.
        Fractures and dislocations of the hand.
        A splint or cast is applied to hold the distal fragment in extension for approximately 4 weeks.
      • Older children incur physeal injuries that resemble closed mallet injuries; the deformity, however, is due to dorsal physeal opening rather than extensor tendon disruption. Typically, closed reduction is easily achieved using gentle traction and extension of the distal fragment. Subsequent immobilization in a splint incorporated into a cast or a cast alone should be maintained for 4 weeks.
        • Dolan M.
        • Water P.
        Fractures and Dislocations of the forearm, wrist, and hand.

      Fractures in adults

      In adults, a closed fracture at the base of the distal phalanx is best treated by splinting the distal and middle phalanges with the distal interphalangeal joint extended for a minimum of 4 weeks. If the fracture is open, it is more likely to be rotationally unstable and may require K-wire insertion to provide internal stability. Penetration of the DIPJ usually can be avoided, however, if the proximal fragment is too small or too comminuted to allow adequate fixation, a transarticular K-wire can be used.

      Intra-articular Fractures of the Distal Phalanx

      Intra-articular fractures of the distal phalanx most commonly are encountered as avulsion fractures.
      • Mallet fractures occur when the dorsal base of the distal phalanx is avulsed by the attached extensor tendon (Fig. 8). In past years, several operative techniques have been used to restore the articular congruity of these fractures. However, closed treatment for 6 to 8 weeks in a DIPJ hyperextension splint results in excellent outcomes with fewer complications than operative treatment.
        • Moss J.G.
        • Steingold R.F.
        The long term results of mallet finger injury. A retrospective study of one hundred cases.
        • Handoll H.H.
        • Vaghela M.V.
        Interventions for treating mallet finger injuries.
        Figure thumbnail gr8
        Fig. 8Mallet fractures are treated as soft tissue injuries. Splinting of the DIPJ in extension or slight hyperextension allows restoration of DIPJ extension. These radiographs show reduction of the fracture fragment in the splinted position and subsequent healing without extensor lag. Radiographs are not necessary to confirm healing, which generally is assessed clinically.
      • FDP avulsion injuries (Jersey finger) can be associated with fracture when the FDP tendon avulses a fragment of the volar distal phalanx. This fracture fragment serendipitously can prevent proximal migration of the tendon through the pulley system. Open reduction and internal fixation (ORIF) of a large fragment might be considered (Fig. 9). Most fragments, however, are small, and are inconsequential when planning reinsertion of the FDP tendon into the distal phalanx.
        Figure thumbnail gr9
        Fig. 9Avulsion of a large fragment of the distal phalanx by the FDP tendon (bony Jersey finger) was treated by ORIF of the fragment to its distal phalanx insertion.

      Treatment of proximal and middle phalanx fractures

      Treatment decisions regarding proximal and middle phalanx fractures merit consideration of the following:
      • Anatomic location within the phalanx (head [condylar], neck, shaft, base)
      • Articular involvement
      • Stability of the fracture
      Inherently stable fractures generally are amenable to nonoperative treatment and protected early mobilization. Unstable fractures or those associated with articular incongruity are candidates for operative intervention.

      Proximal and Middle Phalangeal Condylar (Intra-Articular) Fractures

      Because of their articular involvement and tendency for rotational displacement, fractures of the condylar architecture of the phalangeal head can result in pain, deformity, and loss of motion. Any displacement of a condylar fracture is an indication for operative management.
      • Day C.
      • Stern P.
      Fractures of the metacarpals and phalanges.
      • Weiss A.P.
      • Hastings H.
      Distal unicondylar fractures of the proximal phalanx.
      • Henry M.
      Hand fractures and dislocations.
      Condylar fractures can be classified into the following 3 categories depending on their severity and stability
      • Jupiter J.
      • Axelrod T.S.
      • Belsky M.R.
      Fractures and dislocations of the hand.
      • Harman T.W.
      • Graham T.J.
      • Uhl R.L.
      Operative treatment of extra-articular phalangeal fractures.
      :
      • Type I Condylar Fractures
        • Stable and nondisplaced
        • Can be treated nonoperatively in a digital splint for 7 to 10 days followed by buddy taping and protected mobilization
        • Weekly radiographs are useful to monitor for displacement
      • Type II Condylar Fractures
        • Unicondylar fractures are inherently unstable fractures that result from shearing forces
        • Closed reduction with or without assistance of a manipulative K-wire, compression using a pointed reduction clamp, and percutaneous K-wire fixation or percutaneous screw fixation is preferable if possible to avoid disruption of the tenuous vascular supply
        • Multiple screws or K-wires are necessary to prevent rotation and loosening
        • Superimposition of the condyles on a true lateral radiograph confirms restoration of alignment
        • ORIF is reserved for displaced fractures not amenable to closed reduction (see later in this article)
        • Stable fixation allows early motion, and the PIPJ is splinted in extension, when not in motion, to prevent extensor lag
      • Type III Condylar Fractures
        • Bicondylar or comminuted
        • Require ORIF, first of the condyles to each other using K-wires or screw, followed by fixation of the reassembled head to the diaphysis
        • A minicondylar plate can be used if needed
        • In the case of significant comminution of the condyles and/or the adjacent metaphysis, external fixation can be considered
      Technical Pearls Specific to Open Treatment of Phalangeal Condyle Fracture:
      • The condyle is approached dorsally by using a Chamay approach
        • Chamay A.
        A distally based dorsal and triangular tendinous flap for direct access to the proximal interphalangeal joint.
        or the interval between the extensor tendon/central slip and lateral band
      • Before reduction, the condylar fragment dimensions are evaluated to determine appropriate screw size and the insertion of the collateral ligament is identified
      • The fragment is reduced under direct visualization and fixed provisionally using a 0.028-inch K-wire
      • A 1.5-mm headless compression screw is placed just dorsal and proximal to the origin of the collateral ligament to preserve the vascular supply
      • A mincondylar blade plate can be used as a neutralization or buttress plate if there is metaphyseal or diaphyseal extension of the fracture

      Proximal and Middle Phalangeal Neck Fractures

      These fractures are far more common in children than in adults.
      • Al-Qattan M.M.
      Phalangeal neck fractures in children: classification and outcome in 66 cases.
      Adult fractures usually are amenable to closed reduction and splinting or crossed K-wire fixation.
      • Al-Qattan M.M.
      Phalangeal neck fractures in adults.
      • Al-Qattan M.M.
      Phalangeal neck fractures of the proximal phalanx of the fingers in adults.
      Phalangeal neck fractures in children are divided into the following:
      • Type I: Nondisplaced fractures are treated nonoperatively in a splint for 4 weeks. Bony union and full range of motion without residual deformity is common.
      • Type II: Displaced fractures with persistent bone-to-bone contact account for about 70% of these fractures. Treatment and outcome depend greatly on initial presentation and management. These fractures are unstable and maintaining reduction often requires K-wire fixation. However, the authors note that these frequently present late (as “finger jams”) with radiographic evidence of some healing. It is controversial whether these should be manipulated or left to remodel at that point, but the authors observationally have found that these fractures remodel quite well in young children (Fig. 10).
        Figure thumbnail gr10
        Fig. 10Phalangeal neck fractures often present late, as in the case of this 6-year-old, whose fracture was partially healed 3 weeks following injury (left). Operative treatment was not chosen because of the likelihood of devascularization of the phalangeal head. Closed treatment in a cast resulted in some remodeling even 3 weeks later (right).
      • Type III: Completely displaced fractures often demonstrate rotation of the distal fragment up to 180°; these are treated with ORIF using K-wire fixation.

      Proximal and Middle Phalangeal Shaft Fractures

      Nondisplaced fractures of the phalangeal diaphysis, particularly those that are incomplete, are stable (Fig. 11).
      • Gaston R.G.
      • Chadderdon C.
      Phalangeal fractures: displaced/nondisplaced.
      • Reyes F.A.
      • Latta L.L.
      Conservative management of difficult phalangeal fractures.
      Fractures that are displaced initially can be classified following closed reduction as stable, unstable because of fracture obliquity (spiral, oblique, or transverse), or unstable because of significant bone loss.
      Figure thumbnail gr11
      Fig. 11Incomplete fractures of the phalanx are treated successfully with symptomatic protection, buddy taping, and early mobilization in an adult (A) and in a child (B).
      The initial degree of displacement is more predictive of stability than the direction or number of fracture planes.
      • Kozin S.H.
      • Thoder J.J.
      • Lieberman G.
      Operative treatment of metacarpal and phalangeal shaft fractures.
      Even crush injuries without significant displacement are relatively more stable than less comminuted fractures if the periosteal sleeve is maintained.
      • Henry M.
      Hand fractures and dislocations.
      In terms of obliquity, a transverse fracture is inherently more stable than spiral or long oblique fractures, which tend to angulate, rotate, or shorten with the deforming forces affecting the phalanx.
      Stable fractures can be treated with buddy taping and early mobilization. Fractures that are unstable after reduction or have great potential to displace must be treated operatively or at minimum followed closely to prevent malunion and subsequent malfunction.
      Unstable transverse fractures can be treated with percutaneous fixation or ORIF with plates and screws. The nature of the phalangeal shaft is such that crossed K-wire fixation can be difficult, depending on the configuration of the fracture. The authors prefer to use a retrograde intramedullary K-wire for unstable transverse middle phalanx fractures or a transarticular intramedullary K-wire across the MPJ for unstable transverse proximal phalanx fractures. This prevents translation, while buddy strapping of the digit to its neighbor helps maintain rotational stability.
      • Gaston R.G.
      • Chadderdon C.
      Phalangeal fractures: displaced/nondisplaced.
      Unstable spiral or long oblique fractures can be stabilized by placing K-wires or compression screws across the fracture site (see Technique: Compression Screws). The screw diameter should be less than one-third of the length of the fracture line, and multiple screws are placed to maintain stability. Percutaneous screw fixation is an option, but requires perfect closed reduction; if this cannot be achieved or confirmed, then open reduction before screw fixation is preferred.
      • Harman T.W.
      • Graham T.J.
      • Uhl R.L.
      Operative treatment of extra-articular phalangeal fractures.
      • Horton T.C.
      • Hatton M.
      • Davis T.R.
      A prospective randomized controlled study of fixation of long oblique and spiral shaft fractures of the proximal phalanx: closed reduction and percutaneous Kirschner wiring versus open reduction and lag screw fixation.
      If stable fixation is achieved, digital motion can be initiated immediately as comfort allows. Protective splinting is suggested to prevent extensor lag and accidental reinjury.
      • Day C.
      • Stern P.
      Fractures of the metacarpals and phalanges.
      • Orbay J.L.
      • Touhami A.
      The treatment of unstable metacarpal and phalangeal shaft fractures with flexible nonlocking and locking intramedullary nails.
      • Balaram A.K.
      • Bednar M.S.
      Complications after the fractures of metacarpal and phalanges.

      Proximal and Middle Phalangeal Base Fractures

      Fractures of the proximal and middle phalangeal bases can be either extra-articular or intra-articular:
      • Proximal Phalangeal Base: Intra-articular result from ligamentous avulsions, crush, or rotation. Operative treatment is considered if the fragment interferes with joint motion or if joint stability is compromised.
        • Shewring D.J.
        • Thomas R.H.
        Avulsion fractures from the base of the proximal phalanges of the fingers.
        Most ligament avulsions can be treated successfully with buddy taping or functional bracing of the affected digit to its neighboring digit (Fig. 12A ). Joint instability at the ulnar aspect of the thumb metacarpophalangeal joint (MCPJ) (“boney gamekeeper”) or the radial aspect of the index MCPJ is poorly tolerated and fixation of the fracture fragment versus debridement and ligament repair should be considered. Intra-articular injuries that involve significant joint incongruity and/or are unstable should be treated operatively (see Fig. 12B).
        Figure thumbnail gr12
        Fig. 12(A) This intra-articular avulsion fracture at the base of the proximal phalanx was treated by functional bracing and buddy taping, rendering stability of the joint without pain despite the apparent incongruity. (B) This intra-articular fracture at the base of the proximal phalanx created significant articular incongruity and is considered unstable due to obliquity. This was treated with ORIF using compression screw technique.
      • Proximal Phalangeal Base: Extra-articular are relatively common.
        • Chung K.C.
        • Spilson S.V.
        The frequency and epidemiology of hand and forearm fractures in the United States.
        • Feehan L.M.
        • Sheps S.B.
        Incidence and demographics of hand fractures in British Columbia, Canada: a population-based study.
        They result in an apex volar angulation seen on a lateral radiograph; unfortunately, this might remain unrecognized following attempted closed reduction because the fracture site is obscured by plaster or fiberglass. Although stability sometimes can be achieved following closed reduction, the chance of loss of reduction is high.
        • Coonrad R.W.
        • Pohlman M.H.
        Impacted fractures in the proximal portion of the proximal phalanx of the finger.
        If acceptable reduction cannot be maintained, crossed K-wires inserted through the dorsal proximal phalangeal base, crossing the fracture site, and purchasing the cortex of the distal fragment are helpful (Fig. 13). The hand is splinted in the position of function with unobstructed interphalangeal joint (IPJ) motion until radiographic healing is noted (4 to 6 weeks), at which time the K-wires are removed and range of motion exercises instituted.
        Figure thumbnail gr13
        Fig. 13Fractures at the base of the proximal phalanx are most easily noted on the lateral and oblique radiographic views. Closed reduction can be maintained using crossed K-wires. These are removed in the office setting at 4 to 6 weeks postoperatively and range-of-motion activities are instituted.
      • Middle Phalangeal Base: Intra-articular
        • Partial articular
          • Dorsal: Avulsion fractures of middle phalanx by the central slip (Fig. 14) can be treated with closed reduction and dynamic extension splinting of the PIPJ. If closed reduction fails, operative fixation of the fracture fragment or tendon reinsertion is considered.
            Figure thumbnail gr14
            Fig. 14The central slip attachment to the dorsal base of the middle phalanx can result in avulsion of part of the articular surface, as seen in this lateral radiograph.
          • Volar: Volar plate avulsion fractures most often involve only a small fragment of the middle phalangeal base avulsed by the detached volar plate. Resulting from hyperextension injuries or dorsal dislocations, nonoperative treatment consists of buddy taping or, if there is a potential for redislocation, dorsal block splinting. Active range-of-motion exercises are initiated early to minimize stiffness and edema. Instability of the joint results when the fracture fragment involves more than 40% of the articular surface.
            • Schenck R.R.
            Classification of fractures and dislocations of the proximal interphalangeal joint.
            In this case, volar plate arthroplasty, ORIF (Fig. 15), or hemihamate autograft procedures are indicated to restore joint congruity and stability.
            Figure thumbnail gr15
            Fig. 15This unstable articular fracture of the middle phalangeal base was treated via ORIF using three 1.0-mm screws.
          • Lateral middle phalanx fractures usually are ligamentous avulsion fractures; unless there is unacceptable joint congruity, these are treated with buddy taping and early range of motion.
        • Complete articular, pilon, impaction, and lateral plateau fractures can occur at the base of the middle phalanx. These create unacceptable articular congruity and are treated with ORIF, external fixation, or reconstruction arthroplasty.
          • Harman T.W.
          • Graham T.J.
          • Uhl R.L.
          Operative treatment of extra-articular phalangeal fractures.
          • Henry M.
          Hand fractures and dislocations.
          • Calfee R.P.
          • Kiefhaber T.R.
          • Sommerkamp T.G.
          • et al.
          Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations.
          • Inanami H.
          • Ninomiya S.
          • Okutsu I.
          • et al.
          Dynamic external finger fixator for fracture dislocation of the proximal interphalangeal joint.
          • Parsons S.W.
          • Fitzgerald J.A.
          • Shearer J.R.
          External fixation of unstable metacarpal and phalangeal fractures.
          • Geissler W.B.
          Operative fixation of metacarpal and phalangeal fractures in athletes.
          • Stern P.J.
          Management of fractures of the hand over the last 25 years.
          • Slade J.F.
          • Baxamusa T.H.
          • Wolfe S.W.
          External fixation of proximal interphalangeal joint fracture-dislocations.
          • Kuhn K.M.
          • Dao K.D.
          • Shin A.Y.
          Volar A1 pulley approach for fixation of avulsion fractures of the base of the proximal phalanx.
          • Hastings H.
          • Carroll C.
          Treatment of closed articular fractures of the metacarpophalangeal and proximal interphalangeal joints.

      Surgical Approaches for ORIF of Proximal and Middle Phalangeal Fractures

      When necessary, open approach to the proximal or middle phalanx can be accomplished via dorsal, midaxial, or dorsolateral longitudinal skin incisions.
      • Catalano L.W.
      • Zlotolow D.A.
      • Purcelli Lafer M.
      • et al.
      Surgical exposures of the wrist and hand.
      Rarely, a volar approach is necessary to address intra-articular fractures at the volar base of the middle phalanx. Gentle dissection and thoughtful technique is recommended to minimize soft tissue disruption. Preserving vascular supply will promote union, and minimizing tendon manipulation is thought to decrease adhesion formation.
      • Balaram A.K.
      • Bednar M.S.
      Complications after the fractures of metacarpal and phalanges.
      Stable fixation will allow early mobilization, which also can help prevent tendon adhesions.
      • Kurzen P.
      • Fusetti C.
      • Bonaccio M.
      • et al.
      Complications after plate fixation of phalangeal fractures.
      Repair of periosteum to protect gliding surfaces and repair of the extensor tendon mechanism are critical to ensure a reasonable functional outcome.
      • Jupiter J.
      • Axelrod T.S.
      • Belsky M.R.
      Fractures and dislocations of the hand.

      Dorsal Approach to the Phalanx

      • A midline dorsal incision is made, and the dorsal veins are preserved.
        • Bickel K.D.
        The dorsal approach to silicone implant arthroplasty of the proximal interphalangeal joint.
      • The extensor mechanism is divided longitudinally. Alternatively, in the dorsolateral approach, an interval is created between the extensor tendon/central slip and the lateral band. The extensor tendon can be elevated and retracted ulnar or radially; this can be facilitated by an incision of the transverse retinacular ligament at the PIPJ.
      • PIPJ exposure may require additional approach:
        • Tendon splitting, in which the central slip insertion is reflected but remains attached to the periosteum
        • Chamay
          • Chamay A.
          A distally based dorsal and triangular tendinous flap for direct access to the proximal interphalangeal joint.
          approach, in which the central tendon is divided at the level of the proximal phalanx and the tendon flap with intact central slip insertion is reflected distally

      Midaxial Approach to the Phalanx

      The midaxial approach allows exposure of the lateral phalanges, IPJs, and collateral ligaments for fracture fixation and PIPJ arthroplasty.
      • Catalano L.W.
      • Zlotolow D.A.
      • Purcelli Lafer M.
      • et al.
      Surgical exposures of the wrist and hand.
      • Field L.D.
      • Freeland A.E.
      • Jabaley M.E.
      Midaxial approach to the proximal phalanx for fracture fixation.
      • Carlson M.G.
      • Szabo R.
      • Lipscomb P.
      Principles of hand surgery and surgical approaches to the hand and wrist.
      It is indicated for oblique, spiral, comminuted, or transverse fractures of the diaphysis and metaphysis. It provides visualization of phalangeal fractures for placement of internal fixation (either screws or plates) on the radial or ulnar aspect of the bone. Hardware is less likely to interfere with tendon gliding in the midaxial than in a dorsal or palmar position.
      • The digit is flexed and the dorsal aspect of each flexion crease is marked with a dot. The digit is extended and these markings are connected to create the incisional marking. The digital artery and nerve will lie palmar to this line.
      • The skin is incised, the soft tissues dissected, and Clelands ligaments are divided to expose the neurovascular bundle. The neurovascular bundle is maintained in the palmar flap and the periosteum of the phalanx can be visualized. Palmarly, the flexor tendon sheath can be identified.
      • Two structures limit the proximal dissection of this approach: the dorsal branch of the digital nerve and the lateral band. The nerve should be identified and protected as it travels palmar to dorsal over the proximal phalanx. The lateral band may be incised longitudinally or even excised for better exposure of the proximal phalanx. Repair is optional if the contralateral lateral band is intact.

      Volar Approach to the Middle Phalangeal Base

      The volar approach to the middle phalangeal base (or the PIPJ) is reserved primarily to address PIPJ fracture-dislocations (also discussed in the article “Intra-Articular Fractures” by Lawton elsewhere in this issue)
      • Henry M.
      Hand fractures and dislocations.
      • Catalano L.W.
      • Zlotolow D.A.
      • Purcelli Lafer M.
      • et al.
      Surgical exposures of the wrist and hand.
      :
      • A modified Brunner incision is made centered over the PIPJ.
      • A thick flap of soft tissue is elevated and retracted to reveal the flexor tendon within the pulley system.
      • The A3 pulley is incised and reflected, allowing retraction of the FDS and FDP tendons radially and/or ulnarly.
      • The volar plate may already be avulsed (as in an acute PIPJ fracture dislocation pending volar plate arthroplasty or acute fracture) or remain healed to the middle phalanx (as in chronic or pilon injuries). If necessary, reflection of the volar plate from the base of the middle phalanx allows visualization of the base of the middle phalanx.
      • Further middle phalangeal base exposure is facilitated by release of the collateral ligaments in anticipation of “shotgunning” the joint in preparation for ORIF or hemihamate autograft placement (Fig. 16).
        Figure thumbnail gr16
        Fig. 16The volar approach usually is used to treat volar intra-articular injuries. Here, the volar approach was used as described, allowing “shotgunning” of the joint in preparation for hemi-hamate autograft reconstruction.
      • Following fixation, the volar plate is repaired, the tendons realigned within the pulley system, and the skin is closed with interrupted nylon sutures.

      Specific surgical techniques

      K-wire Insertion into Distal Phalanx

      The tuft of the distal phalanx lies just volar to the sterile matrix. Hence, the starting point for a retrograde K-wire is just volar to the hyponychial fold (see Fig. 6). If the initial pass of the wire is unsatisfactory, leaving the errant wire in place temporarily while passing the next can prevent the second wire from taking that initial course. The distal tip of the exposed wire can be truncated beneath the skin or bent, truncated, and covered with a protective cap until later removal.

      K-wire Cross-Pinning

      Crossed K-wire fixation is one of the most useful methods of fixation of phalangeal fractures. Confirmation of anticipated insertion point and direction are made with the use of fluoroscopic imaging. The fracture is crossed by multiple K-wires to promote rotational and translational stability (Fig. 17). Although K-wires have the potential for migration, careful bending, truncating, and protecting the end will help prevent this from becoming an issue. A useful technique also is to drive the sharp end of the K-wire through the far cortex, through the skin, truncate the sharp tip, and draw it back to the appropriate length. This can minimize symptomatic irritation of soft tissues by the sharp point should the K-wire move. This fixation generally is supplemented by a cast or brace; patients wearing a removable brace are able to shower with running water over the pins but should be cautioned against soaking in standing water to prevent infection.
      Figure thumbnail gr17
      Fig. 17K-wires are inserted in a crossed fashion, aiming to achieve multidirectional stability and maintain reduction.

      Intraosseous Wiring

      Intraosseous wiring involves passing a 26-gauge wire transversely across the fracture line dorsal to the midaxis and looping it around oblique K-wires to help neutralize the rotational forces. Although excellent success has been reported using this technique for transverse fractures and replants,
      • Zimmerman N.B.
      • Weiland A.J.
      Ninety-ninety intraosseous wiring for internal fixation of the digital skeleton.
      it has become less popular in recent years.

      Tension Band Wiring

      Tension band wiring entails inserting K-wires across the fracture site and using supplemental 26-gauge wire looped around the protruding K-wire ends to create a compressive force at the fracture site. Useful for avulsion fractures, its popularity also has decreased, possibly supplanted by the availability of suture anchors.

      Compression Screws

      Despite widespread familiarity of surgeons who treat fractures with compression screw fixation, the unique anatomic considerations in the phalanges (gliding structures, thin cortices, and small fracture fragments with tenuous vascular supplies) render compression screw fixation one of the more technically difficult methods of phalanx fracture surgery. However, the stability achieved affords the option of immediate mobilization, a distinct advantage over some other methods. The following general principles of compression screw placement apply:
      • The screw diameter should not exceed one-third of the length of the fracture.
      • In the diaphysis, the fracture line itself should be at least twice the diameter of the bone.
      • At least 2 and preferably 3 screws should cross the fracture site to provide multiplanar stability (see Fig. 13B).
      • The fracture reduction should be held by either K-wires or a clamp. The tap drill, equal to the core diameter for the chosen screw size, is used to drill both the near and far cortices along a line halfway between a perpendicular to the phalangeal shaft and a perpendicular to the fracture line. The near cortex is then overdrilled with a drill bit that is the same size as the screw’s outer diameter to create a gliding hole. The screw is placed in a lag fashion to provide compression of the fracture site.
        • Harman T.W.
        • Graham T.J.
        • Uhl R.L.
        Operative treatment of extra-articular phalangeal fractures.
        • Henry M.
        Hand fractures and dislocations.
        • Perren S.M.
        • Allgöwer M.
        • Osteosynthesefragen A.F.
        Manual of internal fixation: techniques recommended by the AO-ASIF Group.
      • It is not recommended to countersink the screw head in the metaphysis because of the thin cortex.
        • Harman T.W.
        • Graham T.J.
        • Uhl R.L.
        Operative treatment of extra-articular phalangeal fractures.

      ORIF Plate and Screws

      As in compression screw fixation, ORIF using a small plate and screws is technically difficult but can provide unparalleled restoration of anatomy with stability to allow immediate motion (Fig. 18). T plates are typically used for phalanx fractures.
      • Harman T.W.
      • Graham T.J.
      • Uhl R.L.
      Operative treatment of extra-articular phalangeal fractures.
      The plate is aligned perpendicular to the joint line and secured with a single screw. The distal portion of the fracture is then brought into alignment and secured with an additional screw. The length, angulation, and rotation are all assessed radiographically and clinically before filling the plate with the remaining screws. Plate placement is relevant to outcome in the phalanx. Lateral plate placement effectively resists compressive forces and has less disruption to the extensor mechanism and potentially less risk of adhesions
      • Lins R.E.
      • Myers B.S.
      • Spinner R.J.
      • et al.
      A comparative mechanical analysis of plate fixation in a proximal phalangeal fracture model.
      than dorsal plating. If a plate is applied to the dorsal surface, care must be taken to avoid damaging the flexor tendons with screws that are overdrilled.
      Figure thumbnail gr18
      Fig. 18This unstable intra-articular fracture at the base of the proximal phalanx required early motion and was too comminuted for simple screw fixation. Therefore, a buttress plate and screws were used.
      (Courtesy of Jennifer M. Wolf, MD Farmington, CT)

      External Fixation

      External fixation of phalangeal fractures is useful if there is extensive comminution requiring distraction or if there is significant soft tissue disruption precluding internal fixation.
      • Parsons S.W.
      • Fitzgerald J.A.
      • Shearer J.R.
      External fixation of unstable metacarpal and phalangeal fractures.
      • Slade J.F.
      • Baxamusa T.H.
      • Wolfe S.W.
      External fixation of proximal interphalangeal joint fracture-dislocations.
      Although rarely needed, the authors prefer using the dynamic external fixator described by Ruland and colleagues.
      • Ruland R.T.
      • Hogan C.J.
      • Cannon D.L.
      • et al.
      Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal interphalangeal joint.

      Complications

      Complications can arise with either nonoperative or operative management of phalangeal fractures. Potential complications include delayed union, nonunion, malunion, soft tissue adhesions, joint contractures, infection, posttraumatic arthritis, hardware issues, and tendon rupture.
      • Henry M.
      Hand fractures and dislocations.
      • Balaram A.K.
      • Bednar M.S.
      Complications after the fractures of metacarpal and phalanges.
      • Kurzen P.
      • Fusetti C.
      • Bonaccio M.
      • et al.
      Complications after plate fixation of phalangeal fractures.
      • Page S.M.
      • Stern P.J.
      Complications and range of motion following plate fixation of metacarpal and phalangeal fractures.

      Authors’ Preferred Method of Treatment

      The authors treat phalangeal fractures guided by the principles of restoring anatomy to maximize function. In general, this entails minimizing joint stiffness and pain by restoring articular congruity, minimizing digit deformity and malrotation by addressing phalangeal shortening and angulation, and preventing functional loss by achieving early mobilization without compromising fracture stability. In most cases, this can be accomplished without surgery. However, in the case of an unstable fracture or one that unacceptably disrupts the articular surface, operative fixation balancing the goals of fracture healing, soft tissue preservation, and early return to function is preferred.

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