- •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.
|Anatomic location||Distal phalanx||Subcondylar proximal phalanx|
|Fracture characteristics||Simple, transverse||Short oblique, spiral|
|Displacement||None or minimal||Displaced, malrotated|
|Articular incongruity||None or minimal||Incongruous surface|
|Soft tissue injury||Minimal||Severe|
|K-wires||Unstable fractures amenable to closed reduction||Minimal effect on soft tissue envelope||Need for additional immobilization (cast/brace)|
Often delays mobilization
|Intraosseous wires||Transverse fractures or articular avulsion fractures||Possible early mobilization||Soft tissue irritation||Symptomatic hardware|
|Tension band wires||Avulsion fractures||Biomechanically stable|
|Increased operative exposure|
|Compression screws||Large intra-articular fragments|
Long oblique diaphyseal fractures
|Increased operative exposure|
|Fragmentation of fracture intraoperatively|
|Open reduction internal fixation plate and screws||Complex periarticular or intra-articular fractures||Most stable fixation||Most operative exposure||Prominent hardware|
|Technical difficulty||Adhesion formation|
|External fixation||Open fractures with extensive soft tissue injury||Limits soft tissue injury|
|Potential interference with other digits||Pin site infections|
|Extensive bone loss or severe comminution||Nonanatomic reduction|
Treatment of distal phalanx fractures
- •Type of fracture (transverse, longitudinal split, or comminuted)
- •Anatomically/soft tissue injury16
Distal Phalangeal Tuft Fractures
Distal Phalangeal Shaft Fractures
Distal Phalangeal Base Fractures
Fractures in the skeletally immature
- •The Seymour fracture is a complete physeal separation that occurs from a hyperflexion injury.21Typically 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.19High suspicion and immediate recognition of this fracture pattern is imperative to prevent recurrent deformity, infection, residual nail deformity, DIPJ stiffness, and premature physeal closure.22
- •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.23Although 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.
- •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.22
Fractures in adults
Intra-articular Fractures of the Distal Phalanx
- •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.24,25
- •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.
Treatment of proximal and middle phalanx fractures
- •Anatomic location within the phalanx (head [condylar], neck, shaft, base)
- •Articular involvement
- •Stability of the fracture
Proximal and Middle Phalangeal Condylar (Intra-Articular) 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
- •The condyle is approached dorsally by using a Chamay approach28or 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
- •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).
- •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
Proximal and Middle Phalangeal Base Fractures
- •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.35Most 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).
- •Proximal Phalangeal Base: Extra-articular are relatively common.36,37They 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.38If 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.
- •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.
- ▪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.39In this case, volar plate arthroplasty, ORIF (Fig. 15), or hemihamate autograft procedures are indicated to restore joint congruity and stability.
- ▪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.15,27,40,41,42,43,44,45,46,47
Surgical Approaches for ORIF of Proximal and Middle Phalangeal Fractures
Dorsal Approach to the Phalanx
- •A midline dorsal incision is made, and the dorsal veins are preserved.50
- •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
- ○Chamay28approach, 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 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
- •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).
- •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
Tension Band Wiring
- •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.15,27,54
- •It is not recommended to countersink the screw head in the metaphysis because of the thin cortex.15
ORIF Plate and Screws
Authors’ Preferred Method of Treatment
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The authors have nothing to disclose with relation to this publication.