Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Phalanx Fracture

Basics
Description
  • A phalanx fracture is a break in 1 or more phalanges in the fingers.
  • Finger fractures are classified by:
    • Which phalanx is involved
    • Location within the phalanx
    • Pattern
    • Complexity
    • Open or closed
    • Stable or unstable to motion
Epidemiology
  • Fractures of the metacarpals and the phalanges are common.
  • Occur among all ages
  • Common causes vary substantially with age.
Incidence
The reported incidence varies because patients with phalanx fractures present to a variety of medical practitioners.
 
Risk Factors
Involvement in a sport, job, or hobby that involves power tools or machinery.
 
Etiology
  • The specific cause depends on patient age.
    • Children >10 years old: Compression
    • Adolescents and young adults 10-39 years old: Sports
    • Adults 30-69 years old: Machinery
    • Elderly persons (>60 years old): Falls
  • Other causes include crush injury and motor vehicle accidents.
  • The most common cause of a distal phalanx fracture is a crush injury.
  • The most likely cause of a transverse or comminuted fracture is a direct blow.
  • The most common cause of an oblique or spiral fracture is a twisting injury.
Associated Conditions
Possible additional fractures in the hand and upper extremity
 
Diagnosis
Signs and Symptoms
  • Pain, swelling, or deformity after some trauma to the finger
  • Laceration
  • Decreased ROM
  • Numbness of the affected digit
History
  • Determine the mechanism of injury and where it occurred (whether in a clean or dirty environment).
  • Determine how much time has elapsed since the injury.
  • Ascertain the patient’s age, hand dominance, occupation, and hobbies.
Physical Exam
  • Assess and document the patient’s neurovascular status.
  • Determine the precise area of tenderness and whether any lacerations and possible open fractures are present.
  • Evaluate for injury to soft tissues, including tendons, ligaments, nerves, and blood vessels.
  • Evaluate the digit for length, rotation, and angular alignment by comparing the appearance of the injured digit with that of adjacent digits.
  • Assess the nail plate by comparing with those of the surrounding digits.
Tests
Imaging
  • Radiography:
    • AP and lateral views of the finger should be obtained.
    • Oblique views assess intra-articular fractures.
  • Low-kilovolt mammography film is recommended as an initial screening test for a foreign body (e.g., wood splinter, glass) because many foreign bodies are not visible on plain film.
  • CT is the preferred method for detecting wood and thorns.
  • MRI detects all types of foreign bodies except gravel.
Pathological Findings
  • Proximal shaft fractures are angulated palmarly.
    • The proximal fragment is flexed because of interossei pull and the distal fragment is extended because of central slip insertion.
  • Digital function is impaired not only by fracture stability or deformity, but also by concomitant injury to soft tissues, including tendons, ligaments, blood vessels, and nerves.
  • Injury to soft-tissue structures is common.
Differential Diagnosis
Pathologic fracture, most commonly with an enchondroma (benign cartilage tumor)
 
Treatment
General Measures
  • Most fractures can be treated nonsurgically with closed reduction, splinting, and early motion.
  • Surgery is indicated for:
    • All displaced intra-articular fractures
    • Unstable fractures associated with severe soft-tissue injury
    • A fracture that remains unstable after closed reduction
    • A rotational deformity
  • >25° of palmar angulation causes functional deficits and cosmetic deformity and should be corrected surgically.
  • Nondisplaced and impacted transverse fractures of the phalanges are managed ideally with buddy taping, in which 2 fingers are taped together so that 1 acts as a splint for the other.
    • The fracture must truly be stable with minimal angulation in any plane.
  • Closed reduction and splinting:
    • Use digital nerve block for anesthesia.
    • Manipulate the distal fragment to align with the proximal fragment.
    • Place the splint.
    • The fracture must be stable after reduction for the splint to maintain reduction.
    • Splint the hand in the intrinsic plus position, with the MCP joints at 90° of flexion and the IP joints in full extension.
    • Use a gutter splint for the involved fingers.
Activity
  • Immobilize unstable closed fractures for 3-4 weeks.
  • Children tolerate immobilization better than adults, and adults will likely have more joint stiffness.
Special Therapy
Physical Therapy
  • To prevent stiffness, the patient is encouraged to perform ROM exercises as soon as possible for all fingers not included in the splint.
  • Digital performance deteriorates when active ROM is delayed >3 weeks.
  • Soft-tissue mobilization with active motion is initiated once clinical healing is achieved (as evidenced by minimally tender fracture site that is not painful when manipulated), usually at 3-4 weeks.
  • The radiographic appearance of union lags behind clinical union.
  • ROM exercises for the involved fingers usually are initiated at 2-4 weeks after surgery.
Medication
First Line
  • NSAIDs or acetaminophen usually are sufficient for finger fractures.
  • Opioid medicines may be necessary for severe pain.
Surgery
  • Indications:
    • Failure of closed reduction to maintain rotation, length, or angular alignment
    • Intra-articular fracture in which joint congruity is lost, resulting in small joint dysfunction
    • Unstable fractures associated with severe soft-tissue injury in which fracture instability precludes a normal soft-tissue rehabilitation program
    • Rotational deformity
  • Distal tuft fractures may be treated with nail repair.
    • Pinning may be necessary.
  • Shaft fractures may be stabilized with Kirschner wires, lag screws, miniplates, or intramedullary devices.
  • The direct visualization afforded by an open approach permits more accurate reduction and adequate implant application.
  • Intra-articular volar fractures may be pinned or treated with volar plate arthroplasty.
  • Tension banding can supplement fixation, especially for small, less stable fragments.
  • Segmental defects should be treated with open reduction and internal fixation to preserve digital length and later with bone grafting.
  • Arthroplasty (constrained silicone or nonconstrained bicondylar implants) may be used as a salvage procedure in irreparable IP fractures or after failure for up to 2 years after injury.
  • Arthrodesis may be considered as an alternative to arthroplasty.
Follow-up
Prognosis
  • A poor prognosis is more likely with:
    • Age >50 years
    • Associated tendon injuries (especially extension)
    • Associated joint injury
    • >1 fracture in a finger
    • Crush injury
    • Skin loss
Complications
  • Malunion:
    • Malrotation requiring rotational osteotomy
    • Lateral deviation requiring closing wedge osteotomy
    • Volar angulation requiring volar closing wedge osteotomy
    • Intra-articular realignment osteotomy
  • Tendon adherence:
    • Common, especially in crush injuries
    • Intensive hand rehabilitation is needed.
    • Surgical treatment should be considered only after maximum passive joint motion is regained.
  • Nonunion:
    • Rare, but more common with open than with closed fractures
  • Soft-tissue interposition
  • Infections
  • Stiffness:
    • Immobilization for >3 weeks can result in permanent loss of motion.
    • Comminuted and open fractures treated with internal fixation have a higher rate of stiffness and poor outcomes.
Patient Monitoring
  • Obtain postreduction radiographs immediately and in 3-7 days to check for displacement.
  • Obtain subsequent radiographs every 4 weeks to monitor for displacement and to assess for healing.
  • Monitor the patient until the fracture has healed clinically and finger function is acceptable.
Miscellaneous
Codes
ICD9-CM
  • 816.0 Closed phalanx fracture
  • 816.1 Open phalanx fracture
Patient Teaching
  • Underscore the importance of performing ROM exercises to prevent stiffness in affected and surrounding digits.
  • Emphasize the importance of maintaining therapy and ROM exercises to ensure functional outcome.
Prevention
  • Attention to prevention in sports and leisure activities.
  • Machine-related injuries should be prevented by attention to specific safety precautions.
FAQ
Q: How long should a phalanx fracture be splinted?
A: To prevent stiffness, a fracture should not be splinted for >3 weeks.

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