What is a Phalanx Fracture?

• 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

• Fractures of the metacarpals and the phalanges are common.
• Occur among all ages
• Common causes vary substantially with age.

• 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.

• Pain, swelling, or deformity after some trauma to the finger
• Laceration
• Decreased ROM
• Numbness of the affected digit

Tests

• 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.

• 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.

• 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

• 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.

• 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

• 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.

FAQ