What is a Phalanx Fracture?

finger pain

Table of Contents

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 for Phalanx Fracture in Singapore
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.

Appointment

If you would like an appointment / review with our phalanx fracture specialist in Singapore, the best way is to call +65 3135 1327 or click here to book an appointment at the clinic. If you would like to speak to one of our clinicians first about e.g. finger injuries physiotherapy, tuft fracture splint, comminuted tuft fracture, then please contact contact@orthopaedicclinic.com.sg or SMS/WhatsApp to +65 3135 1327.

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