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