eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Phalangeal Fractures
Updated: Jan 16, 2009
Introduction
Phalangeal fractures (see images below) are common injuries that may significantly affect hand function if not managed appropriately.1 Closed treatment has been the historical mainstay of treatment. Percutaneous pinning allowed the conversion of more unstable fracture patterns to stable configurations capable of tolerating early motion. More recently, minifragment screws and plates were developed to assist in the management of complex phalangeal fractures.
Phalangeal fractures. Acute dorsal proximal interphalangeal joint (PIPJ) fracture-dislocation. Image courtesy of Mark Baratz, MD.
Phalangeal fractures. Treatment with dorsal blocking splint. Image courtesy of Mark Baratz, MD.
Problem
Injuries to the phalanges can result in significant loss of hand function. Even subtle injuries, such as a simple finger jam, if not diagnosed and treated promptly, can lead to decreased motion and a poor outcome. This is especially true with injuries to the proximal interphalangeal joint (PIPJ). Fractures of the phalanges, if unstable, need fixation secure enough to allow early motion in order to prevent adhesion formation.
Frequency
Because many injuries to the phalanges go unreported, defining a true incidence is difficult. Fractures of the phalanges certainly are among the most common in the entire skeleton and may account for up to 10% of all fractures.2
Etiology
Fractures and dislocations of the phalanges occur from a variety of mechanisms. In younger patients, these injuries are more likely to be sports related. Older patients are likely to be injured by machinery or by falls. Crush injuries are common at the distal phalanx, while the PIPJ is usually damaged by an axial blow to the finger.2
Pathophysiology
Stability of phalangeal fractures is dependent on the location, fracture orientation, and degree of initial displacement. Distal tuft fractures usually are stable, despite comminution. Unicondylar and bicondylar fractures involving the interphalangeal joints are inherently unstable. Displaced fractures involving the diaphyses of the proximal and middle phalanges also are unstable secondary to the pull of the intrinsics and flexor tendons. Fractures with an intact periosteal sleeve and no initial displacement usually are stable.
Presentation
Clinical presentation of finger fractures and dislocations depends primarily on the mechanism of injury. Crushing injuries to the fingertip commonly involve the nail bed in addition to the underlying distal phalanx. Injuries at the interphalangeal joints usually manifest with swelling, ecchymosis, and decreased motion. Deformity may also be present at the joint, as well as in the diaphysis of a displaced unstable fracture. Transverse fractures in the proximal phalanx assume an apex volar deformity secondary to pull of the intrinsic tendons on the proximal fragment and the extensor tendon on the middle phalanx. Fractures of the middle phalanx may angulate apex dorsal or volar, depending on whether the fracture occurs proximal or distal to the sublimis insertion, respectively. Care must be taken to evaluate the digit for rotational deformity as well. This is best accomplished by flexing the fingers and viewing the nails on end. Comparison with the contralateral hand is essential.
Indications
Phalangeal fractures that are nondisplaced or stable following reduction are amenable to closed treatment with splinting and early rehabilitation. Indications for operative treatment of phalangeal fractures include the following:
- Open fractures
- Irreducible fractures
- Unstable fractures
- Failed closed reductions
- Displaced intra-articular fractures
In general, management of soft tissues is the first priority. Open wounds are common and are an indication for irrigation and debridement. Wound management is aided by fracture fixation.3 Fractures should be treated with the least invasive method that can result in a stable configuration because this allows for early rehabilitation. If stability cannot be achieved or maintained following reduction, some form of fixation is required. The form of fixation chosen should involve a minimum amount of soft tissue disruption because surgical exposure increases the likelihood of postoperative scar formation between tendon and bone.
Relevant Anatomy
Few places in the body exist where function and anatomy are as closely intertwined as in the finger. Injuries and subsequent scar formation can upset the delicate balance that normally exists, particularly at the PIPJ and extensor apparatus. Anatomic considerations are based on the level of injury.
- Distal phalanx: The terminal extensions of the flexor and extensor tendons insert into the base of the distal phalanx. These tendons can rupture at their insertion or can avulse a fragment of bone. Tuft fractures are commonly associated with injury to the overlying nail bed.
- Distal interphalangeal joint (DIPJ): The head of the middle phalanx consists of 2 condyles that articulate with the base of the distal phalanx. With an axial load, one or both of the condyles may fracture. A closely adherent volar plate provides significant stability. Radial and ulnar collateral ligaments provide resistance to stresses in the coronal plane.
- Middle phalanx: Sublimis tendons insert along a broad expanse on the volar aspect of the proximal half of the phalanx. The profundus tendon is held tightly in the flexor sheath by the important A4 pulley at the mid portion of the phalanx. The middle phalanx region also contains additional cruciate pulleys (C2 and C3), which are located proximal and distal to the A4 pulley, respectively. On the extensor side, the central slip inserts into the base of the middle phalanx. The lateral bands join over the distal portion of this phalanx to form the terminal extensor tendon. The 2 lateral bands are held together by the triangular ligament, which prevents volar subluxation of the lateral bands.
- PIPJ: The anatomy at the PIPJ is similar to that of the DIPJ. The volar plate covers a broad expanse over the joint and is the main stabilizer to joint dislocation. The collateral ligaments are larger at the PIPJ and consist of proper and accessory components.
- Proximal phalanx: Sublimis and profundus tendons run together in the flexor sheath (zone 2) at this level. The A2 flexor pulley covers most of the proximal half of the phalanx, while the C1 pulley is located more distally. The extensor digitorum communis tendon runs the length of the phalanx and is stabilized by oblique and transverse fibers of the intrinsic apparatus. The lateral bands run from a lateral and volar position at the proximal aspect of the phalanx to a more dorsolateral position at the level of the PIPJ.
Contraindications
No absolute contraindications exist in the management of these injuries. Relative contraindications include the use of internal fixation in a reduced and stable fracture or plating a fracture that could be managed with percutaneous pin fixation.
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| References |
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Further Reading
Keywords
phalangeal fractures, phalangeal fractures in sports, finger fractures, finger dislocations, broken finger, finger jam, jammed finger, malunion, hand fractures, metacarpal fractures
