Phalangeal Fracture Surgery Treatment & Management

The appropriate use of splinting is a key component in treating phalangeal fractures. Management must be individualized. Occasionally, immobilization beyond 3 weeks is necessary, especially with PIPJ fracture dislocations. After 3 weeks, removable custom splints can be used.

• Distal phalanx: Stack splints are useful for a variety of distal phalanx fractures and allow for PIPJ motion.
• Middle/proximal phalanx: Radial or ulnar gutter splints are preferable when possible to maintain motion in the noninjured digits. Splint the hand in the safe position with the metacarpophalangeal joint (MCPJ) in 70° of flexion, the DIPJ and PIPJ in extension, and the wrist in 20° of extension. Buddy taping of the injured digit to an adjacent digit can also be useful. However, care must be taken to avoid creating an angular or rotational deformity with the use of buddy taping.
• PIPJ fractures/dislocations, as seen in the first image below: Fractures that involve less than 30% of the base of the middle phalanx are candidates for extension block splinting, as seen in the second image below. Place the splint with the PIPJ flexed to 45°. If a concentric reduction is present, continue splinting for 2 weeks. Protected motion is started at 2 weeks in a custom figure-of-eight splint, as seen in the third image below. Splinting is discontinued at 4 weeks.

Surgical therapy depends on whether the fracture is at the distal phalanx^[4] or middle and proximal phalanx.

Distal phalanx fractures

• Tuft fractures

  • Most tuft fractures are comminuted and involve the nail bed. Management of these injuries focuses on the treatment of the nail.
  • If the nail plate is intact, leave it in place. Drainage of a subungual hematoma can be carried out through the plate. Manage open tuft fractures involving damage or loss of the nail plate with remaining nail removal, meticulous nail bed repair with 6-0 chromic suture, and nail bed protection. Irrigation, debridement, and IV antibiotics are warranted and indicated in open fractures.
• Transverse shaft fractures

  • Nondisplaced fractures are treated with stack splint immobilization.
  • Displaced fractures can be associated with subluxation of the nail base. Reduce the nail plate back under the eponychial fold and consider placement of a single longitudinal Kirschner wire (K-wire), stopping short of the DIPJ.
• Longitudinal shaft fractures

  • Most of these fractures can be treated with stack splint immobilization. Transversely oriented minifragment screws may be used for significant displacement. See image below
• Flexor digitorum profundus avulsions

  • Operative intervention is warranted for loss of active DIPJ flexion. A type I avulsion lacks a bony component, and the tendon retracts into the palm. This injury requires repair with pull-through sutures within 10 days of the injury.
  • Types II and III include a variably sized portion of bone from the base of the distal phalanx. A small fleck of bone is caught at the A2 pulley at the level of the proximal phalanx in type II avulsions, while a larger bony avulsion is lodged at the A4 pulley in a type III avulsion. Types II and III may be managed with pull-through sutures over a button as late as 3-4 weeks after the injury. Larger type III fragments may be amenable to percutaneous pinning.
  • Type IV avulsions involve an avulsion of bone from the distal phalanx as well as an avulsion of the flexor digitorum profundus tendon from the bony avulsion. Manage these as type I fractures.
• Mallet finger avulsions

  • Occasionally, a mallet finger injury may include a bony avulsion. The majority of these can be treated with the standard mallet splint, keeping the DIP in extension for 6 weeks.
  • Controversy exists as to the ideal treatment for bony avulsion involving more than 30% of the joint surface. Some authors recommend operative fixation to prevent the accompanying volar subluxation. Other authors prefer to treat all of these avulsions with splinting. The lone exception is the Salter III fracture, which is treated with percutaneous pin fixation.^[5]

Middle and proximal phalanx fractures

• Unicondylar and bicondylar fractures

  • Even with minimal displacement, these fractures are unstable and warrant fixation. Open reduction often is necessary to assure articular reduction.
  • Unicondylar fractures may be treated with screw fixation.^{[6, 7, 8, 9]} One study retrospectively reviewed the outcomes in 10 patients who underwent intra-articularly placed interfragmentary screw fixation and found that this technique is beneficial for treating difficult condylar fractures of the hand.^[10]
  • Approach bicondylar fractures with restoration of the articular fragments first, followed by fixation of the articular portion to the shaft. Minicondylar plates or intraosseous wiring techniques may be useful.^{[11, 12]}
• Shaft fractures

  • Transverse fractures commonly are unstable and require fixation. These can be managed easily with 2 longitudinal 0.045 K-wires placed either retrograde through the head of the phalanx or anterograde from the base. In either case, the pins should not remain crossing the PIPJ in order to facilitate motion. If placed in the retrograde fashion, the pins must be bent to prevent migration distally into the PIPJ. Longitudinal parallel pinning helps prevent fracture distraction, which can occur with crossed-wire configuration.
  • Oblique and spiral fractures often are unstable as well.^{[13, 14]} Short oblique fractures can be managed with longitudinal K-wires. As the length of the fracture increases, minifragment screws provide a better biomechanical construct. These screws can be placed percutaneously with minimal soft tissue disruption. Make the entrance incision in the midaxial line if possible. This minimizes the risk of injury to flexor and extensor tendons.
• Fractures at the base of the middle phalanx

  • These are common injuries and are often associated with dislocation of the PIPJ. If not treated appropriately, long-term dysfunction of the finger can result. The dislocation usually is dorsal with an avulsion fracture of the volar base of the middle phalanx. Initial treatment is reduction, followed by an assessment of stability. Extension block is the treatment of choice if it can maintain a concentric reduction. If this is unsuccessful, as seen in the first image below, extension block pinning can be utilized
  • Extension block pinning, as seen in the second image below, involves placement of a longitudinal pin retrograde into the head of the proximal phalanx, keeping the PIPJ in flexion.^[15] Placing the joint in too much flexion is impossible. If the fracture involves more than 50% of the articular surface, external fixation, dynamic traction, or volar plate arthroplasty is indicated.^[16] Pilon fractures are especially amenable to dynamic traction.^{[17, 18]}

More formal open reduction and internal fixation (ORIF) may be needed in fractures with comminution in which a more stable construct is necessary to allow early motion. Options for fixation include intraosseous wiring techniques, tension band wiring,^[19] intramedullary pinning,^[20] and plating. These all are associated with increased soft tissue disruption and should be reserved for more unstable fractures that cannot be managed with less invasive fixation. The authors favor using the midaxial approach when possible because implants placed laterally are less likely to interfere with flexor and extensor tendon function. External fixation is more commonly used as a temporary device for maintaining soft tissue balance and skeletal length in fractures with bone loss or contamination.^[21] Many of these fractures subsequently require bone grafting and internal fixation.

Several important intraoperative tips should be considered, including the following:

• Use a countersink when placing screws to avoid prominent hardware.
• Use of a sharp drill bit reduces the risk of fracture comminution.
• Screw tips exiting on the volar aspect of a phalanx must not impinge on the flexor apparatus.
• Avoid placing screws near the apex of the fractures because the risk of fragmenting the fracture is high.

See Treatment, Medical therapy, above.

Distal phalanx fractures

• Tuft fractures

  • The DIPJ should be splinted in extension for 4 weeks with protection of the phalanx.
• Transverse/longitudinal fractures

  • Remove pins at 3-4 weeks, with the DIPJ splinted in extension. Manage nonoperatively treated fractures similarly to tuft fractures.
• Flexor digitorum profundus avulsions

  • Repair is protected with a dorsal blocking splint with the wrist in 10° of flexion and the MCPJ in 80° of flexion. Several days after surgery, passive DIPJ flexion with the place and hold technique is instituted and continued for 4 weeks (if secure pullout fixation was obtained). Sutures and pins are removed at 4 weeks, and active motion is started with protection in a dorsal blocking splint. Splinting is discontinued at 6 weeks, and a 6-week lifting restriction for objects heavier than 10 pounds is initiated.

Middle/proximal phalanx fractures

Following percutaneous pin fixation, use a dorsal block splint with straps that support the middle and proximal phalanges. The PIPJ should be freed 6 times a day to allow gentle passive range of motion. Pins are removed at 4 weeks, and progressive active motion is initiated. Cast padding can be placed between adjacent fingers if rotational control is a concern. In fractures treated with plates and/or screws, institute active motion as early as the fracture pattern allows. This decreases the risk of adhesion formation.^[22]

PIPJ fracture/dislocations

The pins are removed at 2-3 weeks, and a custom figure-of-eight splint blocking the terminal 20° of extension is fashioned. Splinting is continued for an additional 2 weeks. For heavy use or sports after 4 weeks, use buddy taping for an additional 4 weeks.

Loss of motion

Decreased motion may result from either tendon adhesions or joint contracture. Several factors increase the risk of poor motion, including extended immobilization past 4 weeks, severe soft tissue injury, intra-articular injury, and multiple fractures in the same finger.^[23] Management should start with an aggressive therapy program and can be aided with the use of serial splinting or casting. Surgery is indicated when soft tissue equilibrium has been reached and gains in motion have reached a plateau. Tenolysis is the treatment of choice for tendon adhesions, and capsulotomy should be utilized for joint contracture.^{[24, 25]}

Nonunion

This is an uncommon complication of phalangeal fractures. Risk of nonunion rises with injuries involving severe soft tissue damage and bone loss. Consider surgical intervention at 3-4 months following injury. The nonunion site must be properly debrided prior to bone grafting. Fixation choices include K-wires or plates, followed by early motion as in acute fractures.^[26] The results of one study conclude that although complications with smooth K-wire fixation are relatively uncommon, most complications involve minor pin track infections, which are attributed to poor patient compliance with pin site care.^[27]

Malunion

Malunion is the most common complication and can take several forms, including malrotation, volar angulation, lateral angulation, shortening, and intra-articular malunion. Angular malunions most often are volar or lateral. Finger dexterity may be compromised if the malunion is greater than 20° Wedge osteotomies at the site of deformity are the treatment of choice. Rotational malunions can also impact finger function and grip strength. Corrective osteotomies may be performed at the phalangeal or metacarpal level. Fixation is usually accomplished with K-wires or minifragment screws. Shortening rarely is an indication for operative intervention, unless it is accompanied by another deformity. Intra-articular malunions are the most difficult to manage. Intra-articular osteotomies to realign the articular surface can be attempted but are technically demanding. The fundamentals of minimal soft tissue disruption and secure fixation to allow early motion are especially importantwiththeseosteotomies.^[28]

Infection

Infection is a very unusual complication in phalangeal fractures. Risk is increased in the presence of severe contamination, systemic illness, or delay in treatment greater than 24 hours.

Flexor tendon rupture or entrapment

This is an uncommon complication of phalangeal fractures and usually iatrogenic. It has been reported following both percutaneous pin fixation and plate fixation of these fractures.

Outcome following phalangeal fractures depends on patient and injury factors, as well as surgical expertise. Poorer results have been documented with patients older than 50 years and with associated systemic illness. High-energy fractures with comminution and soft tissue injury also lead to poorer outcomes. Tendon injury, especially extensor tendon, in association with fracture, compromises results. Factors that the surgeon can control include selecting the appropriate fixation and assuring that immobilization does not exceed 3 weeks.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Broken Finger and Broken Hand.