Phalangeal Fracture Surgery Treatment & Management
- Author: Brian J Divelbiss, MD; Chief Editor: Harris Gellman, MD more...
Phalangeal fractures that are nondisplaced or stable after reduction are amenable to closed treatment with splinting and early rehabilitation. Indications for operative treatment of phalangeal fractures include the following:
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. Fractures should be treated with the least invasive method that can result in a stable configuration; this will allow early rehabilitation. If stability cannot be achieved or maintained after reduction, some form of fixation is required. The form of fixation chosen should involve a minimum of soft-tissue disruption because surgical exposure increases the likelihood of postoperative scar formation between tendon and bone.
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.
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 proximal interphalangeal joint (PIPJ) fractures and dislocations. After 3 weeks, removable custom splints can be used.
Distal phalanx fracture
Stack splints are useful for a variety of distal phalanx fractures and allow for PIPJ motion.
Middle/proximal phalanx fracture
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 distal interphalangeal joint (DIPJ) and the 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.
Proximal interphalangeal joint fracture/dislocation
Fractures that involve less than 30% of the base of the middle phalanx are candidates for extension block splinting (see the first 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-eight splint (see the second image below). Splinting is discontinued at 4 weeks.
Several important intraoperative tips should be considered, including the following:
Use a countersink when placing screws to avoid prominent hardware
Use a sharp drill bit to reduce the risk of fracture comminution
Ensure that screw tips exiting on the volar aspect of a phalanx do not impinge on the flexor apparatus
Avoid placing screws near the apex of the fractures, because the risk of fragmenting the fracture is high
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 the following:
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. Many of these fractures subsequently require bone grafting and internal fixation.
Distal phalanx fracture
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 and debridement are warranted and indicated in open fractures. A systematic review and meta-analysis by Metcalfe et al did not find antibiotic prophylaxis to have a significant effect on the rate of superficial infection and osteomyelitis in open distal phalanx fractures.
Transverse shaft fracture
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 fracture
Most of these fractures can be treated with stack splint immobilization. Transversely oriented minifragment screws may be used for significant displacement (see the image below).
Flexor digitorum profundus avulsion
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 pullthrough 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. In a type II avulsion, a small fleck of bone is caught at the A2 pulley at the level of the proximal phalanx, whereas in a type III avulsion, a larger bony avulsion is lodged at the A4 pulley. Types II and III may be managed with pullthrough 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 avulsion
Occasionally, a mallet finger injury may include a bony avulsion. The majority of these can be treated with the standard mallet splint, with the DIPJ kept 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.
Middle/proximal phalanx fracture
Unicondylar and bicondylar fracture
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.[14, 15, 16, 17] One study retrospectively reviewed the outcomes in 10 patients who underwent intra-articularly placed interfragmentary screw fixation and found this technique to be beneficial for treating difficult condylar fractures of the hand.
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.[19, 20]
Transverse fractures commonly are unstable and require fixation. These can be managed easily with two 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.[21, 22] 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.
Fracture at base of 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 consists of reduction, followed by an assessment of stability. Extension block splinting is the treatment of choice if it can maintain a concentric reduction. If this is unsuccessful (see the first image below), extension block pinning can be utilized. Extension block pinning (see the second image below) involves retrograde placement of a longitudinal pin into the head of the proximal phalanx, with the PIPJ kept in flexion.[23, 24] 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. Pilon fractures are especially amenable to dynamic traction.[26, 27]
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.
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.[29, 30]
Nonunion is an uncommon complication of phalangeal fractures. The risk of this complication rises with injuries involving severe soft-tissue damage and bone loss.
Consider surgical intervention at 3-4 months after the injury. The nonunion site must be properly debrided before bone grafting. Fixation choices include K-wires and plates, followed by early motion as in acute fractures. 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.
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 important with these osteotomies.
Infection is a very unusual complication in phalangeal fractures. The risk is increased in the presence of severe contamination, systemic illness, or a delay in treatment that exceeds 24 hours.
Flexor tendon rupture or entrapment
This is an uncommon complication of phalangeal fractures and is usually iatrogenic. It has been reported after both percutaneous pin fixation and plate fixation of these fractures.
Distal phalanx fracture
In patients with Tuft fractures, the DIPJ should be splinted in extension for 4 weeks with protection of the phalanx.
In patients with transverse or longitudinal fractures, pins should be removed at 3-4 weeks, with the DIPJ splinted in extension. Nonoperatively treated fractures should be managed in much the same manner as tuft fractures.
In patients with flexor digitorum profundus avulsions, the 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 lb is initiated.
Middle/proximal phalanx fracture
After percutaneous pin fixation, a dorsal block splint should be used, with straps that support the middle and proximal phalanges. The PIPJ should be freed six 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, screws, or both, active motion should be instituted as early as the fracture pattern allows; This decreases the risk of adhesion formation.
Proximal interphalangeal joint fracture/dislocation
The pins are removed at 2-3 weeks, and a custom figure-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, buddy taping should be employed for an additional 4 weeks.
Baratz ME, Divelbiss B. Fixation of phalangeal fractures. Hand Clin. 1997 Nov. 13(4):541-55. [Medline].
De Jonge JJ, Kingma J, van der Lei B, Klasen HJ. Phalangeal fractures of the hand. An analysis of gender and age-related incidence and aetiology. J Hand Surg [Br]. 1994 Apr. 19(2):168-70. [Medline].
Gaston RG, Chadderdon C. Phalangeal fractures: displaced/nondisplaced. Hand Clin. 2012 Aug. 28(3):395-401, x. [Medline].
Kömürcü M, Alemdaroglu B, Kürklü M, Ozkan H, Basbozkurt M. Handgun injuries with metacarpal and proximal phalangeal fractures: early definitive treatment. Int Orthop. 2008 Apr. 32(2):257-62. [Medline].
Lubahn JD, Hood JM. Fractures of the distal interphalangeal joint. Clin Orthop. 1996 Jun. (327):12-20. [Medline].
Lee JJ, Park HJ, Choi HG, Shin DH, Uhm KI. Open Reduction of Proximal Interphalangeal Fracture-Dislocation through a Midlateral Incision Using Absorbable Suture Materials. Arch Plast Surg. 2013 Jul. 40(4):397-402. [Medline]. [Full Text].
Jehan S, Chandraprakasam T, Thambiraj S. Management of proximal phalangeal fractures of the hand using finger nail traction and a digital splint: a prospective study of 43 cases. Clin Orthop Surg. 2012 Jun. 4(2):156-62. [Medline]. [Full Text].
Goorens CK, Van Hoonacker P, Kerckhove D, Berghs B, Goubau J. Treatment of fractures of the proximal phalanx of long fingers with an isometric traction splint. Acta Orthop Belg. 2012 Aug. 78(4):473-8. [Medline].
Pehlivan O, Kiral A, Solakoglu C, et al. Tension band wiring of unstable transverse fractures of the proximal and middle phalanges of the hand. J Hand Surg [Br]. 2004 Apr. 29(2):130-4. [Medline].
Gonzalez MH, Igram CM, Hall RF. Intramedullary nailing of proximal phalangeal fractures. J Hand Surg [Am]. 1995 Sep. 20(5):808-12. [Medline].
Johnson D, Tiernan E, Richards AM, Cole RP. Dynamic external fixation for complex intraarticular phalangeal fractures. J Hand Surg [Br]. 2004 Feb. 29(1):76-81. [Medline].
Metcalfe D, Aquilina AL, Hedley HM. Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg Eur Vol. 2015 Sep 1. [Medline].
Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg [Am]. 1984 Jun. 66(5):658-69. [Medline].
Pun WK, Chow SP, So YC, et al. Unstable phalangeal fractures: treatment by A.O. screw and plate fixation. J Hand Surg [Am]. 1991 Jan. 16(1):113-7. [Medline].
Roth JJ, Auerbach DM. Fixation of hand fractures with bicortical screws. J Hand Surg [Am]. 2005 Jan. 30(1):151-3. [Medline].
Weiss AP, Hastings H 2d. Distal unicondylar fractures of the proximal phalanx. J Hand Surg [Am]. 1993 Jul. 18(4):594-9. [Medline].
Khalid M, Theivendran K, Cheema M, Rajaratnam V, Deshmukh SC. Biomechanical comparison of pull-out force of unicortical versus bicortical screws in proximal phalanges of the hand: A human cadaveric study. Clin Biomech (Bristol, Avon). 2008 Jul 21. [Medline].
Tan JS, Foo AT, Chew WC, Teoh LC. Articularly placed interfragmentary screw fixation of difficult condylar fractures of the hand. J Hand Surg Am. 2011 Apr. 36(4):604-9. [Medline].
Ouellette EA, Freeland AE. Use of the minicondylar plate in metacarpal and phalangeal fractures. Clin Orthop. 1996 Jun. (327):38-46. [Medline].
Henry M. Soft tissue sleeve approach to open reduction and internal fixation of proximal phalangeal fractures. Tech Hand Up Extrem Surg. 2008 Sep. 12(3):161-5. [Medline].
Freeland AE, Benoist LA, Melancon KP. Parallel miniature screw fixation of spiral and long oblique hand phalangeal fractures. Orthopedics. 1994 Feb. 17(2):199-200. [Medline].
Matloub HS, Jensen PL, Sanger JR, et al. Spiral fracture fixation techniques. A biomechanical study. J Hand Surg [Br]. 1993 Aug. 18(4):515-9. [Medline].
Williams RM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg [Am]. 2003 Sep. 28(5):856-65. [Medline].
Bear DM, Weichbrodt MT, Huang C, Hagberg WC, Balk ML. Unstable dorsal proximal interphalangeal joint fracture-dislocations treated with extension-block pinning. Am J Orthop (Belle Mead NJ). 2015 Mar. 44 (3):122-6. [Medline].
Capo JT, Hastings H 2nd, Choung E, Kinchelow T, Rossy W, Steinberg B. Hemicondylar hamate replacement arthroplasty for proximal interphalangeal joint fracture dislocations: an assessment of graft suitability. J Hand Surg [Am]. 2008 May-Jun. 33(5):733-9. [Medline].
Schenck RR. Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg [Am]. 1986 Nov. 11(6):850-8. [Medline].
Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ. Pilon fractures of the proximal interphalangeal joint. J Hand Surg [Am]. 1991 Sep. 16(5):844-50. [Medline].
van Oosterom FJ, Ettema AM, Mulder PG, Hovius SE. Impairment and disability after severe hand injuries with multiple phalangeal fractures. J Hand Surg [Am]. 2007 Jan. 32(1):91-5. [Medline].
Creighton JJ Jr, Steichen JB. Complications in phalangeal and metacarpal fracture management. Results of extensor tenolysis. Hand Clin. 1994 Feb. 10(1):111-6. [Medline].
Yamazaki H, Kato H, Uchiyama S, Ohmoto H, Minami A. Results of tenolysis for flexor tendon adhesion after phalangeal fracture. J Hand Surg Eur Vol. 2008 Jul 28. [Medline].
Chim H, Teoh LC, Yong FC. Open reduction and interfragmentary screw fixation for symptomatic nonunion of distal phalangeal fractures. J Hand Surg Eur Vol. 2008 Feb. 33(1):71-6. [Medline].
Hsu LP, Schwartz EG, Kalainov DM, Chen F, Makowiec RL. Complications of K-wire fixation in procedures involving the hand and wrist. J Hand Surg Am. 2011 Apr. 36(4):610-6. [Medline].
Yong FC, Tan SH, Tow BP, Teoh LC. Trapezoid rotational bone graft osteotomy for metacarpal and phalangeal fracture malunion. J Hand Surg Eur Vol. 2007 Jun. 32(3):282-8. [Medline].
Reyes BA, Ho CA. The High Risk of Infection With Delayed Treatment of Open Seymour Fractures: Salter-Harris I/II or Juxta-epiphyseal Fractures of the Distal Phalanx With Associated Nailbed Laceration. J Pediatr Orthop. 2015 Aug 28. [Medline].
Freeland AE, Hardy MA, Singletary S. Rehabilitation for proximal phalangeal fractures. J Hand Ther. 2003 Apr-Jun. 16(2):129-42. [Medline].