eMedicine Specialties > Plastic Surgery > Hand

Hand, Phalangeal Fracture and Dislocations

Author: Brian J Divelbiss, MD, Attending Staff, Dickson-Diveley Midwest Orthopedic Clinic, Inc, and Kansas City Orthopedic Institute; Associate Clinical Professor, Department of Orthopedic Surgery, University of Missouri-Kansas City
Coauthor(s): Mark E Baratz, MD, Professor, Department of Orthopaedics, Drexel University College of Medicine; Residency Director, Department of Orthopaedics, Allegheny General Hospital; Consulting Staff, Allegheny Orthopaedic Associates
Contributor Information and Disclosures

Updated: Mar 28, 2008

Introduction

History of the Procedure

Phalangeal fractures are common injuries that may significantly affect hand function if not managed appropriately. Closed treatment has been the 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.1 For information on fractures of all kinds, visit the Medscape Fracture Resource Center.

Problem

Injuries to the phalanges can result in significant loss of hand function. Even the mild "jammed" finger, 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 to prevent adhesion formation and permanent stiffness.2

Frequency

Because many injuries to the phalanges go unreported, defining a true incidence is difficult. Fractures of the phalanges are surely among the most common in the entire skeleton and may account for as many as 10% of all fractures.

Etiology

Fractures and dislocations of the phalanges occur from various mechanisms. In younger patients, these injuries are more likely to be sports-related, while older patients are likely to be injured by machinery or falls.3 Crush injuries are common at the distal phalanx, while the PIPJ is usually damaged by an axial blow to the finger.

Pathophysiology

Stability of phalangeal fractures depends on location, fracture orientation, and degree of initial displacement. Distal tuft fractures are usually 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 are also unstable secondary to the pull of the intrinsics and flexor tendons. Fractures with an intact periosteal sleeve and no initial displacement are usually stable.

Presentation

Clinical presentation of finger fractures and dislocations depends primarily on the mechanism of injury. Crushing injuries to the fingertip commonly involve injuries to both the nail bed and the underlying distal phalanx. Injuries at the interphalangeal joints usually present 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 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, and 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:

  1. Open fractures
  2. Irreducible fractures
  3. Unstable fractures
  4. Failed closed reductions
  5. 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. Management of wounds is aided by fracture fixation. Treat fractures with the least invasive method that results in a stable configuration as this allows early rehabilitation. If stability cannot be achieved or maintained following reduction, some form of fixation is required. The form of fixation chosen should involve the minimum amount of soft-tissue disruption as surgical exposure increases the likelihood of postoperative scar formation between tendon and bone.

Relevant Anatomy

There are few places in the body 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: 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 two 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) that 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. Lateral bands join over the distal portion of this phalanx to form the terminal extensor tendon. The two lateral bands are stabilized by the triangular ligament, located just distal to the central slip insertion, which prevents volar subluxation of the lateral bands.

Proximal interphalangeal joint (PIPJ): Anatomy at the PIPJ is similar to the DIPJ. The volar plate covers a broad expanse over the joint and is the main stabilizer to joint dislocation. 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 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 can be managed with a less invasive fixation technique.

More on Hand, Phalangeal Fracture and Dislocations

Overview: Hand, Phalangeal Fracture and Dislocations
Workup: Hand, Phalangeal Fracture and Dislocations
Treatment: Hand, Phalangeal Fracture and Dislocations
Follow-up: Hand, Phalangeal Fracture and Dislocations
Multimedia: Hand, Phalangeal Fracture and Dislocations
References
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References

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Further Reading

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Keywords

phalangeal injuries, phalangeal fractures, phalangeal dislocation, proximal interphalangeal joint, PIPJ, finger injuries, finger fracture, broken finger, dislocated finger, jammed finger, finger dislocation, PIP joint, PIP, axial blow, crush injury, crushed finger

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Contributor Information and Disclosures

Author

Brian J Divelbiss, MD, Attending Staff, Dickson-Diveley Midwest Orthopedic Clinic, Inc, and Kansas City Orthopedic Institute; Associate Clinical Professor, Department of Orthopedic Surgery, University of Missouri-Kansas City
Brian J Divelbiss, MD is a member of the following medical societies: Alpha Omega Alpha and American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Baratz, MD, Professor, Department of Orthopaedics, Drexel University College of Medicine; Residency Director, Department of Orthopaedics, Allegheny General Hospital; Consulting Staff, Allegheny Orthopaedic Associates
Mark E Baratz, MD is a member of the following medical societies: Allegheny County Medical Society, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Surgery of the Hand, Orthopaedic Research Society, and Pennsylvania Orthopaedic Society
Disclosure: Nothing to disclose.

Medical Editor

Milton B Armstrong, MD, FACS, Associate Professor of Clinical Surgery, Associate Professor of Clinical Orthopedics, Department of Surgery, University of Miami Miller School of Medicine
Milton B Armstrong, MD, FACS is a member of the following medical societies: American Association for Hand Surgery, American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, and National Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David W Chang, MD, FACS, Associate Professor, Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Subhas Gupta, MD, PhD, CM, FRCS(C), FACS, Professor of Surgery, Chair, Department of Plastic Surgery, Director of Plastic Surgery Residency, Director of Comprehensive Wound Service, Department of Plastic Surgery, Loma Linda University School of Medicine
Subhas Gupta, MD, PhD, CM, FRCS(C), FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Phlebology, American College of Surgeons, American Medical Association, American Medical Informatics Association, American Society of Plastic Surgeons, California Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, College of Physicians and Surgeons of Ontario, Plastic Surgery Research Council, Quebec Medical Association, Royal College of Physicians and Surgeons of Canada, and Wound Healing Society
Disclosure: Nothing to disclose.

 
 
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