Plastic Surgery for Phalangeal Fracture and Dislocation Treatment & Management
- Author: Brian J Divelbiss, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS more...
Appropriate use of splinting is a key component of treating phalangeal fractures. Management must be individualized but rarely should full-time immobilization exceed 3 weeks, so as to avoid stiffness. After 3 weeks, removable custom splints can be used.
Distal phalanx fractures: Stack splints, which immobilize the DIPJ while allowing for PIPJ motion, are useful for various distal phalanx fractures.
Middle or proximal phalanx fractures: 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 MCPJ in 70 degrees of flexion, the DIPJ and PIPJ in extension, and the wrist in 20 degrees of extension. Buddy taping of the injured digit to an adjacent digit may also be useful. However, care must be taken to avoid creating an angular or rotational deformity with buddy taping.
PIPJ fractures/dislocations: Fractures that involve less than 30% of the base of the middle phalanx are candidates for extension block splinting. Place the splint on with the PIPJ flexed to 45 degrees. If a concentric reduction is present, continue the splint for 2 weeks. Start protected motion at 2 weeks in a custom figure-of-eight splint (see following image). Discontinue splinting at 4 weeks.
The involvement of a hand therapist in the treatment of phalangeal fractures cannot be overemphasized. They are integral to the design and construction of custom splints and are important in aiding the patient in their early motion program.
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 and drain the subungual hematoma through the plate. Open tuft fractures with damage or loss of nail plate should be managed with removal of the remaining nail, meticulous repair of the nail bed with 6-0 chromic suture, and protection of the nail bed. Irrigation, debridement, and IV antibiotics are indicated in open fractures.
Transverse shaft fractures: If nondisplaced, treat these fractures with stack splint immobilization. Displaced fractures can be associated with herniation of the nail plate. Reduce the nail plate back under the eponychial fold and consider placement of a single longitudinal K-wire, stopping short of the DIPJ.
Longitudinal shaft fractures: Treat most with stack splint immobilization. If significant displacement is observed, transversely oriented minifragment screws or percutaneous wires may be used.
Flexor digitorum profundus (FDP) avulsions ("jersey finger"): If loss of active DIPJ flexion occurs, operative intervention is warranted. A type I avulsion lacks a bony component and the tendon retracts into the palm. This injury requires repair with pull-through sutures before the tendon/muscle unit becomes contracted, usually within 10–14 days. Types II and III include a variably sized portion of bone from the base of the distal phalanx. A small fleck of bone typically gets caught at the A2 pulley at the level of the proximal phalanx in type II avulsions. 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 FDP tendon from the bony avulsion. Manage these similar to a type I.
Mallet finger avulsions: Occasionally a mallet finger injury may include a bony avulsion. Most of these can be treated with the standard mallet splint, keeping the DIP in extension for 6 weeks. If the bony avulsion is greater than 30% of the joint surface, the ideal treatment is controversial. Some authors recommend operative fixation to prevent the accompanying volar subluxation. This author prefers to treat all of these avulsions with splinting. The lone exception is the Salter III fracture, which is treated with percutaneous pin fixation.
Middle and proximal phalanx fractures
Unicondylar and bicondylar fractures: Even with minimal displacement, these are often unstable and warrant fixation. Open reduction may be necessary to assure articular reduction. Unicondylar fractures may be treated with screw fixation. Interfragmentary screw fixation may be used intra-articularly when the nonarticular portion is to small to allow stable fixation. The size of the fractured fragment must be 3 times the diameter of the screw. 
Bicondylar fractures should be approached with restoration of the articular fragments first, followed by fixation of the articular portion to the shaft. Percutaneous pins, minicondylar plates, or intraosseous wiring techniques may be useful. 
- Transverse fractures are commonly unstable and require fixation. These can easily be managed 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 to facilitate motion. If placed in the retrograde fashion, bend the pins to prevent migration distally into the PIPJ. Longitudinal parallel pinning helps prevent fracture distraction that can occur with crossed-wire configuration.
- Oblique and spiral fractures are often unstable as well. Short oblique fractures can be managed with longitudinal K-wires.
- As the length of the fracture increases, transversely placed pins or minifragment screws create a better biomechanical construct. Screw fixation may be preferable if the fracture length is at least 2 times the diameter of the bone. These screws can be placed percutaneously as long as an adequate reduction can be achieved. Make an entrance incision in the midaxial line, if possible. This minimizes the risk of injury to the flexor and extensor tendons and can decrease the chance of postoperative adhesions and scar. When using pins or screws, the fixation should be configured perpendicular to both the fracture and the shaft to achieve compression as well as resist shear stress at the fracture site.
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 will result. Dislocation is usually dorsal with an avulsion fracture of the volar base of the middle phalanx.
- Initial treatment is reduction followed by an assessment of stability. As noted previously, if extension block splinting can maintain a concentric reduction, this is the treatment of choice.
- If reduction fails, use extension block pinning. This involves placement of a longitudinal pin retrograde into the head of the proximal phalanx keeping the PIPJ in flexion.
- If the fracture involves more than 50% of the articular surface, the injury can be managed with external fixation or dynamic traction. Though technically challenging, the hemi-hamate arthroplasty as described by Hastings et al offers another treatment for the unstable PIP fracture-dislocations involving more than 50% of the articular surface and may permit early finger motion. Pilon fractures, where the comminuting involves both the dorsal and palmer cortices, are especially amenable to dynamic traction.
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, intramedullary pinning, and plating. These are all associated with increased soft-tissue disruption and should be reserved for the more unstable fractures that cannot be managed with less invasive fixation. The author favors the mid-axial approach when possible, as 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.
Consider several important intraoperative tips.
Use a countersink when placing screws to avoid prominent hardware.
Use a sharp drill bit to reduce 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, as the risk of fragmenting the fracture is high.
See the list below:
Distal phalanx fractures
- Tuft fractures: Splint the DIPJ in extension for 4 weeks with protection of the phalanx.
- Transverse/longitudinal fractures: If pins are placed, remove them at 3-4 weeks with the DIP splinted in extension. Manage fractures treated non-operatively like tuft fractures.
- FDP 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, institute passive DIP flexion with the place and hold technique and continue for 4 weeks (if secure pullout fixation was obtained). Remove sutures and pins at 4 weeks and begin active motion with protection in a dorsal blocking splint. Discontinue splinting at 6 weeks and begin a 6-week lifting restriction for objects greater than 10 lb.
Middle/proximal phalanx fractures: Following percutaneous pin fixation, use a dorsal block splint with straps that support the middle and proximal phalanges. Free the PIPJ 6 times a day to allow gentle passive range of motion. Remove pins at 4 weeks and initiate progressive active motion if there is no bony tenderness. Fractures that are pinned following open reduction may require additional time to heal before the pins can be safely removed. 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. For unicondylar fractures fixed with screws, immediate range of motion exercises can be initiated. Athletes may be able return to competitive sports within 1 week with the finger buddy taped. 
PIPJ fracture/dislocations: Remove pins at 2-3 weeks and create a custom figure-of-eight splint blocking the terminal 20° of extension. Continue splinting for an additional 2 weeks. For heavy use or sports after 4 weeks, use buddy taping for an additional 4 weeks. If a hemi-hamate arthroplasty has been performed, range of motion exercises can be initiated at 1 week, with a 15° dorsal blocking splint. 
See the list below:
Loss of motion may result from either tendon adhesions or joint contracture.  Several factors increase the risk of poor motion, including immobilization beyond 4 weeks, severe soft tissue injury, intra-articular injury, and multiple fractures in the same finger. Management should start with an intensive therapy program and can be aided with serial splinting or casting.  Surgery is indicated when soft tissue equilibrium has been reached and gains in motion have plateaued. This typically takes between 3-6 months. Tenolysis is the treatment of choice for tendon adhesions and capsulotomy is necessary for joint contracture.
Nonunion is an uncommon complication of phalangeal fractures with a reported incidence of less than 1%.  Risk of nonunion rises with injuries with severe soft tissue damage and bone loss. Consider surgical intervention at 3-4 months following injury. Properly debride the nonunion site prior to bone grafting. Fixation choices include K-wires or plates. This should be followed by early motion protected motion.
Malunion is the most common complication and can take several forms.
- Angular malunions are most often volar or lateral. If the malunion is greater than 20 degrees, finger dexterity may be compromised. 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 but are commonly performed through the old fracture site. For every 1 degree of metacarpal rotation, approximately 0.7 degree of correction occurs in the phalanges.[23, 24] Fixation is usually performed with K-wires or minifragment screws. Shortening is rarely 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. Fundamentals of minimal soft tissue disruption and secure fixation to allow early motion are especially important with these osteotomies.
Infection is an unusual complication in phalangeal fractures. Risk is increased in the presence of severe contamination, systemic illness, or delay in treatment.
Outcome and Prognosis
Outcome following phalangeal fractures depends on patient and injury factors as well as surgical expertise. Inferior results have been documented in patients older than 50 years and in those with associated systemic illness. High-energy fractures with comminution and soft tissue injury also lead to worse outcomes. Tendon injury, especially extensor tendon, in association with fracture compromises results. Factors that the surgeon can control include selection of the appropriate fixation and striking the appropriate balance between immobilization to promote healing and motion to minimize adhesions.
Pritsch and Rizzo report that reoperation is common following primary nonconstrained proximal interphalangeal joint arthroplasty, with the most common reason being extensor mechanism dysfunction. No significant change in range of motion and only mild or no pain were reported for the outcomes in this retrospective study.
A study by Onishi et al indicated that the use of plates, rather than screws alone, in the open reduction and internal fixation of unstable proximal phalangeal fractures independently increases the risk for postoperative finger stiffness. The study, which included 70 patients (75 fractures), also found that dorsal implant placement is another independent risk factor for stiffness.
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