Phalangeal Fracture Surgery 

Updated: Nov 07, 2019
Author: Brian J Divelbiss, MD; Chief Editor: Harris Gellman, MD 

Overview

Practice Essentials

Phalangeal fractures are common injuries that can occur at the proximal, middle, or distal phalanx.[1] They may significantly affect hand function.[2]  Even subtle injuries, such as a simple finger jam, can lead to decreased motion and a poor outcome if not diagnosed and treated promptly. This is especially true with injuries to the proximal interphalangeal (PIP) joint. Fractures of the phalanges, if unstable, necessitate fixation secure enough to allow early motion in order to prevent adhesion formation.

Historically, closed treatment has been the therapeutic mainstay. Percutaneous pinning allowed the conversion of more unstable fracture patterns to stable configurations capable of tolerating early motion. Subsequently, minifragment screws and plates were developed to assist in the management of complex phalangeal fractures.

For patient education resources, see the First Aid and Injuries Center, as well as Broken Finger and Broken Hand.

Anatomy

There are few places in the body where function and anatomy are as closely intertwined as they are in the finger. (See Hand Anatomy.) Injuries and subsequent scar formation can upset the delicate balance that normally exists, particularly at the PIP joint and the 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

The head of the middle phalanx consists of two condyles that articulate with the base of the distal phalanx to form the distal interphalangeal (DIP) joint. 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 midportion 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 two lateral bands are held together by the triangular ligament, which prevents volar subluxation of the lateral bands.

Proximal interphalangeal joint

The anatomy of the PIP joint is similar to that of the DIP joint. 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 PIP joint 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; the C1 pulley is located more distally. The extensor digitorum communis (EDC) 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 PIP joint.

Pathophysiology

The stability of phalangeal fractures is dependent on the following factors:

  • Location
  • Fracture orientation
  • Degree of initial displacement

Distal tuft fractures usually are stable, despite comminution. Unicondylar and bicondylar fractures involving the interphalangeal (IP) 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.

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, whereas the PIP joint is usually damaged by an axial blow to the finger.[3]

Epidemiology

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 as many as 10% of all fractures.[3]

Prognosis

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

Kootstra et al compared patient-reported outcome measures and complications for three methods of surgical fixation in 159 patients with 159 proximal phalangeal (thumb excluded) fractures: Kirschner wire (K-wire; 44%), lag-screw (26%), and plate (30%).[4]  The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 5.0, and and the mean Patient-Rated Wrist/Hand Evaluation (PRWHE) score was 8.2. The fixation methods did not differ with regard to functional outcomes, though unplanned reoperation was more common in the plate group. K-wire fixation was found to be associated with better esthetic outcomes than open reduction with internal fixation (ORIF) was.

 

Presentation

History and Physical Examination

The 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 (IP) 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.[5]

Transverse fractures in the proximal phalanx assume an apex volar deformity secondary to pulling of the intrinsic tendons on the proximal fragment and of the extensor tendon on the middle phalanx. Fractures of the middle phalanx may angulate in an apex dorsal or volar fashion, 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.

 

Workup

Imaging Studies

Plain radiography is sufficient for the diagnosis of injuries to the phalanges. (See the images below.) Oblique radiography may be helpful for injuries around the distal interphalangeal (DIP) joint and the proximal interphalangeal (PIP) joint.

Phalangeal fractures. Acute dorsal proximal interp Phalangeal fractures. Acute dorsal proximal interphalangeal joint (PIPJ) fracture-dislocation. Image courtesy of Mark Baratz, MD.
Phalangeal fractures. Treatment with dorsal blocki Phalangeal fractures. Treatment with dorsal blocking splint. Image courtesy of Mark Baratz, MD.

Computed tomography (CT) and magnetic resonance imaging (MRI) generally have not played significant roles in the assessment of the acutely injured finger.

 

Treatment

Approach Considerations

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:

  • 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.[6] 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. Various minimally invasive approaches have been described. Liodaki et al found percutaneous cannulated compression screw osteosynthesis to be superior to simple Kirschner wires (K-wires) for unicondylar proximal interphalangeal (PIP) joint fractures, phalangeal shaft fractures, and simple oblique two-fragment phalangeal fractures.[7]

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.

Medical Therapy

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 PIP joint 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 PIP joint motion.

Middle/proximal phalanx fracture

Radial or ulnar gutter splints are preferable when possible to maintain motion in the noninjured digits. The hand should be splinted in the safe position with the metacarpophalangeal (MCP) joint in 70° of flexion, the distal interphalangeal (DIP) and PIP joints 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.

Non-surgical management of isolated proximal phalangeal fractures with immediate mobilization.

In a prospective observational study, Byrne et al assessed the use of a nonsurgical conservative protocol with immediate mobilization to treat 101 isolated stable or initially unstable proximal phalangeal fractures.[8] The patients achieved a median PIP joint extension of –4° and a mean total active motion of 253°, with minimal pain. The authors concluded that such a protocol could be used for patients with isolated proximal phalangeal fractures without uncorrectable finger rotation or fracture angulation exceeding 25° in the sagittal plane or 10° in the coronal plane after closed reduction.

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). The splint should be placed with the PIP joint flexed to 45°. If a concentric reduction is present, splinting should be continued 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.

Phalangeal fractures. Treatment with dorsal blocki Phalangeal fractures. Treatment with dorsal blocking splint. Image courtesy of Mark Baratz, MD.
Phalangeal fractures. Custom figure-of-eight splin Phalangeal fractures. Custom figure-of-eight splint used once motion is begun. Image courtesy of Mark Baratz, MD.

Surgical Therapy

Surgical therapy depends on whether the fracture is at the distal phalanx[9] or at the middle or proximal phalanx (see below).[10, 11, 2, 12]

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 with 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:

  • Intraosseous wiring techniques
  • Tension band wiring [13]
  • Intramedullary pinning [14]
  • Plating [15]

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.[16] Many of these fractures subsequently require bone grafting and internal fixation.

Distal phalanx fracture

Tuft 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.[17]

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 K-wire, stopping short of the DIP joint.

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).

Phalangeal fractures. Treatment with multiple mini Phalangeal fractures. Treatment with multiple minifragment screws plus Kirschner wires (K-wires). Image courtesy of Mark Baratz, MD.

Flexor digitorum profundus avulsion

Operative intervention is warranted for loss of active DIP joint 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 (FDP) 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 DIP joint 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.[18]

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.[19, 20, 21, 22] 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.[23]

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.[24, 25]

Shaft fracture

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 PIP joint, in order to facilitate motion. If placed in the retrograde fashion, the pins must be bent to prevent migration distally into the PIP joint. Longitudinal parallel pinning helps prevent fracture distraction, which can occur with crossed-wire configuration.

Oblique and spiral fractures often are unstable as well.[26, 27] 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 PIP joint. 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 PIP joint kept in flexion.[28, 29] Placing the joint in too much flexion is impossible.

Phalangeal fractures. Acute dorsal proximal interp Phalangeal fractures. Acute dorsal proximal interphalangeal joint (PIPJ) fracture-dislocation. A concentric reduction could not be maintained in a dorsal blocking splint. Image courtesy of Mark Baratz, MD.
Phalangeal fractures. Treatment with a dorsal bloc Phalangeal fractures. Treatment with a dorsal blocking percutaneous pin. Image courtesy of Mark Baratz, MD.

If the fracture involves more than 50% of the articular surface, external fixation, dynamic traction, or volar plate arthroplasty is indicated.[30] Pilon fractures are especially amenable to dynamic traction.[31, 32]

Complications

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.[33]

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.[34, 35, 36]

Nonunion

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.[37] The results of one study suggested 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.[38]

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[39] 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.[40]

Infection

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.[41] The risk may also be increased when the K-wires used for fixation are left exposed rather than buried.[42]

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.

Long-Term Monitoring

Distal phalanx fracture

In patients with tuft fractures, the DIP joint 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 DIP joint splinted in extension. Nonoperatively treated fractures should be managed in much the same manner as tuft fractures.

In patients with FDP avulsions, the repair is protected with a dorsal blocking splint with the wrist in 10° of flexion and the MCP joint in 80° of flexion. Several days after surgery, passive DIP joint 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 (~4.5 kg) 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 PIP joint 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.[43]

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.