Plastic Surgery for Phalangeal Fracture and Dislocation 

Updated: Nov 01, 2018
Author: Brian J Divelbiss, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS 

Overview

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 for reducible and stable fracture configurations. Unstable or irreducible fracture patterns require open or closed reduction and fixation. Percutaneous pinning allows the conversion of more unstable fracture patterns to stable configurations capable of tolerating early motion. Mini fragment screws and plates assist in the management of complex phalangeal fractures.[1, 2] 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.[3]

Epidemiology

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. A study by Karl et al indicated that phalangeal hand fractures are the second most common upper extremity fractures in the United States, at 12.5 per 10,000 persons annually (behind only distal radius and ulna fractures, at 16.2 per 10,000 persons). The study also found that phalangeal fractures were the most common upper extremity fractures in males and in persons aged 35-49 years. Moreover, the incidence of phalangeal and metacarpal fractures, unlike other upper extremity fractures, was seen to decrease with increasing socioeconomic status.[4]

Fractures of the proximal phalanx are the most common phalangeal fractures, followed by fractures of the distal phalanx and then the middle phalanx. The small finger accounts for more than one third of all hand fractures, with an even distribution among the remaining 4 digits.[5]

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.[6, 7] Crush injuries are common at the distal phalanx, while the PIP joint is usually damaged by an axial blow to the finger.

Pathophysiology

Stability of phalangeal fractures depends on location, fracture orientation, integrity of the periosteal sleeve, 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.[8] 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. Any areas of tenderness or crepitus should be palpated. Loss of length or of normal knuckle contour may be indicative of fracture shortening or angulation.[9] 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, causing it to flex, and the extensor tendon on the middle phalanx, causing it to hyperextend. Unicondylar fractures at the head of the proximal phalanx are common athletic injuries and can often be missed because the athlete can bend his or her finger after the initial injury. Patients present with a history of dislocation reduced by a trainer and present much later if they continue to experience pain and deformity.[10]

Fractures of the middle phalanx angulate with the distal fragment dorsally if the fracture is distal to the flexor digitorum sublimis (FDS) insertion and palmarly if the fracture is proximal to the FDS insertion. Distal phalanx fractures, usually secondary to a crush injury, generally do not displace because both the flexor and extensor tendons insert on the base of the distal phalanx. The nail plate may also provide some support to preserve alignment of the fractured distal phalanx.[9] 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. Subtle overlap may vary from patient to patient; thus, comparison with the contralateral hand can be very helpful.

Classification of these fractures is often done using fracture pattern (transverse, oblique, spira, comminuted), fracture location (head, neck, shaft, intra-articular), and the extent of soft tissue injury (open vs closed).[9]

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

Relative indications include the following:

  1. Multiple fractures

  2. Fractures with bone loss or associated tendon injury[9]

  3. Fractures with associated tendon injury[9]

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 for 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.[11]

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. Studies have shown that even in the face of extensive soft tissue damage (open fractures), achieving solid internal fixation allows early mobilization and is of great importance.[12, 13] 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.

 

Workup

Imaging Studies

Plain radiographs (PA, lateral and oblique views) are sufficient for the diagnosis of most injuries to the phalanges. Oblique radiographs may be especially helpful for injuries around the DIPJ and PIPJ or to detect subtle shaft fractures. Little role exists for CT or MRI in the acutely injured finger.

Acute dorsal proximal interphalangeal joint fractu Acute dorsal proximal interphalangeal joint fracture-dislocation.
Acute dorsal proximal interphalangeal fracture-dis Acute dorsal proximal interphalangeal fracture-dislocation. A concentric reduction could not be maintained in a splint.
Complex unstable fracture of the proximal phalanx. Complex unstable fracture of the proximal phalanx.
 

Treatment

Medical Therapy

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.

Custom figure-of-eight splint used once motion is Custom figure-of-eight splint used once motion is begun.

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.

Surgical Therapy

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.[14]

  • 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.[15]

  • Shaft fractures

    • 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.[9] 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.[9] 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.[16]

  • 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.[17]

    • 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.[18] 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.[19] Pilon fractures, where the comminuting involves both the dorsal and palmer cortices, are especially amenable to dynamic traction.[20]

      Treatment with dorsal blocking splint. Treatment with dorsal blocking splint.
      Treatment with a dorsal blocking percutaneous pin. Treatment with a dorsal blocking percutaneous pin.
      Treatment with multiple minifragment screws plus K Treatment with multiple minifragment screws plus K-wires.

Preoperative Details

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.

Intraoperative Details

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.

Follow-up

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.[10]

  • 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.[19]

    Treatment with dorsal blocking splint. Treatment with dorsal blocking splint.

Complications

See the list below:

  • Loss of motion may result from either tendon adhesions or joint contracture.[21] 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.[22] 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%.[23] 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.[24]

    • Rotational malunions can also impact finger function and grip strength. Corrective osteotomies may be performed at the phalangeal or metacarpal level[24] 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.[25, 26] 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.[27]

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[28] and in those with associated systemic illness. High-energy fractures with comminution and soft tissue injury also lead to worse outcomes.[29] 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.[30]

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.[31]

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Broken Finger and Broken Hand.