Phalangeal Fractures Treatment & Management

Tuft fractures are treated by caring for the accompanying soft-tissue injury and splinting of the finger to prevent further discomfort or injury. A variety of splinting devices can be used for loose protection. In the closed crush fracture of the distal phalanx, the L -shaped Alumafoam splint placed on the volar aspect to protect the soft tissues is considered the best treatment. Tight circumferential taping around the fingertip should not be used because of an increased risk of circulatory compromise. Splinting is generally maintained for about 2-3 weeks.

Avulsion of the nail plate and injury to the nail bed is often associated with tuft fractures. It is necessary to reduce the nail plate under the eponychium, and if this cannot be performed, the plate can be removed. The distal phalanx may be destabilized to some extent, but as there are no tendons attached to the tuft of the distal phalanx, these injuries rarely displace. If the nail is removed during repair, packing of the eponychial space with petroleum gauze is used to prevent scarring and closure of the space, which could lead to stunted nail growth. Tuft fractures may progress to nonunion but are usually asymptomatic.

Open fractures of the distal phalanx require thorough cleansing, debridement, and inspection for foreign bodies. Orthopedic assistance is not required for uncomplicated closures. Open fractures with extensive soft-tissue damage are frequently associated with chronic pain and disability and may need orthopedic assistance. Open fractures of the distal phalanx require a course of antibiotic treatment.

The shaft of the distal phalanx is very narrow and mostly cortical. Fractures at this location can be problematic. Nonunion can be symptomatic; occasionally, these require internal fixation.

Acute phase

The mallet finger is a stable injury. If the patient presents with lack of active extension of the DIP joint, then splinting of the finger in extension or slight hyperextension for 8 weeks is the treatment of choice. It is important to educate these patients not to remove the splint. Observed these patients in the office every 1-2 weeks to ensure that the splint is not being removed.

Patients can be instructed to change the splint every few days to allow cleansing of the skin. However, reapplication of the splint should always be completed with assistance. The DIP joint should not be allowed to flex at any time. If the tendon ruptures from DIP flexion, then the entire 8-week period of splinting must be repeated.

When splinting the mallet finger, the DIP joint should not be severely hyperextended, as the skin over the dorsum of the joint will blanch and slough, and ischemia and necrosis of the dorsal tissue may occur. There are cases in which a patient cannot tolerate an external device, and these patients are treated with transarticular Kirschner wire (K-wire) fixation for 6-8 weeks. The PIP joint should be in full motion, because splinting of the PIP may result in thickening of the collateral ligaments and subsequent joint contracture and stiffness.

Rehabilitation is much longer and more difficult with a stiff PIP and mallet finger. However, it should be noted that the PIP joint is infrequently immobilized in the hyperflexible patient to allow the terminal tendon to heal in a shorter position.

Maintenance phase

Full activity is allowed during the 8-week interval of continuous splinting for a mallet finger. However, additional finger protection and supervision by an athletic trainer or physician is required during contact sports. The splint may be removed during the day after 8 weeks. Tendon stability is maximized if the splint is used at night and during athletic activity for another 8 weeks.

Patients with an undiagnosed or neglected mallet finger may undergo a trial of prolonged splinting for up to 3 months; however, the prognosis is best when a splint is applied within 2 weeks of the injury. Surgical fusion of the DIP joint can provide stability if splinting fails in these cases.

Surgical intervention

The mallet finger is a stable injury. However, treatment is more difficult if a portion of the bone is avulsed from the distal phalanx. If the bone can be reduced closed in an adequate position with less than 2 mm of displacement, then closed treatment is recommended.

Acute phase/surgical consultation

A type 1 jersey finger injury is an avulsion of the flexor digitorum profundus tendon into the palm, losing its blood supply from both the bone and the vincular system. These injuries require reattachment within 7-10 days to avoid necrosis of the tendon.

In type 2 injuries, the tendon retracts to the level of the PIP joint and is held by an intact vincula. A reattachment can be successful anywhere from 3 to 6 weeks after injury.

Type 3 injuries involve avulsion of a large fragment of bone from the palmar base of the distal phalanx. The tendon does not retract past the DIP joint because of the fracture fragment being caught by the A4 pulley. Type 3 injuries are not to be treated with closed reduction because of the possibility of an associated avulsion of the profundus tendon from the osseous fragment. Delayed repair also can be successful.

Acute phase

Nondisplaced middle phalangeal fractures without impaction require only dynamic splinting or “buddy taping” for 2-3 weeks. This allows early motion and decreases joint stiffness.

Angulation and rotation are 2 features of instability that must be examined. Volar angulation is more common than dorsal angulation. Midshaft fractures can result in a dorsal or volar deformity. When angulation is present, closed reduction is necessary for bone realignment. Digital blocking can provide adequate anesthesia. For dorsal angulation, closed reduction is accomplished by longitudinal traction without distal fragment flexion. For volar angulation, closed reduction by longitudinal traction is followed by flexion of the distal fragment to line up with the proximal fragment.

Maintenance phase

A short arm plaster dorsal splint is used for 2-3 weeks to hold the wrist in slight extension, the metacarpophalangeal joint in 70° flexion, and the PIP joint in 45° flexion. Flexion of these joints limits rotation and prevents collateral ligament contracture. The DIP joint has free motion to prevent tendon scarring around the fracture site.

Rehabilitation

Gentle active and passive motion should be initiated as soon as soft-tissue healing occurs, which is usually after 2-3 weeks, as long-term immobilization from extended splinting causes joint stiffness and soft-tissue dystrophy.

Acute phase

Dynamic splinting is the treatment of choice for nondisplaced fractures. Fractures of the shaft usually result in volar angulation, because the intrinsic tendons pass obliquely from a proximal volar to a distal dorsal direction. Angulation is also increased by the influence of the extensors and flexors compressing bone longitudinally. Reduction is accomplished by longitudinal traction and flexion of the metacarpophalangeal joint to lessen the pull of the intrinsic muscles and then followed by longitudinal traction and flexion of the distal fragment.

Maintenance phase

For displaced fractures, splinting is used after reduction, with the wrist in slight extension and the metacarpophalangeal joint flexed to 70°. Free motion is allowed at the PIP and DIP joints for early tendon motion. Oblique and spiral fractures are usually unstable after reduction and require splinting with either ulnar or radial gutter splints that extend to the distal phalanx. In the proximal phalanx, the surrounding tendons lie in close proximity to the periosteum, and there is a susceptibility to adhesions and stiffness during the healing process. Therefore, appropriate fracture alignment, stability, and early motion are very important. ^[11] One study in patients with extra-articular fractures of the proximal phalanges examined the use of a cast that allowed unrestricted motion of the wrist, and that fixed the MCP joints in 70 to 90 degrees of flexion with buddy taping of the fingers. ^[12] This cast allowed quicker return of wrist motion and showed similar healing of fractures compared toastatic forearm-fingercastinan intrinsic-plus position. ^[12]

Fok et al report on 10-year results managing proximal phalangeal fractures with dynamic treatment. ^[13] A dynamic splint that kept the metacarpophalangeal joint maximally flexed while allowing free movement of the proximal and distal interphalangeal joints of the injured finger was applied for at least 4 weeks. Results were evaluated using the Belsky classification and grip strength assessment. The results of 97 patients (103 fractures) were analyzed. At a minimum 1-year follow-up, 75% of patients attained excellent or good results. Neither nonunion nor delayed fracture union was noted. The 25% of patients who attained poor results were older than those who attained excellent or good results (average age, 53.1 vs 35.1 years, respectively) and tended to comply poorly with the rehabilitation program. Using the stabilizing effect of the zancolli complex-metacarpophalangeal retention apparatus and a metacarpophalangeal block splint, bone healing and movement recovery can be achieved simultaneously. ^[13]

Posterior PIP fracture-dislocations occur with volar lip fractures and volar dislocations with dorsal avulsion fractures. Posterior fracture-dislocations usually involve some degree of axial compression, comminution, and involvement of the volar articular surface. Treatment methods are grouped into the following 5 categories: static immobilization, dorsal extension block splinting, longitudinal traction, open reduction and internal fixation, and palmar plate arthroplasty.

Acute phase

A splint or transarticular K-wire can be used for static immobilization. Articular reduction must be monitored serially by radiographs, and immobilization for more than 3 weeks may result in stiffness. The PIP joint must be immobilized in about 30° of flexion for about 2 weeks.

Maintenance phase

PIP motion is initiated, but significant hyperextension of the joint may injure healing tissues. An additional extension block splint prevents the final 30° of extension while allowing joint flexion. The ideal case for extension block splinting is when there is some collateral ligament restraint remaining on the major fragment. Therefore, a fracture involving less than 40% of the articular surface is preferred for extension block splinting. Lateral radiographs must be monitored to ensure that subtle subluxation is not present and that dorsal joint surfaces are reduced adequately.

Rehabilitation phase

At 6 weeks, passive flexion and strengthening should be instituted. As soon as the splint is off, grip and massage exercises and functions are started. Avoid pinching of the involved finger and stretching of the involved joint. When grip strength reaches the 50% level, then full freedom of function is given. When the patient is fully asymptomatic, full PIP motion is encouraged with protective splinting used during athletic activity. Formal rehabilitation is usually discontinued at 3 months after injury.

Acute phase

Stable palmar lip fractures (< 30% of the articular surface) do not cause PIP joint subluxation and are treated by programs that maximize motion. An extension block splint may be used for stable hyperextensible palmar lip fractures or a double Alumafoam splint method to achieve 20° of PIP joint flexion for 3 weeks; then, it is adjusted to 10° of additional extension over the next 2 weeks.

Rehabilitation program

For pilon fractures, traction is discontinued after 6 weeks, and aggressive range of motion is maintained.

Mallet fingers involving fractures of more than 25-30% of the articular surface, or if volar subluxation of the DIP joint is present, then open reduction and internal fixation is indicated. Fixation is continued for 4-6 weeks, after which the pins are removed and motion is begun. The patient wears an external splint for the month after internal fixation is discontinued.

For jersey fingers, with continued extension vector force, the distal phalanx continues into hyperextension. Subsequently, a secondary intra-articular fracture at the base of the distal phalanx occurs as the distal portion of the middle phalanx is driven into the base of the distal phalanx. Avulsion of the flexor digitorum profundus with a separate intra-articular fracture of the distal phalanx has been proposed as a type 4 injury. Treatment consists of open reduction and internal fixation of the intra-articular fracture with reinsertion of the profundus tendon.

For fractures of the middle phalanx, if conservative treatment is not sufficient, then percutaneous pinning or open reduction using K-wires is used. ^[14] Plates or screws are not regularly used at the phalangeal level because there is too much soft-tissue damage in the process (although Giesen et al reported successful treatment of proximal and middle phalangeal fractures in 26 patients with intramedullary headless compression screws ^[15] ). Displacement of the bone around the center of the longitudinal axis is rotational.

A retrospective review study by Ridley et al that included 695 patients who underwent fixation of phalangeal, metacarpal, or distal radius fractures with K-wires reported that pin-site infections were more likely in exposed K-wire cases than in buried K-wire cases. ^[16]

Malrotation is detected clinically, not radiographically. Patients should be asked to fully flex the phalanges; the long axis of the fingers should point to the scaphoid tubercle or the distal radius with the fingers parallel to each other. If suspected, a rotational deformity warrants surgical referral. A rotational deformity is often associated with spiral, oblique, or comminuted fractures.

A comminuted fracture of the base involving the PIP joint can be difficult to treat. In these cases, traction with a transverse K-wire through the middle or distal phalanx can be used. They are removed after 6 weeks, but external splint immobilization is needed for an additional 2-4 weeks.

An alternative method, as described by Eaton, is primary volar plate arthroplasty in which the comminuted volar portion of the middle phalanx is removed and the volar plate is advanced into the defect.

For PIP fracture-dislocations, if a congruent reduction cannot be maintained or if more than 30-50% of the articular surface is involved, then arthroplasty may be required. If there is a large volar fragment, then internal fixation may be necessary. It is believed that fragments with greater than 2 mm of displacement lead to excessive extensor deficit and, therefore, warrant open reduction and internal fixation.

Successful surgical treatment of PIP fracture-dislocations is dependent on the following principles. The first is to reestablish the normal flexion glide of the middle phalanx around the proximal phalanx head during the flexion arc. Hinging at the fracture site must be avoided. The surgeon must eliminate joint subluxation and then reestablish joint stability. Second, early motion is initiated whenever possible to enhance cartilage and soft-tissue healing and also to minimize adhesions or contractures. Anatomic restoration of the fractured joint surface is desirable but is a much less important treatment goal.

The preferred treatment for unstable palmar lip fractures is palmar plate arthroplasty, and referral to a surgeon is necessary. Pilon fractures also require a surgical consult. Pilon fractures are placed in traction, and patients should begin active and passive motion as soon as possible. Percutaneous pinning or limited open reduction and internal fixation may be necessary.

A prospective, longitudinal study by Miller et al found that in patients who underwent open reduction and internal fixation of proximal phalangeal fractures, with rehabilitation begun within 1 week of fixation, the greatest degree of recovery with regard to range of motion, hand use, pain, strength, and work participation was seen by the sixth week postoperatively. The study involved 66 patients. ^[17]

Dorsal PIP joint dislocations

A dorsal PIP joint dislocation is reduced easily with traction on the finger, followed with flexion of the PIP joint. After reduction, joint stability is provided by the intact collateral ligaments. As long as the reduction is stable, the joint congruent, and the fragment, if present, is small and minimally displaced, a dorsal extension block splint is used. Large displaced fragments lead to joint instability and respond best to operative treatment. However, some comminuted fractures can be treated only by traction and early range of motion. No treatment is likely to provide complete pain-free range of motion in these injuries.

The PIP joint should be immobilized in approximately 30° of flexion for 2-3 weeks. Buddy taping or other protective splinting should be used for another 3-4 weeks during activity or sports participation. The most important principle is the prevention of hyperextension, which could reinjure the volar plate.

If the dorsal PIP joint dislocation cannot be reduced because the proximal phalangeal head is impinged between the central slip and the lateral bands, then open reduction is required. Otherwise, these injuries can be treated with buddy taping, which is worn continuously for the first 3 weeks and then only during physical activities for an additional 4-6 weeks. Complete resolution of pain usually takes 4-6 months, although a slight residual swelling is often permanent.

Grade I and II injuries are treated with extension block splints, which limit the last 20-30° of extension but allow full flexion of the distal joint. Active protected extension is begun at 2 weeks, and athletes can be allowed to play with buddy taping. Protection should be continued for 6-8 weeks or until joint motion is pain free.

Grade III injuries, which includes irreducible dislocations, usually require surgery. If left undertreated, grade III injures can lead to permanent deformity, lost motion, and degenerative joint changes. Radiographs should be taken in the AP, lateral, and oblique planes.

Volar PIP joint dislocations

As with dorsal dislocations, the head of the proximal phalanx may become impinged between the central slip and the lateral band, in which case open reduction is necessary. Another indication for open repair is if the joint is functionally unstable (ie, the joint dislocates spontaneously as the patient moves it). A third indication for open reduction is an untreated chronic volar plate avulsion that allows the joint to hyperextend.

After closed reduction of a volar dislocation, the PIP joint should be immobilized in extension for 6-8 weeks.

All patients with closed injuries of the PIP joint should be told that swelling and disability are common for possibly months, with swelling and disability persisting for 6 months to 1 year in some complete ligamentous injuries. In addition, some thickening is likely to be permanent.

Collateral ligament injuries

Grade I or II injuries may be treated by immobilization in 15-20° of flexion for 2-3 weeks, followed by buddy taping for 3-6 weeks or until symptoms subside. Resumption of athletic activities is possible with these injuries, but reinjury is common, with risk of a grade III injury. A radiograph showing joint symmetry and stability should be obtained before administering this treatment.

DIP joint dislocations

If the dislocation is closed, it should be reduced after anesthetizing the digit by applying longitudinal traction. After reduction, the joint should be evaluated for tendon and ligament injuries. They can be irreducible when a condyle of the middle phalanx becomes buttonholed between a collateral ligament and the volar plate.

Treatment consists of digital block anesthesia followed by one gentle attempt at closed reduction by hyperextending the distal phalanx and then sliding the base of the distal phalanx over the head of the proximal phalanx. Rotational force may be necessary. If unsuccessful, open reduction is required.

Open DIP joint dislocations require surgical wound care and reduction to prevent bone or joint infections, even if there is only a small break in the volar skin. Otherwise, the distal joint is splinted in full extension for 1-2 weeks. Active range of motion is begun at 2-3 weeks, and a splint is worn until full, pain-free range of motion is achieved. If the athlete continues to play sports, the DIP joint should be splinted for 4-6 weeks to prevent reinjury.

Boutonniere deformity

Both grade I and II injuries are treated by splinting the PIP joint in full extension, leaving the distal joint free to actively flex. The adjacent metacarpophalangeal and DIP joints should be allowed to have full range of motion. Splinting or buddy taping should continue for 6-8 weeks until there is pain-free motion. During this time, a program of active and passive range of motion at the DIP joint remobilizes the lateral bands and allows the central slip to heal at its proper length.

Grade III boutonnieres demonstrate a PIP joint flexion contracture greater than 30° and loss of flexion of the distal joint. An effort is made to correct the PIP flexion contracture by splinting or casting before an operative procedure that includes release of any residual contracture.

Grade IV deformities present with a fixed PIP flexion contracture and degenerative change in the joint. For treatment, the PIP joint is held in hyperextension. Surgery results in little gain of active motion.

Arthrodesis is often necessary to correct this deformity. Patients with a chronic boutonniere deformity, either from misdiagnosis or neglect, should be referred to a hand surgeon for evaluation and treatment. Complete recovery may not be possible at this time.

Return to play in patients with phalangeal fractures is guided by the patient's symptoms, healing, and potential for reinjury. If the fracture can be adequately protected and immobilized, while not interfering with the patient's ability to participate, then sports participation can be allowed, providing the patient has adequate pain control.