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Phalanx Fractures Hand

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Other Names

  • Finger Fracture
  • Distal Phalanx Fracture
  • Middle Phalanx Fracture
  • Proximal Phalanx Fracture
  • Seymour Fracture
  • Tuft Fracture

Background

  • This page refers to fractures of the 2-3 bones of the finger referred to as Phalanx

History
Epidemiology

  • Approximately 10% of all fractures (need citation)
  • 5th digit is most commonly affected accounting for 38% of all hand fractures (need citation)

Pathophysiology

Comminuted phalangeal tuft fracture of the third digit. The fracture does not extend into the DIP joint. Soft tissue swelling around the distal digit.[1]
Seymour Fracture. Better characterized as a displaced, angulated physeal fracture with metaphyseal fragment (red arrow), consistent with salter harris II fracture[2]

General

  • Very common, however less common than Metacarpal Fractures
  • Can be proximal, middle, distal phalanx
  • Can occur base, neck, shaft or head
  • May be intra- or extra-articular
  • Some may not even seek medical attention if non displaced
  • Location: Distal > middle > proximal phalanx

Etiology

  • Crush
  • Sports
    • Most common under 29
  • Machinery
    • Most common age 40 to 69
  • Falls
    • Most common over 70

Distal Phalanx Fractures & Associated Injuries

  • Tuft Fracture
    • Crush injury of the distal phalanx
    • Typically stable, associated with nailbed lacerations
  • Mallet Finger
    • Forced flexion of an extended finger with extensor tendon rupture
    • Can avulse the proximal aspect of the distal phalanx
  • Seymour Fracture
    • Distal phalanx fracture associated with nailbed injury and growth plate injury
    • Occurs due to hyperflexion
    • Presents with mallet deformity
    • Occurs due to terminal tendon attaches to proximal epiphyseal fragment, FDP tendon attaches to distal fragment
  • Nail Bed Lacerations
  • Nail Bed Avulsions
  • Subungual Hematoma

Middle/Proximal Phalanx Fractures


Risk Factors

  • Male

Differential Diagnosis

Differential Diagnosis Finger Pain

Differential Diagnosis Finger And Hand Pain


Clinical Features

Illustration of scissoring on the right with normal on the left. Note that all fingers are parallel and point towards the thenar eminence or scaphoid[3]

History

  • Characterize mechanism of injury
  • Location of pain, swelling should clue you into injury pattern
  • Be certain to clarify hand dominance, baseline function, occupation and hobbies

Physical Exam: Physical Examination Hand

  • Inspection may reveal ecchymosis, swelling, deformity
  • Important to exclude rotational deformity, open wounds
  • Palpation reveals focal tenderness of the affected bone(s)
  • Range of motion is often reduced
  • Assess for "scissoring" of digits which suggests rotational component
  • Radial and ulnar pulse most often normal, check 2-point discrimination

Evaluation

Minimally displaced 4th middle phalanx fracture

Radiographs

  • Standard Radiographs Hand
    • First line imaging in all suspected phalanx fractures
    • Recommended views: PA, lateral, oblique
    • Generally characterizes lesion well
  • Proximal phalanx
    • Apex volar angulation flexed by interossei, distal fragment extended by central slip
  • Middle phalanx
    • Apex volar angulation if distal to FDS insertion
    • Apex dorsal angulation if proximal to FDS insertion

Ultrasound

  • Ultrasound can be used to diagnose phalanx fractures
    • Exact role in diagnosis compared to XR is not well defined

MRI/CT

  • Generally not needed
  • Indications
    • Assess articular involvement in uncertain cases
    • Rarely, may be indicated in complex or surgical cases
    • Evaluate soft tissue injuries in uncertain lesions

Classification

Proximal and Middle Phalanx

  • Head fractures
    • Type I: stable, no displacement
    • Type II: unstable, unicondylar
    • Type III: unstable, bicondylar or comminuted
  • Neck/shaft fractures
    • Short oblique
    • Long oblique
    • Spiral
    • Transverse
    • Middle phalanx neck fracture often has apex volar angulation
    • Middle phalanx deformity patterns:
      • Apex volar angulation: distal to FDS insertion
      • Apex dorsal angulation: proximal to FDS insertion
      • Without angulation: due to inherent stability provided by an intact and prolonged FDS insertion
  • Base fractures
    • Extra-articular vs Intra-articular, with or without lateral base
    • Middle phalanx deformity is usually apex dorsal angulation
      • Proximal fragment in extension (due to central slip)
      • Distal fragment in flexion (due to FDS)
    • Aan be further classified into
      • Partial articular fractures: volar, dorsal or lateral base
      • Complete articular fractures: pilon fractures, unstable in all directions

Distal Phalanx

  • Tuft fractures
    • Crush facture; usually stable; associated with nailbed injuries
  • Shaft fractures: transverse vs longitudinal
  • Base fractures
    • Usually unstable
    • Mechanism
      • Shearing due to axial load; fracture involving > 20% of articular surface
      • Avulsion due tensile force of terminal tendon or FDP; small avulsion fracture
    • Further classified into: dorsal or volar base
  • Seymour fractures
    • Epiphyseal injury of distal phalanx resulting from hyperflexion

Management

Dorsal blocking splint or extension block splint on digits 2 and 3. The splint is fashioned out of fiberglass, taped in place.[3]

Non-operative

  • Indications
    • Most phalanx fractures are managed nonoperatively
    • Tuft Fractures
    • Generally includes extra-articular, < 10° angulation, < 2 mm shortening, no rotational deformity
    • Intra-articular fractures can be nonoperatively managed if non displaced
  • Distal Phalanx
    • Finger Splinting for non-displaced fractures, typically with a U-shaped splint
    • Immobilize PIP and DIP joints
    • Can consider buddy tape
  • Proximal Phalanx
  • Encourage gentle active range of motion
  • Antibiotics
    • Consider oral antibiotics for open fractures

Operative

  • Indications
    • Extra-articular, > 10° angulation, > 2 mm shortening, or with rotational deformity
    • Displaced intra-articular fractures
    • Unstable or irreducible fracture pattern
    • Open fractures
  • Technique
    • Often uses K-wires or ORIF
    • Traction for comminuted fractures

Rehab and Return to Play

Rehabilitation

  • Post operative care at discretion of surgeon

Return to Play/ Work

  • RTP varies widely
    • Largely depends on sport and position
    • In general, anticipate 4-6 weeks before returning
    • In some sports, can consider playing in a splint or cast if needed

Prognosis and Complications

Prognosis

  • Most patients will have good outcomes

Complications

  • Nailbed Injuries
  • Fracture-dislocations
  • Diminished range of motion
    • Most common complication (need citation)
    • Risk factors: prolonged immobilization, intra-articular fracture, extensive surgical dissection)
    • Treatment: aggressive hand therapy, surgical release if not improving
  • Malunion
    • Types: malrotation, angulation, shortening
  • Nonunion
    • Uncommon, less than 2% of cases (need citation)

See Also

External


References

  1. Case courtesy of Matt A. Morgan, Radiopaedia.org, rID: 48240
  2. Case courtesy of Francis Deng, Radiopaedia.org, rID: 71967
  3. 3.0 3.1 Image courtesy of https://www.rch.org.au/clinicalguide/guideline_index/fractures/, Phalanx Fractures
Created by:
John Kiel on 26 June 2019 22:44:40
Authors:
Last edited:
25 August 2023 22:46:03
Categories:
Trauma | Osteology | Finger | Hand | Fractures