Distal Phalanx Fracture
Distal phalanx fracture is common as distal phalanx of the hand is terminal contact of the upper limb with surroundings and is at risk of injury with nearly every use of the hand.
Distal phalanx fracture can be conceived of as occurring in three primary regions [Anatomy of the distal phalanx]
- The tuft (63%)
- The shaft (36%)
- The base (18%)
Sudden axial load as in ball sports or crush injuries are mainly responsible for injuries to the distal phalanx. Fractures of the tuft are usually stable, kept so by the volar fibrous network and dorsal nail plate. Proximally, due to flexor and extensor forces the the deformities associated with fracture are more significant.
Intrarticular fractures [involving distal interphalangeal joint] occur usually due to axial loading.
Standard anteroposterior and lateral view xrays are sufficient for making the diagnosis and making decision for the treatment.
Treatment of Phalanx Fracture
Most of the distal phalanx fractures are amenable to treatment by non operative methods. A splint that spans distal interphalangeal joint usually suffices.
Region wise detail of the treatment follows
Integrity of the nail plate determines the type of the treatment.
A concomitant nail plate avulsion or step in the nail matrix warrants restoration of the fracture and Kwire fixation
If the nail plate has maintained its seal at the hyponychium and the dorsal surface of the distal phalanx is level, removal of the plate to perform a nail matrix repair is not necessary.
Associated matrix defects should be grafted.
Most of the shaft fractures have minimal displacement and can be treated by non operative means like splinting.
For dorsal base fractures with displacement closed reduction and internal fixation. The mainstay is extension block pinning. Volar Base Fractures
For volar base fractures open reduction and internal fixation is the treatment of choice
Mobilization is begun at about four weeks and coincides with removal of hardware.
Middle Phlanax Fracture
Most of the fractures of the middle phalanx are caused by crushing injury or blunt force.
Fracture of the middle phalanx can be in the head, neck, shaft, and base of the phalanx.
The location of the fracture and type of injury resulting it would determine the fracture pattern and the type of deformity it would result in.
For example fractures of the neck would angulate volar as the proximal fragment is flexed and the distal fragment extended by the flexor and extensor tendons.
In contrast those at base would angulate to opposite direction.
If the forces are axial, it may result in unicondylar or bicondylar fractures of the head or intra-articular fractures of the base.
Fractures of the base could have a dorsal base, volar base, and lateral base.
Complete articular fractures are often referred to as pilon fractures and are unstable in every direction including axially.
Other fracture patterns worth a mention are intra-articular fractures of the head,oblique shaft fractures,longitudinal shaft fractures, and transverse shaft fractures.
Most of the fractures can be diagnosed on routine anteroposterior, lateral and oblique views.
Most of the fractures of the middle phalanx can be managed by nonoperative means.
Undiplaced fractures or fractures which are stable after reduction are managed by non operstive means.
Treatment options includes
Splinting of the affected digit follower by intermittent mobilization starting at three weeks. Following that the affected finger is strapped to the adjacent one.
Closed reduction and internal fixation
Closed reduction and internal fixation is used as treatment most unstable head, neck and shaft fractures
Open reduction and internal fixation
With screws only in condylar fractures of the head
With plates and screws in fractures with bone loss or a high degree of comminution
Dynamic Extension Block Splinting
This nonoperative technique is used specifically for volar base fractures.
Treatment by Fracture Type
Condylar Fractures of the Head
Kwire fixation or screw fixation
Unstable Shaft Fractures
Closed reduction and internal fixation. In case of comminution or axial instability, plate and screw fixation.
Volar and Dorsal Base Fractures
- Temporary Transarticular kwire fixation.
- Force couple device by Agee
Pilon fractures result in the complete articular surface loss along metaphyseal compaction and bone loss. These are highly unstable injuries and associated with is stiffness. For these injuries special traction devices which allow active motion are used.
Proximal Phalanx Fracture
Fractures of proximal phalanx can be
- Intra-articular fractures of the head
- Extra-articular fractures of the neck
- Extra-articular fractures of the shaft
- Extra-articular fractures of the base
- Intra-articular fractures of the base
Fracture pattern can be transverse, short oblique, long oblique or spiral for shaft fractures. Intra-articular fractures can be partial or complete.
Routine AP, lateral and oblique views are able to describe most of the fractures of proximal phalanx.
Non operative management is suitable for minimally displaced fractures and those fractures which are stable after reduction.
These kind of fractures are treated by dorsal splinting with metacarpophalangeal joint in flexion. The splint should discontinued and active range of motion started at 3 weeks.
Closed Reduction Internal Fixation
This is the treatment of choice for the fractures which are reducible but unstable . the fixation is done with Kwires.
Open Reduction and Internal Fixation
For severe open fractures with multiple associated soft tissue injuries and for patients with multiple fractures within the same hand or polytrauma victims. Kwires, screws, Steinmann pin and plates are the implants usually used or fixation of these fractures
Get more stuff on Musculoskeltal Health
Subscribe to our Newsletter and get latest publications on Musculoskeletal Health your email inbox.
Thank you for subscribing.