Last Updated on February 9, 2025
Phalanx fractures are common hand injuries. Phalanges are small long bones of the hand that make our fingers and thumb. A similar arrangement of bones is also found in toes and those bones are also called phalanges.
Phalanx fractures are the most common fractures of the upper limb. A slight male preponderance is noted. Most of these fractures occur in men in the fourth decade of life. Crush and blunt trauma contribute to most of these fractures.
Distal phalanx fractures are most common, followed by middle and proximal phalanx.
Little finger accounts for almost 40% of the cases.
Injuries due to sports are the most common cause in less than 30 years of age. However, after 70 years of age fall is the common cause.
In groups 40-70 years, machine injury is most common.
Nail injuries could be associated with distal phalanx fractures.
Relevant Anatomy
Structure
Each finger is formed by three phalanges.
- Proximal phalanx
- Middle phalanx
- Distal phalanx
The thumb has only two phalanges, proximal and distal.
The proximal and middle phalanges can be subdivided into, proximal to distal
- Base
- Shaft
- Head- formed by two condyles separated by an intercondylar notch.
The distal phalanx is divided into a base, shaft, and tuft and is protected dorsally by the nail plate.
Collateral ligaments support the radial and ulnar aspects of these joints. The volar plate is a strong ligamentous structure over the volar aspect of the joints. It resists hyperextension.
The flexor digitorum superficialis tendon passes over the volar surface of the MCP joint, proximal phalanx, and proximal interphalangeal joint. At PIP joint it splits into two slips, and inserts on the junction of the proximal and middle one-third of the middle phalanx. The flexor digitorum profundus accompanies it dorsally and passes between these two slips to reach the base of the distal phalanx. A complex network of tissue bands called vicula acts as a tether between the flexor tendons and the proximal and middle phalanges.
The extensor tendons on the dorsal aspect of the finger form an extensor hood complex. A central slip from this extensor mechanism attaches es to the base of the middle phalanx on dorsal aspect. Two lateral bands pass to the distal phalanx form a terminal slip and to the base of the distal phalanx.
Lumbricals and interossei, also called the intrinsic muscle of the hand attach to the lateral bands of the extensor mechanism. Sagittal bands on each side of the finger attach the extensor hood to the volar plate and flexor tendon sheath near the PIP joint.
A single digital nerve and artery lie on both the radial and ulnar aspects of the finger to supply the finger tissues.
Joints
- In all five digits, the base of each proximal phalanx articulates with its respective metacarpal to form the metacarpophalangeal joints.
- In all digits except the thumb
- The base of the middle phalanx articulates with the head of the proximal phalanx to form the proximal interphalangeal joint.
- The base of the distal phalanx articulates the head of the middle phalanx to form the distal interphalangeal joint
- In the thumb, the head of the proximal phalanx articulates with the base of the distal phalanx to form the interphalangeal joint of the thumb
[Read about Hand Anatomy]
Pathophysiology of Phalanx Fractures
Phalanx fractures are often caused by blunt, penetrating, or crush trauma. There is an age-wise distribution of the most common causes
- 10-30 years old – sports
- 40-70 years old – machinery or heavy object
- >70 years old – falls
Different forces give rise to varying kinds of injuries-
- Forces that bend the shaft- Transverse fractures
- Torsional and angular forces- Spiral and oblique fractures
- Crushing injuries- Comminuted fractures
- Axial loading – intraarticular fractures
- Avulsion of tendinous insertion sites – angular patterns with or without fractures
- Proximal phalanx
- The attachment of the central slip and the attachment of the intrinsic hand muscles to the extensor mechanism proximally and flexor digitorum superficialis distally causex apex volar angulation of proximal phalanx fractures.
- Middle phalanx
- Fractures near the base of the middle phalanx that occur between the two tendinous insertions result in apex dorsal angulation.
- Middle phalanx fractures distal to FDS insertion have and proximal to terminal slip of extensor mechanism has apex volar
- Distal Phalanx
- Avulsion of flexor/extensor tendon results in deformity due to unchecked force from other side – for example mallet fracture.
- Proximal phalanx
Classification of Phalanx Fractures
Proximal Phalanx Fractures
- Head fractures
- type I – stable with no displacement
- type II – unstable unicondylar
- type III – unstable bicondylar or comminuted
- Neck/shaft fractures
- Oblique
- Spiral
- transverse
- Base fractures
- Extra-articular
- Intra-articular
- Lateral base

Middle Phalanx Fractures
Most of the fractures of the middle phalanx are caused by crushing injury or blunt force.
The location of the fracture and the type of injury causing it determines the pattern of the fracture. For example, fractures of the neck have volar angulation because the proximal phalanx is flexed [by flexor tendons] and the distal extends [by extensor tendons]
In contrast, those at the base would angulate in the opposite direction.

- Head fractures
- Type I – stable with no displacement
- Type II – unstable unicondylar
- Type III – unstable bicondylar or comminuted
- Neck fracture- apex volar angulation
- Shaft fractures
- transverse
- oblique
- spiral
- Deformity could be apex volar when fracture distal to FDS insertion or dorsal when proximal
- Base fractures- Deformity is usually apex dorsal angulation
- proximal fragment in extension (due to central slip)
- distal fragment in flexion (due to FDS)
- Partial articular fractures
- Volar base- results from hyperextension injury or axial loading. represents avulsion of volar plate
- Dorsal base results from hyperflexion injury, represents avulsion of the central tendon
- Lateral base- represents avulsion of collateral ligaments
- Complete articular fractures- also called pilon fractures, unstable in all directions
Distal Phalanx Fractures
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 communicated but stable due to internal splinting by fibrous septae. However, the proximal fractures are often displaced due to due to flexor and extensor forces.
- Tuft fractures
- mechanism is usually crush injury
- Usually stable due to nail plate dorsally and pulp volarly
- often associated with laceration of nail matrix or pulp
- Shaft fractures – transverse or longitudinal
- Base fractures
- Often unstable
- Due to axial load- fracture
- Aavulsion due to tensile force of terminal tendon or FDP- avulsion fracture
- can be further classified into volar base or dorsal base
- Seymour fractures
- Epiphyseal injury of distal phalanx in children often from hyperflexion
- Presents as mallet deformity (i.e. apex dorsal)
Mallet avulsion fractures are caused by rupture or avulsion of the extensor tendon, often following a direct blow to the tip of the finger causing forced flexion of the distal joint. They result in mallet deformity of the finger.

Clinical Presentation of Phalanx Fractures
Patients of phalanx fractures may present with pain, swelling, deformity, and decreased range of motion. The mechanism of injury would guide the pattern of the injury. Physical examination may reveal swelling, deformity or open wounds. The hand should be assessed for the scissoring phenomenon.
On complete flexion, all the digits point to the scaphoid. An overlap or scissoring indicates an abnormality of rotational alignment. However, a bilateral comparison should be made. This examination may need to be done under an anesthetic block because the movements may be painful.
The affected part would be tender to touch.
Neural evaluation involves general sensation, two-point discrimination, and motor function.
Vascular status is examined by looking at skin coloration as well as capillary refill of the distal skin and the nail bed. In general, a finger with a single digital artery laceration will still have a brisk capillary refill. (less than 2 seconds).
Note should be made if the affected hand is dominant or not. Occupation and hobbies should be explored as requirements or expectations need to be taken into consideration while deciding on treatment.
Imaging
Most phalanx fractures are diagnosed and managed with the help of X-rays. Three views are often desired
- Anteroposterior
- True lateral
- Oblique
The contralateral hand can be used for comparison, especially in children.
X-rays would reveal fracture patterns and are usually sufficient for diagnosis.
CT might be helpful further in delineating the anatomy of severely comminuted or intra-articular fractures or differentiating pathologic fractures.
MRI is rarely indicated.
Differential Diagnosis
- Stress fracture
- Pathological fracture
- Infection
- Tumor
Treatment
Each phalanx fracture needs to be treated individually. The various factors that affect treatment include
- pattern of the fracture
- location of the fracture
- open or closed
- Associated soft injuries
- Dominant or non-dominant hand
Proximal and Middle Phalanx Fractures
The indications for operative and nonoperative treatment are similar. The actual choice of splint, splitting position, and fixation methods may differ
Nonoperative Treatment

Image Credit: About First Aid
This typically involves
- Closed reduction if required
- Splinting or casting or buddy taping
- Considered in
- Extraarticular fractures with < 10° angulation or < 2mm shortening and no rotational deformity
- Undisplaced intraarticular fractures
- Unstable fractures
Operative Treatment
This involves surgical procedures and the fixation of fractures.
Closed reduction and percutaneous pinning of phalanx fractures under C-arm image intensifier is the most commonly done procedure. Open reduction and internal fixation using miniplate or screws. The volar plate is repaired where required.
Screws are specially indicated in long oblique fractures. Following fractures need surgery-
- Extraarticular fractures
- More than 10 degrees of angulation
- More than 2 mm shortening
- Rotational deformity
- Displaced intraarticular fractures
- irreducible or unstable fractures
- Volar plate injury
- Fixation can be percutaneous fixation and open fixation Implant – wire, screws, intramedullary screws, plate and screws, external fixators
-
- Crossed K wires: Uses two k-wires to fix the fracture
- Extension block pinning: To treat mallet finger injury and prevent subluxation of the middle phalanx. Also used in intraarticular fractures
- Mini fragment fixation with plate and/or lag screws
- volar plate arthroplasty: Reattaching volar plate
- Miniplate application
Early mobilization and Rehabilitation
For better functional outcomes, early motion is necessary and it should start as soon as the fracture becomes stable. This may vary with the type of treatment/implant chosen but varies from 3-6 weeks.
Distal Phalanx Fractures
For nailbed injuries, please read Fingernail injuries.
Closed reduction with or without splinting works in most of the cases. Operative treatment is required in fractures that are open, displaced, not reducible or unstable.
Fractures of the base with more than 25% of joints are treated surgically. Another indication is displaced volar base fracture with large fragments.
The fracture can be fixed by longitudinal or crossed K wires, and extension block pinning [for mallet finger]. Small fragments can be fixed by lag screws.
Seymour fractures require surgical treatment.
Other Injuries of Fingers
Mallet finger, Jersey finger and Seymour fracture, and phalanx dislocations have been discussed in separate articles
References
- Al-Jasser FS, Mandil AM, Al-Nafissi AM, Al-Ghamdi HA, Al-Qattan MM. Epidemiology of pediatric hand fractures presenting to a university hospital in Central Saudi Arabia. Saudi Med J. 2015 May;36(5):587-92.
- Pandey R, Soni N, Bhayana H, Malhotra R, Pankaj A, Arora SS. Hand function outcome in closed small bone fractures treated by open reduction and internal fixation by mini plate or closed crossed pinning: a randomized controlled trial. Musculoskelet Surg. 2019 Apr;103(1):99-105.
- Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am. 2016 Jun;41(6):712-22. [Link]
- Zelken JA, Hayes AG, Parks BG, et al. Two versus 3 lag screws for fixation of long oblique proximal phalanx fractures of the fingers: a cadaver study. J Hand Surg Am. 2015;40(6):1124-1129.