Phalanx Fracture

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.

Fracture Pattern

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%)

Mechanism

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.

Imaging

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

Tuft Fractures

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.

Shaft Fractures

Most of the shaft fractures have minimal displacement and can be treated by non operative means like splinting.

Base Fractures

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.

Types

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.

Imaging

Most of the fractures can be diagnosed on routine anteroposterior, lateral  and oblique views.

Treatment

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

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
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.

Imaging

Routine AP, lateral and oblique views are able to describe most of the fractures of proximal phalanx.

Treatment

Non-operative Treatment

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