*****NOTE***** - it would be helpful to bold or otherwise
emphasize key terminology, such as “tuft fracture”, “mallet
finger”, subungual hematoma, etc.
Additionally, I note that the author favors the word “also” – it
is overused. You may check other articles for this same
occurrence.
I might suggest an “objectives” section at the beginning of
each chapter to highlight to the student/reader what the take
home messages are.
Lastly, the SKILLS section (last) would be more helpful if it
were presented in bulleted format.
Date: 12-Apr-2014 08:37
Version: 17
Author: Shawn Boomsma
Musculoskeletal
Medicine for Medical
Students
Phalangeal (hand)
fracture
Table of Contents
1
2
3
4
5
6
7
Description 3
Structure and function 4
Patient presentation 5
Clinical evidence 6
Epidemiology 7
Differential diagnosis 8
Red flags 9
8 Treatment options and outcomes 10
9 Risk factors and prevention 11
10 Miscellany 12
11 Key terms 13
12 Skills 14
Phalangeal (hand) fracture
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1 Description
Phalangeal fractures of the finger are typically due to direct blows to the hand. Most phalangeal
fractures are treated non-operatively with splinting, but more serious and unstable fractures may
require surgical treatment to prevent stiffness, malunion and decreased function. Phalangeal
fractures may be seen in the setting of soft tissue injuries (e.g., nail bed, flexor tendon) that are
of
more pressing concern.
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2 Structure and function
The phalanges form the fingers and thumb of the hand. The thumb has 2 phalanges (proximal
and distal) and the other digits have 3 (proximal, middle and distal) for a total of 14.
Each phalanx is comprised of a base, proximally, and a head, distally, with the shaft between
them. The articulation of the proximal and middle phalanges forms the proximal interphalangeal
joint (PIP); and the articulation of the middle and distal phalanges forms the distal
interphalangeal joint
(DIP). These are hinge joints, capable of flexion and extension. The ulnar and radial collateral
ligaments along with the joint capsule are the primary stabilizers. The volar plate, a band of
fibrocartilaginous tissue, prevents hyperextension. The flexor and extensor tendons
attach to bone at their respective insertion sites, and bone injuries there (typically avulsions) can
lead to
functional failure of the affected flexor or extensor tendon.
annotated xray of hand showing regions of phalanx and soft tissue attachment points
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3 Patient presentation
Patients typically present with pain and swelling and a history of a blow or crush to the injured
digit. Ecchymoses may be present.
Distal phalanx fractures are usually caused by a direct blow or crush, which can cause nail
bed injuries (seen as a hematoma beneath the nail).
clinical photo of crushed finger suggesting bony injury
Tuft fractures are fractures of the cancellous bone at the distal tip. The integrity of the flexor and
extensor tendons should be assessed with any injury to the distal phalanx. Nailbed injuries are
also common as part of tuft fractures; a subungual hematoma may need to be drained and the
nailbed repaired after removing the nail.
The middle phalanx is more susceptible to a direct blow to the dorsal side. The middle phalanx
is also injured with an axial force, perpendicular to the shaft.
A direct blow commonly causes proximal phalanx fractures but rotary forces and hyperextension
can also cause injury. Proximal phalanx fractures are often angulated at the time of presentation
(independent of mechanism) as muscle forces deform the unstable shaft. The collateral
ligaments and volar plate at the MCP joint stabilize the proximal portion and the extensor
tendon pulls the distal fragment into extension.
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4 Clinical evidence
AP, lateral and oblique images of each injured digit are needed. The lateral view should be
taken so the other fingers do not obscure the injured digit. The oblique view can help diagnose
fractures of the heads. Radiographs should be examined for angulation and shortening as well
as intra-articular fractures. Rotational deformities are usually diagnosed via physical
examination rather than radiographic findings.
If an intra-articular fracture is suspected but not seen on plain radiograph, CT can be useful.
xray of intra-articular phlanx fracture
xray of oblique displaced phlanx fracture
Once the fracture is reduced and splinted, post-splinting radiographs are taken. There should be
no finger rotation, less than 2 mm of displacement or shortening and less than 10 degrees of
angulation.
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5 Epidemiology
Phalangeal fractures are common. They are seen in athletic and work-related injuries. The
precise incidence is not known, as many patients do not seek medical care.
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6 Differential diagnosis
Collateral ligament tears are seen when there is forced ulnar/radial deviation, especially in the
PIP joint, (i.e., “jamming” of the finger). Applying gentle varus and valgus force to the joint can
test
the ligaments.
Soft tissue trauma can cause swelling within the (confined) fibrous septae found in the pulp of
the distal phalanx; blood can also accumulate. Trauma can also lead to open lacerations (with
neurovascular dysfunction), avulsion of the skin, and nailbed injuries, such as subungual
hematomas.
Flexor/extensor tendon injury may be seen with middle and distal phalangeal fractures. Mallet
finger is an extensor tendon injury from a flexion blow to an extended DIP joint. It is seen as an
inability to actively extend the DIP, leading to a flexion deformity of the DIP joint. Jersey finger is
a
flexor tendon injury (FDP) from forceful extension of the flexed DIP joint. Injury typically occurs
when the finger is caught on a jersey, usually while tackling, and most commonly affects the
fourth digit.
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7 Red flags
Loss of rotational anatomic alignment. Comminuted, oblique, and spiral fractures are
more likely to have loss of rotational alignment
Soft tissue wounds with fracture suggest possible open fractures with soft tissue injury.
Dysfunction of flexion or extension of each phalanx. This can signal a middle phalanx base
fracture, as the base of the middle phalanx is the insertion site of the flexor
digitorum superficialis tendon.
Loss of two-point discrimination (normal is 4-5 mm wide) or capillary refill (normal is less
than 2 seconds).
(clinical photo showing to how Check for malrotation of the proximal phalanx by flexing
the MCP and PIP joints with the forearm in supination. Normally the fingers point
towards the scaphoid with no overlap or rotation).
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8 Treatment options and
outcomes
The goal of treatment is to restore congruence of joint surfaces as well as anatomic alignment.
A majority of non-displaced fractures of the distal phalanx can be splinted with the DIP joint in
extension for 3-4 weeks. Most non-displaced proximal phalangeal fractures can be managed
with a radial or ulnar gutter splint.
clinical photo of non op rx of phalanx fracture, not that it's interesting but to balance subliminal
message of having only surgical picture
Active range of motion should be started after 3 weeks, with clinical healing (no pain with
palpation or movement) taking 6-8 weeks to occur. Ice, elevation, and limitations of use can also
aid healing.
If the nail is separated from the nail root, it should be gently irrigated and then placed beneath
the eponychium (cuticle) in order to assist in future nail growth.
Referral to a hand surgeon is needed with middle phalanx base fractures (as this is the insertion
site of the flexor digitorum superficialis tendon), comminuted, rotational, intra-articular, oblique,
and spiral fractures. Displaced or angulated fractures unable to be reduced adequately also
need prompt referral.
Surgical options include extension block splinting with Kirschner wires, closed reduction and
internal fixation (CRIF) and open reduction and internal fixation (ORIF).
figure: xray of ORIF phalanx fracture
The outcome of phalanx fractures depends on many factors, including the forces
causing the injury, patient compliance, type of treatment, length of immobilization, and medical
expertise.
Stiffness is one of the most common complications following phalangeal fracture, correlating
with the amount of soft tissue injury and age of the patient. Some degree of stiffness
occurs in greater than 50% of proximal phalangeal fractures.
Malunion/deformity is common, especially with nonoperative treatment of fractures that should
have been treated surgically. Osteotomy is performed to correct the deformity.
Nonunion is rare but is most commonly seen with distal phalangeal fractures, especially tuft
fractures. However, non-union of tuft fractures is typically not clinically significant. The union of
the
two fragments is from fibrous union rather than osseous union.
Post-traumatic arthritis is a potential complication of intra-articular fractures in particular.
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9 Risk factors and prevention
Individuals playing ball sports (basketball, football, baseball) are at a high risk for fractures as
well as those with bone/joint disease (osteoporosis) and poor nutrition. Elderly patients are
at a higher risk due to their increased likelihood of falls.
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10 Miscellany
Wearing proper gloves and protective wear can decrease the chance of work-related
phalangeal
fractures.
The plural of phalanx is “phalanges” and the adjectival form is “phalangeal”. Etymology: The
ancient Greek word “phalangos” means "line of battle”, referring to a tight array of 800 soldiers.
The fingers, closely opposed, may be thought to resemble an infantry row –at least to the folks
who thought that the scaphoid looked like a boat, or that the coracoid process of the scapula
resembles a raven's beak.
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11 Key terms
Phalanges, phalangeal, fracture, distal, middle, proximal, tuft, nailbed, jersey, mallet, finger, PIP,
DIP, FDS, FDP
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12 Skills
Accurately diagnose fractures on radiographs. Understand and demonstrate testing of FDS and
FDP. Apply a radial or ulnar gutter splint. Describe and demonstrate testing for radial and ulnar
digital neuropathies. Be able to describe a fracture with proper terminology.