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Fingers are fine structures of the human body which assist in daily routine activities through coordinated movements. Any abnormality affecting the fingers can have a huge impact on quality of life of the patient. A finger fracture is usually a minor injury but if left untreated it may lead to major consequences due to interference with the specialized functions such as grasping or manipulating objects in the palm. A fracture of the finger may disrupt the alignment of whole hand and cause pain and stiffness.

The hand contains approximately 27 small bones. The 8 carpal bones together form the wrist and the 5 metacarpal bones spread out across the palm and join the phalanges of the fingers; the five fingers of each hand comprise of approximately 14 phalanges.

Causes

Fracture of the finger may be secondary to a trauma, direct stress to the finger or any injury to the hand such as a fall or motor vehicle accident. Some other common causes of finger fracture include carelessness while using power tools such as a saw or drill and other physical activities such as sports. Patients with a history of osteoporosis are at an increased risk of finger fracture.

Symptoms

The common symptoms of a finger fracture include swelling, tenderness and bruising at the fracture site. The fractured site is tender to touch and any movement of the finger may be difficult along with a physical deformity of the fractured finger.

Diagnosis

The diagnosis of finger fracture is based on history, physical examinations and X-ray imaging to determine the type and severity of the fracture. X-rays are the most widely used diagnostic tools for the evaluation of fractures.

Treatment

The treatment of the fracture is based on the severity and type of fracture as well as the medical condition of the patient.

Non-surgical treatment

Non-surgical treatment comprises of immobilizing the fractured finger with the help of casts or braces to prevent weight bearing and to help the healing process. Buddy taping can also be used to support the fractured finger. X-rays are taken at regular intervals to assess the healing process.

Surgical treatment

Surgical treatment may be required for severe fractures such as open fractures or crush injuries. Pins, screws or wires may be used for repair of the fracture and to realign the bones.

Rehabilitation

Rehabilitation is essential to avoid complications such as late arthritis. Physical therapy and other exercise regimens are recommended to prevent finger stiffness and swelling and to improve muscle strength and range of motion.

Phalanx Fracture – StatPearls – NCBI Bookshelf

Continuing Education Activity

Phalangeal fractures of the hand are a common injury that presents to the emergency department and clinic. Injuries can be located at the proximal, middle, or distal phalanx. For the vast majority of phalanx fractures, an acceptable reduction can be managed with non-operative treatment. Early intervention is important to allow healing and return of function. This activity reviews the etiology, presentation, evaluation, and management of fractures of the phalanges and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition.

Objectives:

• Review the underlying anatomy and its importance of the mechanism of injury.

• Explain the appropriate history, physical, and evaluation of phalanx fractures of the hand.

• Summarize the treatment and management options available for phalanx fractures of the hand.

• Outline interprofessional team strategies for improving care coordination and communication to improve outcomes with phalanx fracture treatment. Provide education to interprofessional teams that will be treating phalanx injuries.

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Introduction

Phalangeal fractures of the hand are a common injury that presents to the emergency department and clinic. Injuries can occur at the proximal, middle, or distal phalanx. For the vast majority of phalanx fractures, an acceptable reduction is manageable with non-operative treatment. Early intervention is vital to allow healing and return of function. Anatomy

The proximal and middle phalanges of the hand all possess a head, neck, shaft, and base. The distal phalanx divides into the tuft, shaft, and base. The proximal phalanx receives stabilization from the surrounding anatomy, including proper and accessory collateral ligaments, volar plate, and extensor/flexor tendons. The middle phalanx has two main insertions: the central slip (extensor mechanism) and the flexor digitorum superficialis (FDS). The distal phalanx anatomy includes the distal interphalangeal joint (DIPJ), which is enveloped by the extensor and flexor tendons along with the volar plate and collateral ligaments. The flexor digitorum profundus (FDP) inserts at the volar metaphysis of the distal phalanx. At the proximal interphalangeal joint (PIPJ), the flexor digitorum profundus and the flexor digitorum superficialis are within one sheath. The flexor digitorum superficialis is volar, and the flexor digitorum profundus is dorsal. As the tendons transverse the PIPJ the flexor digitorum superficialis bifurcates into two slips that form the Camper’s chiasm which inserts on the volar aspect of the middle phalanx. This important anatomic relationship can lead to a swan neck deformity (a hyperextended PIPJ and flexed DIPJ).[1]

Etiology

Injury to the phalanges occurs with direct, blunt trauma, penetrating trauma, and crush injuries. 

Epidemiology

Phalanx fractures are the most common injuries in the body. They account for 10% of all fractures and 1.5% of all ED visits. The majority of trauma to the hand involves the phalanges (46% phalangeal, 36% metacarpal). The distal phalanx and border digits are most commonly injured. Males are more affected than females. The most common finger injured is the small finger.[2][3]

Pathophysiology

Phalanx fractures displace according to the level at which the fracture occurs due to the eloquent soft tissue and tendon involvement of the phalanx.

Distal Phalanx

Distal phalanx fractures are usually nondisplaced or comminuted fractures. They classify into tuft (tip), shaft, or articular injuries.

• Tuft fractures usually result from a crushing mechanism such as hitting the tip of a finger with a hammer. A tuft fracture is frequently an open fracture due to its common association with injury to the surrounding soft tissues or nail bed. Even without surrounding soft tissue injury, the fracture is considered open in the presence of a nail bed injury. 

• Shaft fractures

• Intra-articular fractures are associated with extensor tendon avulsion (Mallet finger) or flexor digitorum profundus tendon avulsion (Jersey finger). [4]

• Seymour fractures: this is a displaced epiphyseal injury of the distal phalanx associated with nail bed injury. Hyperflexion is usually the mechanism of injury and it presents as a mallet deformity with apex dorsal.

Middle Phalanx

Middle phalanx fractures occur in an apex dorsal or volar angulation depending on location. Apex dorsal angulation results from the fracture occurring proximal to the flexor digitorum superficialis (FDS) insertion so that the fragment becomes displaced by the pull of the central slip. Apex volar angulation occurs if the fracture is distal to the flexor digitorum superficialis insertion. A fracture through the middle third may angulate in either direction or not at all as a result of the inherent stability provided by an intact and prolonged flexor digitorum superficialis insertion. Proximal Phalanx

Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). The proximal fragment flexes due to interossei, and the distal phalanx extends due to the central slip.

History and Physical

The main component to focus on assessment are:

• History – handedness, occupation, time of injury, place of injury (work-related)

• Mechanism of injury – magnitude, direction, point of contact, and type of force that caused the trauma

• Soft tissue damage

• Finger alignment – cascade, digit scissoring, rotational defect

• Open vs. Closed

• Tendon/nerve/vessel damage – tendon ruptures may accompany dislocations such as the terminal extensor tendon rupture in the distal interphalangeal joint dislocation or a central slip rupture in a proximal interphalangeal joint dislocation. Tendon damage otherwise only usually occurs with associated lacerations or open combined injuries. Nerves and vessels are rarely injured as part of a simple fracture or dislocation but often suffer injury in major open hand trauma.

Evaluation

Diagnostic tests to consider include:

• Radiographs – PA and lateral and oblique

• CT – rarely needed. May occasionally be helpful in operative planning with complex peri-articular fractures such as pilon fractures at the base of middle phalanx fractures. It can be used to detect foreign bodies like plastic, glass, and wood.

• Ultrasound – detect objects that lack radiopacity

• MRI – unclear diagnosis, foreign material, or tumor

Mostly phalanx fractures are described by location (head, neck, shaft, base) and pattern (transverse, spiral, oblique, comminuted).[5]

Treatment / Management

Overall

The goal of surgical treatment is to allow stable reduction and early mobilization to prevent stiffness/contracture.[6]

Indications for surgical treatment are: 

• Articular congruity

• Rotational malalignment

• Significant angulation/displacement

• Multiple fractures

• Open fractures

Proximal Phalanx Fractures

Non-operative 

• Extraarticular with less than 10 degrees angulation or under 2 mm shortening and no rotational deformity Stable, transverse fracture

Operative

• Reducible but unstable isolated fractures

• Intra-articular fractures with displacement

Closed reduction and internal fixation of proximal phalanx shaft fractures can be accomplished longitudinally through the metacarpal phalangeal joint but not the metacarpal head, or just through the metacarpal head known as Eaton-Belsky Pinning. The wires for either of these options are run in a parallel fashion, cross, or run transversely into the phalanx. Interfragmentary lag screw fixation would be indicated in long oblique fractures. Other ORIF options would be mini fragment plates and screws.

Middle Phalanx Fractures 

Proximal intra-articular fractures may be comminuted with axial load and considered “pilon” fractures. If the volar portion of the proximal base fracture constitutes approximately 40% of the articular surface, then it carries the majority of the proper collateral ligament insertion. Also, the accessory ligament and volar plate insertions, which make the fracture unstable. Dorsal proximal base fractures may be considered central slip avulsions.

Non-operative 

Operative

• Transverse fractures with greater than 10 degrees angulation or 2 mm shortening or rotationally deformed

• Irreducible and unstable fractures 

• • CRPP vs. ORIF

Distal Phalanx Fractures 

Differential Diagnosis

• Gout

• Osteomyelitis 

• Finger infection

• Kirner deformity[8]

• Sarcoidosis[9]

• Neoplastic disease 

• Endocrine disorder

• Stress fracture

Prognosis

Most phalanx fractures will heal without surgical intervention – (approximately 2% nonunion rate).

Complications

Stiffness[10]: This is the most common complication. There is an increased risk of stiffness in phalanx fractures with prolonged immobilization, intra-articular extension, and where there is extensive dissection during operative management. Stiffness is managed with hand therapy rehabilitation and surgical release would be indicated only as a last resort of management.

Malunion: Either in the form of shortening, angulation, or malrotation. Where there is functional impairment as a result of malunion, surgical intervention would be indicated. This is either in the form of corrective osteotomy at the malunion site or metacarpal osteotomy that offers limited degrees of correction.

Nonunion: Usually of the atrophic type, however, it is an uncommon complication. There are various options of management including debridement, bone grafting, and plating, fusion, or ray amputation

Loss of function

Infection

Deterrence and Patient Education

Prevention is the key in the deterrence of phalanx fractures. Proper working conditions and safety is standardized in most work settings that decrease these injuries when working with machinery. Otherwise, trauma is difficult to control; and educating patients about signs and symptoms of phalanx fracture is an important factor for early management.

Pearls and Other Issues

To minimize tethering to extensor mechanism, use a trocar-tipped K-wire. Ensure passage of the wire through soft tissues before activating wire driver. 

Understand the nature and orientation of the fracture when using the buddy taping technique. Fingers used for buddy taping include: 

• Index – Long

• Long – Index

• Ring – Long

• Little – Ring

Phalanx fractures that require closed reduction and percutaneous pinning may have the procedure performed in the operating room or procedure room. The cost is significantly less in the procedure room without an increase in complications.[11]

Enhancing Healthcare Team Outcomes

Managing phalanx fractures requires an interprofessional team of healthcare professionals that include nurses, occupational therapy, physical therapy, radiology, orthopedic surgery, and primary care physicians.

Since the majority of phalanx fractures initially present in the emergency department, the ED physician should be aware of the management and when to seek a consult from the orthopedic surgeon.

Care is taken to diagnose phalanx fractures correctly with physical exam and radiography, allowing guiding treatment to operative versus non-operative management. Regardless of the procedure, the patient has a period of immobilization, followed by an early range of motion. All patients with phalanx fractures need to be followed to ensure that healing is occurring; improper healing can affect function and quality of life. Nursing can follow up and assess the progress of treatment and subsequent therapy; reporting concerns to the clinical team. Orthopedic specialty nursing can also assist with patient and family education, as well as monitoring progress and coordinate rehab, reporting status changes to the managing clinician. Early intervention with physical therapy, whether formal or informally, will prevent stiffness and secondary complications of phalanx fractures. Ultimately, this results in better outcomes and care for the patient.[12] As is the case in all injuries, a collaborative interprofessional approach, with each specialty keeping the rest of the healthcare team informed of progress, will result in better outcomes. [Level V]

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Figure

Phalanx Fracture
Transverse non-articular fracture of the 5th proximal phalanx neck. Contributed by Mark A. Dreyer, DPM, FACFAS

Figure

AP, lateral, and oblique xray images of a right small finger proximal phalanx fracture. Contributed by Dalton McDaniel, DO

Figure

Distal phalanx fracture of the left index finger: gross image with AP, oblique, and lateral xrays. Contributed by Dalton McDaniel, DO

Figure

Proximal phalanx fracture of right index finger – lateral and AP radiographs. Contributed by Dalton McDaniel, DO

References

1.

Bachoura A, Ferikes AJ, Lubahn JD. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med. 2017 Mar;10(1):1-9. [PMC free article: PMC5344866] [PubMed: 28188545]

2.

Angermann P, Lohmann M. Injuries to the hand and wrist. A study of 50,272 injuries. J Hand Surg Br. 1993 Oct;18(5):642-4. [PubMed: 8294834]

3.

Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001 Sep;26(5):908-15. [PubMed: 11561245]

4.

Yee J, Waseem M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 8, 2022. Mallet Finger Injuries. [PubMed: 29083648]

5.

Packer GJ, Shaheen MA. Patterns of hand fractures and dislocations in a district general hospital. J Hand Surg Br. 1993 Aug;18(4):511-4. [PubMed: 8409670]

6.

Lee SG, Jupiter JB. Phalangeal and metacarpal fractures of the hand. Hand Clin. 2000 Aug;16(3):323-32, vii. [PubMed: 10955206]

7.

Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg Am. 1984 Mar;9(2):247-52. [PubMed: 6715836]

8.

Khalid S, Khalid M, Zaheer S, Ahmad I, Ullah E. Kirner’s Deformity Misdiagnosed as Fracture: A Case Report. Oman Med J. 2012 May;27(3):237-8. [PMC free article: PMC3394366] [PubMed: 22811775]

9.

Terranova WA, Williams GS, Kuhlman TA, Morgan RF. Acute phalangeal fractures due to undiagnosed sarcoidosis. J Hand Surg Am. 1985 Nov;10(6 Pt 1):902-3. [PubMed: 4078278]

10.

Oosterhoff TC, Nota SP, Ring D. Finger Stiffness. J Hand Microsurg. 2015 Jun;7(1):13-7. [PMC free article: PMC4461595] [PubMed: 26078497]

11.

Garon MT, Massey P, Chen A, Carroll T, Nelson BG, Hollister AM. Cost and Complications of Percutaneous Fixation of Hand Fractures in a Procedure Room Versus the Operating Room. Hand (N Y). 2018 Jul;13(4):428-434. [PMC free article: PMC6081793] [PubMed: 28660786]

12.

Ataker Y, Uludag S, Ece SC, Gudemez E. Early active motion after rigid internal fixation of unstable extra-articular fractures of the proximal phalanx. J Hand Surg Eur Vol. 2017 Oct;42(8):803-809. [PubMed: 28589776]

Disclosure: Clarence Kee declares no relevant financial relationships with ineligible companies.

Disclosure: Patrick Massey declares no relevant financial relationships with ineligible companies.

Fracture of the distal metaepiphysis of the radius (fracture of the radius “in a typical place”) – symptoms, diagnosis, treatment at NCC №2 (CCH RAS)

Fracture of the distal metaepiphysis of the radius (“beam in a typical location”)

The distal metaepiphysis is the lower end of the radius, located next to the hand.

A “beam in typical location” fracture usually occurs with a direct fall on an outstretched arm. In addition to a sharp pain in the arm, a bayonet deformity, a change in the position of the hand, may appear. The nerves and vessels of the wrist are involved in the fracture process, which can be compressed by fragments, which is manifested by numbness in the fingers, coldness of the hand.

To clarify the nature of the fracture and the choice of further treatment tactics, radiography is used, in some cases, computed tomography. Sometimes an ultrasound of the wrist joint is required.

Since the radius adjoins the hand, it is very important to restore the anatomy and range of motion in the joint in order to avoid problems with it in the future. Previously, such fractures were treated conservatively, i.e., in a plaster cast, but often the fragments were displaced, the bone healed incorrectly, which later affected the function of the limb – the arm did not bend and / or did not unbend to the end – stiffness of the joint formed (contracture), remained pain syndrome. In addition, a long stay in plaster had a negative effect on the skin.

The duration of the sick leave for a fracture of the distal metaepiphysis of the radius depends on the type of activity of the patient. For example, for office workers, the average period of disability is 1.5 months. For professions related to physical activity, the period of incapacity for work may be extended.

Conservative treatment of a fracture of the radius in a typical location (plaster cast)

For fractures without displacement, conservative treatment can be offered – in a plaster cast. The average stay in plaster is 6-8 weeks. This rarely passes without a trace for the limb – after conservative treatment, the joint requires the development of movements, rehabilitation. In the treatment of a fracture, even with a slight displacement in the cast, secondary displacement of the fragments can occur.

Surgical treatment of a fracture of the radius in a typical location (osteosynthesis)

Almost all displaced fractures of the radius require surgical treatment – comparison and fixation of bone fragments – osteosynthesis . It is this method that allows you to restore the function of the hand most fully and achieve good functional results.

The radius is completely fused in about 6-8 weeks. After this period, the patient can begin to fully use the hand. But it is possible to develop a hand with the help of certain exercises recommended by a doctor, thanks to the use of fixators, already 1-2 weeks after the intervention. Light sports physical activity can be started approximately 3 months after the operation.

Depending on the type of fracture (comminuted, multi-comminuted, with significant or insignificant displacement), several possible options for fixation can be distinguished – with a plate fixed with screws; external fixation device; screws; spokes .

In some cases, with severe edema, an external fixation device is applied, and after the edema subsides, it is replaced with a plate (or other fixator, depending on the type of fracture).

Osteosynthesis of the radius with plate

With a significant displacement of fragments, osteosynthesis of the radius is used with a metal plate specially made for this segment. After comparing the fragments, the plate is fixed with screws to the damaged bone. After installation, the plates are superimposed on the skin, sutures are applied for 2 weeks, as well as a plaster cast for about the same period. After the operation, drug therapy is prescribed: painkillers, calcium preparations for faster bone fusion, if necessary, topical preparations to reduce swelling. The average length of stay in the hospital is 7 days. Stitches are removed on an outpatient basis after 2 weeks. The hand is worn in an elevated position on a kerchief bandage. There is no need to remove the plate.

External fixator

In some cases, in the elderly, with severe swelling of the hand and wrist joint, it is undesirable to make access to install the plate due to various factors (edema, skin condition). In such cases, an external fixation device is installed – it fixes the fragments with the help of spokes that pass through the skin into the bone. The device protrudes above the skin in a small block (about 12 cm long and 3 cm high). The advantage of this type of osteosynthesis is that there is no need to make large incisions, but the device must be monitored – dressings should be done so that the spokes do not become inflamed.

After the operation, the arm is in the splint for 2 weeks, then the patient begins to develop the wrist joint in the apparatus, which does not interfere with this.

The external fixation device is removed after about 6 weeks, after X-ray control, in a hospital setting. The operation of removing the external fixation device does not take much time and is quite easily tolerated by the patient. The average hospital stay is 5-7 days, the duration of the sick leave is about 1.5 months. Dressings should be done every other day, on an outpatient basis. The hand is worn in an elevated position on a kerchief bandage.

Fixation with spokes or screws

With a slight displacement of fragments, the radius is fixed with knitting needles or screws through small skin punctures. A plaster splint is applied for about 2 weeks, then the person begins to develop the arm. After 6-8 weeks, the needles are removed.

In some cases, it is possible to use self-absorbable implants, which do not need to be removed.

Old, malunion fractures of the radius

In case of chronic incorrectly fused fractures, pain may be disturbed, there may be movement restrictions – stiffness of the joint, and other unpleasant consequences (numbness and swelling of the fingers). In such cases, surgical treatment is recommended, most often with fixation with a plate. The bone is disengaged, placed in the correct position and fixed. If there is a zone of bone defect – for example, if the bone has grown together with shortening, this defect is filled either with the person’s own bone (the graft is usually taken from the iliac crest), or with artificial bone, which is rebuilt in 2 years into its own bone tissue.

Further postoperative and restorative treatment for chronic and improperly fused fractures of the distal metaepiphysis of the radius are similar to those described above. However, given the chronic nature of the damage, a longer rehabilitation may be required.

Anesthesia for surgical treatment of a fracture of the distal metaepiphysis of the radius

For all the above operations, as a rule, conduction anesthesia is used – an anesthetic solution is injected into the brachial plexus area, where the nerves that innervate the entire upper limb (responsible for its sensitivity and movement) pass, and the arm becomes completely numb. Such anesthesia is quite easily tolerated, lasts 4-6 hours. In fact, this is a kind of local anesthesia. In addition, premedication is done – a soothing injection, and during the operation the person sleeps with his sleep. General anesthesia may be used. The final choice of anesthesia method is determined by the anesthesiologist on the eve of the operation.

Russians warned about the consequences of arm fractures for the sake of delay e, which have restrictions on medical indications. However, the intentional infliction of fractures and mutilations for the sake of delay is prosecuted by law, human rights activist, director of the human rights organization School of Conscript Aleksey Tabalov warned in an interview with Lenta.ru.

Who is unfit

Russian law provides for five categories of fitness for military service. According to the human rights activist, there are not so many of those who will not be called up under any circumstances.

It’s simple: everyone is fit, except for those who have a fitness category D – they are disabled or have a serious illness. Also not called up with HIV infection. As for hepatitis C, everything seems to depend on the severity of the disease

Aleksey Tabalov human rights activist, director of the human rights organization “Conscript’s School”

“Citizens with fitness category D are not fully called up for mobilization. This actually means disability or a serious illness,” he said.

Medical restrictions

There are also medical restrictions that temporarily prevent citizens from being drafted, Tabalov explained.

“Citizens of category G are not temporarily called up. These citizens currently need to undergo treatment or examination, because it is impossible to confirm their fitness for military service at the time of the medical examination. Also, citizens who are after injuries, burns and exposure to external factors, who need rehabilitation for a certain time, are also temporarily released, ”said the human rights activist.

All other conscripts, even category B, for those who have not completed military service. They are suitable for mobilization

Aleksey Tabalov human rights activist, director of the human rights organization “Conscript School”

Materials on the topic:

Responsibility for evasion

Intentionally injuring yourself will be regarded as an attempt to avoid mobilization. For this, the Criminal Code of the Russian Federation provides for punishment in the form of a fine, forced labor or imprisonment for up to two years. If it is possible to prove that the injury was accidental, the deferment from service will be temporary, said Alexey Tabalov.

If, for example, you deliberately break your arm, it will immediately be regarded as an attempt to evade, this is a criminal article. And this will give a delay of a maximum of six months, until the hand grows together. As soon as the doctors say that the rehabilitation period is over, they will pick you up. Donetsk and Lugansk People’s Republics (DPR and LPR), Kherson and Zaporozhye regions of Ukraine.